Management of

Non carious
lesions of teeth
 Contents
• Introduction
• Attrition
• Abrasion
• Erosion
• Abfraction
• Localized Non- Hereditary Enamel Hypoplasia
• Localized Non- Hereditary Enamel
Hypocalcification
• Localized Non- Hereditary Dentin Hypoplasia
• Localized Non- Hereditary Dentin
Hypocalcification
• Fracture lines
• Amelogenesis imperfecta
• Dentinogenesis imperfecta
• Conclusion
• References
 Introduction

• Non carious tooth tissue loss is defined as surface

loss due to a disease process other than dental
caries. (Pual A Brunton ,Decision making in Operative
Dentistry )

• Although decay is the usual cause of tooth

destruction necessitating operative procedures , it
has been estimated that 25% of tooth destruction
does not originate from a carious process .
 The etiology of the non carious tooth surface lesions
include :

( John O Grippo,Marvin Simmering,JADA 2004

135;1109-1118

Osborne-Smith KL, Burke FJ, Wilson NH.

Int Dent J. 1999 Jun;49(3):139-43. Review)

• Attrition

• Abrasion

• Erosion

• Abfraction
• Localized Non- Hereditary Enamel
Hypocalcification
• Localized Non- Hereditary Dentin
Hypolpasia
• Localized Non- Hereditary Dentin
Hypocalcification
• Fracture lines
• Amelogenesis imperfecta
• Dentinogenesis imperfecta
 Attrition
• Defined as the mechanical wear of the incisal or occlusal
surface as a result of functional or parafunctional
movements of mandible (tooth to tooth contacts)
Sturdevant.

• It is an age dependent ,continuous process usually

physiologic (Marzouk)

• It also includes the proximal surface wear at the contact

area because of the physiologic tooth movement
Attrition can predispose to or
precipitate any of the following :

A) Proximal surface attrition (proximal surface

facets)

• Results from surface tooth structure loss and flattening ,

widening of the proximal contact areas.

• Surface area proximally increases in dimension , which is

susceptible to decay.

• Mesiodistal dimension of the teeth is decreased, leading to

drifting , with the possibility of overall reduction in the dental
arch.
B) Occluding surface attrition
( OCCLUSAL WEAR)
 It is the loss ,flattening , faceting or reverse cusping of
the occluding elements.
 It leads to loss of vertical dimension of the tooth .
a. If the LOSS IS SEVERE & accomplished in a relatively
short time

there would be no chance for the alveolar bone to erupt

occlusally to compensate for the occlusal tooth loss, &
therefore the vertical loss might be imparted to the face
Leading to

overclosure during mandibular functional movements & strain

areas on stomato-gnathic system.
a. if the loss occurs over a long period-

the alveolar bone can grow occlusally, bringing the teeth to

their original occlusal termination.

i.e vertical dimension loss will be confined to teeth but not

imparted to face.
 Deficient masticatory capabilities

 Cheek biting-
vertical overlap between the working inclined planes will be
lost, which will cause surrounding cheek, lip, tongue to be
fed between the teeth.
 Decay- because the underlying dentin will be exposed &
thereby becomes more susceptible to decay.
 Clinical presentation :
• Attrition in its purest form is seen as flattened
occlusal surfaces.

• The degree of wear in both arches is normally equal.

• Sometimes there may be presence of peripheral, ragged,

sharp enamel edges .

• The presence of hypertrophic masseter is a warning

sign of the impact of bruxism .
• TMJ problems can be elicited especially by the over
closure situation ( will overstretch the joint ligaments ).

• Severe occluding surface attrition → predominantly

horizontal masticatory movement of the mandible →
extreme strain on the muscles of stomatognathic system .

• When surface attrition is SLOWER & compensated by,

intrapulpal deposition of secondary & tertiary dentin, then
there will be no pulpal exposure.

• At other times, the attrition is faster than the intrapulpal

dentine deposition, leading to direct pulpal exposure.
 Treatment modalities
The treatment must involve several modalities ,which
should be chosen and initiated in the following sequence:

• Pulpally involved teeth →endodontic therapy /extraction

depending upon their restorability .

• Para functional activities ,( bruxism)-- be controlled with

protecting occlusal splints.
• Myofunctional , TMJ/ any other symptoms in the stomato-
gnathic system -----diagnosed and resolved (modifying the
occlusal splint).

• Occlusal equilibration : should be performed by :

 Selective grinding of tooth surfaces that includes

rounding and smoothening the peripheries of the occlusal
tables.

 And by creating adequate overlap between the working

inclines to prevent further cheek biting.
• Any exposed sensitive dentin should be protected and
actual carious lesion be obliterated .

• Periodontium be examined and any pathology be

treated .

• Restorative modalities can than be initiated.

 Restorations are only needed in the following situations:

 Noticeable loss of vertical dimension

 Or a progressive loss of tooth structure is observed

compromising the tooth strength .

 Caries ,if present

 Defect contributes to a periodontal problem.

 Worn tooth contour, (usually proximal ) which is not

conducive to the maintenance of periodontium .
 A tooth is cracked or endodontically treated.
 Procedure
• The most involved treatment modality is regaining the
lost vertical dimension .

• Verify and reverify its necessity i.e. one should make

sure that alveolar bone did not grow occlusally at the
same pace at which attrition occurred .

• Amount of V.D. lost is estimated .

• It gives an estimate up to what should be the height of

the worn clinical crowns be increased .
• The additional V.D. that the stomognathic system can
accommodate without untoward effects is estimated.

• Hence , if a substantial increase in the dimension is to be

considered (>2mm), it is wise to build a temporary restoration
or removable occlusal splint that can be easily adjusted
through subsequent addition or removal of material .

• Composite temporary restorations are most frequently used.

• Permanent restoration should be done in a cast alloy material

to preserve the remaining the tooth structure and to assure
the integrity of the supporting tissues. .

• A fully adjustable articulator ,hinge axis determination ,use of

pantographic tracings and face bow records are essential for
such cases .
• These restorations should be cemented only temporarily
for an extended period of time ,until it is established
that no untoward symptoms would occur.

• An acrylic splint ( as a stabilization splint) may be

necessary to protect the dentition from further damage
due to attrition and this is frequently the only treatment
required to prevent further tooth tissue loss .

• Can also be used as a diagnostic aid ( esp. if an increase in

the vertical dimension is planned subsequently )
 Stabilization splint
The splint would need to be relined with cold cure acrylic resin to
improve the retention of the appliance and occlusal adjustments
will typically be required
 Restorative treatment
• tooth wear can be followed and re-evaluated during recall
examinations.
• When the wear requires restorative intervention, less
severe anterior wear can be treated with adhesive
composite resin.
(Strassler HE, Kihn PW, Yoon R. Conservative treatment of the worn
dentition with adhesive composite resin. Contemp Esthet Restor Pract.
1999):
• When the wear is more severe, a number of treatment
modalities are available.

