Postgraduate Department of Conservative Dentistry and Endodontics

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)
RESTORATION OF WORN DENTITION-I
(Aetiology)
CONTENTS
• Introduction
• Abrasion
• Abfraction
• Attrition
• Bruxism
• Erosion
• Combined Mechanisms
• Severity of wear
RESTORATION OF WORN DENTITION-II
(Assesment & Role of Occlusion in tooth wear)
CONTENTS
 PATIENT’S HISTORY
 EXAMINATION OF WEAR’s PATIENT
 DIAGNOSIS
 MEASUREMENT OF SEVERITY & PROGRESSION OF WEAR
 DILEMA OF OCCLUSION
RESTORATION OF WORN DENTITION-III
( Treatment Planning)
CONTENTS
 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
 MAINTENANCE PHASE
 CONCLUSION
 REFERENCES
MOUNTING CAST
PROBLEM OF SPACES
MOUNTING CAST RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
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

MOUNTING CAST
PROBLEM OF SPACES
INTER-OCCLUSAL RECORDS : RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
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

Softened interocclusal Buccal cusps visible on record

wax record
Record relined with temporary Rigid, stable, accurate record

cement
Acrylic base with wax rims
located with zinc oxide

and eugenol paste
# Gimmicks don’t do your work
but certainly make your work easier….
MOUNTING CAST
PROBLEM OF SPACES
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

TYPES OF ARTICULATORS…..
Articulator Design….
Arcon - condylar element on

lower
Non Arcon - condylar

element on upper
MOUNTING CAST
DETERMINANTS OF
PROBLEM OF SPACES
RESTORATION
OCCLUSION
REHABILITATION
MAINTENANCE
CONCLUSION
Posterior
1) Right TMJ
2) Left TMJ
Anterior
1) Anterior Teeth
MOUNTING CAST
PROBLEM OF SPACES
Posterior Determinants of RESTORATION

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

REHABILITATION
Occlusion MAINTENANCE
CONCLUSION
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
Programming The Articulator

RESTORATION
REHABILITATION
MAINTENANCE
(Hanau Modular Arcon Articulator) CONCLUSION
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
MOUNTING CAST
ANTERIOR GUIDE
PROBLEM OF SPACES
RESTORATION
TABLE
REHABILITATION
MAINTENANCE
CONCLUSION
Purpose of 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
MOUNTING CAST
PROBLEM OF SPACES
WHAT ABOUT THIS ?????

RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
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)
MOUNTING CAST
PROBLEM OF SPACES
CAST ORIENTATION
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
• 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
CAST ORIENTATION: REHABILITATION

MAINTENANCE
CONCLUSION
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
CAST ORIENTATION REHABILITATION
MAINTENANCE
CONCLUSION
• To Orient the Maxillary Cast – Facebow

• To Orient the Mandibular Cast- Interocclusal record
MOUNTING CAST
PROBLEM OF SPACES
REHABILITATION
MAINTENANCE
FACEBOW TRANSFER : CONCLUSION
“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”.
 2 types of facebows are :
1) Kinematic facebow or
Hinge-axis facebow
2) Arbitary facebow
Glossary Of Prosthodontic Terms
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
 To record patient’s hinge axis REHABILITATION
MAINTENANCE
CONCLUSION
 The Arbitrary Hinge

Axis is adequate for most
clinical procedures
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
 It is located 13 mm from the tip of the tragus of CONCLUSION
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
Finger cots can be
used as a infection
control measure.
Patient can assist with

placement
Orient and
in external
orientation
auditory in external
meatus
auditory meatus
Slide facebow
into bitefork
Extend nasion
support & tighten
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Tighten all
wrenches of
facebow
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Loosen these
tighteners. Release
the recordbase by
breaking the seal, and
removing the facebow.
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Place facebow
support on transfer
jig and attach to
indirect mount
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Remove incisal pin and

set the centric latch
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Attach the maxillary cast to the articulator

via plaster
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
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
ARTICULATED
MANDIBULAR CAST
Clean Up as you go
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
SET THE
CONDYLAR
INCLINATION
(WITH THE HELP OF
CHECK BITES)
SET THE ANTERIOR
GUIDANCE
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
PROBLEM OF SPACES REHABILITATION
(INCREASING VERTICAL DIMENSIONS) MAINTENANCE
CONCLUSION
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
 2 important aspects of vertical dimension :

