rehabilitation, restoration of worn out dentition, clinical cases & their management

1. POSTGRADUATE DEPARTMENT OF CONSERVATIVE
DENTISTRY AND ENDODONTICS
SEMINAR TOPIC:-
RESTORATIVE MANAGEMENT OF WORN
DENTITION - III
(TREATMENT PLANNING)
Presenter- Ashish Choudhary
PG student
UNDER GUIDANCE OF :-
Prof. Dr Riyaz Farooq (HOD)
Dr Aamir Rashid (Asst. Prof.)
Dr Fayaz Ahmed (lecturer)

2. RESTORATION OF WORN DENTITION-I
(Aetiology)
CONTENTS
• Introduction
• Abrasion
• Abfraction
• Attrition
• Bruxism
• Erosion
• Combined Mechanisms
• Severity of wear

3. CONTENTS
 PATIENT’S HISTORY
 EXAMINATION OF WEAR’s PATIENT
 DIAGNOSIS
 MEASUREMENT OF SEVERITY & PROGRESSION OF WEAR
 DILEMA OF OCCLUSION
RESTORATION OF WORN DENTITION-II
(Assesment & Role of Occlusion in tooth wear)

4.  MOUNTING CAST
(Inter-occlusal Records, Articulators and Facebow Transfer)
 PROBLEM OF SPACES
(Increasing Vertical Dimension)
 RESTORATION OF WORN DENTITION
(Restorative Options)
REHABILITATION OF WORN DENTITION
(Localized Anterior & Posterior Wear and Generalized Tooth
wear management Including Case Studies)
RESTORATION OF WORN DENTITION-III
( Treatment Planning)
CONTENTS

5.  MAINTENANCE PHASE
 CONCLUSION
 REFERENCES
RESTORATION OF WORN DENTITION-III
( Treatment Planning)
CONTENTS

6. MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
MOUNTING CAST
INTER-OCCLUSAL RECORDS :
 relate the mandibular and maxillary diagnostic and
working casts
 Extra hard base plate wax is suitable.
 Other materials include zinc oxide and eugenol paste,
elastomers and impression plaster.
Dent Update 2003; 30: 150-157

7. MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
INTER-OCCLUSAL RECORDS :
THE TECHNIQUES……..
1. Waxbite Procedures
2. Anterior Stop Technique
3. Use Of Pre-adapted Bases
4. Central Bearing Point Device
Dent Update 2003; 30: 150-157

8. INTER-OCCLUSAL RECORDS :
Softened interocclusal
wax record
Buccal cusps visible on record
Record relined with temporary
cement
Rigid, stable, accurate record

9. INTER-OCCLUSAL RECORDS :
Acrylic base with wax rims
located with zinc oxide
and eugenol paste

10. # Gimmicks don’t do your work
but certainly make your work easier….

11. MOUNTING CAST
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
ARTICULATORS :
“A mechanical instrument that
represents the temporomandibular joints
and jaws, to which maxillary and
mandibular casts may be attached to
simulate some or all mandibular
movements”
Glossary Of Prosthodontic Terms

12. TYPES OF ARTICULATORS…..

13. Articulator Design….
Arcon - condylar element on
lower
Non Arcon - condylar
element on upper

14. DETERMINANTS OF
OCCLUSION
Posterior
1) Right TMJ
2) Left TMJ
Anterior
1) Anterior Teeth
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

15. Posterior Determinants of
Occlusion
Condylar guidance is
a fixed factor, and
the TMJs are the
posterior controlling
factor in mandibular
movement.
Posterior Determinants
1) Right TMJ
2) Left TMJ
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

16. Anterior Determinants of
Occlusion
The anterior teeth:
Determine the movement of
the anterior portion of the
mandible.
 Anterior guidance is variable
since it can be altered by:
restorations, extractions, orthodontics,
attrition, etc.
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

17. Programming The Articulator
(Hanau Modular Arcon Articulator)
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

18. POSTERIOR ARTICULATOR GUIDES
• Horizontal Condylar Guide
– Angle of Condyle descent
• Protrusive Wax Record
• Bite Registration Materials
• Bennett Angle (there may or may
not be associated Bennett
Movement or Side Shift with lat.
Mandibular Movement)
– Associated with Mediotrusive
side during Laterotrusive
movement
• Lateral Wax Check Bites
• Pre-programmed In Your
Articulator

19. ANTERIOR GUIDE
TABLE
• Maintain the relationship between
casts
– Protecting the cast from wear
• Uses of articulated casts
– Evaluation of occlusion
– Evaluation of tooth position
– Evaluation of tooth form
– Evaluation of gingival tissues
– Fabrication of indirect restorations
Purpose of Guide Table
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

