Severe Wear Patient Case Study

A couple of months ago a patient came into my practice with severe tooth wear relative to his age. His main goal was to have a nicer smile with longer, whiter teeth.

In the video below I am going to share with you some of the initial records for this patients case. As you are watching the video I would like you to consider how you would manage this patient if he entered your practice? What would be your main concerns for providing this patient with a nicer smile and longer, whiter teeth?

Two of the questions (of course there are others as well) that I think are important when you are planning a wear case like this are:

1. Would you alter the vertical dimension?
2. What kind of guidance pattern would you design?

I would like to invite you to a Complimentary New Training Webinar on February 13, 2013 at 8pm EST. The webinar is called Managing The Severe Wear Patient and I will outline the steps involved for treating the patient featured in the video.

During the webinar I will answer the two questions above and share with you how we designed the diagnostic wax-up, provisional restorations and overall Occlusion Design for this patient.

Space is limited. Click Here to reserve your Webinar seat now.

After completing your registration you will receive a confirmation email containing information about joining the Webinar.

As always thanks for participating and feel free to add any comments or questions about this case using the link above.

Best regards,
Dr. Stephen Phelan

Please note that we are experiencing a very large number of registration requests for the webinar and it seemed to overload the system: If you receive an error  message once your information is submitted, we are sent an email notification of the problem and we will manually register you and send you your confirmation email within 24 hours. If you do not receive a registration confirmation please click here for support.

blog 1

Please note: These images below are of the patient in left and right excursions not in centric occlusion.

blog 2

Comments

  1. Joseph Tomlinson says:

    Stephen,

    This is Joseph Tomlinson. Feel free to forward the PDF to Olsa Alklu Latifi of my two articles that I sent to you. Feel free to forward them to anyone else who is interested, as well. Thank you. If you prefer that I send those .pdfs directly to Olsa Alklu Latifi I will need a contact email address. Thank you, and Thank you Olso Alklu Latifi for your interest.

    Joseph Tomlinson

  2. Julian Caplan says:

    Yosef’s treatment plan is based on the Dhal principle. This allows the posterior teeth to overerupt ( about 1mm/month) when the anterior teeth hold the bite open – either with composite or an anterior appliance ( Dahl appliance). This is a great technique for gaining anterior space but not really appropriate in this case where the posterior teeth are heavily worn and require restoration back to functional morphology. Great to use Dahl when only anterior wear predominantly present – not sure how common place this technique is used in America?
    Julian

  3. Hi Dr.Phelan,
    Thank You for the great insight into occlusion.I can’t figure how to register for 13th Feb Webinar.Sorry but can you guide?

  4. Yosef Kowalsky says:

    Hi I am ageneral dentist in Israel. I had case where the patients complaint was “can’t see my teeth when i smile”. She had worn down the incisal edges. I added composite to all 4 canines therby essentially opening her bite. I then prepped the 4 a maxillary anteriors for crowns . I waited about 2 months and all the posterior teeth erupted into occlusion, i thae finished the 4 antrerior crowns and gave her a nightime slpint. She has been happy for 5 years now with no braekage. The concept is called caniine platform i heard it from a Prosthodointist. I realy apprecitte your great inforamtive videos. I have pictures i just can’t figure out how to send them or upload them

  5. Julian Caplan says:

    Interesting thoughts Gerald except that working in CR and increasing vertical will cause the lower incisors down and back which will create space anteriorly and improves the envelope of function

    • Joseph Tomlinson DMD says:

      I fully agree with Julian

    • Joseph Tomlinson DMD says:

      I agree with Gerald’s comments that orthodontic treatment is often an important component of correcting many cases of advanced tooth shifting and wear; and I further agree that cutting teeth and crowning them is often not necessary, and is performed way too often. I am not a fan of a full mouth reconstruction that involves crowning many perfectly sound natural teeth. I am in favor of restoring vertical dimension with composite properly applied, sometimes in combination with orthodontic treatment, as well, and then restoring with crowns only those teeth that were previously heavily restored or heavily worn, where crowns are more durable than other less invasive options. I am not opposed to involving orthodontic treatment in this case, but it would not be my starting point. I would start with restoring vertical dimension with application of composite, and then restoring the anterior teeth with composite, and then a lower removable partial denture. After that, if further refinement and orthodontic repositioning is needed and desired by the patient, and something his financial situation can afford, then I would consider it.

