A multidisciplinary approach for the rehabilitation of a patient with an excessively worn dentition: A clinical report Alireza Moshaverinia, DDS, MS, PhD,a Kian Kar, DDS, MS,b Alexandre Amir Aalam, DDS, MS,c Kazunari Takanashi, RDT,d James W. Kim, DDS,e and Winston W. Chee, DDSf Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, Calif This clinical report describes a multidisciplinary approach to the diagnosis and treatment of a patient with a severely worn dentition. The treatment included osteotomy and immediate implant placement and loading in the mandible. The definitive restorations were implant- and tooth-supported metal ceramic restorations. These restorations were fabricated with metal occlusal surfaces at an increased occlusal vertical dimension, which provided acceptable esthetics and function. (J Prosthet Dent 2014;111:259-263) Dental wear occurs in patients of all ages across the globe.1 Studies have provided important information about the anatomy and origin of dental wear.1,2 Occlusal wear has mostly been attributed to attrition, which is defined as the loss of tooth structure by mechanical wear from another tooth surface.2 However, several other etiologic factors, such as erosion, abrasion, and parafunctional habits (bruxism), have been reported to have a significant role in the process of excessive occlusal wear.1-3 Diet and diseases, such as gastric reflux, congenital abnormalities, and eating disorders, are important contributors to excessive occlusal wear.2,3 A differential diagnosis is not always possible because a combination of these conditions may be present. Nevertheless, identifying the etiology of the excessive wear and evaluating the diagnostic data, especially the occlusal vertical dimension, are important. An estimation of the presenting occlusal vertical dimension, together with the extent of noncarious tooth loss, is essential before deciding upon a treatment plan.2-4 a
Loss of the occlusal vertical dimension caused by physiologic tooth wear does not occur when compensated for by continuous tooth eruption, together with the development of the associated alveolar bone.4 When the rate of tooth wear exceeds the compensatory mechanisms, a loss of occlusal vertical dimension is observed.4,5 Occlusal vertical dimension can be estimated with several methods, for example, phonetics, interocclusal distance, and swallowing.4-10 The management of severely worn dentition is challenging for clinicians, both from a preventive aspect and a restorative aspect. Turner and Missirilian11 classified patients with extensively worn dentitions into 3 categories. Patients in category I exhibit excessive wear, with loss of the occlusal vertical dimension. Patients in category II exhibit excessive wear, without loss of the occlusal vertical dimension but with space available for the placement of restorations. Patients in this group typically have adequate posterior support and a long history of bruxism. The continuous eruption of the teeth in these patients
can maintain the occlusal vertical dimension. Finally, patients in category III present with excessive wear and no loss of occlusal vertical dimension but differ from category II in having limited space available. Providing sufficient space for restorative materials is challenging, and, with any increase in the occlusal vertical dimension, the patient is committed to having all the occluding surfaces of at least 1 arch restored. When there is an occlusal plane discrepancy. This is further complicated because an uneven amount of restorative space across the arch may be required. This clinical report describes a multidisciplinary approach to the diagnosis and treatment of a patient with excessively worn dentition of overerupted mandibular anterior teeth.
