10

IMPLANT-SUPPORTED PROSTHETIC REHABILITATION

OF A PATIENT WITH LOCALIZED SEVERE ATTRITION:
A CLINICAL REPORT

ISIL CEKIC-NAGAS, DDS, PHD AND GULFEM ERGUN, DDS, PHD

Department of Prosthodontics, Faculty of Dentistry, Gazi University, Ankara, Turkey

Keywords ABSTRACT
Full-mouth rehabilitation; dental implant; vertical dimen­
sion; attrition. Patients usually adapt to their existing occlusal vertical
dimension (OVD). It is essential to resolve each of the
Correspondence problems associated with decreased vertical dimension as
Dr. Isil Cekic-Nagas, Servi Sokak 6A/7, Kolej, Ankara, a result of attrition. This report describes the multidiscipli­
Turkey. E-mail: isilcekic@gazi.edu.tr, isilcekic@gmail.com nary dental treatment of a 40-year-old male patient who had
severe tooth wear, resulting in reduced vertical dimension.
This study was presented at the 37 Annual Congress of the After clinical evaluations, extraoral examination showed a
EPA and 41st Annual Meeting of the SSPD in Turku, Finland, reduction of the lower facial height, drooping, and over-
on August 21–24, 2013. closed commissures. Ten dental implants were placed into
the maxillary and mandibular alveolar processes. During the
The authors deny any conflicts of interest. osseointegration period, an interim removable partial denture
was made at increased OVD to use in the first stage of
Accepted March 23, 2014 rehabilitation. It was used for 3 months as a guide for
preparing the definitive restorations. The patient’s adaptation
Published in Journal of Prosthodontics June 2015; to the increased OVD was evaluated. During this period, he
Vol. 24, Issue 4 was asymptomatic. Following the evaluation period, the
provisional fixed restoration was used for 3 months. Then,
doi: 10.1111/jopr.12211 full-mouth definitive prostheses supported by a combination
of implants and teeth were fabricated to upper and lower
jaws. Osseointegration of the implants, peri-implant mucosa
health, prosthesis function, and esthetics were assessed after
1 week and 1, 3, and 6 months. After 3 years of follow-up, no
functional or esthetic difficulties with the implants and
restorations were noted.

Journal of Prosthodontics on Complex Restorations, First Edition. Edited by Nadim Z. Baba and David L. Guichet.
 2016 American College of Prosthodontists. Published 2016 by John Wiley & Sons, Inc.