  6. Dr Stephen Phelan says:

    Thanks for the comments Gerald. Have you had much success intruding teeth with Invisalign?
    If you look at the lip in repose view, the patient had negative tooth display at rest.
    Regards,
    Stephen

    • Dr Stephen Phelan says:

      Hi Gerald,
      Thanks for the information about Invisalign intrusion. I am hoping he has an envelope of function problem and is not a neurological based grinder. It would make the results more stable long term.
      Regards,
      Stephen

    • Joseph Tomlinson DMD says:

      I disagree that the upper incisors are positioned palatally. The spacing of the upper incisors suggests just the opposite, that they have been driven facially due to force on the lingual side. That force from the lower incisors is also accounting for the excessive wear/notching of the lingual side of the upper incisors. The tongue likely contributes to that force by pressing against the lingual side of the lower incisors, possibly moving them facially as well.

      I agree that the patient ‘wants’ more room to function, the reason being due to loss of vertical dimension over time due to missing lower molars. Restoring/increasing vertical dimension is the solution to create a ‘greater envelope of function’. My earlier posts, further down the list, explains this solution in more detail.

  7. Joseph Tomlinson DMD says:

    After reviewing the video and more records presented which I had not initially viewed I would add that I would also build up left side second molars into solid occlusion when opening VDO. Unless that is performed those molars will passively erupt back into occlusal contact over time. By maintaining the position of those teeth it provides greater interocclusal thickness to work with if future crowning of those teeth is planned. Also, I would encourage the patient to proceed with replacement of the missing upper right first premolar soon after placement of a crown on the upper right first molar.

    In my experience, opening VDO with this technique results in a nice increase in overjet for the anteriors. By eliminating all pressure from the lower incisors against the lingual of the upper incisors it allows pressure from the upper lip to act as a weak orthodontic appliance, slowly retracting the upper incisors, potentially closing the spaces between them. At the same time, the ongoing wearing of the lingual surface of the upper incisors is eliminated, and those areas are easily restored, providing extra retention for composite bonded to these teeth to restore the incisal length for improved appearance and improved speech.

    I would also like to apologize for a couple of typos in my first message, including the errant spelling of the word ‘modifications’.

  8. Hello, I have also done like Joseph, at first I raise the bite just by composite, to see If the patient Can accept the height , I then take impressiones and registrations and make a waxup for futter work.

    • Dr Stephen Phelan says:

      Thanks Jeanette,
      It seems like a popular choice to use composite resin in order to stage the case.
      Regards,
      Stephen

  9. Joseph Tomlinson DMD says:

    I would definitely increase VDO utilizing a technique I have used with much success for years. I would proceed as follows: after gaining the patients trust and full understanding of what is planned, and the expected outcome, and making financial arrangements I would start by applying a composite buildup to the upper left second premolar until it was in esthetic harmony with the upper left first molar. I would proceed to buildup the first premolar to be harmonious with the canine and second premolar. At the same visit I would apply composite to buildup to the right side second molars, upper and lower about equally, and to the right second premolars upper and lower such that the lower premolar was about level occlusally with the first premolar.

    I would then adjust these six buildups into a harmony such that they all made equal contact when the patient closed and occluded, and so that he could slide freely laterally and protrusely. I would then send him home with instructions and information about his bite changes, making sure he understood the need to return soon for step two.

    At the second visit I would re-evaluate the composites placed at the first visit, possibly adding to one or two, or reducing them, or simply refining them. Then I would proceed with the use of composite to restore all six upper anterior teeth to achieve an ideal appearance that achieves the esthetic result he wants – probably similar in shape and size to what the teeth looked like when he was much younger. If necessary I might add a little composite to a lower canine or lower incisor, as well,to achieve proper incisal guidance and canine guidance.

    I would then follow this at visit three with refinements of what has been performed to date, and proceed to make any minor modifacations as needed of the lower teeth to allow fitting of a lower partial to replace missing lower molars. I would design this to provide solid occlusal contact and function where none exists currently at the new VDO position.

