The previous article discussed changes in the occur when posterior tooth support is occlusion that take place when teeth wear. reduced or lost. In these cases, the mandible Reconstruction of the Severe wear, particularly when coupled with requires a new support which is usually found in dentition extensively tooth loss, can produce marked changes in the the anterior region of the mouth. Consequently, damaged through occlusal relationships and significant aesthetic an excessive occlusal load affects the anterior tooth surface loss may deficit. A removable prosthesis may be the teeth. Such an event is known as occlusal require the use of appropriate restorative approach particularly collapse. Russell,12 supports this concept. He when wear is advanced. Determination of the considers that an FWS in excess of 56 mm is removable prostheses. correct vertical dimension for the occlusion abnormal and that the occlusal wear which has This can be the most and an appropriate jaw relationship form the produced it, has occurred at a rate faster than appropriate type of basis of treatment whether this employs fixed the physiological mechanisms designed to com- treatment when either or removable prostheses. Later articles will pensate for it. This presumption is disputed in a examine both adhesive and more traditional recent paper by Smith and Robb.13 the teeth are very fixed approaches to restoration. However, this These apparently contrasting opinions are severely worn or the paper describes the use of removable appliances reflected in the following clinical observations. patient wishes a for restoring dentitions affected by tooth sur- Dawson is adamant that as wear does not simpler and more face loss and how the aesthetic and technical decrease the occlusal vertical dimension economical approach difficulties created by the lack of space may be (OVD), there is no case for its increase during overcome. treatment.14 Nonetheless, he subsequently than a fixed states that: If the contacting surface enamel is reconstruction. The maintenance of anterior facial worn severely on both the upper and lower height by compensatory growth anterior teeth, there is sometimes no room to The craniofacial complex is not a static entity restore the surfaces... without either invading in the adult;1 there is evidence that growth, the pulp or increasing the vertical dimension. though slower than takes place during adoles- This type of problem is usually treated by open- cence, continues into late middle age.2 An ing the vertical. Watson and Tulloch too, find a aspect of such growth ie the increase in ante- seeming paradox in relation to OVD. They rior facial height has been reported.24 One of comment, that: Clinically one frequently finds the mechanisms for this increase (in the that despite considerable TSL there is very little absence of excessive tooth wear) is thought to interocclusal clearance...on the other hand...the be from the eruption of teeth because of an extent of the freeway space is sometimes com- increase in alveolar height.5,6 mensurate with a natural FWS together with Tallgren noted that with the complete denti- the TSL. tion, anterior facial height tends to increase with This apparent conflict can be resolved by age and that this increase is paralleled by the rest modifying Pindborgs original classification of of the face height;3 in other words, the free-way TSL.16 The latter makes a distinction between The Series Editors are Richard Ibbetson and Andrew Eder of the Eastman Dental space (FWS) remains constant. This relation- generalised and localised tooth wear.12,16 Institute for Oral Healthcare Sciences ship appears to hold as long as there is no appre- Compensated TSL: Tooth surface loss with- and the Eastman Dental Hospital ciable destructive change in the dentition. out loss of OVD. It generally involves a com- Where uniform wear of the occlusal surfaces plete or nearly complete dentition and the and incisal edges does take place, Sicher sug- free-way space remains within the normal gests that this is compensated by continuous range. vertical eruption and thus attrition does not Non-compensated TSL: Tooth surface loss affect