73
74 IMPLANT-SUPPORTED PROSTHETIC REHABILITATION OF A PATIENT WITH LOCALIZED SEVERE ATTRITION
Dental wear could be a potential chronic problem for
dentition, since it is multifactorial and is generally a combi­
nation of abrasion, attrition, and erosion.1–3 Although several
factors affect the type and rate of wear, attrition could be a
physiologic process that occurs by the loss of tooth tissue due
to friction between opposing teeth.3,4 In addition, pathologic
wear occurs when the normal rate of physiologic process is
accelerated by endogenous or exogenous factors. The etiol­
ogy of wear should be diagnosed properly to prevent these
pathological changes.5 The tooth wear process might lead to
destruction of the stomatognathic system with severe tooth
surface loss and is associated with decreased occlusal vertical
dimension (OVD).6–8 Since alterations in OVD could cause
adaptable reactions in the temporomandibular joint (TMJ),
periodontium, and tooth surfaces, some patients do not
always need their stomatognathic system with decreased
vertical dimension to be restored.9 However, in some severe
cases, decreased vertical dimension with worn teeth could
result in an unesthetic appearance, decreased masticatory
efficiency, loss of muscle tone, dentin hypersensitivity, and
pulpitis.10,11 Therefore, for managing a complete oral reha­
bilitation, a systematic approach should be followed by
increasing the vertical dimension progressively. Thus, occlu­
sal splints or fixed or removable partial dentures (RPDs)
might be the treatment options for situations where loss of
OVD has occurred.12–15
The use of dental implants integrated into the living
tissues of the jaws to replace a single tooth or multiple
adjacent missing teeth is a predictable procedure in consid­
eration of optimal esthetic characteristics and long-lasting
stability.11,16 Furthermore, the size of the edentulous space
between existing teeth might be critical for the subsequent
implant placement.17,18 To improve treatment success, a
multidisciplinary approach with collaboration between the
maxillofacial surgeon and prosthodontist for implant plan­
ning and placement should be considered.19
The aim of this clinical report is to illustrate the restorative
treatment of a patient with worn anterior dentition by a
sequence of treatment, including surgical and prosthetic
multidisciplinary approaches.
CLINICAL REPORT
A 40-year-old man was referred to Gazi University, Depart­
ment of Prosthodontics with a chief complaint concerning
inability to chew and unpleasant esthetics, because of his
worn anterior teeth and loss of posterior teeth. He reported
that he had lost his posterior teeth 3 years ago because of
periodontal disease. The patient’s general medical history
was not significant, and he had no temporomandibular
disorder or pain in the mastication muscles. Extraoral exami­
nation showed a reduction of the lower facial height, protu­
berant lips, wrinkles, drooping and overclosed commissures,
and an unpleasant smile caused by collapsed OVD. The
general standard of oral hygiene and gingival situation were
not satisfactory. In addition, periodontal condition and soft-
tissue examination showed no pocket depth over 2 mm or
mobility of any remaining teeth; however, there was loss of
gingival papillae between the maxillary right and left central
teeth (#11 and #21), possibly due to maxillary and mandib­
ular incisor contact resulting in loss or cratering of the
interdental alveolar crest. Radiographic evaluation demon­
strated adequate bone support for the remaining teeth. Clini­
cally, the patient demonstrated partial edentulism, and
localized severe attrition was seen, especially in the right
anterior teeth (Fig 10.1). In addition, the intraoral and
radiographic examination verified that maxillary left and
right first premolars, second premolars, first molar, maxillary
left second molar, mandibular right and left first premolars,
second premolar, and first and second molars were lost
(#14–16, #24–27, #34–37, and #44–47; Fig 10.1). A treat­
ment plan was formulated that required communication
between the surgeon and the prosthodontist. To assist the
interdisciplinary consultation process, a diagnostic setup was
prepared by the prosthodontist. The patient’s casts were
mounted on a semiadjustable articulator (Stratos 200;
Ivoclar Vivadent, Schaan, Liechtenstein) using a facebow
record and an interocclusal record made with the aid of a
Lucia jig and poly(vinyl siloxane) occlusal registration mate­
rial (Exabite II; GC Corp., Tokyo, Japan). After careful
assessment, it was determined that a 6 mm loss of OVD
had occurred. To restore the lost OVD, the occlusion,
function, and esthetics of the patient, increasing the OVD
by interim removable partial prosthesis, interim fixed pros­
thesis, and full-mouth rehabilitation with implant-teeth-sup­
ported metal ceramic restorations were planned. Informed
consent was obtained from the patient before beginning the
treatment.
Surgical Procedure
Decisions regarding implant length and width were based on
an examination of periapical and panoramic radiographs of
the maxillary and mandibular bone. In total, ten implants
(five in the maxilla, five in mandible) were planned by the
prosthodontist. Mounted diagnostic casts were used to fabri­
cate a guide for implant placement by the surgeon. The
implant surgery was undertaken under local anesthesia and
following the guidelines determined by the manufacturer.
The surgical procedure started with an intraoral crestal
incision followed by subperiosteal dissection of the muco­
periosteum. Flattening of the alveolar crest was performed
with a bur and under copious sterile saline irrigation. At the
insertion stage, the implants were placed at a depth according
to the guidelines given by the manufacturer (Standard Plus
Implants; Straumann AG, Basel, Switzerland). Five implants
were placed in both the maxilla and mandible (Table 10.1).
 CLINICAL REPORT 75

FIGURE 10.1 Intraoral view of the patient before treatment. (A) Facial aspect. (B) From left side.
(C) View of maxilla. (D) View of mandible. Arrow indicating the main attrition (#11, #12, #21).

