Nov 15 / Dennis Hartlieb

Incisal Edge Chipping - NCIL

Incisal Edge Chipping – Look Out For The NCIL!

How many patients did you see last week in your hygiene schedule that had small, minor chips on their anterior teeth? Maybe just on the maxillary teeth, maybe on the lower teeth, or perhaps, both the uppers and the lowers;  I’m guessing more than one or two patients. If your practice is like mine, these patients are a regular occurrence. Some of the patients are aware of the chipping. Other patients are completely unaware. As dentists, we tend to shy away from treating these chips because our experience is that if we do minimally invasive bonding techniques, the composite will break, with both the patient and dentist becoming frustrated. In today’s blog, I want to share with you a technique that I use commonly in my practice to restore these nuisance chips at the incisal edges of the maxillary and mandibular incisors, in an efficient, and predictable manner.

Our conversations with patients typically reference the visible chipping from the facial view, very often the teeth can look similar to these:

It was actually the incisal facial chip on tooth #8 that brought the patient to the practice:

When you see these incisal chips, especially on the maxillary anterior teeth, I want you to pull out your 5c mirror and look at the incisal edges of the teeth, from a lingual view. This is the view that we need to use to help our patients understand why their teeth are chipping. This patient’s teeth looked like this:

I refer to the ditches along the incisal edges as NCIL’s, or Non-Carious Incisal Lesions.

It seems that these lesions are epidemic in our practice, both on the maxillary and mandibular incisors.

Here’s a case from a different patient with lower anterior NCIL’s:
Let’s talk about the NCIL – the causes, and the treatment solutions for our patients.  I believe that photographs, either with an intraoral camera or with a 35 mm camera and photographic mirrors, are essential to educate our patients. Additionally, photographs also influence our patients towards treatment. We use DigiDoc in our practice for our intraoral camera, but there are many other excellent options available today. For 35 mm photography, I use a Canon 5D body with a 100 mm macro-lens with a ring flash attachment for these types of images. If you’d like more information on shooting high quality photographs on  your patients, check out our course – Digital Dental Photography on our website.

These photographs are an essential first step to helping your patients understand what is happening to their teeth. In my experience, rarely do patients have sensitivity with these lesions. What I have observed in practice is that patients will comment on three issues when these NCIL’s have progressed.

1. Visible chipping of the edges or facial incisal surfaces of the maxillary teeth.

2. Chipping of the lingual incisal wall of the mandibular anterior teeth.

3. Severe translucency or shine thru of the maxillary central or lateral incisors.

Occasionally, I will hear a complaint from a patient that they get small seeds stuck in the grooves of the maxillary anteriors, but that has only happened a couple of times that I can recall. So essentially, the patient reports most often when there has been breakage of the tooth, or severe shine thru of the maxillary anteriors. Again, rarely, if ever, will a patient report pain or sensitivity related to the NCIL.

While I think it is important not to over-educate (i.e. overwhelm with information) our patients, I have found it critical to help patients understand what is happening, before we talk about possible solutions.  I want the patient to understand that they have an issue or issues that need to be addressed before we even start talking about the possible solution(s). My conversations with the patient, before I even look in the mouth, will typically go something like this:

Dennis Hartlieb: Boy, it’s really interesting to me that your front teeth are chipping. Is that something new that is going on, or has it been happening for a while now?

Patient: It's funny you say that. It just happened last weekend. I bit on a fork when I was eating breakfast, and the tooth just chipped!

Dennis Hartlieb: Wow, that’s crazy! It broke on a fork! You must have really bitten hard on the fork?

Patient: No, I wasn’t biting hard at all which is what is so weird about the tooth chipping.

Dennis Hartlieb: Did you know that enamel, the outside surface of the tooth, is the hardest substance in the human body? That’s right – your enamel is harder than your bones! Enamel is harder than your bones [I say it twice for emphasis].

Patient: [Stares back trying to take in this new information.]

Dennis Hartlieb: “That’s really interesting” [Yep, I say that again too.].

“I wonder if the tooth has gotten weakened over time, and because the tooth was weak, that’s why it broke.  I wonder, sometimes we’ll see this happening with patients that grind or clench their teeth”.

At this point, I try to not say anything, and let the patient talk.  They will typically respond saying one of  two things:

1. “You know, my last dentist told me that I grind my teeth at night, but my husband said that he never hears me grinding. So I don’t think that I do”.

2. “Yeah, I know that I grind my teeth, and my last dentist made me one of those grinding guards, but I don’t wear it anymore”.

Dennis Hartlieb: “How interesting!  I wonder if maybe there is something going on – maybe your grinding has something to do with  the chipping of the front teeth. I tell you what, how about I take a look. If I see anything interesting, do you mind if I take a couple photographs so that I can share with you what I am seeing?”