• Bonded porcelain veneers have been used to treat incisal

wear.
(Ibsen RL, Ouellet DF. Restoring the worn dentition. J Esthet Dent.
1992;4:96-101.)
• In some cases, the incisal edges can be restored to the
original vertical dimension with direct composite resin.

(Strassler HE, Kihn PW, Yoon R. Conservative treatment of the worn dentition
with adhesive composite resin. Contemp Esthet Restor Pract. 1999)

• Hemmings and coworkers reported on the restoration of

severe anterior wear with composite restoration
including re-establishment of the occlusal vertical
dimension. They reported a 89.4% success at 30
months.

( Hemmings KW, Darbar UR, Vaughan S. Tooth wear treated with direct
composite restorations at an increased vertical )dimension: results at 30
months. J Prosthet Dent. 2000;83:287-293.
• Adhesive cast metal restorations have also been
used to replace missing tooth structure.

( Nohl FS, King PA, Harley KE, et al. Retrospective survey of resin-
retained cast-metal palatal veneers for the treatment of anterior
palatal tooth wear. Quintessence Int. 1997)

• In cases where the occlusion is severely altered by

attrition, the only treatment choice may be a
reconstruction with crowns and bridges.

(Stewart B. Restoration of the severely worn dentition using a

systematized approach for a predictable prognosis. Int J
Periodontics Restorative Dent. 1998;18:46-57.)
 The Dahl concept
• In this approach, space is created by placing restorations
intentionally ‗high‘ – i.e. in supra-occlusion – allowing axial tooth
movement that, over time, re-establishes complete occlusion.
• This principle was known prior to the publication of Dahl‘s work
in 1975. For example, the anterior bite platforms of removable
orthodontic appliances have long made use of this effect
(Cousins AJ, Brown WA, Harkness EM, 1969).
• Dahl and his coworkers (1975) were, however, the first to
describe how it may be used in the management of the worn
dentition. They described the use of a ‗partial bite raising
appliance‘ to create inter-occlusal space in an 18-year-old patient
with severe localised attrition.
• The removable appliance was cast in cobalt-chromium, placed on
the palatal aspects of the upper anterior teeth, and worn 24
hours a day.
• After a period of eight months sufficient
space was created
to restore the worn upper anterior teeth.

• once sufficient inter-occlusal space had been

created. However, the creation of inter-
occlusal space significantly reduced the
amount of tooth preparation required,
especially on the already compromised palatal
surface.

• teeth were restored with full coverage

porcelain bonded crowns
 2 schools of thought to increase the V.D.

• Addition of increments : gradual increments by

progressively adding to the hard splint at 1mm /week,
until the patient reaches the increased V.D. for
restorative purposes----time consuming

• The second approach ----taking the patient immediately

to a needed increase in V.D.----considerably lesser
adjustments are made ,lesser time consuming
•To ensure that the patient is able to tolerate the increase in
the vertical dimension , it is necessary to wear the appliance
for at least 6- 8 weeks

(12 hours /day ,generally evenings and nights)

• At this time if the muscles of mastication are flaccid and

show no tenderness to palpation and the TMJ‘s are free
from pain , palpation and opening clicks , then it is usually
safe to proceed , to the restorative care .
 Anterior Bite plane

• Used in the reduction of overbite.

• Occurs by altering the rate of eruption of posterior teeth relative to the eruption
of lower incisors that are in contact with the bite plane.

• Overbite reduction by this method ---most successful in actively growing patients

.
• Overbite reduction should be evident within first two
months of fitting the appliance .

• It is important to increase the thickness of bite plane

slowly with progressive additions of cold cure acrylic
as the overbite reduces .
 Endodontic considerations
• In certain cases intentional endodontic therapy has to be
performed in hyper erupted teeth or drifted teeth, worn
that have to reduced drastically, that pulp is certain to be
involved.
• Careful examination of the color changes in pulp chamber
floor ,along with aids like magnification and
transillumination can help safely locate the canals .

• Additional aids like:

 staining the pulp chamber floor with 1%methylene blue dye .
 searching for canal bleeding points .
 Performing the sodium hypochlorite ―champagne bubble test
―are helpful in locating calcified.
 Long ,thin Ultrasonic tips can also be used
 Treatment strategies for Dentinal
hypersensitivity
( DCNA 53 ,2009; 47-60)
There are a number of treatment options for managing
dentinal hypersensitivity .
Can be broadly be categorized into :
1. Nerve desensitization
Potassium nitrate

2 .Anti-inflammatory agents
Corticosteroids

3. Covering or plugging dentinal tubules

• calcium hydroxide
• sodium fluoride
• Sodium monoflourophosphate
• Stannous fluoride
• Oxalates
• Strontium chloride

Protien precipitants
formaldehyde
glutaraldehyde
Flouride iontophoresis

Resins and Adhesives

4) Restorative materials
5) Periodontal surgery
6) Lasers
Nerve desensitization
Potassium nitrate
• A number of studies have reported the efficacy of
potassium nitrate for managing dentinal hypersensitivity .

• Tarbet et al demonstrated that potassium nitrate at a

concentration of 5%in a low abrasive tooth paste was able
to desensitize dentin for up to 4 weeks compared to a
control paste .

• In bio adhesive gels at a concentration of 5% and 10% has

also been shown to be effective in reducing dentinal
hypersensitivity .(Freschoso SC,Menendez M,2003)
 Anti inflammatory agents
Corticosteroids
• It has been suggested that application of anti-inflammatory
drugs such as glucocorticoids to the cavity preparation may
reduce dentinal hypersensitivity by their effect on pain
mediators .

• Lawson and Huff found that paramethasone had a significant

desensitizing action.

• Furseth and Mjor reported complete obturation of dentinal

tubules after corticosteroid application to exposed dentin ,thus
reducing dentin permeability.