CLINICAL REPORT A 64-year-old white man was referred by his previous dental provider to the Advanced Prosthodontics Department, Ostrow School of Dentistry, University of Southern California, for treatment. His stated chief complaint
Assistant Professor, Division of Biomedical Science, Center for Craniofacial Molecular Biology. Associate Professor of Clinical Dentistry, Clinical Director of Advanced Periodontology. c Assistant Clinical Professor, Advanced Periodontology. d Director, Oral Design Center of Los Angeles, Calif. e Associate Professor of Clinical Dentistry, Clinical Director of Advanced Prosthodontics. f Ralph and Jean Bleak Professor of Restorative Dentistry, Program Director, Advanced Prosthodontics. b
Moshaverinia et al
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Volume 111 Issue 4
1 Pretreatment intraoral view. was, “I grind my teeth and all of them are worn out; I would like to have good looking teeth again” (Fig. 1). The patient reported that he lost his teeth because of fracture and recurrent caries. Upon examination, the patient was found to have worn and supraerupted mandibular anterior teeth (Fig. 1). Sharp enamel edges with dentinal craters were observed on the anterior mandibular teeth, which indicated active wear and an erosive component that caused loss of tooth structure.12 Abrasive wear facets also presented on the maxillary anterior sextant. An occlusal plane discrepancy where the mandibular anterior teeth were supraerupted and the porcelain had fractured also was observed in the intraoral examination. Noncarious cervical lesions were noted on teeth in the maxillary arch. However, the patient had no tooth sensitivity or pain. Results of clinical and radiographic examinations revealed the presence of carious lesions. Also, the previous dental provider had placed 6 implants for the patient, 3 Mk III RP (Nobel Biocare) in the mandibular posterior, 2 Osseospeed TX (Dentsply Implants) in the maxillary left posterior, and 1 regular neck Straumann implant (Standard Plus RN; Straumann USA LLC) in the mandibular right posterior (Fig. 2). The 2 implants on the left mandible exhibited periimplant bone loss (Fig. 3). Both of the implants were mobile, and the patient experienced moderate levels of pain upon loading. A diagnosis of
2 Pretreatment panoramic radiograph. periimplant bone loss associated with malplaced implants was made. Extraoral examination revealed no facial asymmetry or muscle tenderness. The patient did not have any symptoms of temporomandibular joint dysfunction. The dental disease diagnosis of the patient included dental caries, periapical periodontitis, generalized moderate with localized severe chronic periodontitis, partial edentulism, and nocturnal bruxism. He was also diagnosed with loss of tooth structure due to abrasion. The patient was classified as class III, according to the prosthodontic diagnostic index (PDI) classification.13 The treatment objectives were to improve oral hygiene and restore function by providing implant-supported partial fixed dental prostheses to replace teeth in the mandible, together with a combination of implant-supported fixed restorations (single units and fixed dental prostheses) and metal ceramic restorations for the remaining teeth in the maxilla. The available treatment options were presented and discussed with the patient, as was the need to increase the occlusal vertical dimension to obtain restorative space, especially in the anterior region of the maxilla and mandible. At this point, an esthetic intraoral interim acrylic resin (Jet Acrylic; Lang Dental Manufacturing Co Inc) restoration was fabricated to establish parameters of esthetics to include the incisal edge position of the maxillary anterior teeth and to display the teeth when smiling.
The Journal of Prosthetic Dentistry
3 Intraoral view of failing implants and related periapical radiograph.
To provide space for the components and develop proper contours for the implant-supported restorations, 10 mm of space from the implant platform to the opposing occlusal surface has been recommended.14 Therefore, an occlusal device was provided at an increased occlusal vertical dimension (4 mm at the incisal pin) with instructions that the patient wear the device constantly except for hygiene and eating. After a 4-week period, the patient did not report any muscle tenderness or temporomandibular joint discomfort. A diagnostic waxing was completed at this occlusal
Moshaverinia et al
April 2014
261
vertical dimension, which satisfied the esthetic parameters for the maxilla. In spite of the increased occlusal vertical dimension, the supraeruption of the mandibular anterior teeth demanded additional restorative space. A variety of procedures were considered, including orthodontic intrusion,15 crown lengthening surgery together with reduction of clinical crown height, elective endodontic therapy with reduction of clinical crown height, extraction of the supraerupted teeth, and an increase in the occlusal vertical dimension.16,17 These options also were
4 Diagnostic waxing.
considered in combination. After considering the severity of the malposition of the mandibular anterior teeth, their remaining tooth structure, and the length of treatment time, the restoration with the best long-term outcome was determined to be an implant-supported restoration. Apart from the 2 failing implants of the mandibular left side, this patient had a history of success with implant integration and presented with no systemic risk factors; moreover, the anterior mandible was anatomically conducive to implant placement. A space analysis indicated that an
ostectomy would also be required after the removal of the mandibular anterior teeth to allow for appropriate contours of the implant-supported restoration. If the implants were deemed to have adequate primary stability, then they were to be loaded at the time of placement. In accordance with the diagnostic waxing (Fig. 4), a surgical template was fabricated to guide both the ostectomy and implant placement after the extraction of the mandibular anterior teeth. The posterior mandibular implants were used to index the surgical template. This procedure was carried out by attaching three 6-mm-long healing abutments (4-mm-diameter Healing cap; 3i Biomet) to the implant analogs on a cast in positions of the existing posterior mandibular implants, then replicating the diagnostic waxing in polymethyl methacrylate (Jet Acrylic; Lang Dental Manufacturing Co Inc) on this cast. Similar healing caps were placed on the implants intraorally to allow accurate placement of the surgical guide (Fig. 5). With this surgical guide, 5 implants (Osseotite; 3i Biomet) were placed in the mandibular anterior region. All the procedures were
5 A, B, Six-mm-long healing abutments on implants as indices for surgical template. C, D, Extraction of remaining teeth followed by osteotomy and immediate loading of implants.