TABLE 10.1 Region and Type of Implants

Region #14, #24, #35, #26 #16, #27, #34, #44 #37, #46
Type 4.1 mm in diameter, 12 mm total length 4.1 mm in diameter, 10 mm total length 4.1 mm in diameter, 8 mm total length

Postoperative treatment consisted of standard analgesics,
chlorhexidine 0.2% mouthrinses, antibiotics, and non­
steroidal analgesics for three consecutive days. Sutures
were removed 1 week after surgery. After a bone-healing
period of 6 months, a second-stage surgery was undertaken;
the healing abutments were connected and left in place for
3 weeks for peri-implant soft-tissue healing. Standard oral
hygiene instructions, including brushing of the healing abut­
ments, were given to the patient.
Prosthetic Stage
The new OVD was set to increase by approximately 6 mm in
the incisal guidance pin of the articulator. Then, the maxillary
right and left central incisor and right lateral incisor and
canine (#11, #12, #13, #21) had root canal therapy and
postcore restorations. An RPD was made at the increased
OVD to use at the first stage of the rehabilitation (Fig 10.2).
This interim removable denture was used for 3 months as a
guide for the definitive oral rehabilitation. The patient’s
adaptation to the increased OVD was evaluated. During
this period, the patient’s functions, muscle sensitivity, mas­
tication, TMJ discomfort, swallowing, speech, and anterior
and posterior speaking space were assessed. No muscle
tenderness or temporomandibular discomfort was found,
and the patient was asymptomatic. Development in facial
esthetics, speech, and mastication showed the patient’s tol­
erance capacity.
The proper OVD was determined using the physiologic
rest position of the mandible as a guide and noting the
existing interocclusal distance. It was decided that all of
the teeth should be restored with full-mouth rehabilitation to
restore lost vertical dimension. After preparation of the
remaining teeth (Fig 10.3), the provisional crowns were
fabricated (autopolymerizing acrylic resin, ALIKETM; GC
America, Alsip, IL) using a vacuum-formed matrix (Drufo­
len H; Dreve Dentamid GmbH, Unna, Germany). The
interim fixed restoration was cemented with temporary
cement (Temp Bond NETM; Kerr, Salerno, Italy).
The previous interim removable denture made at
increased OVD was adapted to the interim fixed prostheses.
These interim prostheses were used for 3 months as a guide
for the definitive oral rehabilitation. In addition, protrusive
contact, canine guidance, esthetics, and phonetics of the
interim prosthesis were assessed, and 1-, 2-, and 3-month
check-ups were performed.
76 IMPLANT-SUPPORTED PROSTHETIC REHABILITATION OF A PATIENT WITH LOCALIZED SEVERE ATTRITION

FIGURE 10.2 (A) The increased vertical dimension by RPD. (B) Intraoral view of the patient at
increased vertical dimension after postcore restorations of right central and lateral teeth. (C) View from
right side. (D) View from left side.

FIGURE 10.3 Intraoral view after preparation of the teeth (A) maxilla (B) mandible.