• However there is a little experimental evidence to support or

refute the use of such agents .
Covering or plugging dentinal tubules .
Calcium hydroxide
• It has little or no effect on the dentine sensory nerve
activity (Trowbrdge H ,Edwall L ,1982)

• However it is thought that it induces peritubular dentin

remineralization and less hypersensitive dentin .(Mjor IA
1967)

• Levin and colleagues found that application of Ca(OH)2

paste to hypersensitive exposed dentine resulted in an
immediate decrease of dentinal hypersensitivity in over
90%of treated teeth .
 Sodium fluoride

• Many clinical studies have shown that the treatment of

exposed root surface with fluoride toothpaste (1.1%)
and conc. fluoride solutions(0.2%) is very efficient in
managing dentinal hypersensitivity. (Minkow
B,1975;Kerns D G 1991)

• Tal et al suggested that the probable desensitizing

effects of fluorides are related to precipitated
fluoride compound mechanically blocking the exposed
dentinal tubules.
Sodium monoflourophosphate
• Tooth pastes containing sodium monoflourophospshates have
been shown to be effective in managing dentinal
hypersensitivity
(Hernandez F,Mohammed C,1972)

• It does not appear to act by occluding dentinal tubules since

scanning electron microscopic studies have failed to
demonstrate any visual changes to the dentinal surface
treated with it .(Addy M ,1983)

• Any tubule occlusion which might occur does not appear to be

permanent .(Tarbet WJ et al ,1983)

• Its mechanism of action is unclear (,Scherman A et al 1992)

 Stannous flouride

• Stannous fluoride in aqueous solution or in glycerin gelled

with carboxymethylcellulose is effective in controlling
dentinal hypersensitivity.
(Miller JT et al 1969)

• Mode of action appears to be through induction of high

mineral content which creates a calcific barrier blocking
the tubular openings on the dentine surface .
(Furseth R ,1970)

• Alternatively ,it may precipitate on the dentine surface

leading to occlusion of the exposed dentinal tubules
Flouride iontophoresis

• It is the process of influencing ionic motion by an

electric current and has been used as a desensitizing
procedure in conjunction with sodium fluoride .(Mc Fall
WT ,1986)

Studies report that there is a immediate reduction in

sensitivity after treatment with iontophoresis, but the
symptoms gradually return over the next six months
(Kern DA et al 1989 )

This method has gained popularity but more controlled

studies are required .(Gillian DG et al 1990)
Oxalates

• It has been shown that potassium oxalates have both tubule

obturation properties and inhibitory effects caused by
potassium ions on nerve activity (Pashly DH ,1986)

• Oxalate ion reacts with calcium to form insoluble calcium

oxalate crystals that bind tightly to dentin and obturate
dentinal tubules (TrowbridgeHO,1990)

• Three types of oxalates are available :

• 6% ferric oxalate (Sensodyne Sealant )
• 30% dipotassium oxalate( Butler Protect )
• 3% monohydrogen monopotassium oxalate
Strontium chloride
• It has been proposed that the ions occlude dentinal tubules by
binding to the tooth substance and stimulating reparative
dentin formation.

• It has also been suggested that strontium ions have the

capacity to reduce sensory nerve activity, but less effectively
than potassium ions.
(MarkowitzK , kim S 1990).

• Dentifrices containing 10% strontium chloride (Sensodyne) --

widely used as desensitizing agents and were one of the first
agents to be marketed for that purpose.

• Cohen found that 67% of the subjects using a strontium

chloride containing toothpaste reported complete relief of
dentinal hypersensitivity within a 2 month period.
• Protein precipitants
(Formaldehyde and glutaraldehyde )

• Claims have been made that Formaldehyde and

glutaraldehyde through their ability to precipitate salivary
proteins in the dentinal tubules, can be used to manage
dentinal hypersensitivity .

• However this effect has been questioned since various

formulations have been found to have little or no effect on
dentinal hypersensitivity (Addy M,Mostafa P,1988)

• Given that these agents are very strong fixatives ,they should
be used with extreme caution too ensure they do not come in
contact with vital gingival tissues.
 Resins and Adhesives
• The rationale for the use of resins and adhesives is to
seal the dentinal tubules and hence to preclude the
transmission of pain causing stimuli to the pulpal nerve
fibers.

• This mode of treatment is performed on localized

hypersensitive dentin.

• Resin-based materials have been reported to

successfully reduce dentinal hypersensitivity.(Kakaboura
A ,2005)
• Copeland reported successful treatment of dentinal
hypersensitivity for up to 18 months in 89% of
hypersensitive teeth treated by Scotchbond.

• A combination product consisting of an aqueous solution

of 5% glutaraldehyde and 35% hydroxyethyl
methacrylate (Gluma Desensitizer) has been reported to
be an effective desensitizing agent for up to 9 months.
.( Kakaboura A ,2005)

• The glutaraldehyde intrinsically blocks dentinal tubules

counteracting the hydrodynamic mechanism that leads to
dentinal hypersensitivity
• In summary, resin restorations have been used to cover
areas
of denuded dentin. This would seem to be a rational
treatment strategy.
 Bioactive glass:

• NovaMin is the brand name of a particulate bioactive

glass that is used in dental care products
for remineralisation of teeth, treating
hypersensitivity.

• The active ingredient is called Calcium Sodium

Phosphosilicate.

• NovaMin is an ionic form of calcium, phosphorus, silica,

and sodium which are necessary for bone and tooth
mineralization.
 Lasers
• There are a number of reports that suggest that laser
treatment may be useful in the treatment of, dentinal
hypersensitivity although definitive trials are
lacking(Cooper LF et al ,1988).
• A recent review of the literature by Kimura and colleagues
reported that effectiveness of laser treatment of dentinal
hypersensitivity ranged from 5% to 100%.
• In a clinical and SEM study, Kumar and Mehtas (2005) found
that Nd:YAG laser irradiation in combination with 5%
sodium fluoride varnish has higher efficacy in the
management of DH
than either treatment alone.
• Slutzky-Goldberg (2008)and colleagues have demonstrated
that CO2 laser treatment resulted in decreased permeability
of dentinal tubules as shown by a dye penetration test.
 Restorative materials

• The use of restorative materials is generally an invasive

solution to the problem of hypersensitivity.

• Commonly used materials include composite resins and

glass ionomer restorations.

• Generally this approach is reserved for situations where

there has been significant prior loss of cervical tooth
structure or as a last resort for a tooth which does not
respond to other less invasive desensitizing protocols.
Part- 2
 Abrasion
• Abnormal tooth surface loss resulting from direct
frictional forces between the teeth and external objects
or from frictional forces between contacting teeth
components in the presence of abrasive medium.
(Sturdevant 5 th edition)

• It occurs most frequently on the cervical neck of the teeth.

• The labial or buccal surfaces. (tooth brush abrasion )

• Labial or buccal and lingual surfaces( in case of poorly fitted

clasps and artificial dentures ) .
Causes of abrasion :

• Traumatic occlusion .

• Improper brushing technique .

• Occupational (Habits such as holding bobby pins in between

the teeth .)

• Tobacco chewing /tobacco pipe .

• Vigorous use of tooth picks between the adjacent teeth.

• Excessive mastication of coarse foods .

Iatrogenic causes:

• Dentures with porcelain teeth opposing natural teeth.

• Extremely rough occluding surface of the restoration

enhancing its abrasive capability .

• ill fitting dentures and clasps ,producing a constant

wear of the affected surfaces.
 Tooth brush abrasion results in a
horizontal cervical notches on the
buccal surfaces of exposed radicular
cementum and dentin .

