Wooddell & Passaro

Treating the Worn Dentition – Part 1

Wooddell & Passaro — Thu, 19 Apr 2012 03:23:17 +0000

This is the first in a three part series from the Chesapeake Dental Education Center (CDEC) covering the topic of treating the worn dentition. Part I will focus on diagnosis and etiology. Part II will cover esthetics – the first phase of treatment planning, and Part III will discuss occlusal issues relative to treatment planning.

Classically, in dental school, we are taught how to diagnose and treat periodontal disease and caries. In fact, dentistry has done such a good job treating dental disease and teaching preventative care that more and more people are keeping their teeth longer and longer. This has created an ever-increasing dilemma – more people with worn teeth and little to no dental school training in how to treat them.

As teeth wear, compensatory changes occur. Teeth will tend to stay in contact even thought they are diminishing in size. As teeth change their positions to stay in contact, the position of the entire alveolar housing surrounding them will change. Often, it becomes difficult to iminagine what the dentition looked like in youth, before the wear problem began. In other words, many of the wear cases are a problem of tooth position. And the two factors involved in determining ideal tooth position are esthetics and occlusion.

The first key in treating the worn dentition is diagnosing the etiology.

In our practice, we often see patients with moderate to advanced wear, that when asked about the condition of their teeth, tell us their previous dentist told them they grind their teeth. However, when we ask them about grinding, they tell us they were not aware of it.

Historically, tooth wear has been related to bruxisim. But now, it is commonly known there are other etiologic factors – erosion, both intrinsic and extrinsic, abrasion, abfraction and parafunctional habits other than bruxism. Properly diagnosing the etilogy allows both the dentist and the patient to understand the risk assessment of performing treatment.

Etiologic Factors in the Worn Dentition:

Attrition is the loss of tooth structure by mechanical forces from opposing teeth. The most common cause of attrition is bruxism. Functional actions, such as chewing, speaking and swallowing usualy put very little force on the opposing teeth. Parafunctional habits, such as clenching and grinding, fingernail or cuticle biting, place greater amounts of force on opposing teeth.
Erosion is the irreversible loss of tooth structure due to chemical dissolution by acids not of bacterial origin. The source of the acidity can be either extrinsic (like citris fruit or carbonated beverages), intrinsic (like gastric reflux or bulimia) or both.
Abrasion is the loss of tooth structure by mechanical forces from a foreign element. If this force begins at the cemento-enamal junction, then progression of tooth loss can be rapid since enamel is very thin in this region of the tooth. Once past the enamel, abrasion quickly destroys the softer dentin and cementum structures.
Abfraction is the pathologic loss of hard tooth substance caused by biomechanical loading forces. Such loss is thought to be due to flexural and chemical fatigue degradation of enamel and/or dentin from some location distant to the actual point of loading.

To determine which of these factors are involved when evaluating a patient with tooth wear, a careful patient history and clinical examination are necessary. Some wear patterns are pathognomonic and easily diagnosed (like bulimia). Other patterns are more difficult to diagnose (like non-carious cervical lesions) and can be multifactorial. By identifying the source or sources of wear, the patient can be counseled to eliminate or control them and understand the risks involved with either treatment or non-treatment of their wear.

Part II will focus on the esthetics of treating the worn dentition and expose portions of our Systematic Treatment Evaluation Protocol (STEP^TM) that allows for an effecient and predictable process of determing…

The Turbyfill Denture Technique

Wooddell & Passaro — Thu, 05 Apr 2012 13:00:35 +0000

Even though there has been a 10% decrease in edentulism each decade for the last three decades, the huge increase expected in the population group over 55 years of age will actually increase the demand for denture fabrication. And when patients desire dental implants to assist or support their prostheses for the treatment of edentulism, a well-fitting, esthetically pleasing and functionally stable set of dentures, which also allow for good phonetics, must be made first to determine the definitive tooth positions prior to planning the dental implants.

After being taught and mentored by Dr. Walter “Jack” Turbyfill (Dr. “T”), we have implemented and follow his denture technique to a “T”. From the preliminary impressions and the “training” denture (it’s actually a provisional denture) to the functional impressions and porcelain teeth to hold the patient’s vertical dimension, his technique produces the most esthetically pleasing and functionally stable dentures possible. The end result can be a long-term success for the patient (and he shows many cases where patients have had their dentures for decades) or it can be a starting point to plan implant supported or implant assisted prostheses.

Let’s focus our attention to just one component of Dr. Turbyfill’s technique, the training denture.

