Vailati, Francesca

Von den zahlreichen, für pathologischen Zahnverschleiß ursächlichen Faktoren sind Erosion und mechanische Überlastung die wichtigsten. Zahnärzte sollten vor allem bei Schäden an den Inzisalkanten zu einer korrekten Differenzialdiagnostik in der Lage sein. Der vorliegende Artikel liefert eine praktische Anleitung für die Analyse des Anteils von Erosion und Überlastung bei der Schädigung der Frontzähne, um im Gespräch mit den Patienten den Zeitpunkt der Therapie und die zu erwartende Lebensdauer der Restaurationen besser begründen zu können. Außerdem werden Funktionskonflikte im Frontzahnbereich und die Entwicklung des betroffenen Gebisses bei übermäßiger Kaumuskelaktivierung diskutiert. Keywords: Funktionskonflikt, Bruxismus, Erosion, explosive Entwicklung, Gnathologie, implosive Entwicklung, Überlastung, Prothetik, restaurative Zahnmedizin, Zahnverschleiß

Among all the factors responsible for pathologic tooth wear, erosion and mechanical overload are the most important. Clinicians should be capable of making a correct differential diagnosis, especially in the case of damage to the incisal edges. The present article provides pragmatic guidelines to evaluate the detrimental role of erosion and overload on the anterior teeth in order to better discuss with patients when to start the therapy and what to expect about the longevity of the restorations delivered. Anterior functional conflicts and the evolution of the affected dentition in the case of excessive masticatory muscle activation are also illustrated. Keywords: anterior functional conflicts, bruxism, erosion, explosive evolution, gnathology, implosive evolution, overload, prosthodontics, restorative dentistry, tooth wear

Purpose: To evaluate biologic and esthetic outcomes, as well as the patient-reported outcome measures (PROMs), of full-mouth rehabilitations in patients suffering from generalized erosive and/or abrasive tooth wear following the 3-step technique. Materials and methods: Patients who received a minimally invasive full-mouth rehabilitation according to the 3-step technique and who were treated at the University of Geneva and/or in a private practice were considered for inclusion. The minimum service time of the restorations was 12 months. The biologic outcomes were analyzed by assessing pocket probing depth (PPD), Plaque Index (PI), and bleeding on probing (BOP). Furthermore, secondary caries, tooth vitality, and sensitivity to temperature were evaluated using the modified United States Public Health Service (USPHS) criteria. The esthetic outcomes were rated with the White Esthetic Score (WES). Finally, PROMs were evaluated using visual analog scales (VAS). Results: A total of 19 patients with 406 restorations (149 direct composite resins, 110 indirect composite resin/ceramic onlays, and 147 composite resin/ceramic veneers) were examined after a mean follow-up of 71.8 ± 28.6 months. Periodontal parameters were good (mPPD = 2.9 ± 0.4; mPI = 0.1 ± 0.2; and mBOP = 0.05 ± 0.1). No secondary caries were found, and no abutment tooth had lost vitality. A total of 36 abutment teeth had moderate sensitivity, but none presented pronounced sensitivity. The rehabilitations exhibited good esthetic outcomes (mWES = 8.4 ± 1.9). Patients reported satisfying esthetic results of their rehabilitations (mean VAS = 9.2 ± 1.6) and considered their treatment as comfortable (mean VAS = 8.2 ± 2.1), while the least favorably rated parameter was the cost of treatment (mean VAS = 4.1 ± 3.2). Conclusion: Minimally invasive full-mouth rehabilitations of patients with generalized tooth wear by means of the 3-step technique exhibit very good clinical medium-term results with respect to biologic and objective/subjective esthetic outcomes. The patient satisfaction with this treatment was high.

Purpose: To evaluate the survival rates and technical outcomes of minimally invasive full-mouth rehabilitations in patients affected by dental erosion and attrition. Materials and Methods: For this retrospective study, 28 subjects (8 women, 20 men; mean age: 45.6 years) who suffered from generalized erosions and attrition and who were treated according to the 3-step technique were invited to participate. The patient records were reviewed, and the restorations were clinically and radiographically examined. This part of the study (Part 1) evaluated restoration survival and technical outcomes using the modified United States Public Health Service criteria (mUSPHS). Survival analysis was performed using Kaplan-Meier survival statistics, and comparison between subgroups was made using log-rank test. For all other comparisons, cross tabulations of occurrence were performed, and significance was tested using Pearson chi-square test. The level of statistical significance was set at P < .05. Results: A total of 19 patients (3 women, 16 men; mean age: 45.6 years) agreed to participate. In these patients, 406 restorations (149 direct composites, 110 onlays, 147 veneers) supported by 365 teeth were examined. The mean time in service was 71.8 ± 28.6 months. Six failed restorations were identified; all were direct composites. The 6-year survival rates were 97.3% for direct composites, 98.2% for onlays, and 100% for veneers (P > .05). No differences were found among materials or locations of the restorations. Nineteen technical complications included 14 partial fractures, 3 fissures, 1 wear, and 1 decementation. The mUSPHS evaluation showed good technical outcomes. Presence or absence of a nightguard influenced restoration survival (P = .003). Conclusion: Minimally invasive rehabilitations of patients with erosions/attrition with the 3-step technique are a reliable treatment option in the medium term. Protective nightguards are recommended.