Notching in right central incisor caused

by improper use of bobby pins .
 The clinical signs and symptoms of an
abrasion are :
• The surface of the lesion is extremely smooth and polished
and it seldom has any plaque accumulation or caries activity
in it .

• The surrounding walls tend to make a V shape ,by meeting at

an acute angle axially.

• Peripheries of the lesion are angularly demarcated from the

adjacent tooth surface.

• Probing or stimulating the lesion can elicit pain .

• Hypersensitivity may be intermittent in character appearing and

disappearing at occasional or frequently repeated periods .
 Treatment modalities
 Diagnose the cause of the presented abrasion.

 A detailed history is to be taken considering various factors such

as:
• Oral hygiene techniques ( use of abrasive tooth cleaning techniques
and materials)

• Habits- pipe smoking, chewing tobacco, professional habits

• Iatrogenic causes,if any.

 Avoidance or counteraction of the causes which may lead to its

production.

 Instituting proper oral hygiene measures.

Judiciously tooth brushing with a dentifrice i.e. incorporating
correct method of tooth brushing .
 Have the habit of chewing tobacco ,toothpick , etc
discontinued . If successful in breaking the habit proceed
with the restorative treatment as planned.

 Correcting or avoiding ill fitting metal clasps and dentures

 Abrasive lesions at non-occluding tooth surfaces should be:

• Evaluated critically for the need for restoring them.

• If the lesions are multiple, shallow( not exceeding 0.5 mm in

dentin) and wide → no need to restore them .
• If there is involvement of cementum / enamel only → no
need to restore .

• If lesion is wedge (V) shaped and exceeds 0.5 mm into

dentin → restoration is performed .

 If restoration is not indicated for a lesion, then :

• Edges of the defect should be eradicated to a smooth, non-

demarcating pattern relative to adjacent tooth surface.

• Tooth surface then should be treated by fluoride solution

to improve caries resistance
If the involved teeth→ extremely sensitive:
• Desensitize the exposed dentin before restoration .

Desensitization:
• 8-10%sodium/stannous fluorides for 4-8 minutes.

• Iontophoresis- --using an electrolyte containing

fluorides( galvanic energy supplied to the tooth in the
presence of electrolyte, drives ions deep into the
dentin)
 Restoring cervical abrasions
In many instances no treatment is necessary but
restoration is
indicated when :

• Caries ,if present .

• Sensitivity is present.

• Lesion is esthetically objectionable .

• If the defect contributes to a periodontal problem

• The area to be involved in the design of a removable
partial denture.

• When the depth of defect is found to be close to pulp

• Or a progressive loss of tooth structure is observed

compromising the tooth strength .
 Restoration
Restorative materials :

• Glass ionomer restorative material.

• Resin modified glass ionomer.

• Polyacid-modified resin composites.

• Resin composites.
• High modulus restorative materials are unable to flex
in the cervical regions when the tooth structure is
deformed under occlusal load and ,therefore the
restorative materials can be displaced from the
cavity .

(Heymann HO ,Sturdevant Jr ,Baynes S ,JADA,122(2) 41-

57 )
 An intermediate material with reduced elastic
modulus may function as a stress absorbing layer
and improve marginal sealing .

• (Kemp-Scholte CM ,Davidsson,CL complete marginal seal of

class V resin composite restorations affected by increased
flexibility .JDR 1990 ;69:1240 -3 )
As a result materials with low elastic modulus such as :

 Microfilled composites (Heymann and others ,1991 :Levitch

and others ,1994 )
 Flowable resins (Unterbink ,Liebenberg ,1999: Li and others
2006 )
 Glass ionomer cements (Loguercio and others ,2003:Burgess
and others ,2004)

Have been used in restoring cervical lesions ,with the aim of

absorbing the stresses generated during the polymerization
shrinkage of composites and mechanical loading in which the
teeth are subjected during function .
 Two-year clinical evaluation of four polyacid-
modified resin composites and a resin-modified
glass-ionomer cement in Class V abrasion/erosion
lesions. Ermiş RB.. Quintessence Int. 2002 Jul-
Aug;33(7):542-8

• The aim of the study was to compare the clinical

performances of four polyacid-modified resin composites
(F2000, Dyract AP, Compoglass F, and Elan) and one resin-
modified glass-ionomer cement (Vitremer) in Class V
abrasion/erosion lesions.
Result

• Retention levels at 2 years were 90% for F2000, 90% for

Dyract AP, 89% for Compoglass F, 84% for Elan, and 95%
for the Vitremer restorations. No statistically significant
differences were found among the materials after 2 years
for any evaluation category
Discussion
• It is generally well accepted that glass-ionomer
cements have an inhibitory effect on secondary
caries, and the release of fluoride is considered to be
one of the major benefits associated with glass-
ionomer cements,
• However, it bas been demonstrated that polyacid-
modified resin composites may not be recharged again
with fluoride as are glassionomer cements.
 comparative analysis of techniques of restoring
cervical lesions- (Quintessence Int 1993:24:553-
559.)
• The clinical significance of this investigation is that two of the
techniques tested, ie, the sandwich technique and the glass-
ionomer cement restoration, have definite potential to
successfully restore cervical lesions, from the standpoint of
marginal leakage.

• While glass-ionomer cement may not have as good esthetic

properties as resin materials, the sandwich technique does not
have universal application, because it requires space and hence
may not be the technique of choice in relatively shallow cavities.

• When the lesion is relatively shallow and esthetic demands

necessitate the use of a resin material, the all-composite
restoration would be a compromise in terms of marginal seal.

• This result should be kept in mind when cervical lesions are to

be restored with these materials.
The success of modern-day restorative materials depends,
on the ability to stop marginal leakage. Within the
limitations of this study, the following conclusions may be
drawn:

1. The acid-etch technique was effective in reducing marginal

leakage along the tooth - composite resin interface in
enamel.
2- None of the techniques studied consistently provided a
complete seal at the gingival aspect of cervical restorafions.
3. The dentina! adhesive used with the composite resin did not
always provide a leak-free seal at the gingival margins of
the restorations.
4.Composite resin restorations inserted over a
glassionomer liner demonstrated significantly
less leakage than when the liner was not used.
5. In general, the use of the sandwich technique
or glass-ionomer restorative material alone
provided the most effective seals in cervical
wedge-shaped cavities, compared to the all-
composite restoration.
6. There was no significant difference between
the marginal leakage of glass-ionomer cement
and sandwich technique restoration
5-year clinical performance of resin composite versus
resin modified glass ionomer restorative system in
non-carious cervical lesions.
Franco Eb, Benetti A , SK Ishikiriama,SL Santiago
,JRP Lauris

AIM: To comparatively assess the 5-year clinical

performance of a resin composite system with a
resin-modified glass ionomer restorative in non-
carious cervical lesions.

