You are on page 1of 6



J Am Dent Assoc 2000;131;1279-1283

The following resources related to this article are available online at

Downloaded from on December 5, 2008 ( this information is current as of December 5, 2008 ):

Updated information and services including high-resolution figures, can be

found in the online version of this article at:

This article appears in the following subject collections:


Information about obtaining reprints of this article or about permission to

reproduce this article in whole or in part can be found at:

2008 American Dental Association. The sponsor and its products are not endorsed by the ADA.



Downloaded from on December 5, 2008

sthetic dentistry has created a revolution in dental materials A B S T R A C T
and technology. Our health- and beauty-conscious society,
Background. Developments
with the largest discretionary income in history, has creat-
in adhesive dentistry have
ed an ever-increasing demand for esthetic dental pro-
given the dental profession new
cedures. Many patients seek esthetic dental care
restorative materials and technol-
because of worn dentitions (Figure 1). Unfortunately,
ogy to restore esthetics and func-
in the past, esthetic dentistry publications, lectures
tion to the worn anterior dentition.
and continuing education courses placed little
This article illustrates, through a clin-
emphasis on the relationship between function
ical case study, the clinical require-
and esthetics. But todays esthetic practices recognize the
ments for restoring esthetic harmony and
importance of restoring both function and esthetics.
functional stability to the worn anterior
Providing esthetics with the correct anterior guidance is
the key to long-term occlusal stability. The blending of con-
Case Description. The author presents the
servative esthetics with the traditional science of occlu-
case of a 24-year-old man who sought esthetic
sion is creating a new standard of care for dental
dental treatment because he was unhappy with
patients. This article presents a conservative multidis-
the appearance of his maxillary anterior teeth. The
ciplinary approach to restoring esthetics and function
review of his dental history revealed that he ground
in a patient with a worn anterior dentition.
his teeth at night. The author performed a complete
evaluation of the causes of the patients bruxism and
created a diagnostic preview to, among other things,
develop the relationship between the condylar and anterior
Diagnosis is paramount in developing a guidance and to establish the esthetic requirements for the
treatment plan and sequence of treatment final restorations. Treatment included periodontal recontour-
that will yield a predictable, stable, func- ing, tooth preparation and placement of temporary and then
tional and esthetic result. A comprehen- permanent restorations; the patient also was given an occlusal
sive examination, mounted diagnostic guard to protect the restorations against future bruxing.
casts and other associated diagnostic Clinical Implications. Whatever the cause of occlusal instability, it
instrumentation are necessary to is important that the restorative dentist be able to recognize its
determine the causes of instability signssuch as tooth hypermobility, tooth wear, periodontal breakdown,
and the treatment that will cre- occlusal dimpling, stress fractures, exostosis, muscle enlargement and
ate stability and reduce wear of loss of posterior disclusion. When restoring the worn dentition, the clini-
the dentition. In restoration of cian should bear in mind the five Ps: proper planning prevents poor
the worn dentition, the performance.
most important factor for

JADA, Vol. 131, September 2000 1279

Copyright 1998-2001 American Dental Association. All rights reserved.

Figure 1. A patient with worn anterior dentition. Figure 2. The stereographic tracing technique.

teeth at night. nizing signs of instability such

Downloaded from on December 5, 2008

Bruxism as tooth hypermobility, tooth
was classified wear, abfractions, periodontal
by Ramfjord breakdown, occlusal dimpling,
and Ash1 into stress fractures, exostosis, mus-
two categories: cle enlargement and loss of pos-
centric (verti- terior disclusion, the restorative
cal loading dentist can interpret the wear
during waking patterns and design a treat-
hours) and ment that will protect the teeth
eccentric or at least reduce the rate of
(grinding into wear.5 A dentist can recognize
lateral excur- the signs of instability only by
sion while taking a thorough medical and
sleeping). dental history; conducting a
There are a complete head, neck and oral
number of rea- examination; and reviewing
sons why peo- accurate diagnostic casts
Figure 3. The Behren Hanau Clinometer (Waterpik
Technologies). ple clench and mounted on a semiadjustable
grind their articulator in centric relation.
teeth, and To develop the functional
success is the recognition of they generally fall into one of stability necessary for the suc-
the causative factors and nec- two categories: psychological cess of the treatment, the den-
essary restorative corrections. and odontogenic. A number of tist must evaluate the determi-
The case presented in this studies discuss the etiology of nants of occlusion. The muscles
article is that of a 24-year-old bruxism and the controversial of mastication must be exam-
man who was seeking esthetic role that teeth play in the ined and palpated for tender-
dental treatment because he process.1-4,10,12-14 ness. The condition of the tem-
was unhappy with the appear- Whatever the cause of poromandibular joints, or TMJs,
ance of his maxillary anterior occlusal instability, it is impor- should be evaluated. A determi-
teeth. He was unaware of the tant that the restorative dentist nation of the relationship of the
causal relationships between be able to recognize its signs. It condylar guidance to the anteri-
the severe wear of his anterior is these signs that give the or guidance has to be evaluated
teeth and the alteration of his clues to the location and extent in cases associated with severe
smile. His concerns were of damage to the teeth and the anterior wear.5 For the results
esthetic, not functional. During corrections that are necessary of the patients treatment to be
the review of his dental history, to reduce the wear caused by stable, the following criteria
he related that he ground his the patients bruxism. By recog- must be satisfied:

1280 JADA, Vol. 131, September 2000

Copyright 1998-2001 American Dental Association. All rights reserved.