the proportions of the face.7 Niswonger leading to the loss of OVD. This is often con- (cited by Tallgren3) among others6,8 supported fined to the anterior segments and associated 1Honorary Clinical Senior Lecturer, this view. He found that 80% of severe wear with a lack of posterior occlusion. The rate of Department of Prosthetic Dentistry, cases had a normal FWS ie 3 mm. wear, confined to a smaller number of teeth, Eastman Dental Institute for Oral Healthcare Sciences, University of However, there is a contrary view (Thomp- results in an apparent lack of compensatory London, 256 Grays Inn Road, London son,4 Mershon,9 and Kazis,10) which affirms eruption and the free-way space is greater WC1X 8LD and Specialist in that the FWS is affected by wear and its mag- than normal. Prosthodontics, 25 Devonshire Place, London W1N 1PD nitude is proportionate to the degree of attri- With compensated TSL, the occlusal plane is REFEREED PAPER tion. Stern and Brayer11 state that: generally not in doubt. During treatment, the British Dental Journal Pathological changes of the occlusion may increase in vertical dimension is usually 1999; 186: 273276
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PRACTICE tooth surface loss dependent on the space required to restore the Assessment of non-compensated TSL teeth. Repositioning of the mandible will re- The patient affected by non-compensated establish a normal FWS but the anterior lower TSL with loss of facial height poses the same facial height (ALFH) will be increased. problem as in complete denture prosthodon- With non-compensated TSL, the collapse of tics; how to establish a functional OVD. The ALFH necessitates an increase in the vertical absence of an acceptable occlusal plane also dimension to restore the subjects to their pre- complicates the determination of an appro- sumed, original OVD before TSL took place. priate intercuspal position (ICP). As patients with compensated TSL rarely pre- Two characteristics may be of value in guid- sent for removable partial denture (RPD) treat- ing the operator toward the optimal retruded ment, the following discussion will, in the axis position (RAP) and hence a convenient main, be directed to non-compensated TSL. occlusal vertical dimension (OVD).17 Firstly, when teeth are found distal to the worn anterior surfaces, a facet may be present which often appears to be coincident with the retruded contact position (RCP). (It will be obvious if this first contact is a result of over- eruption.) Secondly, this contact will fre- quently produce an acceptable OVD. This can be confirmed by reference to the patients appearance and in particular to an unstrained relationship of the lips in apposition. Figures 1 to 5 illustrate this suggestion. The unstable contacts seen in figures 3a and b may be responsible for deflecting the mandible for- Fig. 1 Anterior view of a patients intercuspal position ward into ICP, a position to which the func- (ICP) showing exceptionally heavy wear of the upper tional movements of mastication and incisors. Note the shiny surface of the apparently non- swallowing are normally directed.18 The poste- functional amalgam surface on the |5 rior contacts no longer being used, the anterior teeth suffer progressive wear which is probably a combination of attrition and erosion.19 When the mandible is held at the retruded contact position, the original occlusal plane, common to both arches, can be envisaged and there is no longer any evidence of significant over-erup- tion. The outline of anterior tooth form can be extrapolated from the proportions of the remaining tooth structure and the available interarch space (fig. 4); a diagnostic wax-up will show this more accurately. Thus, an examination of the casts mounted in RCP, will often allow the operator to visualise the degree of tooth loss and the extent of restoration required. This can be the starting point for the proposed restoration.
Treatment of non-compensated TSL
The following is a schematic outline for the treatment of TSL with a removable prostheses. Management can be divided into three stages: 1. Preliminary investigations 2. Restorative phase 3. Maintenance.
