R E S T O R A T I V E D E N T I S T R Y

Restorative Management of
the Worn Dentition: 4.
GeneralizedToothwear
FREDERICK C.S. CHU, ADAM S.C. SIU, PHILIP R.H. NEWSOME,
TAK W. CHOW AND ROGER J. SMALES
tooth preparation with better
Abstract: This is the final paper of a four part series on the management of worn retention and resistance forms.
dentition. The factors affecting the selection of restorative techniques for generalized
l In cases where there is no stable
toothwear, such as pulpal vitality, jaw relationship and occlusal guidance are discussed.
The practical steps of oral rehabilitation using fixed prostheses are illustrated with two occlusal relationship because the
clinical cases. existing dentition is severely
damaged or the patient is partially
Dent Update 2002; 29: 318–324 edentulous, the need for a
reorganized approach is obvious.
Clinical Relevance: Generalized toothwear requiring complex rehabilitation
should be managed by a systematic step-by-step approach.
With extensively broken teeth, pulpal
vitality must also be determined before
restorative treatment is carried out.

lthough ‘full-mouth reconstruction’ also reduces the costs involved. The

A is a treatment option for generalized
toothwear, it is not always necessary
major drawbacks are the need to sacrifice
the tooth substance of the already
Non-vital Teeth
For non-vital teeth endodontic treatment
because a dentition may still function shortened clinical crown, and a more can be carried out with the root canal
adequately for mastication and speech, subgingival placement of preparation space prepared for subsequent crowns
and patients may accept the appearance of margins for retention of extra-coronal and the support of removable partial
their teeth. restorations. dentures. Removable partial dentures may
A ‘conformative’ occlusal approach If multiple restorations are required it is also be used to increase the OVD and to
may be used for management of important to decide whether a protect the worn teeth as an onlay
generalized toothwear when the coronal ‘reorganized’ occlusal scheme should be denture, an overlay denture or an
tissues are moderately worn, and if only a used for the management of the overdenture1 (Figure 1).
few teeth require restorative treatment. moderately worn dentition, even though
Placement of a small number of intra-/ the OVD may still be satisfactory. l An onlay denture extends over the
extracoronal restorations in a moderately incisal or occlusal surfaces of worn
worn dentition with a satisfactory existing l The reorganized approach with an abutment teeth with tooth-coloured
occlusal vertical dimension (OVD) and increased OVD is appropriate when acrylic resin, and forms a ‘butt joint’
stable occlusal relationships not only the worn teeth still have an adequate on the labial or buccal surfaces. Use of
simplifies the treatment procedures but amount of crown height because an onlay denture is not recommended
there is virtually no need to reduce if the resin/tooth junction is visible.
Frederick C.S. Chu, BDS(Hons), MSc, FRACDS, further occlusal tooth substance for l An overlay denture ‘laminates’ the
MRDRCS, FADM,Assistant Professor, Adam S.C. adhesive or conventional castings. labial surfaces of the worn teeth with
Siu, BDS, Postgraduate Student, Philip R.H. l When the worn teeth are short and tooth-coloured acrylic resin, which is
Newsome, BChD(Hons), MBA, PhD, FDS require restorations, an increase in usually supported by a metal
RCS(Edin.), MRDRCS(Edin.),Associate Professor, OVD is frequently combined with framework or polymeric denture base
Tak W. Chow, BDS, MSc, PhD, FRACDS, FDSRCS,
DRDRCS,Associate Professor, Faculty of Dentistry, surgical crown lengthening. This material.
The University of Hong Kong, and Roger J. approach may allow more l An overdenture with fully extended
Smales, MDS(Hons), DDSc, FDSRCS, FADM, supragingival placement of margins, flanges may be constructed if a border
Visiting Research Fellow, Dental School,Adelaide reduce the risk of pulpal exposure seal is required for retention of the
University,Australia. during tooth reduction, and create prosthesis. Retention of the

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rate the patient will present with normal