Downloaded from on December 5, 2008

Figure 4. Tooth-size indicator (Trubyte, Dentsply). Figure 5. Cephalometric tracing of the patient.

dthe patient can function from the final restorations. The diag- I created the diagnostic pre-
centric relation without occlusal nostic preview will be used to view for this patient on the
interferences; develop the relationship between Denar Combi articulator (Water-
dthe TMJ can be loaded with- the condylar and anterior guid- pik Technologies). I used this
out tenderness; ance; to establish the esthetic articulator because it allowed for
dthere are centric stops ante- a more precise mapping of the
riorly between the maxillary condylar movements by means
and mandibular anterior teeth; In many cases, of a stereographic tracing tech-
danterior coupling allows for dentists overlook nique (Figure 2). The maxillary
disclusion of the posterior teeth; cast was mounted on the articu-
dthe teeth are positioned in or misunderstand lator using a spring bow, and to
balance with the tongue and the importance of ensure that the technician
facial muscles.5 would have an accurate repre-
establishing anterior sentation of the incisal edges to
the pupillary line, I used the
AND ANTERIOR guidance.
GUIDANCE: DIAGNOSTIC Behren Hanau Clinometer
(Waterpik Technologies) to
Once the restorative dentist has transfer the relationship to the
a thorough understanding of requirements for the final articulator (Figure 3). To deter-
the causal factors related to the restorations; to create templates mine the size and shape of the
damage of the patients teeth, for periodontal surgery, tooth maxillary central incisor, and
he or she then can begin gath- preparation and temporization; develop the relationship of
ering the information necessary and to set up the incisal guide tooth size and shape for the
to create a diagnostic preview of table on the articulator. lateral aspect and canine from

JADA, Vol. 131, September 2000 1281

Copyright 1998-2001 American Dental Association. All rights reserved.

Figure 6. Developing a diagnostic preview. Figure 7. Preparation design.


Downloaded from on December 5, 2008

patient, I used
information The clinical treatment began
gathered from after completion of the diagnos-
the tooth size tic preview, which allowed me
indicator and to visualize the final restoration
the cephalo- and to fabricate the templates
metric tracing for perioesthetic recontouring,
to determine tooth preparation and
the maxillary temporization.
incisal edge The initial stage in the clini-
position of the cal treatment of the patient was
Figure 8. Final restorations. central incisor periodontal recontouring. The
(Figure 5). severe wear of the anterior
The cephalo- teeth had created eruption of
a denture mold guide, I used a metric tracing is valuable for the anterior teeth. The eruption
tooth-size indicator (Trubyte, determining the interincisal patterns were varied owing to
Dentsply) (Figure 4).6 angle, the position of the the unequal wear of the teeth,
In many cases, dentists upper central incisors and the leaving gingival asymmetry.
overlook or misunderstand the position of the lower central Using information gathered
importance of establishing incisors and for facilitating a from intraoral photographs and
anterior guidance. With this profile analysis.7 By transpos- from the diagnostic preview, I
particular patient, establish- ing the length of the central fabricated clear plastic tem-
ing anterior guidance was incisor on the cephalometric in plates for the periodontist, so
paramount to the success of relation to the NA line, I estab- that the gingival asymmetry
the treatment. In cases in lished the position of the max- could be corrected and the max-
which the anterior teeth exhib- illary incisal edge and meas- illary premolar could be
it stability, anterior guidance ured the overjet and overbite exposed to improve the buccal
can be developed using the on the cephalometric tracing. corridor.
existing guidance. However, in I used information gathered After healing, the patient
this case, the instability dic- from intraoral photographs to was scheduled for tooth prepa-
tated an alternate approach. establish gingival symmetry at ration. The design of the tooth
(As a point of interest, it has the proper height on the diag- preparation should encompass
been suggested that anterior nostic casts. Then, on the basis necessary reduction relative to
guidance can be developed of information from the cephalo- tooth position and the require-
using phonetics, computer gen- metric tracing, I developed the ments of the restorative materi-
erated axiography or cephalo- diagnostic preview of the final al. The review of the cephalo-
metric tracing.5) restorations (Figure 6). metric tracing indicated the

1282 JADA, Vol. 131, September 2000

Copyright 1998-2001 American Dental Association. All rights reserved.

