Journal of Oral Rehabilitation, 1975, Volume 2, pages 209-214

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An alternative treatment in cases with advanced localized attrition

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AIJG 7 197c;
O F PENriSVL

BJ0RN L. DAHL, OLAF KROGSTAD ami KJELL KARLSEN Departments of Prosthetic Detitistry atid Orthodontics, Dental faculty. University of Oslo

Summary A combined orthodontic/prosthetic treatment of patients with advanced localized attrition has been described. In one patient the effect of the orthodontic treatment upon the morphological face height has been studied using an X-ray cephalographic technique and the results have been discussed. Introduction Physiological attrition has been defined as the gradual and regular loss of tooth substance as a result of natural mastication, whereas attrition confined to groups of teeth or localized areas only, and caused by abnormal function or position of teeth, has been termed pathological attrition (Pindborg, 1970). This type of attrition may progress so rapidly that secondary dentine formation fails to keep up with it, and exposure of the pulp may occur even in adolescents. Wear of teeth may be influenced by salivary factors (Carlsson, Hugoson & Persson, 1965; 1966), by the consistency of the diet (Carlsson et al., 1967) and by occupational factors (Frykholm, 1963). Excessive wear of the palatal surfaces of the upper incisors has been ascribed to involuntary bruxing movements (Krogh-Poulsen & Carlsen, 1973), V When advanced attrition is observed, steps must be taken to protect the teeth against further loss of substance. This is usually done by covering the worn surfaces with some sort of a crown prosthesis. Additional removal of tooth substance or grinding of the opposing teeth to provide space for the crown material is usually undesirable. A general bite raising by means of crowns or bridges covering all the teeth in the involved jaw is therefore the solution most frequently resorted to. It may well be agreed that this procedure has the character of an emergency exit rather than that of an ideal solution to the problem. In an effort to avoid capping a great number of teeth, with its many jeopardizing consequences, a technique has been developed by which the necessary space for the crown material has been obtained by orthodontic measures. Such a treatment could be regarded as an experiment designed for the study of the balance of the vertical dimension of the face. The opportunity was taken in one of our patients to analyse the behaviour of the teeth and the jaws in response to the orthodontic treatment. Correspondence: BJ0rn L. Dahl, University of Oslo, Department of Prosthetic Dentistry, Dental Faculty, Geitmyrsvegen 69, Oslo 4, Norway.

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Fig, I. Photograph showing advanced attrition of palatal surfaces of upper incisors (x 2/3).

Fig. 2. Photogrctph showing the chrome-cobalt splint Materials and methods

The patient was a male, 18 years of age, with heavy wear of the palatal surfaces of the upper incisors (Fig. 1). A pink hue from the underlying pulp was apparent, especially on the central incisors. None of the upper front teeth had interproximal contacts. Following alginate impressions casts were poured in Vel-Mix Stone *' (Kerr Europe, Scafati, Italy) and mounted on a Dentatus articulator (Type ARH, AB Dentatus, Stockholm, Sweden) according to a wax index with the lower jaw in the retvuded contact position. A removable chrome-cobalt splint, approximately 2 mm thick, was made covering the palatal surfaces of the upper front teeth (Fig. 2). Retention was achieved by means of buccal clasps on canines and first premolars. Final occlusal adjustments were made in the mouth. Figure 3 indicates the distance between the upper and lower premolars and molars with the splint in situ at the beginning of the treatment. The patient was instructed to wear the splint day and night, to remove it for cleaning after every meal, and was prescribed the daily use of a fluoride-containing mouthwash and toothpaste.

Alternative treatment in cases with adranced iocatizcd attrition

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Fig. 3. Photograph showing the distance between upper and lower premolars and molars when biting on the splint at the beginning of the treatment (x 2/3).

Fig. 4. Photograph showing paiat;

if pinlays after cementation f x 2/3),

To enable a detailed study of the changes in the vertical dinietision of the face a technique worked out b> Bjork (1968) was applied. Tantuium needles were implanted near the midline of the basal portions of the upper and lower jaws. Immediately upon insertion of the splint and after 2, 5 and 8 months lateral head plates were taken in an X-ray cephalostat with and without the splint in situ and with the jaws in the closest relationship possible. The distance from the focus to the mid-sagittal plane was 160 cm and from the film to the mid-sagittal plane was 10 cm, thus giving an enlargement of 6-25%. Approximately 12 months after the treatment was initiated, the heavily worn palatal surfaces of the upper incisors were protected by means of gold pinlays (Figs. 4 and 5), and a final cephalogram was taken immediately after cementation.

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B. L. Dahl 0. Krogstad and K. Karlsen

F ^ . 5. Pholograph showing frontal view of piniays after cementation ( x 2/3).

Table 1. Distance (mm) between tantalum implants 0 months Chrome-cobalt splint in situ Chrotne-cobalt splint removed DitTerence After cetnentation of pinlays 2 months 5 months 8 months 12 months

39-2 36-9 2 3

3S-7 37-8 0 9

38-7 38-2 0-5

38-8 38'6 0 2

Results

After 4 weeks a space could clearly be observed clinically between the upper and lower incisors when the splint was removed and the leeth brought together in the intercuspal position. Visually this space seemed to increase gradually until after 8 months it appeared to be equal to the thickness of the splint. The results of the cephalometric measurements are presented in Table I. The figures are the mean of three measurements and the error is expected to be in the range of 0 2-0-3 mm (Krogstad & Kvam, 1971). h will be seen that after 2 months there was a slight decrease in the distance between the implants with the splint in situ, whereupon it. remained constant. The distance without the splint showed a steady increase which was greatest during the first 2 months. The increase in the distance without the splint exceeded by far the decrease with the splint in situ. After cementation of the piniays the distance between the implants was well in agreement with the distance without the splint after 8 months. Measurements of the distance between the upper implant and nasion gave a mean of 60-3 mm both at the beginning and at the end of the treatment. The patient never complained about any discomfort in relation to the treatment.