METHOD AND MATERIALS: One operator placed 70

restorations (35 resin modified glass ionomer
restorations and 35 resin composite restorations) in
30 patients under rubber dam isolation.
• CONCLUSIONS : After 5 years of evaluation, the
clinical performance of resin modified glass ionomer
restorations was superior to resin composite
restorations.
 Erosion
• Loss of surface tooth structure by chemical action in the
continued presence of demineralizing agents(acids).
(Sturdevant- 5 th edition)

• It is one of the most predominant oral pathologic changes .

• There is no convincing etiology ,and multiple factors have

been theorized for its pathogenesis:

Mechanical factors:
The action of the muscles of lips and cheeks , and of tooth
brush against affected surfaces .
 Chemical factors :

• Ingested acids : citric acids (lemon and citrus fruits

) esp. if use in large amounts , can precipitate or
initiate erosive lesion

• Secreted acids : the acidity of crevicular fluid has

been correlated to cervical erosion
(Bodecker CF. Local acidity: a cause of dental erosion-
abrasion.Ann Dent 1945)
• Acid fumes : acid vapours from nitric acid and
sulphuric acids, acting in the mouths of workers in
the factories ,where these acids are largely used or
manufactured ( Miller)

• Refused acids : as a result of chronic , frequent

regurgitation ,the stomach‘s hydrochloric acid can hit
the teeth at specific locations ( atypical pattern of
erosion affecting buccal surfaces of lower posterior
teeth)

 The latter defective surfaces are associated with

gastro esophageal reflux .(GERD)
Clinical presentation

• Extensive loss of buccal and

occlusal tooth structure
• Raised amalgam restoratins .

• Occlusal view of maxillary dentition

exhibiting concave dentin depressions
surrounded by elevated rims of enamel
 Multiple cupped out depressions
corresponding to the cusp tips

Extensive loss of enamel and dentin on

the Buccal surface of maxillary
bicuspids. ( pt had sucked chronically
on tamarinds )
 Palatal surfaces of maxillary dentition
in which the exposed dentin exhibits a
concave surface and a peripheral
white line of enamel

Perimylosis (decalcification of the teeth caused

by exposure to gastric acid in patients with
chronic vomiting, as may occur in anorexia or
bulimia)
• Loss of lingual enamel and dentin due to acid
regurgitation aggravated by circular movements of
tongue.
• Associated with stress reflux syndrome
• A similar appearance is found in patients with eating
disorders-
Anorexia ( is an eating disorder characterized by immoderate
food restriction and irrational fear of gaining weight, as well
as a distorted body self-perception)
Bulimia nervosa (is an eating disorder characterized by
consuming a large amount of food in a short amount of time
followed by an attempt to rid oneself of the food consumed
, typically by vomiting)
Rumination ( a chronic condition characterized by effortless
regurgitation of most meals following consumption) have all
been closely associated with dental erosion .

• Chronic alcoholism produces a similar pattern of erosion,

although usually more generalized.

( ND Robb and BGN Smith, Anorexia and bulimia nervosa (the eating
disorders): conditions of interest to the dental practitioner, J Dent
(1996)
• It has been reported that any food substance with a
critical pH value of less than 5.5 can become a
corrodent and demineralize the teeth.
( Stephan RM, JADA 1940) ,( Gray JA, J Dent Res 1962) ,
(Zero DT. Cariology. Dent Clin North Am 1999)

• Holding ,swilling or retaining acidic drinks and foods

in the mouth prolongs the acid exposure on the teeth
increasing the risk of erosion .
(Mossazzez R ,Smith BGN,Barlett DW,Oral Ph and drinking
habit during the ingestion of carbonated drink in a group of
adolescents with dental erosion ,J Dent 2000)
• As reported by Lussi ,the corrosive potential of an
acidic drink does not depend exclusively on its ph
value, but also is strongly influenced by its buffering
capacity of the acid and by the frequency and
duration of ingestion.
(Lussi A. Dental erosion: clinical diagnosis and case
histor taking. Eur J Oral Sci 1996 )
 The other substances that can corrode teeth.

• chewable vitamin C tablets

• aspirin tablets
• aspirin powders
• use of the amphetamine drug Ecstasy
have been associated with corrosion on the occlusal
surfaces of posterior teeth.
 The potential effects of pH and buffering
capacity on dental erosion.
Owens BM.
Gen Dent. 2007 Nov-Dec;55(6):527-31

• This in vitro study sought to evaluate five different

soft drinks (Coca-Cola Classic, Diet Coke, Gatorade
sports drink, Red Bull high-energy drink, Starbucks
Frappucino coffee drink) and tap water (control) in
terms of initial pH and buffering capacity.

• Initial pH was measured in triplicate for the six

beverages. The buffering capacity of each beverage
was assessed by measuring the weight (in grams) of
0.10 M sodium hydroxide necessary for titration to
pH levels of 5.0, 6.0, 7.0, and 8.3.
 Mean ph values for each beverage

• Coca cola 2.49

• Diet Coke 3.12
• Gatorade 2.93
• Red Bull 3.24
• Starbucks Frappucino 6.59
• Tap water 7.12
• Coca-Cola Classic produced the lowest mean pH,
while Starbucks Frappucino produced the highest pH
of any of the drinks except for tap water.

• Red Bull had the highest mean buffering capacity

(indicating the strongest potential for erosion of
enamel), followed by Gatorade, Coca-Cola Classic,
Diet Coke, and Starbucks Frappucino.

• Buffering capacity is the measure of total no. of acid

molecules and determines the actual hydrogen ion
availability for interaction with tooth surface
(Boulton R,1980)
• Beverages with high buffering capacities compete
with natural buffering characteristics of saliva and
resist ph changes as a result .

• Greater the buffering capacity , more time it takes

for saliva to restore the pH value ,which causes
beverage pH to decline to a sustained level ---------
prolonged periods of oral acidity ---- thus increasing
the erosive potential .
 Monitoring tooth wear
• Recognizing how the appearance of teeth change with
tooth wear ,can be helpful in assessing the activity.

 Most effective way to monitor wear is :

• comparing the dated study casts to the clinical

conditions of teeth over time .

• It can also be used as a part of preventive regime .

• Active wear → smooth and unstained ,clean surfaces.
→ erosion of tooth around the existing
restoration .
(Restoration is resistant to acid ,remains
unchanged ,but the tooth is gradually
dissolved leaving the restoration proud)

• Inactive wear — stained .

 Protocol for the prevention of
progression of erosion
(Beatrice K,Edmond L ,J Contemp.Dental practise ,1999)
 Diminish the frequency and severity of acid challenge.