 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
Dawson PE. Evaluation, Diagnosis & Treatment of Occlusal Problems;
2nd ed; St Louis: Mosby; 1989; 56-71
MOUNTING CAST
RESTORATION
REHABILITATION
 The fact that a patient has severely abraded MAINTENANCE
their teeth does not indicate a loss of VDO nor CONCLUSION
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
RESTORATION
Assessing the existing Vertical Dimension REHABILITATION
MAINTENANCE
CONCLUSION
Posterior  If posterior teeth in both arches have

teeth : 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

MOUNTING CAST
RESTORATION
Assessing the existing Vertical Dimension REHABILITATION
MAINTENANCE
CONCLUSION
Gingiva  in a patient who exhibits severe anterior wear

levels: & 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

MOUNTING CAST
DETERMINING VERTICAL DIMENSION RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
 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

MOUNTING CAST
RESTORATION
STABILITY OF VERTICAL DIMENSION REHABILITATION
MAINTENANCE
CONCLUSION
 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

MOUNTING CAST
STABILITY OF VERTICAL DIMENSION RESTORATION
REHABILITATION
MAINTENANCE
 Because the joint & the muscle are very close CONCLUSION
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
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
Evaluation, diagnosis and treatment of occlusal problems, 2 edn. Mosby, St. Louis
J Am Dent Assoc 33:151
 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
MOUNTING CAST
CONSTANT VERTICAL DIMENSION RESTORATION
REHABILITATION
MAINTENANCE
 VDR and OVD are changeable and adaptable CONCLUSION
to certain extent
Atwood stated that VDR remains constant even following loss

of tooth contacts J Prosthet Dent 8:698
 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 52:867–870
MOUNTING CAST
RESTORATION
MAXIMUM MASTICATORY FORCE REHABILITATION
MAINTENANCE
CONCLUSION
 Boos stated that optimum masticatory force occurs in

OVD
J Am Dent Assoc 27:1193–1199
 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
MOUNTING CAST
RESTORATION
Encroaching Into Freeway Space REHABILITATION
MAINTENANCE
CONCLUSION
 Increasing OVD and encroaching the
freeway space is detrimental and is considered to result
in elongation and increased activity of stomatognathic
muscles
 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
 Thus increasing OVD up to VDR can be advantageous

in relieving symptoms in TMJ and muscle disorders
MOUNTING CAST
RESTORATION
Decreased OVD: Costen Syndrome REHABILITATION
MAINTENANCE
CONCLUSION
 Costen concluded through clinical observations that

decreasing OVD resulted in condylar displacement posteriorly
causing compression of chorda tympani, auriculotemporal
nerves and eustachian tubes
Ann Otol Rhinol Laryngol 43:1
 Beyron contradicted deliberation and proved that

condyles are not displaced posteriorly by decrease in OVD
J Am Dental Asssoc 48:648–656

MOUNTING CAST
Factors Indicating Loss of OVD RESTORATION
REHABILITATION
MAINTENANCE
 Decreased crown height and deep anterior CONCLUSION
over bite
 Increased overbite may also be because of continuous

teeth eruption and over closure
J Prosthet Dent 34:278
 Attrition can cause short crowns in spite of continuous

eruption of tooth
 Hence these two factors cannot be considered as valuable

factors indicating loss of OVD
MOUNTING CAST
RESTORATION
EXACT LOCATION OF OVD REHABILITATION
MAINTENANCE
CONCLUSION
 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 50:700–709 J Prosthet Dent 33:321–327
MOUNTING CAST
‘Unloading’ of Condyles RESTORATION
REHABILITATION
MAINTENANCE
 Dawson , Weinberg stated that bite raising CONCLUSION
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
Evaluation, diagnosis and treatment of occlusal problems, 2 edn. Mosby, St. Louis
MOUNTING CAST
RESTORATION
Comfortable Jaw Position REHABILITATION
MAINTENANCE
 Tryde et al. revealed that its not a comfort CONCLUSION
zone and had an interval of 1.3 mm on
average around VDO J Oral Rehabil 4:9–15
 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
MOUNTING CAST
RESTORATION
REHABILITATION
MAINTENANCE
Bite Raising in Full Occlusal Rehabilitation CONCLUSION
 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
 By exploring the various controversies and RESTORATION
myths regarding vertical dimension and its REHABILITATION
alteration, discarding the erroneous beliefs and MAINTENANCE
CONCLUSION
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”