Moshaverinia et al
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Volume 111 Issue 4
7 Definitive restorations.
6 Interim restorations.
9 Posttreatment panoramic radiograph.
8 Definitive restorations, including metal occlusal surfaces.
completed at the same appointment. Similar to the surgical guide, the diagnostic waxing was duplicated with polymethyl methacrylate (Ena Temp; Micerium) to form an interim restoration, which was inserted immediately after placing the implants. At another appointment, 2 implants (Osseotite; 3i Biomet) were placed in the maxilla, and the fixed interim restorations (Ena Temp; Micerium) were fabricated and cemented with TempBond (Kerr Dental). After confirming that the patient was satisfied with the form, color, shape, and function of the interim restorations (Fig. 6), the tooth preparations were
completed and impressions were made with polyvinyl siloxane impression material (Extrude; Kerr Corp). The framework (Au-Pd alloy, Argdent30; Argen Corp) was fabricated with posterior teeth with metal occlusal surfaces because of the self-reported parafunction. In the maxillary arch, singleunit tooth-supported metal ceramic restorations were inserted and cemented with resin-modified glass ionomer cement (FujiCEM; GC America). Splinted screw–retained metal ceramic restorations were inserted for the maxillary left posterior implants, whereas single-unit screw-retained implant-supported restorations were placed in the anterior maxilla. In addition, screw-retained implant-supported splinted metal ceramic restorations were inserted in the mandible in 2 segments. The restorations were satisfactory in terms of form, color, phonetics, and function (Figs. 7-9).
The Journal of Prosthetic Dentistry
DISCUSSION The management of excessively worn dentition is a major challenge for dental professionals. One of the most important considerations before diagnosis and treatment planning is to identify, eliminate, or reduce the factors that caused the excessive wear. Failure to eliminate the cause may compromise the long-term survival of restorations and lead to further deterioration of the dentition.18-21 Attrition has been assumed to be a physiologically normal process that is necessary for function.18 Xhonga19 found the rate of normal attrition for nonbruxers to be 35 to 65 mm in 6 months. In another study, Lambrechts et al20 reported that the normal amount of tooth wear is 68 mm per year. The patient in this clinical report presented with excessive wear with limited space available for restorations
Moshaverinia et al
April 2014 and excessive wear in existing restorations, attributed to nocturnal bruxism. A sufficient amount of restorative space was gained by combining surgical osteotomy in the anterior region of the mandible, with an increase in the occlusal vertical dimension. Approximately 5 mm of restorative space was obtained with the surgical procedure in addition to a 5-mm increase in the occlusal vertical dimension. Maxillary and mandibular metal restorations were inserted at the new occlusal vertical dimension, which resulted in acceptable esthetics and function. In addition, the patient presented with 3 different types of implant systems, which complicated procedures for the restorative dentist because 3 different sets of screws, drivers, and wrenches were required. This further illustrates the benefit of having a comprehensive treatment plan before implant placement and mutual understanding among different specialists of interdisciplinary treatment planning.
SUMMARY In this clinical report, the patient presented with excessive wear without loss of the occlusal vertical dimension, with limited restorative space together, and with overerupted mandibular anterior teeth. The treatment plan used osteotomy, immediate implant placement, and loading in the mandible, and delivery of implant and tooth-supported
Moshaverinia et al
263 metal ceramic restorations in the maxilla and mandible. These restorations used metal for the posterior occluding surfaces at an increased occlusal vertical dimension, which provided acceptable esthetics and function.