• ↓ the amount and frequency of acidic foods or drinks

• Acidic drinks should be drunk quickly rather than sipped.
• Use of straw reduces erosive potential

 Treating the underlying medical disorder or disease.

• GERD ,anorexia ,bulimia → refer to a physician
/psychologists
 Enhance the defense mechanisms of body:

• Saliva provides buffering capacity→ increases with

salivary flow rate.
• Saliva supersaturated with Ca, P → inhibits
demineralization of tooth structure.
• Stimulation of salivary flow → sugarless lozenge,
candy/gum is recommended
 Enhance acid resistance, remineralization and
rehardening of the tooth surfaces.

• Daily use topical flouride at home

• Fluoride application in office- 2-4 times a year

,flouride varnish recommended.

 Decrease abrasive forces.

• Use a soft bristled toothbrush and brush gently.

• No brushing should be done immediately after
consuming acidic food and drink as teeth will be
softened.

• Rinsing with water is better than brushing after

consuming acidic foods and drinks.
(Gandara, B.K; E.L Truelove ,Diagnosis and management of dental
erosio. Journal of Contemp.Dental Practice 1999)
 Improve chemical protection

• Neutralize acids in mouth ---dissolving sugar free antacid tablets

5 times a day ,particularly after an intrinsic or extrinsic acid
challenge.

• Dietary components- hard cheese ( provides Ca and PO4), held in

mouth after acidic challenge.

 Mechanical protection

• By application of composites and direct bonding where

appropriate – to protect exposed dentin

• Occlusal guard /Acrylic splint in the form of stabilization splint

necessary to protect dentition from further damage due to
erosion .
 Monitor stability

• by use of casts /photos to document tooth wear

status.

• Regular recall examinations to review diet, oral

hygiene methods, compliance with medications, topical
flouride and splint usage.
 Restoration

• Metallic restorations should be the choice of material

,if restoration indicated .
(more resistant to erosion )

• Tooth colored materials may also be used with minimal

or no tooth preparation, with the assumption that
restoration may require periodic replacement .
 Abfraction

 Some authors explain the formation of cervical,

wedge shaped defect by the heavy force in eccentric
occlusion resulting in flexuring (elastic bending) of the
tooth.

 When the tooth is loaded in long axis ,the forces are

dissipated with minimal stress on enamel and dentin .

 If the direction of force changes laterally ,teeth are

flexed towards both the sides .
 Changes in stress pattern continuously in the same area

compresssive ↔ tensile
(esp. ,underneath the enamel)reaches to the fatigue limit.

rupture of chemical bond between hydroxyapetite

crystals is termed as Abfractures . (Grippo JO,1991: Levitch
LC , Bader JD, Heymann HO ,1994 )

• This occurs most commonly in the cervical regions of the

tooth where the flexure may lead to breaking away of
extremely thin enamel rods ,as well as microfractures of
cementum and dentin .
 Microfractures can foster loss of tooth structure
from tooth brush abrasion and from acids in the diet
or plaque or both .
 The resulting defect has a smooth surface .
• Also known as idiopathic erosion.
(Lee WC, Eakle WS, J Prosthet Dent 52(3): 374-
380, 1984.)
• Abfraction has a possibility of being the initial factor and
the dominant progressive modifying factor in producing
cervical lesions.
• Stresses that concentrate to produce abfractions in teeth
usually are transmitted by occlusal loading forces.
( Whitehead SA, Wilson NHF, Watts DC. J Esthet Dent
2000),(Pintado MR, DeLong R, Ko C, Sakaguchi RL, Douglas
WH. Correlation J Prosthet Dent 2000)

• Occlusal interferences, premature contacts, habits of

bruxism and clenching all may act as stressors.
 Monitoring abfraction lesions
• A novel method of determining the activity of abfraction
lesions over time ----Scratch test . ( Kaidonis JA.The tooth
wear :view of anthropologists ,Clin Oral Investig 2008)

• A no.12 scalpel blade is used to superficially scratch the

tooth surface .

• Visual observation gives an indication of rate of tooth

structure loss

• Loss of scratch definition or loss of the scratch

altogether signifies active tooth structure loss.
 Restoration
• when clinical consequences (e.g. dentin
hypersensitivity ) have developed or likely to be
developed .

• Aesthetics demands are a concern .

 Tyas recommended the RMGIC should be the first
preference
(Tyas MJ,the class V lesion –aetiology ,restoration,Aust. Dental
Journal.1995)

• In esthetically demanding cases,

• RMGIC/GIC liner laminated with resin composite.

Vandelwalle and Vigil ( Gen Dent 1997)

• Recommended the use of microfilled resin composite(low
modulus of elasticity ) as it will flex with tooth and not
compromise retention .
 Occlusal adjustments
 Occlusal adjustment may involve (Piotrowski BT
JADA 2001 and Ichim IP Dent Mater 2007):

• Altering cuspal inclines,

• Reducing heavy contacts
• Removing premature contacts.

 Occlusal splints
Aimed at reducing the amount of nocturnal bruxism
and non axial tooth loading when constructed properly
Part- 3
 Fracture lines
The cause of these fractures may include :

• Physical trauma
• Occlusal prematurities
• Repetitive heavy and stressful chewing
• Resorption weakened teeth
• Iatrogenic dental treatment

It has been suggested that the determination of a

fractured tooth is often more of a prediction rather
than a definitive diagnosis based on a collective analysis
of subjective and objective findings.
Five types of longitudinal fractures have been described
(American Association of Endodontists,2008 ):

(1) Craze line: affect only the enamel, originate on the

occlusal surface, are typically from occlusal forces or
and are asymptomatic .
2) Fractured cusp: occur on the cusps and cervical margins of
the root and can have acute pain to
mastication and cold.

3) Cracked tooth : occurs on the crown

and may extend into the root ,develop
from damaging occlusal forces or
weakened tooth structure
(4) Vertical root: occur and originate only in the roots,
have variable but a lesser degree of signs and
symptoms, and are caused by wedging forces within
the roots (i.e. root canal obturation or posts)
5) Split tooth: a fracture through the crown and roots,
developing from damaging occlusal forces or
weakened tooth structure, separating the tooth into
two segments, with the tooth typically being painful
to mastication
• Cracked teeth are thought to occur as a result of
parafunctional habits or from weakened tooth
structure
• The symptoms that develop subsequent to these cracks
have been termed as ―cracked tooth syndrome‖

• This has been described as acute pain that results

during the mastication (or release) of small hard food
substances and also exacerbates with cold.
(Cameron CE,JADA,1964 : American Association of
Endodontists,2008)

• However, the signs and symptoms of a cracked tooth

may also be consistent with an irreversible pulpitis or
necrosis.
• In summary there are two main groups of cracked
teeth :

A) Tooth infarctions:(incomplete tooth fractures

extending partially through a tooth ) that includes :

 Craze lines
 Cuspal fractures
 Cracked teeth

B) Vertical root fractures : (that occur in

endodontically treated teeth )
 Characteristics of tooth infarctions
Problems in diagnoses :

• Infarctions typically originate internally and extend

peripherally → not likely to be identified by percussion until the
fracture extends to involve the periodontal ligament .