MOUNTING CAST
Effects of Increasing Vertical Dimension RESTORATION
REHABILITATION
 When OVD is increased within or equal to the MAINTENANCE
CONCLUSION
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
Quintessence Int 31:275–280
MOUNTING CAST
Effects of Increasing Vertical Dimension RESTORATION
REHABILITATION
MAINTENANCE
 The inference that can be arrived by studying CONCLUSION
the effects of altering OVD is that any attempt
to restore OVD in excessively worn dentition
results in increasing the OVD
 This increase will ultimately lead to adaptive recoil of

muscles resulting in tooth intrusion and OVD will return to
pre-treatment level

MOUNTING CAST
RESTORATION
REHABILITATION
Indications for Increasing OVD MAINTENANCE
CONCLUSION
 Inadequate space for the restoration
 For temporarily relieving the symptoms in

intracapsular TMJ disorders

MOUNTING CAST
Functional Adaptation RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
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
RESTORATION
REHABILITATION
Principles Behind Increasing Vertical MAINTENANCE
Dimension CONCLUSION
(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

MOUNTING CAST
RESTORATION
TURNER AND MISSIRLIAN REHABILITATION
MAINTENANCE
Classification of tooth wear : CONCLUSION
Category 1 excessive wear with loss of vertical dimension of

occlusion
 Exact location of OVD must be identified and

restored by full occlusal rehabilitation
J Prosthet Dent 1984; 52: 467–474

MOUNTING CAST
RESTORATION
MAINTENANCE
excessive wear without loss of vertical

Category 2
dimension of occlusion, but with space available
 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
J Prosthet Dent 1984; 52: 467–474

MOUNTING CAST
RESTORATION
MAINTENANCE
excessive wear without loss of vertical

Category 3
dimension, but with limited space
 Bite raising with OVD not encroaching VDR can be

made followed by full occlusal rehabilitation
J Prosthet Dent 1984; 52: 467–474

MOUNTING CAST
THE PROBLEM OF SPACE…….. RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
 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
Dent Update 2003; 30: 150-157

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

MOUNTING CAST
RESTORATION
 A number of methods can be employed to REHABILITATION
MAINTENANCE
create space for restorations. These may be
CONCLUSION
subdivided into methods based on using:
Conformative occlusion Reorganized occlusion

 Existing position of mandibular  Postion of mandibular closure
closure is maintained is altered
 Suitable for restoration of  Suitable for full mouth
single tooth or small group of rehabilitaion
teeth  e.g,
 e.g, 1. mandibular repostioning
1. reducing the teeth in same or 2. localized minor axial tooth
opposing arch movements
2. surgical lengthening of the 3. increasing the vertical
crown dimension of occlusion
MOUNTING CAST
CREATION OF LOCALISED INTER-OCCLUSAL SPACE RESTORATION
REHABILITATION
MAINTENANCE
 Increasing the occlusal vertical CONCLUSION
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
Increasing the occlusal vertical RESTORATION
REHABILITATION
dimension (OVD) : MAINTENANCE
CONCLUSION
Generalized tooth wear

restored with PFM crowns
in the anterior and posterior segments at an overall increase
in OVD
MOUNTING CAST
Reduction of teeth in RESTORATION
REHABILITATION
same / opposing arch : MAINTENANCE
CONCLUSION
 undesirable in a dentition where there has already been
loss of tooth tissue
 for single unit restorations
Occlusal reorganization :
 It is suitable in those patients who have
a large horizontal discrepancy between
ICP and the retruded axis position