REFERENCES 1. Rivera-Morales WC, Mohl ND. Restoration of the vertical dimension of occlusion in the severely worn dentition. Dent Clin N Am 1992;36:651-64. 2. Winstanley RB. The treatment of severe attrition. Dent Update 1984;11:629-34. 3. Bartlett D. The implication of laboratory research on tooth wear and erosion. Oral Dis 2005;11:3-6. 4. van’t Spijker A, Kreulen CM, Creugers NH. Attrition, occlusion, (dys)function, and intervention: a systematic review. Clin Oral Implants Res 2007;18:117-26. 5. Phuhong DD, Goldstein GR. The use of a diagnostic matrix in the management of the severely worn occlusion. J Prosthodont 2007;16:277-81. 6. Smith BG. Tooth wear: etiology and diagnosis. Dent Update 1989;16:204-12. 7. Dawson PE. Functional occlusion: from TMJ to smile design. New York: Elsevier; 2008. p. 430-52. 8. Shanahan TE. Physiologic vertical dimension and centric relation. J Prosthet Dent 1956;6: 741-7. 9. Silverman MM. Determination of vertical dimension by phonetics. J Prosthet Dent 1956;6:465-71. 10. MacGregor AR, Watt ME, Brown J. Vertical dimension in edentulous patients. J Dent 1984;12:287-96. 11. Turner KA, Missirilian DM. Restoration of the extremely worn dentition. J Prosthet Dent 1984;52:467-74. 12. Johansson A, Omar R. Identification and management of tooth wear. Int J Prosthodont 1994;7:506-16.
13. McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, et al. Classification system for partial edentulism. J Prosthodont 2002;1:181-93. 14. Phillips K, Wong KM. Vertical space requirement for the fixed detachable implants supported prosthesis. Compen Contin Educ Dent 2002;23:750-6. 15. Spear F. A patient with severe wear on the anterior teeth and minimal wear on the posterior teeth. J Am Dent Assoc 2008;139: 1399-403. 16. Spear F. A patient with severe wear on the posterior teeth and minimal wear on the anterior teeth. J Am Dent Assoc 2009;140: 99-104. 17. Misch CE. Clinical indications for altering vertical dimension of occlusion. Objective vs subjective methods for determining vertical dimension of occlusion. Quintessence Int 2000;31:280-2. 18. Carlsson GE, Johansson A, Lundquist S. Occlusal wear. A follow-up study of 18 subjects with extensively worn dentitions. Acta Odontol Scand 1985;43:83-9. 19. Xhonga F. Bruxism and its effect on teeth. J Oral Rehabil 1977;4:65-72. 20. Lambrechts P, Vanherle G, Vuylsteke M, Davidson CL. Quantitative evaluation of the wear resistance of posterior dental restorations: a new three-dimensional measuring technique. J Dent 1984;12: 252-61. 21. Johansson A, Johansson AK, Omar R, Carlsson GE. Rehabilitation of the worn dentition. J Oral Rehabil 2008;35: 548-66. Corresponding author: Dr Alireza Moshaverinia Center for Craniofacial Molecular Biology Ostrow School of Dentistry University of Southern California 2250 Alcazar Street - CSA 103 Los Angeles, CA 90033 E-mail: [email protected] Copyright ª 2014 by the Editorial Council for The Journal of Prosthetic Dentistry.
Loss of the occlusal vertical dimension caused by physiologic tooth wear does not occur when compensated for by continuous tooth eruption, together with the development of the associated alveolar bone.4 When the rate of tooth wear exceeds the compensatory mechanisms, a loss of occlusal vertical dimension is observed.4,5 Occlusal vertical dimension can be estimated with several methods, for example, phonetics, interocclusal distance, and swallowing.4-10 The management of severely worn dentition is challenging for clinicians, both from a preventive aspect and a restorative aspect. Turner and Missirilian11 classified patients with extensively worn dentitions into 3 categories. Patients in category I exhibit excessive wear, with loss of the occlusal vertical dimension. Patients in category II exhibit excessive wear, without loss of the occlusal vertical dimension but with space available for the placement of restorations. Patients in this group typically have adequate posterior support and a long history of bruxism. The continuous eruption of the teeth in these patients
can maintain the occlusal vertical dimension. Finally, patients in category III present with excessive wear and no loss of occlusal vertical dimension but differ from category II in having limited space available. Providing sufficient space for restorative materials is challenging, and, with any increase in the occlusal vertical dimension, the patient is committed to having all the occluding surfaces of at least 1 arch restored. When there is an occlusal plane discrepancy. This is further complicated because an uneven amount of restorative space across the arch may be required. This clinical report describes a multidisciplinary approach to the diagnosis and treatment of a patient with excessively worn dentition of overerupted mandibular anterior teeth.