RVD, FWS and OVD.
Many authors have been concerned
that further increase of the OVD may
jeopardize the balanced activities of
masticatory muscles, which may lead to
tooth mobility, repeated failure of
restorations, clenching, and even
myofascial pain.2,3 In dentate patients, in
contrast to edentulous patients, an
increase of OVD and a ‘change’ of FWS
appear well tolerated. Electromyographic
studies have shown that the muscles of
mastication are able to adapt to an
increased OVD when there are stable
Figure 1. Worn dentition and denture designs. occlusal contacts:4 as OVD is increased
the mandible adopts a new resting
overdenture may be further improved An appropriate OVD for treatment (postural) position, with a decrease in
by incorporation of magnets, should allow adequate space available for activity of the elevator muscles and an
precision attachments on natural restorations and maintain contacts increase in activity of the depressor
roots or implants. between the restored anterior teeth. If muscles;5–7 the FWS will thus be re-
toothwear is not compensated for by established. Such re-establishment of
Irrespective of the denture design dentoalveolar growth, then restoration of FWS has also been reported in patients
selected, oral health measures are OVD would be well tolerated. with temporomandibular dysfunction who
imperative to maintain the periodontal A decision on whether dentoalveolar were treated with occlusal splints.8
health, pulp vitality, and caries-free crown/ growth has compensated for toothwear The difference between edentulous
root surfaces of denture abutments. relies on the crude clinical assessment of and dentate patients may be explained
the relationship between resting vertical by the mechanoreceptors in the
dimension (RVD), freeway space (FWS) periodontal ligaments, which are
Vital Teeth and OVD. Theoretically, if the RVD and responsible for input of changes to the
With the deposition of secondary dentine, OVD are reduced, and FWS is normal, nervous system for generating
it is not unusual to find severely worn restoration of the OVD and RVD are adaptation.
teeth with vital pulps. A combination of straightforward. With a normal RVD, There is no firm clinical
periodontal surgery and core build-up reduced OVD, and an increased FWS, recommendation available for clinicians
techniques may be considered to preserve restoration of the OVD with a reduction of to determine if an increased OVD will be
the pulp vitality before elective FWS is also generally acceptable (Figure adapted. With extensive restorative
devitalization. Increasing the OVD using 2). If dentoalveolar growth has treatment, it seems prudent to use an
post crowns may increase the risk of successfully compensated for the wear occlusal splint as a reversible means of
longitudinal root fracture unless adequate
full-mouth contacts at the increased OVD
can be established and maintained.

VERTICAL DIMENSION
In dentate patients presenting with
generalized toothwear, interocclusal
clearance can be provided with an
increase of OVD. The amount of OVD
increase required depends on:

l whether one or both arches have to

be restored;
l the chosen restorative technique;
l the properties of the restorative
material; and
l the patient’s ability to adapt. Figure 2. Consideration of the vertical dimension.

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becomes available between the maxilla in ICP or ‘delayed’ if there is no contact