MOUNTING CAST
Surgical crown lengthening….. RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Periodontal surgical crown

lengthening on worn lower
anterior teeth prior to the
construction of a fixed bridge
prosthesis.
MOUNTING CAST
Surgical crown lengthening….. RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
 requires a period of healing,

of ideally 3 months
 invasive procedure….
1. postoperative
sensitivity
2. proximal spacing
3. crown margins on
root
Triangular spaces

MOUNTING CAST
Elective root treatment &

RESTORATION
REHABILITATION
placement of post crowns : 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

MOUNTING CAST
Dahl appliances……
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
 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
MOUNTING CAST
RESTORATION
REHABILITATION
Localized MAINTENANCE
CONCLUSION
anterior
tooth wear
Dahl appliance Posterior disclusion

cemented in place
Irish Dentist July 2011
MOUNTING CAST
RESTORATION
Regained REHABILITATION
posterior MAINTENANCE
CONCLUSION
tooth contacts
after 6 months
Inter-incisal space recreated Following periodontal

following the removal of the surgical crown lengthening,
Dahl appliance teeth prepared for PFM
crowns
MOUNTING CAST
RESTORATION
RECENT TRENDS IN REHABILITATION
“THE DAHL CONCEPT” MAINTENANCE
CONCLUSION
Individual Definitive
Adhesive Restorations
Maxillary arch following placement of

6 palatal gold veneers

MOUNTING CAST
RESTORATION
RECENT TRENDS IN “THE DAHL REHABILITATION
CONCEPT” 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.

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

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

MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
RESTORATIVE OPTIONS : 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.
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
Conventional Fixed Restorations REHABILITATION
MAINTENANCE
CONCLUSION
 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

MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
Conventional Fixed Restorations REHABILITATION
MAINTENANCE
CONCLUSION
Anterior crowns constructed to conform to the existing worn

teeth without recreation of lost inter-incisal space resulting in
poor aesthetics and retention form.

MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
Removable Onlay/Overlay Prosthesis REHABILITATION
MAINTENANCE
CONCLUSION
 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

MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
MAINTENANCE
CONCLUSION

MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
MAINTENANCE
CONCLUSION
 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

MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
MAINTENANCE
CONCLUSION
Gingival fitting anterior

tooth facings on removable Butt fitting anterior
prosthesis tooth facings

MOUNTING CAST
PROBLEM OF SPACES
Removable Onlay/Overlay Prosthesis RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Fractures common
Acrylic resin facings which

were then replaced with a
metal framework

MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
Minimal Preparation Adhesive REHABILITATION
Restorations MAINTENANCE
CONCLUSION
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

MOUNTING CAST
Minimal Preparation Adhesive PROBLEM OF SPACES
RESTORATION
Restorations REHABILITATION
MAINTENANCE
ANTERIOR TOOTH WEAR CONCLUSION
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
 Creation of inter-occlusal space by Dahl’s appliance

or veneers at inc OVD
 an opaque resin based cement

MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Nickel-chromium Alloy
Resin Bonded Palatal
Veneers
Labial demonstrating re-

establishment of posterior
occlusal contacts
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
Incisal/palatal tooth wear : REHABILITATION
MAINTENANCE
CONCLUSION
Direct acid-
etch retained
composite
resin
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
Incisal/palatal tooth wear : 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.
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
Labial/incisal/palatal wear : 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

MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
Direct composite resin at an REHABILITATION
increased OVD MAINTENANCE
CONCLUSION
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
Posterior (generalized) REHABILITATION
MAINTENANCE
tooth wear:
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

MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
Resin bonded gold alloy and indirect composite MAINTENANCE
CONCLUSION
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
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
Resin-bonded laminate porcelain veneers for MAINTENANCE
CONCLUSION
the anterior teeth, and resin-bonded bridges
and onlays for the posterior teeth at an
overall increase in OVD.
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION OF WORN DENTITION REHABILITATION
MAINTENANCE
CONCLUSION
Management of :
 Localized Anterior Tooth Wear
 Localized Posterior Tooth Wear
 Generalized Tooth Wear

