DentaltownUK October 2017 - 43

W

e as dentists, as mostly selfless
and helpful creatures - want to
try and realise dreams for our
patients, and we often forget to
mention, ' it will be ok' - works sometimes,
but when it doesn't - we lose sleep. When
we see ' broken tooth' in our day list - after
a restoration, our heart sinks - how can we
limit this stress? There are certain factors we
can control, and some we cannot. If we limit
those we cannot control, we have done all we
can to deliver a successful restoration. If we
do not know what to look for, we will always
leave controllable factors uncontrolled, and
are treating patients with a ' fingers crossed'
approach, which is high risk.

Occlusion, Occlusion, Occlusion...
Occlusion is something that sends
dentists into frenzy, with multiple definitions,
complicated terminology, and various schools
of thought. There are few topics that get
discussed and argued with such passion or
rage, than occlusion. However something
we can all agree on, is that if we ignore the
occlusion, we are heading into the dark.
Without understanding the existing situation,
and planning for success, the longevity of
our anterior restorations is compromised.
The existing tooth wear, and chewing
pattern:
' I believe that the more you know about the
past, the better you are prepared for the future.'
~ Theodore Roosevelt
When assessing an anterior aesthetic case,
the first intra oral examination I conduct is
a bite assessment. We can learn from the
existing presentation, what risks we may be
faced with and if there are any limitations we
must then discuss with the patient. An extra
oral muscle examination can give us valuable
information on the muscles of mastication,
TMJ, and helps us identify any ligament laxity,

tension, or other abnormalities. Alongside
this we can assess the degree of opening, any
deviation or deflection on opening and any
pain on movement.
Fig 3 shows a typical presentation of
lower incisal attrition. We come across
patients with this appearance regularly, and
often this will be teamed with no posterior
wear at all. Or we will see a similar pattern
of wear inconsistent with the patient's age.
These patients fall into the "avoidance"
category, where they may be avoiding a
posterior interference and posturing forwards
as a result. Thorough assessment of their
anterior guidance will be needed prior to
considering restorative work to ensure that
we are within the limits of centric occlusion,
or if we require restoration in centric relation.
The risk of restoring the opposing teeth, or
these lower incisors in a situation such as
this, without detailed occlusal assessment,
is fracture, and incisal chipping. The reasons
for this can either be natural interferences,
or previous orthodontics, or multiple single
tooth restorations over time.
An alternative pattern is knows as a
"destructive" pattern, which can be identified
in a mouth with obvious decreased OVD and
generalised attrition across the dentition. This
is more, and can be challenging to rectify.
A case such as in Fig 4 can be managed,
after all the discussions as mentioned in
part 1 are taken into account, the occlusion
is then assessed in detail and in addition a
horseshoe shaped articulating paper is used
by asking the patient to chew.
This highlights any heavy occlusal
contacts in the anterior segment - these
should be faint or non-existent entirely.
K nowing this will aid our treatment
planning, and may indicate a place for pre
restorative orthodontics to reposition the lower
incisors prior to restoration of the upper
anterior teeth.
Deprogramming the patient using an

Fig 1 Natural and functional porcelain
restorations, harmonious with the lips

Fig 2: We can sometimes have a cracking time
in dentistry! A fractured porcelain veneer

Fig 3 Male patient in his mid 60s - a common
sight - worn lower anterior teeth

Fig 4: A patient in her mid 50s, with a
constricted chewing pattern, multiple single
tooth restorations, some over-erupted
posterior teeth and anterior wear. One of the
patient's complaints was a repeatedly debonding anterior composite restoration (UL2).

Fig 5: Male patient in his late 30s, treated
in centric relation

dentaltownuk.com \\ OCTOBER 2017

43
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Table of Contents for the Digital Edition of DentaltownUK October 2017