Preliminary investigations: 1. Routine examination 2. Note the presence and position of facets and their relationship on opposing teeth (this is Fig. 2a and 2b Lateral views of the casts in ICP. The posterior segments are collapsed and there appears to most easily seen on the casts) be gross over-eruption. Note the relationship of the 3. Assess the amount of free-way space (FWS) apparently over-erupted upper second premolar teeth to 4. Manipulate the mandible into RCP and the lower first premolar. The arrows indicate the presence of wear facets observe the effect on the facial appearance 5. Make impressions of the complete arches
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PRACTICE tooth surface loss and verify the accuracy the resultant casts20 6. Make duplicates of these casts after blocking out undercuts 7. Using a measuring device (eg Willis Bite Gauge) record the rest vertical dimension (RVD) 8. Take an interocclusal record at a jaw separa- tion approximating the RVD recorded 9. Note the occlusal vertical height (OVD) when the teeth are in ICP 10. Deduct the OVD from the RVD to obtain the FWS 11. With the casts mounted and the interoc- clusal record in situ, note the reading on the scale of the incisal pin (ie this is equivalent to the RVD, see 8 above) 12. Close the articulator until first tooth con- tact and again take note of the reading on the incisal pin. (If there is no posterior contact close the articulator until the upper and lower occlusal planes appear to coincide) 13. Close the articulator into ICP and note the reading at the incisal pin 14. Compare these results with those found in vivo. If the first contact (or coincidence of the occlusal plane) produces an acceptable Fig. 3a and 3b Lateral views of the casts after the FWS and facial appearance, use this as a mandible has been guided into RCP. Note that the guide for restoration facets are now in contact and the apparent 15. An occlusal splint is constructed, as overeruption of the 753|578 has resolved into an described in Part 3 of this series. It is usually acceptable occlusal plane most convenient to construct a maxillary appliance. Little, if any, alterations should be made to occlude be made to the teeth at this stage. This is to The lower cast is articulated against a cast of allow abandonment of treatment with a the occlusal splint. An idealised occlusal minimum of recrimination. Teeth can be plane is set up, stone from the opposing added to the splint, making it, in effect, an cast being removed to allow this. The overlay denture. When adjustments and definitive lower denture is fitted and habituation have produced a satisfactory appropriate adjustments are made to the functional and aesthetic result, the next splint. stage can be embarked upon. Choice of the denture base material 2. Restorative phase This will depend on various factors including The OVD and ICP having been established by the opposing materials and whether coverage is the upper occlusal splint, it is possible to envis- mainly on hard or soft tissue: age two situations: 1. Where the lower dentition produces a satis- factory occlusal plane, there is no need for a lower denture to complement the upper splint/denture unless there are specific rea- sons eg aesthetics 2. Where the loss of teeth and tooth substance in the lower arch have created a need for a lower denture to establish a harmonious occlusal plane. The occlusal splint having fol- lowed the irregular lower occlusal plane, it itself is unaesthetic as it overlays the teeth. Two methods can be used: The casts are articulated as described above Fig. 4 Anterior view of the teeth in RCP. Note that the and the lower denture is waxed up to meet facet on the upper left premolar is on the amalgam the upper contacts, care being taken to pre- restoration and its lustre indicates wear during function sent an harmonious occlusal plane to which (figures 1 and 5). This is belied by its situation in ICP, as seen in figure 2b the definitive upper denture can eventually
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PRACTICE tooth surface loss 1 Crothers A, Sandham A. Vertical height differences in subjects with severe dental wear. Eur J Orthod 1993; 15: 519-525. 2 Behrent R G. Growth in the aging craniofacial skeleton. Craniofacial Growth series. Monograph No.17 Center for Human Growth and Development. Michigan: University of Michigan, Ann Arbor, 1985. 3 Tallgren A. Changes in adult face height due to ageing, wear and loss of teeth and prosthetic treatment. Acta Odont Scand 1957; 15: Suppl.24, 73. 