20. WHAT ABOUT THIS ?????
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

21. Programming the condylar
guidance
Horizontal condylar guidance
Use protrusive record (protrude mandible 6mm)
Lateral condylar guidance
Use lateral record or Hanau’s Formula (H/8 +12)
Programing the incisal
guidance
Horizontal guidance
controls the anteroposterior movement
of the lower jaw
Lateral guidance
 influence lateral movement of the jaw
(canine guidance)

22. CAST ORIENTATION
• Hinge Axis is a
repeatable reference
• For the highest
possible accuracy cast
should be mounted as
close to this axis of
rotation as possible.
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

23. CAST ORIENTATION:
Centric Relation vs. Maximum
Intercuspation
If the patient is asymptomatic, and has a
sufficient number of teeth to consistently close
into maximum intercuspation, then maximum
intercuspation should be used for cast
orientation.
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

24. CAST ORIENTATION
• To Orient the Maxillary Cast – Facebow
• To Orient the Mandibular Cast- Interocclusal record
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

25. MOUNTING CAST
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSIONFACEBOW TRANSFER :
“A facebow is a caliper-like device that is used
to record the relationship of the jaws to the TMJ
and to orient the same relationship
to the opening axis of the articulator”.
Glossary Of Prosthodontic Terms
 2 types of facebows are :
1) Kinematic facebow or
Hinge-axis facebow
2) Arbitary facebow

26. MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
 To record patient’s hinge axis
 The Arbitrary Hinge
Axis is adequate for most
clinical procedures

27. MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
 It is located 13 mm from the tip of the tragus of
the ear on a line joining this point to the outer
canthus of the eye.
To record 3rd reference point
some facebows use the infra-orbital
notch and others have a plastic
‘nose piece’ that rests on the bridge
of the nose during the recording

28. Finger cots can be
used as a infection
control measure.
Orient in external
auditory meatus
Patient can assist with
placement and
orientation in external
auditory meatus

29. Slide facebow
into bitefork
Extend nasion
support & tighten

30. Tighten all
wrenches of
facebow
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

31. Loosen these
tighteners. Release
the recordbase by
breaking the seal, and
removing the facebow.
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

32. MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Place facebow
support on transfer
jig and attach to
indirect mount

33. Remove incisal pin and
set the centric latch
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

34. MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Attach the maxillary cast to the articulator
via plaster

35. Mandibular Cast Orientation
• Hand articulation when
patient has sufficient
number of teeth to
place casts into MI
• Interocclusal records
• -Bimanual manipulation
• -With insufficient
number of teeth to
establish a reproducible
relationship

36. ARTICULATED
MANDIBULAR CAST
Clean Up as you go
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

37. MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
SET THE
CONDYLAR
INCLINATION
(WITH THE HELP OF
CHECK BITES)
SET THE ANTERIOR
GUIDANCE

38. PROBLEM OF SPACES
(INCREASING VERTICAL DIMENSIONS)
The vertical dimension of occlusion refers to the vertical position
of the mandible in relation to the maxilla when the upper &
lower teeth are intercuspated at the most closed position
 Mandible goes repetitiously to the position dictated by the
contracted elevator muscles
 Vertical position of each tooth is adaptable to the space
provided, not vice versa, & that the capacity of the teeth to erupt
or intrude is present throughout life
 2 important aspects of vertical dimension :
Dawson PE. Evaluation, Diagnosis & Treatment of Occlusal Problems;
2nd ed; St Louis: Mosby; 1989; 56-71
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

39.  The fact that a patient has severely abraded
their teeth does not indicate a loss of VDO nor
does it indicate that they have not loss vertical
dimension
 In treatment planning the critical issue is whether a patient
can be restored at a different vertical dimension that is still
within the adaptive range & whether the patient will accept the
therapeutic occlusion created
Charles McNeill. Science & Practice of Occlusion
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

40. Assessing the existing Vertical Dimension
Posterior
teeth :
 If posterior teeth in both arches have
unworn occlusal surfaces & normal axial
inclinations that oppose each other in
occlusion, it would be very difficult for the
patient to have lost vertical dimension
Charles McNeill. Science & Practice of Occlusion
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

41. Assessing the existing Vertical Dimension
Gingiva
levels:
 in a patient who exhibits severe anterior wear
& subsequent eruption of anterior teeth without
posterior wear or vertical closure, the gingival
margins on the central & lateral incisors are
often significantly coronal to the canines, which
is evidence that these teeth have erupted
Charles McNeill. Science & Practice of Occlusion
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

42. DETERMINING VERTICAL DIMENSION
 Niswoger’s method
 Willis method
 Use of electronics to monitor muscle function ( oscilloscope )
 use of phonetics (sibilant or ‘s’ sound ) / concept of closest
speaking space
 Provisionals followed by speech evaluation
 Trial splints
Charles McNeill. Science & Practice of Occlusion
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

