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 denitive 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 dened
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 signicant
role in the process of excessive occlusal
wear.1-3 Diet and diseases, such as
gastric reux, 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 classied
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 sufcient
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 classied
as class III, according to the prosthodontic diagnostic index (PDI) classication.13
The treatment objectives were to
improve oral hygiene and restore function by providing implant-supported
partial xed dental prostheses to replace teeth in the mandible, together
with a combination of implant-supported
xed restorations (single units and
xed 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 satised 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.

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Volume 111 Issue 4

7 Denitive restorations.

6 Interim restorations.

9 Posttreatment panoramic radiograph.

8 Denitive 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 xed interim restorations (Ena Temp;
Micerium) were fabricated and cemented
with TempBond (Kerr Dental).
After conrming that the patient was
satised 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-modied glass ionomer
cement (FujiCEM; GC America). Splinted
screwretained 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 sufcient 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 benet 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. vant 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. Identication 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.
Classication system for partial edentulism.
J Prosthodont 2002;1:181-93.
14. Phillips K, Wong KM. Vertical space
requirement for the xed 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: moshaver@usc.edu
Copyright 2014 by the Editorial Council for
The Journal of Prosthetic Dentistry.