• The fractures are incomplete, tend to present in a mesial distal

orientation and are generally centered on the occlusal table
,radiogarphs are not very diagnostic .

• Also difficult to differentiate masticatory pain /pain from

infarction /pain from microleakage associated with restorations .

• Infarctions ….not readily visualized without magnification (unless

they are at least 20um )
 Distribution
• Molars and premolars are the teeth are almost
exclusively involved

• Teeth with restorations are most likely to develop

infarctions
Pain characteristics

• Occurs when there is release of pressure from biting

(rebound pain or relief pain )

• Can be duplicate diagnostically by having the patient

bite on a moist cotton roll ( if rebound pain occurs
on release ,it is very likely that one of the two teeth
,maxillary or mandibular ,has an infarction )
Clinical test for detecting infarction :
• The patient bites onto the moist cotton roll
and on release the pain will often be quite noticeable .
Etiology

• Excessively large and incorrectly designed

restorations .

• Use of pins for supporting large restorations ,esp.

self threading and friction locked )

• Abrasion ,erosion ,caries ,along with age changes in

dentin.
• Act of chewing is also implicated

• Biting onto hard objects ,bruxism and clenching ,

wedging effect of the cusp in the opposing fossa

• Use of both high speed handpieces and course

diamond burs can lead to infarctions

• Acute trauma to the teeth.

 Clinical examination

• Begins with the chief complaint i.e. pain on chewing

,elevated sensitivity to cold food and sweets

• Absence of carious etiology …trigger a suspicion of

infarction

• Visual examination by …….Transillumination and

…..Dyes (methylene blue)

• Any existing restoration in the tooth should be

removed to reveal the infarction lines
 Removal of the restoration and
highlighting with the dye to
detect infarction

• Use of optic light source to identify an

infarction .

•Note that the beam of light does not

cross the infarction
 Biting test :

• Biting on rubber wheels, cotton tip applicators ,moist

cotton, commercial biting appliances like tooth slooth.

• Tooth slooth …….. Differentiates biting pain from

restorations with microleakage /pain from infarction
……pressure is placed first onto the restoration
followed by tooth cusps .
Use of tooth Slooth to test biting sensitivity to differentiate between
pain from infarction and pain from micro leakage related to a restoration
• Significant response to biting ….when pain is experienced
release of biting pressure (rebound pain ) /relief pain

• Pain …….with the release of pressure ……due to fluid

movement as the crack rapidly closes .

• Cold stimulus application and Electric pulp testing(EPT ) :

Gives information about the pulpal status ,teeth with
infarctions respond to a lower threshold to cold and EPT as
compared to the non cracked teeth.

• Cameron suggested the use of thin sharp explorer tip to

probe around the cervical circumference of the suspected
teeth….the click of the explorer‘s tip and the patient ‗s
response can provide a clue
 Radiographic examination

• The fractures are incomplete, tend to present in a

mesial --distal orientation and are generally centered
on the occlusal table ,radiographs are not very
diagnostic .

• Even cone beam volumetric tomography (CBVT) scans

cannot consistently visualize these fractures, the
coronal-apical progression of fractures cannot always
be objectively assessed until the tooth has been
extracted.
• Treatment
Aims :
 Preventing the separation of the hard tissue entities ,

 Keeping the bacteria's from colonizing the space

caused by infarction .
It is not clear whether all the teeth with infarction
require root canal therapy, it depends on the extent
of the fracture .
 • Orthodontic band was placed to bind
the crown together .

• After 3 weeks the tooth was

completely asymptomatic and the
patient chose to restore it with a crown

Treatments designed to bind the infarcted segments of

teeth together .,that includes the use of adhesives , full
coverage crowns .
 Localized Non Hereditary Enamel Hypoplasia
DEFINITION CAUSE CLINICAL TREATMENT
PRESENTATION
During enamel formation , a) Systemic Isolated pits to In contrast with
AMELOBLASTS are widespread linear the caries and
disorders
injured/irritated ,their defects, erosion and
metabolic product i.e b) Localized
depressions, or loss abrasion lesions,
enamel matrix, would not disorders
be properly formed c) Fluorides
of a segment in enamel
the enamel .
resulting in formation of
either hypoplastic or
hypoplasia
hypomineralized enamel does not
progress

When the teeth a) Systemic These defective If defects are

erupt,these defects will disorders areas will have minimum ( narrow
Exanthematus
be apparent in the diseases
different color lines /isolated pits
crown portion of teeth NutritionaL from the /shallow
(tooth) which is called Deficiencies surrounding enamel. depressions) -
as localized non (especially vitamins then selective
A,C and D)
hereditary enamel Hypocalcemia odontomy/esthetic
hypoplasia Microbial process reshaping can be
e.g . (syphilis) performed .
CAUSE
PRESENTATION
b) Localized disorders- These
include periapical infections of
the preceding deciduous tooth
(Turner‘s hypoplasia ),
traumatic intrusion of the
preceding deciduous tooth etc
c) Fluorides :
Metabolizing fluorides in
excessive amounts could poison
the ameloblasts and disturb
their activities to variable
degrees, leading too slightly
mottled enamel or a completely
disfigured crown in its enamel
CLINICAL TREATMENT
If odontomy and esthetic
reshaping of the tooth
enamel can‘t produce a
pleasing functional
effect, then-
Direct tooth colored
resinous material
(composite material)
is inserted with /without
tooth preparation
Localized Non Hereditary Enamel Hypocalcification
DEFINITION CAUSE CLINICAL TREATMENT
PRESENTATIO
N
Hypomineralized 1.childhood 1.Appear chalky If diagnosis is made
enamel results when fever, early in tooth‘s life
normal amount of 2.Trauma / 2.soft to ,while the uncalcified
enamel matrix fails to Flourosis- indentation. enamel is still intact
achieve full during an attempt at
mineralization and is a developmental 3.Stainable. remineralization
usual consequence of stages of tooth should be made .
damage to ameloblasts formation
.