43. STABILITY OF VERTICAL DIMENSION
 AN AREA OF CONCERN
1. THE DIMENSION OF ANTERIOR TEETH
2. THE LENGTH OF THE MASSETER MUSCLE
3. THE DIMENSION OF THE TEMPEROMANDIBULAR JOINT
 The key to understanding the stability of vertical
alterations is to determine if the change increases the
contracted muscle length
Charles McNeill. Science & Practice of Occlusion
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

44. STABILITY OF VERTICAL DIMENSION
 Because the joint & the muscle are very close
together , seating the condyle 1mm results in
nearly a 1mm decrease in contracted muscle
length
 This means that if the patient presents with slide from CR to
ICP, one can calculate how far the anterior teeth can be
opened with no change in contracted muscle length by
determining how far the condyle moves superiorly when
placed in centric relation
 According to McNeil, for every 1mm of condylar seating (by
using SAM Mandibular Position indicator) , it is possible to open the
anterior teeth 2mm
Charles McNeill. Science & Practice of Occlusion
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

45. An Appraisal on Increasing the Occlusal Vertical Dimension (OVD)*
ESTABLISMENT OF OVD / LOSS OF OVD WITH
TOOTH WEAR
 Dawson, Thompson stated that loss of VD is compensated by
tooth eruption, alveolar bone expansion & muscle action
 After loss or alteration of OVD, muscles tend to restore OVD to
its original level by tooth intrusion or extrusion
(FUNCTIONAL MATRIX THEORY)
 OVD is preserved by the adaptive mechanism of stomatognathic
system. So the term ‘to restore lost OVD’ is a misnomer and any
such attempt will be actually ‘bite raising’ resulting in increased
OVD *J Indian Prosthodont Soc ;2011 11(2):77–81
Evaluation, diagnosis and treatment of occlusal problems, 2 edn. Mosby, St. Louis
J Am Dent Assoc 33:151

46. CONSTANT VERTICAL DIMENSION
 VDR and OVD are changeable and adaptable
to certain extent
Atwood stated that VDR remains constant even following loss
of tooth contacts
 The establishment of position and length of muscle after
mandibular osteotomy surgery substantiates the position of
inconstant OVD
 Hellsing study on adaptability of the stomatognathic system
for temporary increase in the OVD by splints in TMJ disorders
confirms this belief
J Prosthet Dent 8:698
J Prosthet Dent 52:867–870
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

47. MAXIMUM MASTICATORY FORCE
 Boos stated that optimum masticatory force occurs in
OVD
 But Manns stated that high masticatory force is exerted at 7
mm mouth opening followed by a decrease in biting force
between 7 and 15 mm and maximum force at 15 to 20 mm
mouth opening
J Am Dent Assoc 27:1193–1199
J Prosthet Dent 42:674–682
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

48. Encroaching Into Freeway Space
 Increasing OVD and encroaching the
freeway space is detrimental and is considered to result
in elongation and increased activity of stomatognathic
muscles
 Thus increasing OVD up to VDR can be advantageous
in relieving symptoms in TMJ and muscle disorders
 Weinberg’s , Herbert proved that there is minimal muscle
activity in VDR and encroaching into freeway results in
reduced muscle activity
J Prosthet Dent 47:290 J Prosthet Dent 14:635
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

49. Decreased OVD: Costen Syndrome
 Costen concluded through clinical observations that
decreasing OVD resulted in condylar displacement posteriorly
causing compression of chorda tympani, auriculotemporal
nerves and eustachian tubes
 Beyron contradicted deliberation and proved that
condyles are not displaced posteriorly by decrease in OVD
Ann Otol Rhinol Laryngol 43:1
J Am Dental Asssoc 48:648–656
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

50. Factors Indicating Loss of OVD
 Decreased crown height and deep anterior
over bite
 Hence these two factors cannot be considered as valuable
factors indicating loss of OVD
 Increased overbite may also be because of continuous
teeth eruption and over closure
 Attrition can cause short crowns in spite of continuous
eruption of tooth
J Prosthet Dent 34:278
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

51. EXACT LOCATION OF OVD
 Warren stated that OVD, like any other
quantifiable aspect of the body functions such as BP,
pulse, etc., is a highly variable entity and the exact
restoration of OVD is near impracticable
MUSCULAR DYSFUNCTION
 Manns et al. , Kovaleski showed that increase in OVD by
splint therapy up to VDR reduces muscle activity and relieves
symptoms of muscle dysfunction syndromes
J Prosthet Dent 65:547–553
J Prosthet Dent 50:700–709 J Prosthet Dent 33:321–327
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

