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abstract
Article history:
Objectives: The purpose of this study was to report on the management and treatment
Methods: Partially edentulous patients with severe tooth wear who underwent the same
22 July 2011
protocols for full prosthodontic rehabilitation were eligible for this observational study.
Their clinical diagnoses were based on a complete oral examination, photos, functional and
cast analysis, general health conditions and behavioural aspects, such as acidic diets and
bruxism. A 6-month preliminary phase with splints and provisional prostheses was main-
Keywords:
tained prior to the final fabrication of fixed and removable prostheses. All patients com-
Tooth wear
pleted a follow-up period of 3 years. The outcomes were technical and biological
Attrition
Bruxism
core or veneering, and implants, plaque index, caries, endodontic and periodontal lesions,
Partial edentulism
tooth fractures and periimplantitis) and oral health-related quality of life (using the oral
Prosthetic rehabilitation
Results: Data from 42 patients (33 men, 9 women) with a mean age of 62 8 years were
complications
available. The probability that a first, second or third technical complication occurred was
Quality of life
49%, 38% and 21%, respectively. About 50% of the patients remained without any complication. The average OHIP-value was 5 7, which represents high oral health-related quality of
life. No statistically significant correlations between the OHIP values and the type of
prostheses or the occurrence of complications were observed.
Conclusions: From multiple perspectives, the rehabilitation of partially edentulous patients
with severe tooth wear is a complex task, and more information regarding treatment
protocols, prosthetic indications and treatment outcome is needed.
# 2011 Elsevier Ltd. All rights reserved.
1.
Introduction
* Corresponding author at: Department of Prosthodontics, School of Dental Medicine, University of Bern, Freiburgstrasse 7, 3010 Bern,
Switzerland. Tel.: +41 31 632 25 86, fax: +41 31 632 49 33.
E-mail address: joannis.katsoulis@zmk.unibe.ch (J. Katsoulis).
0300-5712/$ see front matter # 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jdent.2011.07.008
663
2.
Methods
2.1.
Patients
2.2.
Study protocol
Patients admitted
Diagnosis
Planning
Provisional
phase
24 months
6 months
Final
treatment
3-6 months
36 months
Questionnaire
OHIP
End of study
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Fig. 2 (ac) Severe tooth attrition with over-closure in a partially edentulous 56-year-old male patient who did not wear his
RPDs for a long period of time. Many teeth have lost >50% of the original tooth substance.
2.3.
Oral and prosthetic status before and after prosthetic
rehabilitation
In the context of the present study, two trained examiners
who had not been involved in the treatment of the patients
anonymously collected data based on an abstraction of the
oral examinations, radiographs and medical files.
1. Initial status:
Presence and type of old prosthetic reconstruction in the
mandible and maxilla: RPD, OD, CD, and FPP.
Overclosure and loss of VDO.
Locked bite with premature contacts.
Large overjet and overbite (both >5 mm), as well as a deep
bite with impingement of the palatal soft tissue.
Awareness of bruxism (self-reported or by others).
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Fig. 3 (a and b) Example of a patient with tooth wear on the front teeth, tooth elongation in the opposed gaps and
subsequently locked occlusion due to strong premature contacts. VDO in the retruded contact position exceeds the normal
height. A regular occlusal plane cannot be re-established when the mandibular premolar is maintained in its current position.
2.4.
Treatment complications
2.4.1.
Technical complications
2.4.2.
Biological complications
2.5.
Questionnaire (OHIP)
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2.6.
Tooth wear
and occlusion
Statistical analysis
3.
TMJ
Awareness of
parafunctional
habits
Criteria
Number of
patients
Overclosure, loss of
VDO 37 mm
Locked bite
Deep bite, OB 5 mm
Large OJ 6 mm
Eruption of mandibular
front segment
Incisal edge bite
Pain, problems self-reported
Muscle tenderness on palpation
Clicking joint
Limited jaw movements
Self-reported
32
By others
7
11
6
11
9
1
6
2
1
14
Results
Table 2 Preliminary treatment.
Occlusal rehabilitation
Pre-treatment
Criteria
No. of
patients
RPD
Splint
Both
Extractions
Fillings
Crown lengthening
Endodontic treatment
22
17
3
34
27
7
19
667
Patients
Removable
CD
OD: root copings, RPD
OD: implants and bara
OD: teeth and implantsa
Fixed
FPP: teeth
FPP: implantsa
FPP: teeth and implantsa
SDA: Natural teeth, crowns
a
b
24
9
8
2
5
18
6
2
5
5
Mandible
Patients
Removable
CD
OD: root copings, RPD
OD: implantsb/bar
21
1
12
8
Fixed
FPP: teeth
FPP: implantsb
FPP: teeth and implantsb
SDA: Natural teeth, crowns
21
3
1
12
5
Total 37 implants.