4 Thompson J L, Kendrick G S. a b c Changes in the vertical dimension of the human male skull during the Fig. 5 The patients profile is seen in his rest position (fig. 5b) third and fourth decades of life. Anat and at the RCP (fig. 5c). In ICP the patients lower anterior Rec 1964; 27: 209. facial height is very much reduced. However, at RCP the face 5 Manson J D. Passive eruption. Dent takes on a more normal appearance. In particular note that Pract 1963; 14: 2-8. the lips appear to be in unstrained contact 6 Murphy T. Compensatory mechanisms in facial height adjustment to functional tooth attrition. Aust Dent J 1959; 4: 312- 323. Because a well-supported denture is of pri- Maintenance 7 Sicher H. Oral biology. St Louis, CV mary importance; the best design for the One objective of treatment is to produce an Mosby Co. 1949 (in Tallgren 1957.) definitive lower denture is based on a metal appliance which is resistant to degradation but 8 Berry D C, Poole D F G. Attrition: framework nonetheless is capable of simple servicing at possible mechanisms of compensation. J Oral Rehabil 1976; 3: The definitive upper denture will benefit routine checkups. Overlay dentures will nor- 201-206. from a metal construction if the splint has mally be worn at night to prevent parafunc- 9 Mershon J V. Possibilities and shown signs of excessive wear resulting in tional attrition of the teeth. If it is thought that limitations in the treatment of closed-bites. Int J Orthodont 1937; 23: breakage this will place the denture at too much risk an 581-589 (in Tallgren A. 1957). The final prosthesis can be veneered over its occlusal splint may be substituted. 10 Kazis H. Complete mouth entire occlusal surface with cobalt chromium rehabilitation through restoration of which will strengthen the appliance and Conclusion lost vertical dimension. J Am Dent Ass 1948; 37: 19-39 (in Tallgren A. avoid the need to attempt the reproduction The article has discussed the effects of tooth sur- 1957). of the appearance and functional occlusion face loss on anterior facial height and how this 11 Stern N, Brayer L. Collapse of the de novo. When using cobalt chromium can be related to the distribution of wear within occlusion aetiology, attention must be paid to the likelihood the mouth. Identification of the changes that symptomatology and treatment. J Oral Rehabil 1975; 2: 1-19. that the opposing arch may suffer acceler- have taken place is important in making a com- 12 Russell M D. The distinction between ated wear. plete assessment of the patient and forming a physiological and pathological restorative plan. Removable appliances may be attrition: a review. Ir Dent Assoc 1987; 33: 23. Management of the appearance the treatment of choice for some individuals, 13 Smith B G N, Robb N D. The Two options are available for restoring the worn particularly when the time and cost of fixed prevalence of toothwear in 1007 teeth: restorations are considered. The complexities of dental patients. J Oral Rehabil 1996; 1. Complete facings with or without a flange treatment of the severely worn dentition serve to 23: 232-239. 14 Dawson P. Evaluation, diagnosis and 2. Butt joint. re-emphasise the importance of effective pre- treatment of occlusal problems. 2nd The materials can be purpose-made acrylic vention as discussed in the first three parts of ed. Mosby-Toronto, 1989. facings, hollowed-out denture teeth or custom this series. There may also be a case for early 15 Watson I B, Tulloch E N. Clinical assessment of cases of tooth surface made in the mouth with autopolymerising restoration to prevent the extensive damage to loss. Br Dent J 1985; 159:144-148. resin, composite, or light curing resin. An opa- the teeth which necessitates extensive recon- 16 Pindborg J J. Pathology of dental hard quer may be necessary to mask the colour of a struction. Parts 1 and 2 mentioned a possible tissues. pp300-309. Copenhagen: metal base. In the latter case, special provisions role for early restorative intervention to min- Munksgaard, 1970. 17 Hemmings KW, Howlett JA, will also need to be made for retention either imise further wear: this is sometimes considered Woodley N J, et al. Partial dentures mechanically or chemically. controversial as concerns have been expressed for patients with advanced tooth The choice of restoration will depend over wear continuing around the margins of wear. Dent Update 1995; 22: 52-59. upon: restorations. However, there is merit in such an 18 Ramfjord S P. Bruxism, a clinical and electromyographic study. JADA 1961; Path of insertion of the denture approach, particularly if the restorative tech- 62: 21-44. The ability of the lip to tolerate labial cover- niques are relatively non-invasive and it is cou- 19 Lewis K J, Smith B G N. The age of the teeth pled with an overall preventive approach. Part 5 relationship of erosion and attrition in extensive tooth tissue loss. Br Dent The height of the lip during function ie if the examines the role of adhesive dentistry in the J 1973; 135: 400-404. butt joint is visible management of the worn dentition. 20 Faigenblum M J. Advice on The occlusion This article is based on a presentation at The Medical Society of producing an accurate impression The ability to match the colour of the over- London on 15 December 1994 as part of the Alpha Omega lecture and working cast for construction of partial dentures. Br Dent J 1985; 159: laid tooth with the restorative material. programme. 45-46.
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