52. ‘Unloading’ of Condyles
 Dawson , Weinberg stated that bite raising
increases the OVD, not by displacing the
condyle away from the eminence, but rather by rotating the
condyle, hence TMJ remains ‘loaded’ during bite raising
Condylar Access to Centric
 Dawson stated that as far as the starting point of centric
relation is maintained during bite raising, condylar access to
this position is not disturbed
J Prosthet Dent 39:654–669
Evaluation, diagnosis and treatment of occlusal problems, 2 edn. Mosby, St. Louis
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

53. Comfortable Jaw Position
 Tryde et al. revealed that its not a comfort
zone and had an interval of 1.3 mm on
average around VDO
 Any discomfort in this position can be due to centric
discrepancy or TMJ disorder or bruxism
 In these conditions, comfort can be achieved by correction of
the disorder or by OVD alteration
 With adequate evidence available currently from various
studieS, the comfort zone can be proved to be wide of the mark
J Oral Rehabil 4:9–15
J Prosthet Dent 12:912–921
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

54. Bite Raising in Full Occlusal Rehabilitation
 From the critical reviewing, it is ascertained that restoring
OVD to original level rather than increasing is needed and
patient’s response should be tested during each stage of
increase in OVD
J Indian Prosthodont Soc ;2011 11(2):77–81
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

55.  By exploring the various controversies and
myths regarding vertical dimension and its
alteration, discarding the erroneous beliefs and
accepting the essentials, two logical hypotheses
can be arrived, they are:
(1) OVD is not altered following tooth wear (except in case of
amelogenesis / dentinogenesis imperfecta)
Any method to restore OVD will result in increased OVD
(2) Free way space can be manipulated and new VDR will get
established if OVD is not increased beyond pre-existing rest
position
“OVD is almost always preserved”
J Indian Prosthodont Soc ;2011 11(2):77–81
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

56. Effects of Increasing Vertical Dimension
 When OVD is increased within or equal to the
pre-existing VDR position, muscle activity/tonus
is kept to minimal levels and hence there is no
muscular tendency to rebound
 If OVD is increased above VDR, muscles tend to re-establish
the original dimension by compressing tooth into the socket
results in tooth mobility, bone resorption, tooth intrusion,
strain or fatigue of muscles and bruxing tendency
 Harper documented that increase in OVD leads to
encroachment of freeway space causing exaggerated
respiratory problems
J Indian Prosthodont Soc ;2011 11(2):77–81
Quintessence Int 31:275–280
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

57.  The inference that can be arrived by studying
the effects of altering OVD is that any attempt
to restore OVD in excessively worn dentition
results in increasing the OVD
Effects of Increasing Vertical Dimension
 This increase will ultimately lead to adaptive recoil of
muscles resulting in tooth intrusion and OVD will return to
pre-treatment level
J Indian Prosthodont Soc ;2011 11(2):77–81
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

58. Indications for Increasing OVD
 Inadequate space for the restoration
 For temporarily relieving the symptoms in
intracapsular TMJ disorders
J Indian Prosthodont Soc ;2011 11(2):77–81
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

59. Functional Adaptation
TMJ & MUSCLES
PERIODONTIUM OCCLUSAL
MORPHOLOGY
 Clinically, it can be related as: OVD increase within VDR will
get adapted only if occlusion is stable without interferences and
stabilized in new OVD position
J Prosthet Dent 14:635
Quintessence Int 31:275–280
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

60. Principles Behind Increasing Vertical
Dimension
(1) Starting point for reconstruction/increase in
OVD must be with in centric relation
(2) Reconstruction to be within the range of the
patient’s neuromuscular adaptation
J Indian Prosthodont Soc ;2011 11(2):77–81
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

61. Category 1 excessive wear with loss of vertical dimension of
occlusion
TURNER AND MISSIRLIAN
Classification of tooth wear :
J Prosthet Dent 1984; 52: 467–474
 Exact location of OVD must be identified and
restored by full occlusal rehabilitation
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

62. Category 2
excessive wear without loss of vertical
dimension of occlusion, but with space available
J Prosthet Dent 1984; 52: 467–474
 Conventional fixed/removable restorative treatments
towards full occlusal rehabilitation can be done without
altering OVD
 If the demand for aesthetic enhancement is present then
crown lengthening can be performed
TURNER AND MISSIRLIAN
Classification of tooth wear :
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

63. Category 3
excessive wear without loss of vertical
dimension, but with limited space
J Prosthet Dent 1984; 52: 467–474
 Bite raising with OVD not encroaching VDR can be
made followed by full occlusal rehabilitation
TURNER AND MISSIRLIAN
Classification of tooth wear :
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