After 3 months, the impression copings were placed.
Definitive impressions of the maxillary and mandibular teeth
and abutments were made with a polyether impression
material (Impregum; 3M ESPE, Seefeld, Germany). The
impression copings were fixed onto the abutment analog.
Then, cement-retained prostheses were completed on abut­
ment level models from a base metal alloy (Master-Tec;
Ivoclar Vivadent AG, Schaan, Liechtenstein) and porcelain
(VITA VM 13, VITA Zahnfabrik, Bad Sackingen, Germany;
Fig 10.4).
Centric occlusion, protrusive contacts, and canine guid­
ance were assessed in the definitive anterior restoration. The
scheme of occlusion was mutually protected articulation. The
right lateral tooth (#12), which was below the plane of
occlusion, created a reverse occlusal plane. To offset this
reverse occlusal curve, the incisal guidance was increased.
As a result, a flat mandibular plane of occlusion was estab­
lished (Fig 10.4). The occlusal plane and esthetics were used
as a guide to establish anterior guidance.
Phonetics was assessed using the closest speaking space
technique. The technique, suggested by Silverman, was
reported to give constant and reproducible results. The
closest speaking space was considered to be between the
lower centric occlusion line and the upper closest speaking
line.20 Finally, the definitive restoration was cemented with
temporary cement (Temp Bond NETM). Oral hygiene and
regular check-up were emphasized. Following evaluation of
the patient after 24 hours, 48 hours, and 1 week, occlusal
corrections were made. Once the occlusal adjustments,
speech, and esthetics seemed satisfactory, all restorations
were cemented definitely with zinc polycarboxy-late cement
(Adhesor® Carbofine, Kerr, Salerno, Italy; Fig 10.4). Com­
pared with the pretreatment profile (Fig 10.5A), the post­
treatment profile photographs (Fig 10.5B) showed a marked
improvement in the facial profile (Fig 10.6). Following the
definitive cementation of all restorations, a protective occlu­
sal splint was manufactured to protect the restorations.
Routine radiographs consisted of panoramic radiographs
 DISCUSSION 77

FIGURE 10.4 Posttreatment intraoral views showing restored teeth (A) maxilla, (B) mandible, (C)
maxilla and mandible from facial aspect.

FIGURE 10.5 Posttreatment facial photographs showing the marked improvement in the facial
profile (A) before treatment (B) after treatment.
taken preoperatively, after placement of implants, at the time in facial and masticatory muscles, and phonetic and esthetic
of prosthetic loading, and annually thereafter until the end of satisfaction. The patient acknowledged having improved
follow-up (Fig 10.7). function and esthetics and was pleased with the results.

Follow-Up Period
Routine clinical assessments were made after 1 and 4 weeks,
3 and 6 months, and 1, 2, and 3 years with visual and
radiographic examinations. Criteria for success included
functional harmony, absence of pain, no tension or tiredness
DISCUSSION
Loss of tooth substance or even severe tooth wear might be a
contributing factor to dental occlusion problems.14 Patients
with these problems often seek treatment because of an
78 IMPLANT-SUPPORTED PROSTHETIC REHABILITATION OF A PATIENT WITH LOCALIZED SEVERE ATTRITION

FIGURE 10.6 (A) Pretreatment smile of the patient, (B) posttreatment smile of the patient.

FIGURE 10.7 (A) Radiograph of the patient before treatment. (B) Radiograph of the patient after implant surgery. (C) Radiograph of the
patient after treatment.

unpleasant appearance, impaired mastication, and speech
difficulties. In addition, the lack of uniformity of the occlusal
plane, supereruption, loss of vertical dimension, and bone
morphology in edentulous areas may cause prosthodontic
challenges.11 When there is tooth loss, to maintain the oral
functions properly, the oral system should be reestablished.21
In this case, severe dental wear was seen in the right anterior
maxilla. This could be related to the malocclusion problems
associated with the loss of posterior teeth. Once the anterior
teeth attrited, the anterior guidance was lost. Furthermore, the
position of the remaining teeth in the dental arch was altered,
as well as in relation to the antagonist teeth.
Tooth surface loss associated with decreased OVD could
be recovered by continuous tooth eruption and alveolar bone
growth in some cases. Moreover, the treatment might include
surgical crown lengthening or orthodontic movements.8
If tooth wear could not be compensated by dentoalveolar
growth, and the loss of OVD is severe or associated with