and mandible for re-establishment of between anterior teeth in ICP, such as
occlusal scheme. with Class II division 1 malocclusion.
Delayed disclusion may occur when a
small amount of protrusive jaw
OCCLUSAL GUIDANCE movement (or ‘long centric’ movement)
is required before anterior teeth contact
and cause disclusion of posterior teeth.
Definitions Regardless of the timing for
Figure 3. Case 1: generalized occlusal toothwear ‘Anterior occlusal guidance’ can be disclusion, it is desirable to have all
of the lower dentition (occlusal view). defined as the effects of the articulating anterior teeth sharing the guidance,
surfaces of anterior teeth on the except when a tooth is heavily restored
assessing the patient’s acceptance of mandibular movements, and ‘posterior or periodontally compromised. At ICP,
increased OVD. occlusal guidance’ as the effects of ‘palatal platforms’ may be incorporated
posterior teeth. For patients with severe in upper anterior restorations to allow
Class II division 1 and Class III incisal occlusal forces to dissipate more along
ANTEROPOSTERIOR JAW relationships, the occlusal guidance will the long axes of the teeth. These
RELATIONSHIP rely on posterior teeth only. platforms may also reduce the risk of
Although an increased OVD can ‘Posterior determinant’ can be broadly over-eruption and labial drifting of the
instantly create interocclusal clearance defined as the effects of upper anterior teeth.
for restorations, the existing occlusal temporomandibular joints on mandibular
relationship will be lost. Therefore a new movements. ‘Anterior determinant’ refers
occlusal scheme has to be planned and to effects of dental articulation including Lateral Excursion
tested before any irreversible changes both anterior and posterior teeth. Occlusal guidance is also responsible
are made. The differences between, and for lateral excursion contacts.
the advantages of, various occlusal
schemes have been summarized Mandibular Protrusion l Canine guidance occurs when only
elsewhere.9 For restorative dentistry, The selected anterior occlusal guidance the canine on the working side
different occlusal schemes have should be aesthetically and contacts in lateral mandibular
different requirements for physiologically acceptable to the movement.
anteroposterior jaw relationship patient, and convenient for the dentist l Group function occurs when two or
between retruded contact position (RCP) and technician to prepare. more pairs of teeth on the working
and intercuspal position (ICP), and In mandibular protrusion, the concept side contact and provide disclusion
occlusal guidance. of posterior disclusion by anterior of the non-working side.
The anteroposterior jaw relationship occlusal guidance is recognized as the
affects the relationship between basis for physiological desirability: There is little evidence to support one
maxillary and mandibular teeth. posterior disclusion/elimination of occlusal scheme over another but,
Extensive occlusal restoration should posterior contacts in mandibular irrespective of the occlusal guidance
not even be contemplated until the protrusion, rather than canine contacts selected, there must be disclusion of the
desired jaw relationship has been alone, reduces the elevating activity of non-working side. Achievement of
established. For practical purposes, it is temporal and masseter muscles.10 group function is technically demanding
generally accepted that the RCP is Posterior disclusion may be ‘immediate’ and usually requires intra-oral
reproducible, and the retruded axis of if there is contact between anterior teeth adjustments, using only a semi-
rotation of the mandible can be used as
a reference for extensive rehabilitation to
make the anteroposterior jaw a b
relationship of a new ICP coincident
with that of RCP. When there is a large
horizontal and small vertical difference
between RCP and original ICP, it is very
difficult to achieve occlusal contacts in
the case of a small amount of protrusive
jaw movement.
Once the new OVD and the axis of
Figure 4. Case 1: (a) Occlusal view showing generalized occlusal toothwear of the upper
mandibular rotation have been dentition. (b) Frontal view of occlusion at original OVD.
determined, a static jaw relationship

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provided is open to question. 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.11,12
Once the patient has adapted to the
new occlusion, a sequential posterior-
anterior-posterior approach (PAP) can be
adopted for full mouth reconstruction.13
Figure 5. Case 1: right buccal view The first ‘P’ refers to establishment of Figure 7. Case 1: right buccal view showing resin
demonstrating the amount of increase in OVD. posterior stability/support by temporary composite build-up for posterior stability.
restorations, which is a pre-requisite for
adjustable articulator. However, with the introduction of anterior guidance
canine guidance, consideration must (represented by ‘A’) using temporary or
still be given to the contacts that may permanent restorations. With temporary
develop should wear occur on the restorations, anterior guidance can be
canine surfaces. further evaluated before its transfer to
Disclusion of the non-working side permanent restorations, using a custom-
can be ‘immediate’ or ‘delayed’ in lateral made incisal guidance table. The second
excursion. A ‘delayed’ disclusion of the ‘P’ refers to the provision of posterior
non-working side (or ‘wide centric’) stability/support by permanent
Figure 8. Case 1: the restored upper dentition
occurs when a small amount of lateral restorations. (occlusal view).
jaw movement is needed to enable the The following cases illustrate how
guiding teeth, such as the canines, to generalized toothwear could be managed
contact and provide disclusion in lateral with fixed and removable prostheses.
excursion.