    After that I would crown the upper right first molar which appears to need one. After that- we take a breather and give the claimant time to adjust and adapt and possibly reduce some of the composite contacts as needed to enhance his comfort with the occlusion. From here is it possible to leave the patient in this status for several years, or to begin placing crowns on one or two teeth at a time over several years. Eventually we would like to place implants in the lower arch to replace missing teeth that the partial denture replaces.
    With this approach most everyone can achieve ideal dentistry over time, within the limits of their insurance coverage, or within a reasonable budget they might have to work with.

    I have published articles on this technique in the Journal of the Colorado Dental Association and the Journal of the Nevada Dental Association. I have also lectured on this technique. For more information feel free to contact me.

    • Dr Stephen Phelan says:

      Thanks Joseph,
      These are great ideas about staging a case like this!
      Do you have a PDF version of your article?
      Regards,
      Stephen

      • Joseph Tomlinson DMD says:

        Yes I do have PDF versions of the articles. I will be happy to forward them to you.

        • Dr Stephen Phelan says:

          Thanks Joseph, I received it and plan to read it this weekend. Great job!
          Stephen

          • Olsa Alklu Latifi says:

            Dr Joseph Tomlison may I also have that PDF version of your article.Its just what I was looking for.Thankyou in advance.

          • Olsa Alklu Latifi says:

            Dr Joseph Tomlison may I also have that PDF version of your article.Its just what I was looking for.Thankyou in advance.

  10. Alvin Matteson says:

    1. Altering OVD, What are facial thirds, how much space dose he have form rest to MIP? Deterring the turners classification would determine if you could open up OVD? The fricative sounds is there any issue with speech. Dose the patient have altered passive eruption. How doe the patient feel about excessive gingival display? How open is Centric Occlusion? With this information and start of wax up form 6-11, with out the alteration of 22-27, the look at the posterior occlusal plane and may have to alter further for posterior plane.

    2. I like to set up the case with mutually protected, progressive disclusion, Once the provisional are in there will be some time to adjust them to a guidance the patient can tolerate. The provisional will be guide for final restrations.

  11. Julian Caplan says:

    The initial assessment shows that at rest the patient does not show any incisal edge. On a full smile with a hypermobile lip the patient shows less than 2mm of gingivae. The conclusion from this is to lengthen the upper teeth incisally. Now the question is how ? There is a slide from CR to CO – working in CR position will stop any restriction in the patients anterior envelope of function. Opening the bite by.5 to .75mm on the molar teeth , with the 3:1 ratio anterior to posterior, will gain approx 2mm anteriorly. If the patients posterior teeth were good quality I would use a Dahl appliance to gain anterior space. However as the patient has heavily restored teeth full cover crowns will be more appropriate. By opening the bite the lower incisors move down and back – they do not require restoring or lengthening. In order to establish anterior guidance full crowns will also be required on the upper anterior teeth. My occlusal design will be low angle canine guidance to allow immediate disclusion of posterior teeth but not with a steep vertical component. Upper and lower missing teeth will require replacement( probably ideally with implants bone allowing) for posterior stability and function . All restorative phases worked out in provisionals to ensure stability and function before converting to final restorations.

    • Dr Stephen Phelan says:

      Excellent feedback Julian! That sounds very similar to what we have done. We had a cool technique to work out the vertical and overbite in the wax-up that I will share during the webinar.
      Regards,
      Stephen

      • Julian Caplan says:

        OVD increase is often determined by aesthetic considerations as well as functional. In this case I would increase the incisal length using flowable composite directly in the mouth until an aesthetic length is achieved and approved by the patient. This can then be removed from the teeth and replaced on the mounted study models. This will then give a guide to the appropriate OVD for this patient – the required increase in OVD for the posterior teeth and the required anterior guidance to allow transitional anterior group function from canine to lateral/central incisors for this increased incisal length.
        Very interested in seeing how you deal with this issue.
        Kind regards,
        Julian

  12. Upen Vithlani says:

    Hi,

    I am trying to register for the webinar, but a 404 error shows indicating that the page no longer exists.
    Can you please assist?

    Thanks,

    Upen

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