CLINICAL REPORT A 64-year-old white man was referred by his previous dental provider to the Advanced Prosthodontics Department, Ostrow School of Dentistry, University of Southern California, for treatment. His stated chief complaint
Assistant Professor, Division of Biomedical Science, Center for Craniofacial Molecular Biology. Associate Professor of Clinical Dentistry, Clinical Director of Advanced Periodontology. c Assistant Clinical Professor, Advanced Periodontology. d Director, Oral Design Center of Los Angeles, Calif. e Associate Professor of Clinical Dentistry, Clinical Director of Advanced Prosthodontics. f Ralph and Jean Bleak Professor of Restorative Dentistry, Program Director, Advanced Prosthodontics. b
Moshaverinia et al
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Volume 111 Issue 4
1 Pretreatment intraoral view. was, “I grind my teeth and all of them are worn out; I would like to have good looking teeth again” (Fig. 1). The patient reported that he lost his teeth because of fracture and recurrent caries. Upon examination, the patient was found to have worn and supraerupted mandibular anterior teeth (Fig. 1). Sharp enamel edges with dentinal craters were observed on the anterior mandibular teeth, which indicated active wear and an erosive component that caused loss of tooth structure.12 Abrasive wear facets also presented on the maxillary anterior sextant. An occlusal plane discrepancy where the mandibular anterior teeth were supraerupted and the porcelain had fractured also was observed in the intraoral examination. Noncarious cervical lesions were noted on teeth in the maxillary arch. However, the patient had no tooth sensitivity or pain. Results of clinical and radiographic examinations revealed the presence of carious lesions. Also, the previous dental provider had placed 6 implants for the patient, 3 Mk III RP (Nobel Biocare) in the mandibular posterior, 2 Osseospeed TX (Dentsply Implants) in the maxillary left posterior, and 1 regular neck Straumann implant (Standard Plus RN; Straumann USA LLC) in the mandibular right posterior (Fig. 2). The 2 implants on the left mandible exhibited periimplant bone loss (Fig. 3). Both of the implants were mobile, and the patient experienced moderate levels of pain upon loading. A diagnosis of
2 Pretreatment panoramic radiograph. periimplant bone loss associated with malplaced implants was made. Extraoral examination revealed no facial asymmetry or muscle tenderness. The patient did not have any symptoms of temporomandibular joint dysfunction. The dental disease diagnosis of the patient included dental caries, periapical periodontitis, generalized moderate with localized severe chronic periodontitis, partial edentulism, and nocturnal bruxism. He was also diagnosed with loss of tooth structure due to abrasion. The patient was classified as class III, according to the prosthodontic diagnostic index (PDI) classification.13 The treatment objectives were to improve oral hygiene and restore function by providing implant-supported partial fixed dental prostheses to replace teeth in the mandible, together with a combination of implant-supported fixed restorations (single units and fixed dental prostheses) and metal ceramic restorations for the remaining teeth in the maxilla. The available treatment options were presented and discussed with the patient, as was the need to increase the occlusal vertical dimension to obtain restorative space, especially in the anterior region of the maxilla and mandible. At this point, an esthetic intraoral interim acrylic resin (Jet Acrylic; Lang Dental Manufacturing Co Inc) restoration was fabricated to establish parameters of esthetics to include the incisal edge position of the maxillary anterior teeth and to display the teeth when smiling.
The Journal of Prosthetic Dentistry
3 Intraoral view of failing implants and related periapical radiograph.
To provide space for the components and develop proper contours for the implant-supported restorations, 10 mm of space from the implant platform to the opposing occlusal surface has been recommended.14 Therefore, an occlusal device was provided at an increased occlusal vertical dimension (4 mm at the incisal pin) with instructions that the patient wear the device constantly except for hygiene and eating. After a 4-week period, the patient did not report any muscle tenderness or temporomandibular joint discomfort. A diagnostic waxing was completed at this occlusal
Moshaverinia et al
April 2014
261
vertical dimension, which satisfied the esthetic parameters for the maxilla. In spite of the increased occlusal vertical dimension, the supraeruption of the mandibular anterior teeth demanded additional restorative space. A variety of procedures were considered, including orthodontic intrusion,15 crown lengthening surgery together with reduction of clinical crown height, elective endodontic therapy with reduction of clinical crown height, extraction of the supraerupted teeth, and an increase in the occlusal vertical dimension.16,17 These options also were
