Treating Tooth Wear Resulting From Malocclusion

Tooth wear, which occurs at a faster rate in patients who suffer from conditions that cause dry mouth, is typically caused by a combination of three distinct processes: attrition, abrasion, and erosion. Attrition refers to the loss of tooth structure resulting from physical tooth to tooth contact, abrasion refers to the loss of tooth structure caused by physical means other than the opposing teeth, and erosion refers to the chemical dissolution of tooth structure by acids. All of these processes can lead to a more problematic tooth wear condition known as abfraction, in which a hard-tissue lesion forms at the cervical margin of the tooth as a result of stress caused by extrinsic forces on the enamel. The loss of tooth structure from abfraction is caused by minute flexure of the tooth under occlusal loading. More simply put, this means that a notch forms at the intersection of the tooth and gumline that is caused by bending forces applied to the tooth.^2,3

Most tooth wear occurs while individuals are sleeping. The grinding and clenching of teeth that occurs during sleep, a condition known as bruxism, is the most common cause of tooth fracture. Although bruxism can be related to stress and other factors, one of the primary causes is malocclusion. Over time, misalignment of the teeth can result in damage to the enamel and the accumulation of bacterial deposits that lead to the development of caries.⁴ In these cases, treatment for tooth wear should include a combination of orthodontic treatment and restorative treatment as well as the use of an occlusal guard or other appliance.

Occlusal guards and combination guards are great devices to protect teeth during the day or night from destructive habits like bruxism. Patients who could benefit from an occlusal guard include those who exhibit symptoms such as jaw pain or stiffness, fractured or worn down teeth and/or dental restorations, headaches in the morning, disrupted sleep, and facial pain. Patients demonstrate greater compliance with combination guards because they offer a soft, comfortable inner surface and a hard durable outer surface.⁵

A 46-year-old female patient presented to our office with the chief complaint that she did not like how her teeth "stuck out." During the examination, it was noted that she exhibited severe Class III attrition from maxillary first premolar to first premolar (teeth Nos. 5 through 12), abfraction lesions on her maxillary right and left canines (teeth Nos. 6 and 11), and severe overjet. She stated that she was not in any pain, and she had no other significant dental needs. In addition, the patient specified that she did not like the shape of her teeth and that she was really bothered by how short her top teeth were (Figure 1).

Previously, the patient demonstrated more severe protrusion as well as crowding of the teeth in the anterior region of her maxillary arch, but she had begun clear aligner treatment (SmileDirectClub clear aligners, SmileDirectClub) to improve her alignment for restoration and was presently on the last tray of her treatment plan. This clear aligner system was selected for this case because it is a great option to help achieve the most esthetic results for restorative cases that require minor to moderate tooth movements. It is an economical and expedient system in which patients receive a doctor prescribed and monitored treatment plan that they complete through a teledentistry platform. Misaligned teeth can be moved and properly placed in an efficient and safe manner, and patients tend to have great compliance because they don't have to disrupt their daily commitments with in-office visits. By presenting this economical option, clinicians are able to correct issues that patients may not have known could be corrected. For example, many adults have some form of tooth wear related to malocclusion but are unaware of the options to correct it. For the patient in this case, porcelain-fused-to-zirconia crowns were recommended for teeth Nos. 5 through 12 once her orthodontic treatment was completed.

After the patient finished her clear aligner treatment, she returned to the office, and great improvement of her alignment and crowding was noted (Figure 2 and Figure 3). Her teeth were prepared for the crowns, and temporary restorations were placed for a period of 4 weeks to ensure that she had no severe sensitivity. After 4 weeks, the final porcelain-fused-to-zirconia crowns were seated (Figure 4 through Figure 8). The patient expressed that she was very excited and pleased with the final result. She was recalled for a 4-week follow-up appointment and demonstrated no postoperative issues. In addition to stating that she was happy with the improved esthetics and the alignment and shape of her new crowns, she also stated that her bite felt better. At this time, a combination occlusal guard was fabricated and delivered to the patient in order to protect and preserve her natural teeth and new porcelain crowns.

When correcting the consequences of tooth wear, especially in the anterior region, esthetics are critical. An important factor in restoring teeth damaged from moderate to severe bruxism is improving their occlusion to prevent future damage of the teeth and restorations; therefore, it is ideal to move misaligned teeth to more favorable positions prior to restoration. Clear aligner treatment offers a great way to accomplish the tooth movement needed to facilitate the fabrication of natural and esthetic restorations for anterior teeth.

Loray Spencer, DDS
Private Practice
Rock Hill, South Carolina

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