64. THE PROBLEM OF SPACE……..
 The localized loss of anterior tooth tissue is
often accompanied by alveolar bone growth,
which maintains contact between the opposing
dentitions. This is called dento-alveolar
compensation
 As result of this compensation
tooth Eruption and alveolar bone
growth the Occlusal vertical
dimension (OVD) is maintained
and the inter-occlusal space
remains constant
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Dent Update 2003; 30: 150-157

65. Considerations of vertical dimensions
Dent Update 2003; 30: 150-157

66.  A number of methods can be employed to
create space for restorations. These may be
subdivided into methods based on using:
Conformative occlusion Reorganized occlusion
 Existing position of mandibular
closure is maintained
 Suitable for restoration of
single tooth or small group of
teeth
 e.g,
1. reducing the teeth in same or
opposing arch
2. surgical lengthening of the
crown
 Postion of mandibular closure
is altered
 Suitable for full mouth
rehabilitaion
 e.g,
1. mandibular repostioning
2. localized minor axial tooth
movements
3. increasing the vertical
dimension of occlusion
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

67. CREATION OF LOCALISED INTER-OCCLUSAL SPACE
 Increasing the occlusal vertical
dimension (OVD)
 Reduction of teeth in same / opposing arch
 Occlusal reorganization
 Elective root treatment & placement of post crowns
 Surgical crown lengthening
Orthodontics
 Dahl appliances
Dental update; 2004 (31)
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION

68. Generalized tooth wear
restored with PFM crowns
in the anterior and posterior segments at an overall increase
in OVD
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Increasing the occlusal vertical
dimension (OVD) :
Dental update; 2004 (31)

69. Reduction of teeth in
same / opposing arch :
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Occlusal reorganization :
 undesirable in a dentition where there has already been
loss of tooth tissue
 for single unit restorations
 It is suitable in those patients who have
a large horizontal discrepancy between
ICP and the retruded axis position
Dental update; 2004 (31)

70. MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Surgical crown lengthening…..
Periodontal surgical crown
lengthening on worn lower
anterior teeth prior to the
construction of a fixed bridge
prosthesis.
Dental update; 2004 (31)

71. MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
 requires a period of healing,
of ideally 3 months
Surgical crown lengthening…..
 invasive procedure….
1. postoperative
sensitivity
2. proximal spacing
3. crown margins on
root
Triangular spaces
Dental update; 2004 (31)

72. Elective root treatment &
placement of post crowns :
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
 post-retained crown
 high risk of endodontic failure and root fracture
Orthodontics :
 Conservative method of providing inter-occlusal space
 Extended treatment time and poor patient compliance
 intrusion associated with root resorption
Dental update; 2004 (31)

73. MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Dahl appliances……
 simple orthodontic appliance acting as an
anterior bite platform
 Principle: Coverage of the palatal surfaces of the
anterior teeth causes posterior disclusion.
 The thickness of this material placed should
directly relate to the required amount of inter-
occlusal space
Removable FIXED
appliance Irish Dentist July 2011

74. MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Localized
anterior
tooth wear
Dahl appliance
cemented in place
Posterior disclusion
Irish Dentist July 2011

75. MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Regained
posterior
tooth contacts
after 6 months
Inter-incisal space recreated
following the removal of the
Dahl appliance
Following periodontal
surgical crown lengthening,
teeth prepared for PFM
crowns

76. RECENT TRENDS IN
“THE DAHL CONCEPT”
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Individual Definitive
Adhesive Restorations
Maxillary arch following placement of
6 palatal gold veneers
Irish Dentist July 2011

77. RECENT TRENDS IN “THE DAHL
CONCEPT”
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Increasingly, composite resin is
being used as a Dahl appliance, as
well as acting as a semi-permanent
restoration of worn anterior teeth.
Irish Dentist July 2011

78. RESTORATIVE MANAGEMENT OF WORN
DENTITION
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
To restore or not to restore is a central question???
Biological
Loss of tooth substance
Pulpal exposure
Weakening of tooth
structure
Functional
 reduced masticatory efficiency
Aesthetic
Toothwear: ABC of the worn dentition; 1st ed

79. Oral environment at the time of presentation
UNBALANCED BALANCED
 Sensitivity
 Shiney facets
 Little or no calculus
 Little or no staining
 Frothy or bubbly saliva
 Dry mucosa
 Mucosal changes
 Missing restorations
 No sensitivity
 Matt/dull surfaces
 Significant calculus
 Staining present
 Pooling saliva
 Moist mucosa
 existing restorations intact
Heavy preventive
emphasis
Only proceed if
underlying aetiology
cannot be controlled
Restore/Rehabilitate Restore/Rehabilitate
Toothwear: ABC of the worn dentition; 1st ed

80. How to provide restorative care ?
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
 A multidisciplinary approach
 Patient’s Oral Condition & Degree Of Compliance
evaluated
 For restorative treatment planning, the patient should be
assessed in terms of Periodontal, Endodontic, Coronal, Occlusal,
Functional and Aesthetic (PECOFA) factors
 A systematic treatment approach
Dent Update 2002; 29: 162–168

81. RESTORATIVE OPTIONS :
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
• Conventional Fixed Restorations
• Removable Onlay/Overlay Prosthesis
• Minimal Preparation Adhesive Restorations
Tooth Wear And Sensitivity - ClinicalAdvances In
Restorative Dentistry; Martin Dunitz; first ed.