For the dentate patient with a mutilated dentition, a critical part of the reconstructive procedures to rehabilitate the dentition is to fabricate provisional restorations to “test drive” the occlusion, the envelope of function during mastication, the esthetics, patient comfort with the vertical dimension of occlusion and the phonetics. Why, for a patient undergoing complete denture fabrication, would one not fabricate a provisional denture?

What are the advantages of fabricating a training denture?

Patients that present for new dentures typically have old dentures with aberrant tooth positions, lost vertical dimension, poor esthetics, discomfort and, if their old dentures have plastic posterior teeth, there are heavy occlusal forces in the anterior due to the wear of the plastic teeth. Even worse, if the patient who presents for new dentures has no old dentures or teeth, there are no reference points to start from and denture fabrication can seem even more daunting for the practitioner.

The training denture allows the dentist and the patient the opportunity to evaluate all the factors mentioned above. Prior to the fabrication of the definitive dentures, any alterations deemed necessary from the “test drive” can be made. This ensures dentures of the highest quality for the patient.

In addition, when the training dentures are fabricated from the preliminary impressions, there is relief in the intaglio surface of the denture that provides room for a functional impression material (Hydrocast – Sultan Dental). Hydrocast is essentially a soft acrylic material that takes weeks to set and will record the differing redundancies of the various soft tissues in the mouth in function. It makes a very accurate final impression and border molds beautifully.

Certainly, the cost of fabricating a set of dentures in this manner will be greater, but there are many advantages of this technique. First, of course, is the quality of the final product for the patient. Second, the patient will have a back-up set of dentures that will fit beautifully if repairs are ever necessary to the definitive dentures.

There are also advantages with patient management using the training denture technique.

When making tooth position changes to idealize esthetics and function, many times patients don’t feel comfortable with such a dramatic change in their appearance. It sometimes takes a while for them to realize how much better they look with their lips supported or their vertical dimension opened back to where it had been previously or both. Fabricating a training denture allows the practitioner to get the patient most of the way to where he thinks the patient should be, and then additional changes can be made going from the training dentures to the definitive dentures.

The training denture also provides a cut-off point of patient acceptance. Because of the additional lab fees (second set of dentures) the fees with this process are higher. The fee for the entire process is quoted, but the patient can be told that a portion of the fee will cover treatment through the end of the training denture. Then, if they don’t see the value of the treatment, they can stop treatment at the end of the training denture. Likewise, the dentist can decide if the patient has unrealistic expectations and would be best not proceeding with treatment.

Future topics relative to complete denture fabrication will cover:

Making great preliminary impressions.
Esthetically positioning the anterior teeth.
Using photography to communicate with the laboratory technician to predictably and efficiently achieve great esthetics.
Denture occlusion and tooth design – where and why.
Making a bite registration with a central bearing point – easy and unbelievably accurate.

A Team Approach

Wooddell & Passaro — Sat, 10 Dec 2011 17:27:37 +0000

When it comes to choices about care, the more involved a patient is in the decision making process, the more likely the patient will understand and accept treatment. That’s why we spend more time with our patients.

A general dentist alone cannot always solve some of the more complex oral or facial problems from which a patient may suffer. Traditionally, a general dentist simply refers these cases to a trusted specialist, or several specialists when one cannot deal with all aspects of a complex problem. This multidisciplinary approach to patient care provides more knowledge and experience than a dentist working in isolation. Often times with this approach information travels between the dentist and the specialists with little collaboration between them or the patient.

We take an interdisciplinary team approach to patient care, focusing on open communication between the primary dentist, the specialists and the patient, including the patient in the process as a member of the team. The patient is intimately involved in discussions about their treatment plan, offering them better understanding of their options and empowering them to actively participate in the development of the final therapy.

The beauty of collaborative work is that everyone can offer each other advice and build on each others ideas. Rather than passing down orders, team members can ask for input and suggestions. Learning about alternative treatments and options allows us to increase the level of patient care, in terms of both the final outcome and the process itself.

Each specialist of the interdisciplinary team is selected based on their area of expertise and the desired outcomes for the patient. The ultimate goal is to create and maintain an ideal treatment environment in which the patient feels comfortable and the doctors can work effectively.

Open lines of communication reduce stress and confusion for all members of the team, including the patient. Clear expectations of the intended treatment outcome are built into the interdisciplinary team’s framework. As a result, and by its very nature, this approach allows for better efficiency and a healthier treatment outcome.

Members of our team meet at the beginning to discuss the patient’s diagnosis and treatment plan together. During treatment, the team members participate in periodic scheduled meetings as well as informal discussions to review the patient’s progress and adjust the plan, if necessary.

By including the patient in the development of their treatment plan, they cultivate personal relationships with us and the specialists. Trust grows from these relationships and the patient feels that he or she is an active, respected member of the team.