short worn teeth, then progressive increase in OVD with
interim prostheses for 2 to 6 months could be used as an
appropriate approach.8,12 Previous studies recommended the
use of RPDs as interim prostheses for patients with attrition
of anterior teeth and multiple missing anterior teeth.13,14,22,23
In this case, the attrition was severe in the right anterior
region, and the patient had a concave profile (Figs 10.1 and
10.5A). Following the determination of 6 mm loss of OVD,
the interim RPD was made to be used for about 3 months for
restoring the lost OVD. Since provisional crowns had been
prepared from autopolymerizing acrylic resin, they might
demonstrate dimensional degeneration and marginal accu­
racy problems in long-term use.24 In addition, use of a fixed
interim prosthesis on prepared teeth might cause pulpitis or
periodontal problems in the long term. Therefore, initially an
RPD was chosen to restore loss of OVD.25 Then, a fixed
interim prosthesis was used for 3 months. During the 3­
month period, to evaluate temporomandibular discomfort,
wear, and muscle fatigue, the restorations were cemented
temporarily, and no complication occurred.
To restore lost OVD, the multidisciplinary team should be
in close collaboration in terms of planning the immediate,
transitory, and long-term phases of treatment.16,26 To reha­
bilitate these patients with esthetics and for functional suc­
cess, prosthetic, orthodontic, and surgical collaboration
might be required. The use of dental implants in supporting
fixed prosthetic rehabilitations can provide high success
when certain conditions are met during the manufacture of
the implant, in its placement, in its eventual functional
loading, and in its maintenance.15,17 In this report, because
of the long treatment period and the difficulty of the treatment
procedure, surgical/orthodontic/prosthodontic treatment was
not preferred by the patient. Therefore, to restore the missing
teeth, surgical/prosthodontic multidisciplinary rehabilitation
was planned, and a total of ten implants were placed in the
maxilla and mandible.
Mutually protected articulation is described as an occlusal
scheme in which the posterior teeth prevent excessive contact
of the anterior teeth in maximum intercuspation, and the
anterior teeth disengage the posterior teeth in all mandibular
excursive movements.27 In this report, a mutually protected
occlusal scheme was used to prevent the destruction of
the provisional and definitive restorations. Furthermore,
the patient had an end-to-end incisor relationship in right
anterior maxilla and concave facial profile at the beginning of
the treatment (Figs 10.5A and 10.6A). At the end of the
prosthetic rehabilitation, both the facial appearance and the
occlusion were improved (Figs 10.5B and 10.6B).
CONCLUSION
Restoring lost OVD by RPD and full-mouth rehabilitation
should be done progressively and carefully for maintaining
REFERENCES 79
the health and structure of the masticatory system in the
patient who has severely worn teeth. In addition, these
prosthetic rehabilitations play a major role in the patient’s
physical attractiveness and social confidence.
ACKNOWLEDGMENT
The authors wish to thank Asst. Prof. Suleyman Bozkaya for
his great effort and expert in surgical part of this case report.
REFERENCES
1. Sierpinska T, Konstantynowicz J, Orywal K, et al: Copper
deficit as a potential pathogenic factor of reduced bone mineral
density and severe tooth wear. Osteoporos Int 2014;25:
447–454.
2. Abrahamsen TC: The worn dentition-pathognomonic patterns
of abrasion and erosion. Int Dent J 2005;55(4 Suppl 1):
268–276.
3. Carlsson GE, Johansson A, Lundqvist S: Occlusal wear. A