A full-mouth rehabilitation should be correctly planned from the start by using a diagnostic wax-up to reduce the potential for remakes, increased chair time, and laboratory costs. However, determining the clinical validity of an extensive wax-up can be complicated for clinicians who lack the experience of full-mouth rehabilitations. The three-step technique is a simplified approach that has been developed to facilitate the clinician's task. By following this technique, the diagnostic wax-up is progressively developed to the final outcome through the interaction between patient, clinician, and laboratory technician. This article provides guidelines aimed at helping clinicians and laboratory technicians to become more proactive in the treatment planning of full-mouth rehabilitations, by starting from the three major parameters of incisal edge position, occlusal plane position, and the vertical dimension of occlusion.

Um das Risiko von Neuanfertigungen, einer längeren Behandlungszeit und erhöhter Laborkosten zu senken, sollte eine Gesamtrehabilitation von Anfang an korrekt und mithilfe eines diagnostischen Wax-up geplant werden. Allerdings kann die klinische Beurteilung eines solchen Wax-up für Zahnärzte, die noch keine Erfahrung mit Gesamtrehabilitationen haben, problematisch sein. Die Three-Step-Technik wurde als vereinfachte Methode entwickelt, um die Aufgabe der Zahnärzte zu erleichtern. Im Rahmen dieser Technik wird das diagnostische Wax-up schrittweise in einem Interaktionsprozess zwischen Patient, Zahnarzt und Techniker entwickelt, bis der endgültige Zustand erreicht ist. Dieser Artikel stellt Richtlinien vor, die Zahnärzten und Zahntechnikern bei ihrer Planung von Gesamtrehabilitationen helfen. Ausgangspunkte hierfür sind die drei Hauptparameter Schneidekantenposition, Lage der Okklusionsebene und okklusale Vertikaldimension.

Due to an increasing awareness about dental erosion, many clinicians would like to propose treatments even at the initial stages of the disease. However, when the loss of tooth structure is visible only to the professional eye, and it has not affected the esthetics of the smile, affected patients do not usually accept a full-mouth rehabilitation. Reducing the cost of the therapy, simplifying the clinical steps, and proposing noninvasive adhesive techniques may promote patient acceptance. In this article, the treatment of an ex-bulimic patient is illustrated. A modified approach of the three-step technique was followed. The patient completed the therapy in five short visits, including the initial one. No tooth preparation was required, no anesthesia was delivered, and the overall (clinical and laboratory) costs were kept low. At the end of the treatment, the patient was very satisfied from a biologic and functional point of view.

Das Bewusstsein für dentale Erosionen ist mittlerweile bei vielen Zahnärzten vorhanden. Daher schlagen sie den Patienten oft bereits in der Anfangsphase dieser Erkrankung eine Behandlung vor. Die Betroffenen akzeptieren aber normalerweise keine Full-mouth-Versorgung, wenn der Zahnhartsubstanzverlust nur dem Arzt auffällt und ihre Ästhetik nicht beeinträchtigt ist. Die Patientenakzeptanz kann jedoch durch reduzierte Therapiekosten, vereinfachte Behandlungsabläufe und das Vorschlagen nichtinvasiver Adhäsivtechniken verbessert werden. Dieser Beitrag zeigt die Behandlung einer ehemaligen Bulimiepatientin. Die Behandlung folgte der modifizierten Variante der Three- Step-Technik und war nach fünf kurzen Terminen (einschließlich der Erstvorstellung) abgeschlossen. Es waren weder Zahnpräparationen noch eine Anästhesie erforderlich und die Gesamtkosten (Behandlung und Zahntechnik) konnten niedrig gehalten werden. Nach Behandlungsabschluss war die Patientin mit dem biologischen und dem funktionellen Ergebnis sehr zufrieden.

This two-part case presentation describes the prosthetic challenge of managing complications in a 50-yearold female patient after inadequate esthetic risk assessment, treatment planning, and implant placement in the anterior maxilla. In Part I, the clinical situation was described, and different restorative solutions were proposed to correct the extreme facial inclination of the implants, excluding major surgical procedures, namely implant removal. In Part II, different prosthetic options are discussed, and the final treatment is revealed. A noninvasive treatment protocol was applied to transform a severely compromised postsurgical situation into an esthetically acceptable result. An unconventional prosthesis design was implemented, including the use of ceramic veneers bonded to the CAD/ CAM -generated screw-retained zirconia- based fixed dental prosthesis (FDP), to correct major axis-related problems and spatial discrepancies.

In diesem zweiteiligen Fallbericht wird die Problematik des prothetischen Komplikationsmanagements beschrieben, nachdem bei einer 50-jährigen Patientin eine unzureichende ästhetische Risikoanalyse, Behandlungsplanung und Implantatsetzung im Oberkiefer-Frontzahnbereich vorgenommen worden war. Im ersten Teil wurde die klinische Ausgangssituation geschildert und verschiedene restaurative Lösungen zur Korrektur der extremen Labialneigung der Implantate vorgeschlagen. Größere chirurgische Maßnahmen, insbesondere die Implantatentfernung, wurden dabei ausgeschlossen. Im zweiten Teil werden unterschiedliche prothetische Optionen diskutiert und die definitive Behandlung vorgestellt. Letztlich wurde ein nichtinvasives Vorgehen gewählt, um die extrem ungünstige Situation nach der Implantation zu einem ästhetisch akzeptablen Ergebnis zu führen. Hierzu diente eine unkonventionelle Restaurationsgestaltung mit Keramikveneers, die adhäsiv auf einer CAD/CAMgefertigten, verschraubten Brücke mit Zirkonoxidgerüst befestigt wurden. Die Hauptschwierigkeiten mit der Implantatachse und den Platzproblemen konnten damit gelöst werden.