Patient: “Sure, that would be fine”.

Dennis Hartlieb: “Ok, let’s take a look!”

It is important, before we even talk to the patient about why the chipping is occurring, to have them start thinking about what they are doing that is causing this chipping. Was it really the fork’s fault? I want them to start thinking as I’m looking in their mouth  - “Maybe the other dentist was right – maybe I am grinding my teeth”.

Following my examination of their teeth (and how their teeth rub together), I show the patient my intraoral camera. “This is my little spy camera,” I tell the patient. ”I’m going to take some pictures of your teeth so you can see exactly what I am looking at”.

The first photos are from the facial – the view of the teeth that the patient already sees. I’ll identify the same chip(s) that the patient has identified with their chief complaint. After the patient is seated upright, we put the photographs from the intraoral camera on the monitor in front of the patient.

The conversation will go something like this:

Dennis Hartlieb: “Ok, so here's the view of your teeth that brought you in today…that’s the chip that I think that you saw [or felt] – correct?”

Patient: “Yep, that’s it…it looks bigger on this screen!”

Dennis Hartlieb: [chuckles] “I know, these cameras and screens sure show everything! Now, I want to show you a view of your tooth that you cannot see. Imagine that we shrunk you, and now you’re inside your mouth, lying down on your tongue looking up at the clouds – or the roof of your mouth. This is what the inside of those upper teeth look like”.

And then I show them the lingual incisal view. I’ll start out by pointing out the chipped facial incisal areas.

Dennis Hartlieb: “This chip here is the same chip that you see from the front – what brought you here today.”

Then I’ll continue on…

Dennis Hartlieb: “Can you see this darker yellow area? It looks almost like a groove. Can you feel that? Some people, once I point it out, can feel it with their tongue. Others feel it with their fingernail”.

Patient: “Yeah, I never noticed that before. What is that?”

Dennis Hartlieb: “You’re not going to believe this, but that is the inside of your tooth! You’ve actually rubbed away all of the enamel over the edge of your tooth and now you have the inner part of the tooth exposed. We call that tooth area ‘dentin’.”

Patient: “Wow!”

Dennis Hartlieb: “So before we talk about how we fix these, we need to talk about one other possible issue.”

Now I need to be careful here: I really don’t want to overwhelm the patient, but I do need to address a possible erosion issue secondary to the wear.

Dennis Hartlieb: “In my experience, when I have a patient that just grinds their teeth, I’ll see their teeth get shorter as their upper and lower teeth rub against each other” [I use my hands to demonstrate how the lower teeth rub against the uppers]. “Does that make sense?”

Patient: “Yep, I get that.”

Dennis Hartlieb: “Now as the teeth are rubbing together, the front edges of the teeth might chip, but edges where the teeth are rubbing against each other are usually flat – they’re sort of sanding each other down.”

Patient: [Nods head in agreement]

Dennis Hartlieb: “So here’s what I’m wondering – why do you have these ditches in the edges of the teeth?”

[I pause].

“What I’ve seen with other patients that have these ditches, is that there is something else going on besides just grinding of their teeth – they tend to have a high acid level that is weakening the tooth structure”.

Patient: [Looks at me puzzled]

Dennis Hartlieb: “If we’re just grinding our teeth, then our teeth would just be worn and flat. But, if we put some acid over the edges, the acid will start eroding the weak part of the tooth – the part where the enamel has been rubbed away…right here on the edge.”

Patient: [Nods their head in agreement]

Dennis Hartlieb: “I want to talk about how we fix and protect your teeth, but I wonder if at some point we should have a conversation about the wear and erosion of the teeth, and what might be causing that. Should we talk about that now – or should we talk about it down the road after you’ve had some time to digest our conversation from today?”

Then I’ll let the patient dictate where the conversation goes:

1. Restoration of the teeth;

2. What’s causing the erosion/wear?

I have found that many of my patients do want to know why the teeth are eroding, but there are many patients that are just looking for a simple solution now.  It may be that they are overwhelmed with work, family, or life issues. The patient simply may not be ready to start dealing with issues that they know that they should deal with. In my opinion, that’s ok. When they’re ready, we’ll be ready to talk. But if they are not ready, let's at least protect their teeth for the time being. Even if they are not ready to talk about the issues that are causing the teeth to fail, and those issues may cause our dentistry to fail earlier than ideal, it’s still an option to treat their teeth.

I will tell the patient this if they decide not to talk about what is causing the problem:

Dennis Hartlieb: “I totally understand that now is not a good time for you to take a deep dive into this. So let's put it on the back burner for now. When you’re ready, I’ll be ready. It’s important to understand that whatever is causing your teeth to breakdown will have the same effect on the dentistry. We need to do the dentistry to protect the teeth, but the lifespan on the dentistry will be affected.”