Total 44 implants.
Before treatment
(number of
patients)
After treatment
(number
of patients)
24a
12b
13c
13
5c
17
27
Per patient
1 Material
2 Materials
3 Materials
Number of patients
8
1
0
6
5
5
17
A, acrylic denture teeth, adhesive resin and composite reconstructions; C, ceramic material; E, enamel of teeth.
The PLI remained low but raised slightly during the maintenance period.
The OHIP-14 questionnaire was completed 3 years after
delivery of the prostheses. A total of 36 out of the 42 patients
returned the questionnaire properly completed. Two patients
did not complete it because the OHIP was not available in their
native language, and four patients did not return it for
unknown reasons. The mean score for the questionnaire was
5 7. Fig. 5 shows that 80% of the patients gave a rating of 0
(never) or 1 (seldom) for all 14 questions. Few patients gave a
rating of 4 (very often) for four items, namely item 2 (bad taste)
and items 4, 5, and 8, which are related to stress and tension.
The total mean rating of seven patients was >10 up to 23. The
Pearson correlations did not reveal any clear tendencies
between the OHIP values and the types of prosthesis (r = 0.013)
or the numbers of failures (r = 0.207). Patients who received
removable prostheses or experienced technical complications
at various instances did not give statistically significant higher
ratings. Thus, the hypothesis was not confirmed.
Number of
patientsa
12
1
1
0
2
8
1
1
0
17
2
7
2
6
8
a
The numbers cannot be added since some patients experienced
more than one technical complications.
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Number of
patientsa
4
1
2
2
1
1
4
1
4
1
a
The numbers cannot be added since some patients experienced
more than one biological complication.
4.
Discussion
most cases. In patients with removable dentures, a combination of various materials was found, such as enamel,
composite, natural teeth or application of veneers to ceramic
crowns, where continued irregular wear can be expected. Most
in vitro studies investigated the quantity of tooth surface loss
during a certain period of time. Surface quality was less often
reported, but would have the potential to account for
particular surface characteristics that determine how future
loss might progress.35
Some studies have reported that TMJ problems are not an
indicator of bruxism16,31 and that many bruxing patients do
not exhibit TMJ problems. In the present study, no overt signs
of TMJ problems were detected. Bruxism can be considered a
dyskinesia36 that appears to be controlled by the central
nervous system.37 Various cofactors play important roles,
such as stress, coping strategies, genetics and behavioural
characteristics. Interestingly, the results from the OHIP
questionnaire revealed that the most negative ratings were
given for the items concerning stress and physical tension.
Currently, no simple method exists that can assess bruxism,38
and the subjective and normative assessments of treatment
need may be different. Prosthetic treatment is not a causal
therapy for strong biting and bruxism habits, although
prosthetic rehabilitation was indicated for all patients in the
present study. Thus the probability of encountering a problem
after a short time was relatively high. The type of technical
complications and fractured natural teeth indicates that
strong biting and parafunctional habits were a major cause
of complications. This was also confirmed by the fact that
night-guards hat to be remade after a short time. Ioannidis
et al. investigated the possible influence of age on the
longevity of tooth supported fixed prosthetic restorations.39
The results of this systematic review showed that increased
patients age should not be considered as a risk factor for the
survival of fixed prostheses. Although the majority of studies
did not show any effect of age on the survival of fixed
prostheses, there was some evidence that middle-aged
patients may present with higher failure rates.
The patients had 2 scheduled visits per year and were fully
compliant. Thus, biological problems such as development of
periodontitis, insufficient oral hygiene and periimplantitis
were well under control. The experience was that in these
patients with severe tooth wear and bruxing habits the
periodontal and periimplant tissues are healthy, remain stable
and bone was of good quality and quantity for implant
placement. Biological complications were related to minor
carious lesions but not in first line to periodontal problems and
only one implant exhibited a periimplant lesion that was
successfully treated. A rather good level of hygiene was
maintained during the follow up time and only a few patients
fell back in spite of the regular recall.
Altogether, technical complications occurred with a higher
rate than was reported in studies of fixed prostheses.4042
Minor ceramic chipping required the polishing and recementation of crowns, while short-span bridges were
required for FPPs. Problems with the anchorage system of
removable prostheses supported by implants were typical for
this type of reconstruction and were comparable with results
associated with non-symptomatic patients.4345 Twenty
patients in all (48%) experienced various technical problems
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5.
Conclusions
670
references
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
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