need for a modification in were sent to the laboratory for masticatory system. Dentists
preparation design that result- use in fabricating the final must blend the new materials
ed in the conservation of tooth restorations (Figure 8). Brux- and technology with traditional
enamel. Because of the position ism may continue even after functional concepts to be suc-
of the teeth in the arch, facial the teeth have been reposi- cessful. As the case presented
reduction was reduced, while tioned to reduce wear and to here demonstrates, this combi-
lingual incisal reduction was establish esthetics and a new nation of innovation and tradi-
increased to accommodate the anterior guidance.11 Therefore, tion is achievable with careful
more labial position of the final after placing the final restora- planning.
restorations (Figure 7). Reduc- tions, I provided the patient
Dr. McIntyre is a clinical associate profes-
tion of the labial surface of the with a hard acrylic occlusal sor of restorative dentistry; the director,
tooth accommodated the manu- guard to protect the restora- Postgraduate Prosthodontics; and the direc-
tor, Esthetic Dentistry Education Center,
facturers requirements for the tions during his bruxing University at Buffalo, State University of
material to circumvent the episodes. New York, School of Dental Medicine, 222
Squire Hall, Buffalo, N.Y. 14214. Address
porcelain veneers propensity to Many steps are involved in reprint requests to Dr. McIntyre.
crack,8 while conserving labial

Downloaded from on December 5, 2008

1. Ramfjord SP, Ash MM, eds. Occlusion.
enamel. The lingual-incisal Philadelphia: Saunders; 1971:177-82.
reduction satisfied the manu- The use of the 2. Ramfjord SP. Bruxism: a clinical and
electromyographic study. JADA 1961;62:21-
facturers requirements for the diagnostic preview 44.
restorative material to prevent 3. McLoughlin PJ. Clinical strategies to
fracture as a result of occlusal and of the help patients reduce jaw clenching and brux-
ing behaviors. Int J Orofacial Myology
loads. The use of the diagnostic 1990;16:13-7.
cephalometric tracing 4. Sayers P. The bruxer. Ann R Australas
preview and of the cephalomet- Coll Dent Surg 1986;9:158-66.
ric tracing allowed for addition- allowed for additional 5. Dawson PE. Evaluation, diagnosis and
treatment of occlusal problems. 2nd ed. St.
al contour of the porcelain Louis: Mosby; 1989.
veneers, which is a key element contour of the 6. Sellen PN, Jagger DC, Harrison A.
Methods used to select artificial anterior
in enamel preservation.9 After porcelain veneers, teeth for the edentulous patient: a historical
preparing the teeth, I took an overview. Int J Prosthodont 1999;12:51-8.
impression and, using an ante- which is a key 7. McNeill C. Science and practice of occlu-
sion. 1st ed. Chicago: Quintessence; 1997:
rior jig, a new centric relation element in enamel 341-7.
8. Magne P, Kwon K, Belser UC, Hodges
record. JS, Douglas WH. Crack propensity of porce-
Temporization was accom- preservation. lain laminate veneers: a simulated operatory
evaluation. J Prosthet Dent 1999;81:327-34.
plished by means of a template 9. Magne P, Douglas WH. Additive contour
fabricated from the diagnostic of porcelain veneers: a key element in enamel
preservation, adhesion, and esthetics for
preview and a resin-based com- creating restorative excellence aging dentition. J Adhes Dent 1999;1(1):81-
posite material (Provipont DC, in a case such as this. When 92.
10. Lobbezoo F, Lavigne GJ. Do bruxism
Ivoclar). The composite tempo- restoring the worn dentition, and temporomandibular disorders have a
rary restorations were placed the clinician should bear in cause-and-effect relationship? J Orofac Pain
with spot etching and allowed to mind the five Ps: proper plan- 11. Ekfeldt A, Karlsson S. Changes of mas-
remain in place for three ning prevents poor performance. ticatory movement characteristics after
prosthodontic rehabilitation of individuals
months as a test of the vitality with extensive tooth wear. Int J Prosthodont
of the diagnostic workup. I pro- 1996;9:539-46.
12. Rugh JD, Barghi N, Drago CJ. Experi-
vided the patient with a soft Advances in dental materials mental occlusal discrepancies and nocturnal
mouthguard at the time of tem- and technology have given prac- bruxism. J Prosthet Dent 1984;51(4):548-53.
13. Okeson JP, Phillips BA, Berry DT, Cook
porization to protect the restora- ticing dentists the ability to cre- YR, Cabelka JF. Nocturnal bruxing events in
tions during his bruxing ate beautiful smiles for their subjects with sleep-disordered breathing and
control subjects. J Craniomandib Disord
episodes. patients. In doing so, dentists 1991;5:258-64.
Photographs, the diagnostic have the responsibility of devel- 14. Sjholm TT, Polo OJ, Alihanka JM.
Sleep movements in teethgrinders. J
preview and the articulator oping proper form and function Craniomandib Disord 1992;6:184-91.
with the custom anterior guide to protect the integrity of the

JADA, Vol. 131, September 2000 1283

Copyright 1998-2001 American Dental Association. All rights reserved.