Alternative treatment in eases with advanced iocalized attrition Discussion

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Clinically a reduction in the morphological face height is commonly observed as a result of loss of teeth or heavy wear. Restitution of what is considered to be the 'normal' face height of a patient by means offixedprosthetic restorations is therefore a widely accepted technique in clinical dentistry. In some patients restorations interfering with the habitual occlusal relationships will cause dysfunctional problems (Posselt, 1968), while in others the teeth and muscles seemingly adjust themselves without the patient making complaints. In cases with adjustment it is an open question whether the interfering teeth are intruded or whether the remaining teeth erupt. Therefore it is difficult to ascertain whether a permanent change in the morphological face height has occurred in cases where the vertical dimension has been altered. In a review based on 50 years of experience in oral rehabilitation, Schweitzer (1974) has claimed that in most cases where the vertical dimension had been inereased in the treatment, the original relationship usually returned after some time. Blichi (1950) and Tallgren (1957) have found that an increase in the morphological face height may take place even in adult age. It seems reasonable, therefore, that at least in those patients a certain degree of permanent increase in the morphological face height by fixed appliances might be tolerated. The results of the present study indicate that an increase in the morphological face height has occurred after insertion of the splint. After 8 months the distance between the tantalum needles without the splint in situ was 38-6 mm while at the beginning of the experiment it was 36-9 mm. The differenee. 1-7 mm, represents the increase in the morphological face height and is not due to basic growth since the distance between the upper implant and nasion has remained constant. Therefore the action of the splint has been one of letting the posterior teeth erupt rather than causing intrusion of the front teeth. Certainly, after 2 months the measurement with the splint in situ showed a decrease in the distance between the tantalum needles of 0-5 mm. Henceforth this distance remained constant (Table 1). This observation may indicate that the initial reaction is also one of intrusion of those teeth whieh carry the full load of the occlusal forces. This would be in agreement with the findings in monkeys (Breitner, 1941). However, the decrease in distanee was so small that it is not far from the combined error of method and measurements (Krogstad & Kvam, 1971). To establish whether the morphological face height eontinues to undergo changes a follow-up will be made with lateral head plates approximately every 6 months. A total of twelve patients from 17 to 60 years old have been treated aecording to this combined orthodontic/prosthetic technique with good results. However, this report is based on the analysis of one case only, and definite conclusions or recommendations are not justified. A study of a larger group of patients treated in the same way has therefore been initiated.
References BJORK, A. (t96S) The use of metallic implants in the study of facial growlh in children: Method and application. American Jownat ofPhvsimt Aiilhwpology, 29, 243. BREITNER, C. (1941) Further invesligations of bone changes resulting from experimental orthodontic treMment. American Journal of Onhoihiitic<,n. (05. , . , BuCHi, E.C. (1950) Anderungen der Korperform beim erwachsenen Menschen. Anihropotogische FoTOAuilfen, Heft l,p. 3I.Horn-Wien, Osterreich. , u i .1. CMLSSON G E., HUGOSON, A. & PERSSON, G. (1965) Dental abrasion and alveolar bone loss m the white rat. I. Effect of ligation of the major sahvary gland ducts. Odontologisk Revy, 16, 308.

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CARLSSON, G.E., HUGOSON, A. & PERSSON, G . (1966) Dental abrasion and alveolar bone loss in the white rat. II. Effect of selective ligalion of the ducts of the major salivary glands. Odontologisk Revy, 17, 44. CARLSSON, G.E., HUGOSON, A. & PERSSON, G . (1967) Dental abrasion and alveolar bone loss in the white rat. IV. The importance of the consistency of the diet and its abrasive components. Odontologisk Revy, 18, 263. FRYKHOLM, K . O . (1963) Undensokning av tandforhailanden hos jarnverksarbetare inom ett sinterverk med sarskild hansyn till abrasionsskador. Odontologi.^k Tidskrift, 71,199. KROGH-POULSON, W . & CARLSEN, O . R . (1973) BidfimktionjBettfysiohgi, p. 269. Munksgaard, Kobenhavn, Dan mark. KROGSTAD, O . & KVAM, E . (1971) Geometric errors in measurements on X-ray films. A methodologic study on lateral model exposures. Acta odontologica Scandinavica, 29, 185. PiNDBORG^J.3.(\910)Pathology of the dental hard tissues, p.294.Munksgaard,Copenhagen,Denmark. POSSELT, U . (1968) Physiology of occlusion and rehabilitation, 2nd edn., p. 75. Blackwell Scientific Publications, Oxford. SCHWEITZER, J.M. (1974) Restorative dentistryA half century of reflections, .lournal of Prosthetic Dentistry, 31, 22. TALLGREN, A. (1957) Changes in adult face height due to ageing, wear and loss of teeth and prosthetic trealment. Acta odontohgica Scandinavica, 15,. Suppl, 24.

Manuscript accepted 16 December 1975