If the patient is open to further discussion at this point, we’ll talk about common acid insults on teeth. We’ll talk first about dietary issues: beverages that are highly acidic, sucking on citrus, etc. I’ll then talk about vomiting and the effect that can have on teeth. Finally, I talk about gastric reflux, or GERD.  Most patients will deny acid reflux when sleeping, though there are some that will note that they are taking an over-the-counter med to combat their reflux. The conversation on reflux will then open the doorway to talk about sleep apnea, or sleep disordered breathing. I explain that I have seen in my practice a lot of patients that grind their teeth and have these NCIL’s, that it turns out that they have an undiagnosed sleep apnea issue. I explain that wear and erosion of the teeth are the first clue to issue with not breathing well while we are sleeping. From here, we might screen the patient with a pulse-oximeter or refer to the patient’s primary care doc for evaluation given our insights. I very much let the patient determine the flow of this conversation as it is most certainly the first time that many of them have had anyone talk to them about sleep apnea issues.

Besides cosmetic dental patients, I see quite a few new patients who are looking for comprehensive care or a general examination. It never fails to amaze me how many new patients, who are only looking for general dental care treatment, have these undiagnosed NCIL’s. I have found these patients open to conversations about the wear and erosion that I find during the examination. I am very careful to allow the patient to determine the level of conversation that we get into during the exam. If they are not ready to go into the deep dive, it's ok. It is my obligation to bring the information to their attention (standard of care), but if they are not ready to proceed with treatment at this time, it’s ok. We just need to be there to support them for when they are ready to move forward ("Standard of Caring, Dr. Paul Homoly)

Alright, so let’s get into the restoration of the NCIL.  There are three types of maxillary incisor NCIL restorations:

1. NCIL – No Facial Coverage

1. Anesthesia (local infiltrate) – this is optional, though I typically anesthetize my patients

2. Shade Selection

3. Pumice teeth aggressively to eliminate plaque, staining and pellicle

4. Use Brasseler Microbur - to create trough - about 1 mm depth – internal enamel rim from mesial to distal

5. Use Brasseler Microbur - to remove sharp edges and blend internal axial wall of trough to incisal edge

6. Total Etch or Selective Etch protocol (previous post on this topic if desired)

7. Inject Nanofill composite, blend with composite instrument, polymerize

8. Contour with ET9, OS1 (Brasseler)

9. Polish with Featherlite wheels (Brasseler)
Worn and chipped incisal edges
Worn and chipped incisal edges
Brasseler 889M012
Incisal Trough complete
Brasseler 830M012
Brasseler 830M012
Nanofill composite
Nanofill composite

2. NCIL – Facial Coverage, no length added

1. Anesthesia (local infiltrate) – this is optional, though I typically anesthetize my patients

2. Shade Selection

3. Pumice teeth aggressively to eliminate plaque, staining and pellicle

4. Use Brasseler 889M012 Microbur - to create trough - about 1 mm depth –internal enamel rim from mesial to distal

5. Use Brasseler 830M012 Microbur - to remove sharp edges and blend internal axial wall of trough to incisal edge

6. Flame shape diamond to bevel

7. Total Etch or Selective Etch protocol (see previous post on this topic if desired)

8. Inject Nanofill composite, blend with composite instrument to build lingual wall, continuation of bevel, polymerize

9. Place Microfill composite, blend onto etched, unprepared enamel, polymerize

10. Contour with ET9, OS1 (Brasseler), Flexidiscs (Cosmedent)

11. Polish with Featherlite wheels (Brasseler)
Incisal Chipping
Brasseler 889M012
Brasseler 889M012
Brasseler 830M012
Brasseler 830M012
Flame shaped diamond bur
Brasseler 830M012
Nanofill and Microfill

3. NCIL – Facial Coverage, Adding Length

1. Anesthesia (local infiltrate) – this is optional, though I typically anesthetize my patients

2. Shade Selection

3. Pumice teeth aggressively to eliminate plaque, staining and pellicle

4. Use Brasseler 889M012 Microbur - to create trough - about 2 mm depth – internal enamel rim from mesial to distal

5. Use Brasseler 830M012 Microbur - to remove sharp edges and blend internal axial wall of trough to incisal edge

6. Flame shape diamond to bevel – length of bevel should equal amount of tooth to add

7. Total Etch or Selective Etch protocol (see previous post on this topic if desired)

8. Inject Nanofill composite, blend with composite instrument to build lingual wall, continuation of bevel, polymerize

9. Opaquer as needed to blend composite to tooth structure (Creative Colors, Cosmedent

10. Place Microfill composite, blend onto etched, unprepared enamel, polymerize

11. Contour with ET9, OS1 (Brasseler), Flexidiscs (Cosmedent)12) Polish with Featherlite wheels (Brasseler)

Dennis Hartlieb, DDS, AAACD

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