follow-up study of 18 subjects with extensively worn denti­
tions. Acta Odontol Scand 1985;43:83–90.
4. Malkoc MA, Sevimay M, Yaprak E: The use of zirconium and
feldspathic porcelain in the management of the severely worn
dentition: a case report. Eur J Dent 2009;3:75–80.
5. Verrett RG: Analyzing the etiology of an extremely worn
dentition. J Prosthodont 2001;10:224–233.
6. Dawson PE: Evaluation, Diagnosis and Treatment of Occlusal
Problems (ed 2) St. Louis, Mosby, 1989.
7. Turner KA, Missirlian DM: Restoration of the extremely worn
dentition. J Prosthet Dent 1984;52:467–474.
8. Chu FC, Siu AS, Newsome PR, et al: Restorative management
of the worn dentition: 4. Generalized toothwear. Dent Update
2002;29:318–324.
9. Cura C, Saraçoğlu A, Oztürk B: Prosthetic rehabilitation of
extremely worn dentitions: case reports. Quintessence Int
2002;33:225–230.
10. Guttal S, Patil NP: Cast titanium overlay denture for a geriatric
patient with a reduced vertical dimension. Gerodontology
2005;22:242–245.
11. Ergun G, Cekic-Nagas I: Implant-prosthetic rehabilitation of a
patient with nonsyndromic oligodontia: a clinical report. J Oral
Implantol 2012;38:497–503.
12. Song MY, Park JM, Park EJ: Full mouth rehabilitation of the
patient with severely worn dentition: a case report. J Adv
Prosthodont 2010;2:106–110.
13. Sato S, Hotta TH, Pedrazzi V: Removable occlusal overlay
splint in the management of tooth wear: a clinical report.
J Prosthet Dent 2000;83:392–395.
14. Windchy AM, Morris JC: An alternative treatment with the
overlay removable partial denture: a clinical report. J Prosthet
Dent 1998;79:249–253.
80 IMPLANT-SUPPORTED PROSTHETIC REHABILITATION OF A PATIENT WITH LOCALIZED SEVERE ATTRITION
15. Listgarten MA, Lang NP, Schroeder HE, et al: Periodontal
tissues and their counterparts around endosseous implants. Clin
Oral Implants Res 1991;2:1–19.
16. Lee RL, Gregory GG: Gaining vertical dimension for the
deep bite restorative patient. Dent Clin North Am 1971;15:
743–763.
17. Worsaae N, Jensen BN, Holm B, et al: Treatment of severe
hypodontia-oligodontia–an interdisciplinary concept. Int J Oral
Maxillofac Surg 2007;36:473–480.
18. Ergun G, Egilmez F, Cekic-Nagas I, et al: Effect of platelet-rich
plasma on the outcome of early loaded dental implants: a three
year follow-up study. J Oral Imp 2013;39:256–263.
19. Ng DY, Wong AY, Liston PN: Multidisciplinary approach to
implants: a review. N Z Dent J 2012;108:123–128.
20. Silverman MM: The comparative accuracy of the closet-speak­
ing-space and the freeway space in measuring vertical dimen­
sion. J Acad Gen Dent 1974;22:34–36.
21. Okeson JP: Occlusion and functional disorders of the mastica­
tory system. Dent Clin North Am 1995;39:285–300.
22. Chu FC, Yip HK, Newsome PR, et al: Restorative management
of the worn dentition: I. Aetiology and diagnosis. Dent Update
2002;29:162–168.
23. Ganddini MR, Al-Mardini M, Graser GN, et al: Maxillary and
mandibular overlay removable partial dentures for the restora­
tion of worn teeth. J Prosthet Dent 2004;91:210–214.
24. Burns DR, Beck DA, Nelson SK: A review of selected dental
literature on contemporary provisional fixed prosthodontic
treatment: report of the Committee on Research in Fixed
Prosthodontics of the Academy of Fixed Prosthodontics.
J Prosthet Dent 2003;90:474–497.
25. Brännström M: Reducing the risk of sensitivity and pulpal
complications after the placement of crowns and fixed partial
dentures. Quintessence Int 1996;27:673–678.
26. Ergun G, Kaya BM, Egilmez F, et al: Functional and esthetic
rehabilitation of a patient with amelogenesis imperfecta. J Can
Dent Assoc 2013;79:157–162.
27. The glossary of prosthodontic terms. J Prosthet Dent 2005;94:
10–92.