82. Conventional Fixed Restorations
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Tooth Wear And Sensitivity - ClinicalAdvances In
Restorative Dentistry; Martin Dunitz; first ed.
 Porcelain-fused to metal crowns
 All metal crowns
Durable but invasive!!!
 Need to recreate inter-occlusal space lost as a result of
dento-alveolar compensation

83. MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Tooth Wear And Sensitivity - ClinicalAdvances In
Restorative Dentistry; Martin Dunitz; first ed.
Conventional Fixed Restorations
Anterior crowns constructed to conform to the existing worn
teeth without recreation of lost inter-incisal space resulting in
poor aesthetics and retention form.

84. Removable Onlay/Overlay Prosthesis
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Tooth Wear And Sensitivity - ClinicalAdvances In
Restorative Dentistry; Martin Dunitz; first ed.
 simple, non invasive and cost effective
 particularly when missing strategic teeth
to be replaced
As a provisional restoration to assess the
predictability of treatment plan

85. Removable Onlay/Overlay Prosthesis
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Tooth Wear And Sensitivity - ClinicalAdvances In
Restorative Dentistry; Martin Dunitz; first ed.

86. Removable Onlay/Overlay Prosthesis
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Tooth Wear And Sensitivity - ClinicalAdvances In
Restorative Dentistry; Martin Dunitz; first ed.
 avoid any significant tooth preparation
 Available space determines ,whether or not an anterior labial
flange can be used, or alternatively gingival fitting and/or butt-
fitting tooth facings
 Final decision may to some extent depend on the patient’s
aesthetic demands & desire to avoid or limit any necessary
tooth reduction

87. Removable Onlay/Overlay Prosthesis
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Tooth Wear And Sensitivity - ClinicalAdvances In
Restorative Dentistry; Martin Dunitz; first ed.
Gingival fitting anterior
tooth facings on removable
prosthesis
Butt fitting anterior
tooth facings

88. Removable Onlay/Overlay Prosthesis
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Tooth Wear And Sensitivity - ClinicalAdvances In
Restorative Dentistry; Martin Dunitz; first ed.
Fractures common
Acrylic resin facings which
were then replaced with a
metal framework

89. Minimal Preparation Adhesive
Restorations
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Tooth Wear And Sensitivity - ClinicalAdvances In
Restorative Dentistry; Martin Dunitz; first ed.
CERVICAL TOOTH WEAR :
 Composite resin or glass ionomer-based, or a
combination of both
 use of a microfine or polishable densified composite
resin, in conjunction with acid etched enamel
 DBA’s + composite resins / GIC / RMGIC

90. Minimal Preparation Adhesive
Restorations
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Tooth Wear And Sensitivity - ClinicalAdvances In
Restorative Dentistry; Martin Dunitz; first ed.
ANTERIOR TOOTH WEAR
Palatal tooth wear :
 Resin-bonded palatal metal alloy veneers
 Either heat treated gold alloys or nickel-chromium
alloys, as used in resin bonded bridge frameworks
 an opaque resin based cement
 Creation of inter-occlusal space by Dahl’s appliance
or veneers at inc OVD

91. MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Nickel-chromium Alloy
Resin Bonded Palatal
Veneers
Labial demonstrating re-
establishment of posterior
occlusal contacts

92. Incisal/palatal tooth wear :
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Direct acid-
etch retained
composite
resin

93. Incisal/palatal tooth wear :
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Resin bonded porcelain laminate veneers used to restore the
incisal and palatal aspects of maxillary central incisor teeth,
with resin bonded gold alloy palatal veneers used for the
remaning worn anterior teeth.

94. Labial/incisal/palatal wear :
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
 Labial porcelain laminate veneer + metal alloy
veneer,
 Resin bonded minimal ceramic crown, or
 An adhesive metal-ceramic crown restoration
 Direct composite resin at an increased OVD
Tooth Wear And Sensitivity - ClinicalAdvances In
Restorative Dentistry; Martin Dunitz; first ed.

95. MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Direct composite resin at an
increased OVD

96. Posterior (generalized)
tooth wear:
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
 Resin bonded heat treated gold alloy restoration
 Resin bonded ceramic or indirect composite resin onlay, if
aesthetic concerns
 Resin-bonded ceramic restorations
Direct acid-etch retained composite resin materials at an
increased OVD
Tooth Wear And Sensitivity - ClinicalAdvances In
Restorative Dentistry; Martin Dunitz; first ed.

97. MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Resin bonded gold alloy and indirect composite
resin onlays used to restore the mandibular
posterior teeth in conjunction with
conventional PFM crowns for the maxillary
anterior teeth at an increased in OVD

98. MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Resin-bonded laminate porcelain veneers for
the anterior teeth, and resin-bonded bridges
and onlays for the posterior teeth at an
overall increase in OVD.

99. REHABILITATION OF WORN DENTITION
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Management of :
 Localized Anterior Tooth Wear
 Localized Posterior Tooth Wear
 Generalized Tooth Wear

100. MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Management
of localized
anterior
tooth wear
Dent Update 2002; 29: 214–222

101. MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Case study I :
27yrs female
Mild sensitivity
No medical history
Stressful job
Consume citrus juices
 localized anterior palatal tooth wear
with dentine exposure
 Enamel chipping of 1|1
 little discrepancy between RCP and the
intercuspal position (ICP)

102. Treatment planning for case I:
 Soft Vinyl Occlusal Splint
 Home-use Fluoride Gel Application
 Dietary Advice And A 6-month Monitoring Period,
 Incisal Edges Of 1|1 Were Repaired With Resin
Composite
 Palatal surfaces were restored with nickel-
chromium veneers at an increased OVD (0.5 mm)

103. Ni-Cr palatal veneers with
palatal platform
Frontal view after placement
of the palatal veneers
Right & left buccal view showing posterior occlusion after 4 weeks

104. MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Management
of localized
posterior
tooth wear
Dent Update 2002; 29: 267–272

105. Case study I:
21-year male
Painful |7
Carious
 |7 was associated with marginal gingivitis
 pulp was exposed,
 minimal remaining clinical crown length
 no interocclusal space between the
overerupted |7 and the worn |7 in the
intercuspal position
 patient declined fixed orthodontic
treatment
 restoration of |7 only

106. Treatment planning :
 Aims included the restoration of |7 to its original occlusal plane
and intrusion of |7.
 Crown lengthening surgery was performed on |7 after initial
endodontic instrumentation and dressing
 4 wks later, obturation done
 Radicular resin composite core was placed using a packable
composite
 Orthodontic separators were then placed mesial and distal to |6
 4 months after the
periodontal surgery, an
onlay preparation was
carried out on |7

107.  working impression was taken with an orthodontic
band on|6
 supra occluding cast onlay with a soldered buccal
tube was cemented on |7
 a rectangular wire was used to splint |6 and |7
together

108. Follow-up :
 Reviewed 1 week later and had no discomfort, except for
some difficulty in chewing
All teeth were in contact again after 2 months
Orthodontic band and buccal
tube were removed at the end
of treatment

109. MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Management
of generalized
tooth wear
Dent Update 2002; 29: 318–324

110. PRACTICAL CONSIDERATIONS OF
ORAL REHABILITATION
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
 Use a reversible device, such as a hard maxillary occlusal splint
or removable overlay denture
 For examination of the occlusion in RCP recommendations for
splint wear have varied from 24 hours to as much of the day and
night as possible for 3 weeks
 a sequential posterior-anterior- posterior approach (PAP) can
be adopted for full mouth reconstruction

111. Case study I :
67-year-old man
• severe pain from 6|
 Exposed 6|
 Dentine sensitivity
 Minimal difference between ICP and RCP
 Incisors were responsible for mandibular protrusion, while the
canines and all posterior teeth were involved in lateral excursions.

112. Treatment Planning:
 Endodontic treatment of 6|
 Occlusal splint was constructed
at a 4 mm increase of OVD
‘Mutually protected’ occlusal
scheme was used
 Canine guidance was used for lateral excursions
 Temporary nickel chromium palatal veneers were
constructed on 3| and |3 according to an incisal guidance
table fabricated with the occlusal splint

113. Amount of anterior & posterior space created by palatal
veneers bonded on upper canines
 Resin composite
build-up for posterior
stability

114. Anterior guidance was re-established with:
 Gold palatal veneers on 21|12,
 Labial porcelain veneers on 1|1 and
 Incisal resin composite restorations on 2|2

115.  One month after anterior guidance was re-established the
premolars and molars on both sides were prepared in two visits.
 Full-arch impressions were taken for the construction of
adhesive gold onlays on 654|6 and |56, full gold crowns on 76|
and a cantilever conventional ceramometal bridge to replace a
missing first premolar.
 After cementation of all posterior
restorations with a resin cement
the palatal veneers on 3|3 were
debonded and it was confirmed
that group function could be
achieved in the absence of canine
guidance.