4 Diagnostic waxing.
considered in combination. After considering the severity of the malposition of the mandibular anterior teeth, their remaining tooth structure, and the length of treatment time, the restoration with the best long-term outcome was determined to be an implant-supported restoration. Apart from the 2 failing implants of the mandibular left side, this patient had a history of success with implant integration and presented with no systemic risk factors; moreover, the anterior mandible was anatomically conducive to implant placement. A space analysis indicated that an
ostectomy would also be required after the removal of the mandibular anterior teeth to allow for appropriate contours of the implant-supported restoration. If the implants were deemed to have adequate primary stability, then they were to be loaded at the time of placement. In accordance with the diagnostic waxing (Fig. 4), a surgical template was fabricated to guide both the ostectomy and implant placement after the extraction of the mandibular anterior teeth. The posterior mandibular implants were used to index the surgical template. This procedure was carried out by attaching three 6-mm-long healing abutments (4-mm-diameter Healing cap; 3i Biomet) to the implant analogs on a cast in positions of the existing posterior mandibular implants, then replicating the diagnostic waxing in polymethyl methacrylate (Jet Acrylic; Lang Dental Manufacturing Co Inc) on this cast. Similar healing caps were placed on the implants intraorally to allow accurate placement of the surgical guide (Fig. 5). With this surgical guide, 5 implants (Osseotite; 3i Biomet) were placed in the mandibular anterior region. All the procedures were
5 A, B, Six-mm-long healing abutments on implants as indices for surgical template. C, D, Extraction of remaining teeth followed by osteotomy and immediate loading of implants.
Moshaverinia et al
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Volume 111 Issue 4
7 Definitive restorations.
6 Interim restorations.
9 Posttreatment panoramic radiograph.
8 Definitive restorations, including metal occlusal surfaces.
completed at the same appointment. Similar to the surgical guide, the diagnostic waxing was duplicated with polymethyl methacrylate (Ena Temp; Micerium) to form an interim restoration, which was inserted immediately after placing the implants. At another appointment, 2 implants (Osseotite; 3i Biomet) were placed in the maxilla, and the fixed interim restorations (Ena Temp; Micerium) were fabricated and cemented with TempBond (Kerr Dental). After confirming that the patient was satisfied with the form, color, shape, and function of the interim restorations (Fig. 6), the tooth preparations were
completed and impressions were made with polyvinyl siloxane impression material (Extrude; Kerr Corp). The framework (Au-Pd alloy, Argdent30; Argen Corp) was fabricated with posterior teeth with metal occlusal surfaces because of the self-reported parafunction. In the maxillary arch, singleunit tooth-supported metal ceramic restorations were inserted and cemented with resin-modified glass ionomer cement (FujiCEM; GC America). Splinted screw–retained metal ceramic restorations were inserted for the maxillary left posterior implants, whereas single-unit screw-retained implant-supported restorations were placed in the anterior maxilla. In addition, screw-retained implant-supported splinted metal ceramic restorations were inserted in the mandible in 2 segments. The restorations were satisfactory in terms of form, color, phonetics, and function (Figs. 7-9).
The Journal of Prosthetic Dentistry
DISCUSSION The management of excessively worn dentition is a major challenge for dental professionals. One of the most important considerations before diagnosis and treatment planning is to identify, eliminate, or reduce the factors that caused the excessive wear. Failure to eliminate the cause may compromise the long-term survival of restorations and lead to further deterioration of the dentition.18-21 Attrition has been assumed to be a physiologically normal process that is necessary for function.18 Xhonga19 found the rate of normal attrition for nonbruxers to be 35 to 65 mm in 6 months. In another study, Lambrechts et al20 reported that the normal amount of tooth wear is 68 mm per year. The patient in this clinical report presented with excessive wear with limited space available for restorations
Moshaverinia et al
April 2014 and excessive wear in existing restorations, attributed to nocturnal bruxism. A sufficient amount of restorative space was gained by combining surgical osteotomy in the anterior region of the mandible, with an increase in the occlusal vertical dimension. Approximately 5 mm of restorative space was obtained with the surgical procedure in addition to a 5-mm increase in the occlusal vertical dimension. Maxillary and mandibular metal restorations were inserted at the new occlusal vertical dimension, which resulted in acceptable esthetics and function. In addition, the patient presented with 3 different types of implant systems, which complicated procedures for the restorative dentist because 3 different sets of screws, drivers, and wrenches were required. This further illustrates the benefit of having a comprehensive treatment plan before implant placement and mutual understanding among different specialists of interdisciplinary treatment planning.