4. If extensive- Can be done using-

these lesions A)fluoride
predispose to applications
attrition and B)fluoride
abrasion. iontophoresis
5. Enamel C)strict prevention of
chipped if lesion plaque accumulation
involves the in these areas .
entire surface
CLINICAL PRESENTATION TREATMENT

Vital bleaching

Laminated veneering

Composite

Crowns
 Localized Non Hereditary Dentin Hypoplasia
DEFINITION CAUSE CLINICAL TREATMENT
PRESENTATION
Odontoblasts are It appears to be a There would be NO Various
the specialized cells hereditary apparent intermediary bases
,any disturbance in disease, destruction to be that can be used
their function- transmitted as an diagnosed or are :
deficient or autosomal treated ,till the Zinc oxide eugenol
complete absence dominant time the lesion is Calcium hydroxide
of dentin matrix characteristics covered with Zinc phosphate
enamel cement
deposition
Leads to the During tooth Polycarboxylate
development of preparation for a cement
localised non- restoration , these Varnishes
hereditary dentin defects may get Glass ionomer
hypoplasia exposed cement
LOCALIZED NON-HEREDITARY DENTIN HYPOCALCIFICATION

DEFINITION CAUSE CLINICAL TREATMENT

PRESENTATION

In a) Systemic There would be NO Various

hypocalcification, disorders apparent intermediary bases
there is failure of b) Localized destruction to be that can be used
union of many disorders diagnosed or are :
globules,the dentin c) Fluorides treated ,till the Zinc oxide eugenol
will be present in time the lesion is Calcium hydroxide
substance ,but covered with Zinc phosphate
would be softer enamel cement
,more penetrable ,
and less resilient

During tooth Polycarboxylate

preparation for a cement
restoration , these Varnishes
defects may get Glass ionomer
exposed cement
 Amelogenesis imperfecta
DEFINITION CLINICAL TREATMENT
PRESENTATION
developmental HYPOPLASTIC AI- AIM OF TREATMENT-
alterations in the •Thin enamel •Reducing tooth
structure of enamel in • Open contact sensitivity
the absence of a •Enamel is glossy •Improving esthetics
systemic disorder •Enamel can look wrinkled. •Correcting or maintaining
• Signs of severe occlusal vertical dimension
wear •Restoring masticatory
• Missing teeth. function
•Delay in eruption.
4 MAIN TYPES- Temporary phase –
1)Hypoplasia undertaken during
2)Hypocalcification primary or mixed
3)Hypomaturation dentition
4)Hypomaturation Transitional phase –when
–hypoplasia with all the permanent teeth
taurodontism Small yellowish teeth exhibiting have erupted
hard, glossy enamel with Permanent phase –
numerous open contacts points
and anterior open bite
occurs in adulthood
CLINICAL PRESENTATION
HYPOCALCIFIED-
•Enamel is usually stained (yellow/Black)
• Enamel chips easily ,very soft in
consistency
•stains become darker with time
•Enamel- worn easily in life with all signs
and symptoms of severe attrition
TREATMENT
Reducing tooth sensitivity-
topical fluoride products ,CPP-ACP
products , dietary modification
Maintaining good oral hygiene
Correcting or maintaining vertical
dimension –
Placement of GIC ( sensitivity ,if any )
on grossly worn down molars followed
by placement of composite restorations
,assist in restoring the occlusal vertical
dimension
Esthetic improvements
Bonding direct or indirect resin
composite restorations
CLINICAL PRESENTATION
HYPOMATURATION AI
• Affected teeth ---normal in shape ,
but exhibit mottled, opaque white
brown –yellow discoloration .
• Enamel is softer than normal ,tends
to chip from underlying
diffuse yellow white dentition
TREATMENT
Restoring masticatory function
• Performed by full veneering ,includes
procedures -
1)metallic
2) Cast ceramic restorations
 Dentinogenesis imperfecta
DEFINITION CAUSE CLINICAL TREATMENT
PRESENTATION
Autosomal Caused by mutation Teeth affected Early diagnosis and
dominant disorder in the DSPP gene. vary in color from care (preventing
with variable yellow brown – loss of enamel and
expressivity brownish ,violet subsequent loss
/grey with a typical through attrition).
translucency and
opalescence.
Primary teeth are Atypical color of In patients without
normally more teeth → dentin cracks and rapid
severely affected showing through attrition of enamel,
than permanent the relatively intracoronal
teeth translucent restorations and
opalescence enamel veneers used.

Classification : External bleaching

(Witkop) (notably prolonged
Type I : dentin night guard vital
mineralization bleaching ) with
defects are carbamide
coupled with peroxide has been
a CLINICAL TREATMENT
PRESENTATION

Enamel tends to chip In anterior teeth →

Type II: Hereditary and fracture off stainless steel crowns with
Opalescent dentin from the tips of composite facings may be
teeth → exposed given
Type III: Brandy wine
dentin , leaving the
type (Shell teeth )
occlusal surface of At a later stage porcelain
posterior teeth flat . crowns are suggested .

Splinting between these

teeth- to avoid root
fracture.

Loss of pulp chamber

radiographically
 ABFRACTION- Use of
RMGIC, sandwich
FRACTURES- Bind the
ATTRITION- dentinal technique,occlusal
infarcted segment &
hypersentivity using F ions, acrylicadjustments,
stabilized with
splints, treatment of bruxism,
adhesives/crowns
restorative treatment with LN DENTIN HYPOPLASIA/
composite 7 cast metal HYPOCALCIFICATION- intermediary bases-
ABRASION- proper Zinc oxide eugenol, Calcium hydroxide ,Zinc
tooth brushing, use of phosphate, Polycarboxylate cement
RMGIC, sandwich Varnishes,GIC
AMELOGENESIS IMPERFECTA-
technique, composite
LN ENAMEL HYPOPLASIA- F application,composite &
restoration crowns
Odontomy/ reshaping,
EROSION- F composite restoration
application, splints, DENTINOGENESIS
LN ENAMEL
composite, antacid IMPERFECTA-
HYPOCALCIFICATION- F
tablets, reduction in Veneers, crowns,
Remineralisation, Vital bleaching
acidic drink consumtion. Laminated veneering,Composite bleaching
Crowns
 References
1. Art and science of operative dentistry- Sturdevant 5
th edition
2. Operative Dentistry- Modern Theory and Practice:
Marzouk

3. Shafer‘s Textbook of Oral Pathology- Shafer, Hine,

Levy
4. Abfraction : separating fact from fiction --ADJ 2009

5. Fracture necrosis :Diagnosis ,Prognosis assesment

and Treatment Recommendations –Louis H
Berman,Sergio Kettler
6. Non carious cervical lesions and abfractions :A re –
evaluation –JADA 2003 ;134:845—850

7) Role of erosion in tooth wear :aetiology ,prevention

and management ---IDJ(2005) 55,277-284
8) Erosion –Chemical and biological factors of
importance –IDJ (2005 ) 55 285-290
9 ) Removable Orthodontic Appliances—K.G.Isaacson

10) Quintessentials 3 – Decision–Making in Operative

Dentistry Brunton, Paul A.
THANK YOU