116.  Incisal edges of the lower canines were then restored
with resin composite, and two gold palatal veneers
without incisal overlap were cemented on 3|3.
Frontal view of the restored dentition at
increased OVD

117. MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
MAINTENANCE PHASE
 Aim should be to maintain stability in the oral
environment
 Regular review of the rehabilitated dentition
(atleast 6-12 months )
 Clinical and radiographic examination of abutments
 Sequential clinical photographs & Periodic study casts
 Sectional silicone index used as a reference guide
 Use of computerised software to map changes in tooth
surface profiles

118. CONCLUSION
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
 The most obvious feature of tooth wear is shortened clinical
crowns, generally accompanied by dento-alveolar compensation.
This may complicate definitive conventional rehabilitation,
although research, newer technologies and materials offer broader
possibilities for rationalizing treatment modalities.
 Tooth wear is a multifactorial process which can
make it difficult to identify a single cause at the individual
patient level.
 Recognition of the early signs of tooth wear, and especially
erosion, could bring about timely prevention and improve the
life span of teeth.

119. CONCLUSION
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
 Rehabilitation of worn teeth will be needed in only some
patients, and the measures with which need for treatment is
assessed is one of the keys to a successful outcome.
 In broad terms, the decision to restore or not should be guided
by the patient’s stated and/or perceived need, severity of the
wear as determined by morphological changes and potential for
progression in the context of the patient’s age.

120. CONCLUSION
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
The combination of appropriate preventive and maintenance
measures has the best potential as a treatment concept to
restore and stabilize tooth biomechanics, and avoid or
postpone a more costly and invasive prosthetic solution
The converse of this, namely disregarding the consequences of
poor diagnosis, inappropriate management, overambitious
intervention and uncertainty about prognosis, can only augur
for very unfortunate outcomes.

121. CONCLUSION
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
 Nonetheless, rehabilitation of the worn dentition,
whilst challenging, can be rewarding and satisfying to both the
patients and the clinician if careful and thorough lead up work has
been completed in line with the The ABC OF WORN DENTITION.
“Rehabilitation of dentition is not all about restoring the mouth
with 28 crowns or an aesthetic smile”
“Itz about Cosmetic Functional Oral Rehabilitation”

122. REFERENCES…..
• Tooth Wear And Sensitivity - Clinical Advances In Restorative
Dentistry; Martin Dunitz; first ed.
• Toothwear: The Abc Of Worn Dentition; First Ed; Farid Khan
And William George Young.
• PETER E. DAWSON; Evaluation, diagnosis & treatment of
occlusal problems; 2ND EDITION.
• Occlusion in Restorative Dentistry: Technique and Theory;
Martin D. Gross; 1st edition.
• Science and Practice of Occlusion; Charles McNeill.

123. REFERENCES…..
• Fundamentals of Occlusion and Temperomandibular Disorders;
Jeffrey P. Okeson.
• Text book of Operative Dentistry; Marzouk.
• Sturdevant’s Art and Science of Operative Dentistry; Theodore
M. Roberson; Harald O. Heymann; Edward J. Swift;5th edition.
• Summit’s Fundamentals of Operative Dentistry; 3rd edition.
• Restorative management of worn dentition: I.Aetiology and
Diagnosis; Dent Update 2002; 29: 162–168.

124. REFERENCES…..
• Restorative management of worn dentition: 2.Localized
Anterior Tooth wear; Dent Update 2002; 29: 214–222.
• Restorative management of worn dentition: 3.Localized
Posterior Tooth wear; Dent Update 2002; 29: 267–272.
• Restorative management of worn dentition:
4.Generalized Tooth wear; Dent Update 2002; 29: 318–
324.
• Conformative, Reorganized Or Unorganized; Dent
Update 2004; 31 No.6; Page334.
• British Dental Journal;2012;212: 17-27.

125. REFERENCES…..
• Didier Dietschi; Ana Argente; The European Journal Of
Esthetic Dentistry; Vol.6 No.2; Summer2011.
• An appraisal on increasing the occlusal vertical dimension in
full occlusal rehabilitation and its outcome. N. Gopi Chander;
R. Venkat; J Indian Prosthodont Soc (Apr-June 2011) 11(2):77–
81
• Making Occlusion Work: I. Terminology, Occlusal
Assessment And Recording; Dent Update 2003; 30: 150-157
• The dahl principle revisited; Irish Dentist July 2011
• Functional occlusion : I. A Review; JO Vol.28 no.1.