SUMMARY In this clinical report, the patient presented with excessive wear without loss of the occlusal vertical dimension, with limited restorative space together, and with overerupted mandibular anterior teeth. The treatment plan used osteotomy, immediate implant placement, and loading in the mandible, and delivery of implant and tooth-supported
Moshaverinia et al
263 metal ceramic restorations in the maxilla and mandible. These restorations used metal for the posterior occluding surfaces at an increased occlusal vertical dimension, which provided acceptable esthetics and function.
REFERENCES 1. Rivera-Morales WC, Mohl ND. Restoration of the vertical dimension of occlusion in the severely worn dentition. Dent Clin N Am 1992;36:651-64. 2. Winstanley RB. The treatment of severe attrition. Dent Update 1984;11:629-34. 3. Bartlett D. The implication of laboratory research on tooth wear and erosion. Oral Dis 2005;11:3-6. 4. van’t Spijker A, Kreulen CM, Creugers NH. Attrition, occlusion, (dys)function, and intervention: a systematic review. Clin Oral Implants Res 2007;18:117-26. 5. Phuhong DD, Goldstein GR. The use of a diagnostic matrix in the management of the severely worn occlusion. J Prosthodont 2007;16:277-81. 6. Smith BG. Tooth wear: etiology and diagnosis. Dent Update 1989;16:204-12. 7. Dawson PE. Functional occlusion: from TMJ to smile design. New York: Elsevier; 2008. p. 430-52. 8. Shanahan TE. Physiologic vertical dimension and centric relation. J Prosthet Dent 1956;6: 741-7. 9. Silverman MM. Determination of vertical dimension by phonetics. J Prosthet Dent 1956;6:465-71. 10. MacGregor AR, Watt ME, Brown J. Vertical dimension in edentulous patients. J Dent 1984;12:287-96. 11. Turner KA, Missirilian DM. Restoration of the extremely worn dentition. J Prosthet Dent 1984;52:467-74. 12. Johansson A, Omar R. Identification and management of tooth wear. Int J Prosthodont 1994;7:506-16.
13. McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, et al. Classification system for partial edentulism. J Prosthodont 2002;1:181-93. 14. Phillips K, Wong KM. Vertical space requirement for the fixed detachable implants supported prosthesis. Compen Contin Educ Dent 2002;23:750-6. 15. Spear F. A patient with severe wear on the anterior teeth and minimal wear on the posterior teeth. J Am Dent Assoc 2008;139: 1399-403. 16. Spear F. A patient with severe wear on the posterior teeth and minimal wear on the anterior teeth. J Am Dent Assoc 2009;140: 99-104. 17. Misch CE. Clinical indications for altering vertical dimension of occlusion. Objective vs subjective methods for determining vertical dimension of occlusion. Quintessence Int 2000;31:280-2. 18. Carlsson GE, Johansson A, Lundquist S. Occlusal wear. A follow-up study of 18 subjects with extensively worn dentitions. Acta Odontol Scand 1985;43:83-9. 19. Xhonga F. Bruxism and its effect on teeth. J Oral Rehabil 1977;4:65-72. 20. Lambrechts P, Vanherle G, Vuylsteke M, Davidson CL. Quantitative evaluation of the wear resistance of posterior dental restorations: a new three-dimensional measuring technique. J Dent 1984;12: 252-61. 21. Johansson A, Johansson AK, Omar R, Carlsson GE. Rehabilitation of the worn dentition. J Oral Rehabil 2008;35: 548-66. Corresponding author: Dr Alireza Moshaverinia Center for Craniofacial Molecular Biology Ostrow School of Dentistry University of Southern California 2250 Alcazar Street - CSA 103 Los Angeles, CA 90033 E-mail: [email protected] Copyright ª 2014 by the Editorial Council for The Journal of Prosthetic Dentistry.