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

MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
Case study I : REHABILITATION
MAINTENANCE
CONCLUSION
27yrs female
Mild sensitivity
No medical history  localized anterior palatal tooth wear
Stressful job with dentine exposure
Consume citrus juices  Enamel chipping of 1|1
 little discrepancy between RCP and the
intercuspal position (ICP)
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)
Ni-Cr palatal veneers with Frontal view after placement
palatal platform of the palatal veneers
Right & left buccal view showing posterior occlusion after 4 weeks
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Management
of localized
posterior
tooth wear
Dent Update 2002; 29: 267–272

 |7 was associated with marginal gingivitis
Case study I:  pulp was exposed,
 minimal remaining clinical crown length
 no interocclusal space between the
21-year male overerupted |7 and the worn |7 in the
Painful |7 intercuspal position
Carious  patient declined fixed orthodontic
treatment
 restoration of |7 only
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
 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
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
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
REHABILITATION
MAINTENANCE
CONCLUSION
Management
of generalized
tooth wear
Dent Update 2002; 29: 318–324

MOUNTING CAST
PROBLEM OF SPACES
PRACTICAL CONSIDERATIONS OF RESTORATION
REHABILITATION
ORAL 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
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.
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
Amount of anterior & posterior space created by palatal
veneers bonded on upper canines
 Resin composite
build-up for posterior
stability
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

 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.
 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
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
MAINTENANCE PHASE REHABILITATION
MAINTENANCE
CONCLUSION
 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
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
CONCLUSION REHABILITATION
MAINTENANCE
CONCLUSION
 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.
 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.
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
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.
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
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.
MOUNTING CAST
PROBLEM OF SPACES
RESTORATION
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”

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.

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.
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.

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.

Postgraduate Department of Conservative Dentistry and Endodontics

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Postgraduate Department of Conservative Dentistry and Endodontics

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POSTGRADUATE DEPARTMENT OF CONSERVATIVE

DENTISTRY AND ENDODONTICS

Presenter- Ashish Choudhary

 EXAMINATION OF WEAR’s PATIENT

 MEASUREMENT OF SEVERITY & PROGRESSION OF WEAR

 RESTORATION OF WORN DENTITION

REHABILITATION OF WORN DENTITION

 relate the mandibular and maxillary diagnostic and

 Extra hard base plate wax is suitable.

 Other materials include zinc oxide and eugenol paste,

Dent Update 2003; 30: 150-157

2. Anterior Stop Technique

3. Use Of Pre-adapted Bases

4. Central Bearing Point Device

Dent Update 2003; 30: 150-157

Softened interocclusal Buccal cusps visible on record

Record relined with temporary Rigid, stable, accurate record

Acrylic base with wax rims

located with zinc oxide

“A mechanical instrument that

Glossary Of Prosthodontic Terms

Arcon - condylar element on

Non Arcon - condylar

Posterior Determinants of RESTORATION

Anterior Determinants of RESTORATION

The anterior teeth:

Programming The Articulator

Purpose of Guide Table

• Uses of articulated casts

WHAT ABOUT THIS ?????

Lateral condylar guidance

Programing the incisal

CAST ORIENTATION: REHABILITATION

If the patient is asymptomatic, and has a

• To Orient the Maxillary Cast – Facebow

“A facebow is a caliper-like device that is used

 The Arbitrary Hinge

To record 3rd reference point

Patient can assist with

Remove incisal pin and

Attach the maxillary cast to the articulator

• Hand articulation when

The vertical dimension of occlusion refers to the vertical position

 2 important aspects of vertical dimension :

 Vertical position of each tooth is adaptable to the space

 In treatment planning the critical issue is whether a patient

Charles McNeill. Science & Practice of Occlusion

Posterior  If posterior teeth in both arches have

Charles McNeill. Science & Practice of Occlusion

Gingiva  in a patient who exhibits severe anterior wear

Charles McNeill. Science & Practice of Occlusion

 Use of electronics to monitor muscle function ( oscilloscope )

 use of phonetics (sibilant or ‘s’ sound ) / concept of closest

 Provisionals followed by speech evaluation

Charles McNeill. Science & Practice of Occlusion

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

Charles McNeill. Science & Practice of Occlusion

together , seating the condyle 1mm results in

 According to McNeil, for every 1mm of condylar seating (by

ESTABLISMENT OF OVD / LOSS OF OVD WITH