CASE STUDIES
PRACTICAL
CONSIDERATIONS OF ORAL
REHABILITATION Case 1
Before irreversible fixed prostheses are A healthy 67-year-old man presented
provided it is advisable to use a with severe pain from 6|. On examination,
Figure 9. Case 1: left buccal view showing the
reversible device, such as a hard maxillary exposure of secondary dentine and the space after debonding palatal veneer on canine.
occlusal splint or removable overlay root canals of 6| could be seen clinically
denture, to evaluate a patient’s adaptive as a result of severe occlusal wear (Figure
ability to the new occlusal scheme and 3). Dentine sensitivity, especially to for mandibular protrusion, while the
protect the remaining tooth tissues. contact with cold water, was associated canines and all posterior teeth were
However, quite how an asymptomatic with teeth showing generalized toothwear involved in lateral excursions.
patient with worn dentition should be (Figure 4). There was minimal difference
monitored with splint wearing before the between ICP and RCP. The upper and Treatment
definitive restorative treatment is lower central incisors were responsible After completion of endodontic treatment
of 6|, an upper acrylic occlusal splint was
constructed at a 4 mm increase of OVD to
a b protect the worn dentition, and to assess
the adaptation of the patient to a
reorganized occlusal scheme (Figure 5). A
‘mutually protected’ occlusal scheme was
used. Canine guidance was used for
lateral excursions, while anterior guidance
was shared among all the anterior teeth.
After the patient had adapted to the
new occlusal scheme, temporary nickel-
Figure 6. Case 1: (a) occlusal view showing the amount of anterior space created by palatal chromium palatal veneers were
veneers bonded on upper canines. (b) The amount of posterior separation is visible on the right constructed on 3| and |3 according to an
buccal view.
incisal guidance table fabricated with the

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After cementation of all posterior

restorations with a resin cement (Panavia
F, Kuraray, Osaka 530, Japan) the palatal
veneers on 3|3 were debonded (Figure 9)
and it was confirmed that group function
could be achieved in the absence of
canine guidance. The incisal edges of the
lower canines were then restored with
resin composite, and two gold palatal
Figure 10. Case 1: frontal view of the restored veneers without incisal overlap were Figure 13. Case 2: prepared lower anterior teeth
dentition at increased OVD. cemented on 3|3 (Figure 10). after core build-up using a cermet cement.

occlusal splint. The palatal veneers final restorations for all anterior teeth
Case 2
established an accurate increase in OVD, except |2, for which a pontic with cervical
and provided occlusal guidance (Figure A 50-year-old woman was referred pink porcelain was used. The posterior
6). Initial posterior support and because of generalized worn dentition. teeth were then prepared in four sextants
restoration of the worn posterior teeth The patient’s periodontal health was for ceramometal and gold crowns
were achieved using a posterior resin excellent, but endodontic treatment was (Figures 14 and 15).
composite (SureFil, Dentsply, Milford, performed for 4|, |7 and 7|. All of the
DE 19963-0359, USA) (Figure 7). Anterior posterior teeth had been extensively and
guidance was re-established with gold repeatedly restored with amalgam SUMMARY
palatal veneers on 21|12, labial porcelain because of caries and toothwear. The In addition to fixed adhesive and
veneers on 1|1 and incisal resin- upper anterior teeth had been previously conventional castings, removable partial
composite restorations on 2|2 (Figure 8). restored with porcelain jacket crowns, dentures, or a combination of both fixed
One month after anterior guidance was which accelerated the wear of the lower and removable prostheses, may be
re-established the premolars and molars anterior teeth (Figure 11). Little difference considered in the management of
on both sides were prepared in two visits. was found between the RPC and ICP. generalized toothwear.
Full-arch impressions were taken for the There was Class II division 2 incisal It is very uncommon for the severity
construction of adhesive gold onlays on malocclusion, with mandibular protrusion of toothwear to be the same in different
654|6 and |56, full gold crowns on 76| and guided by the lower incisors against the parts of the dentition, even in patients
a cantilever conventional ceramometal coarse porcelain surfaces of upper with ‘generalized’ toothwear, and
bridge to replace a missing first premolar. crowns. Group function was present for patients with generalized toothwear
lateral excursions on both sides. From the
articulated study casts, unstable contacts
between the heavily restored upper and
lower posterior teeth in ICP were noted.

Treatment
To evaluate the patient’s ability to adapt to
an increased OVD and a new reorganized
occlusal scheme, a lower overlay denture
was constructed to cover 321|123. An
upper onlay denture was also used to
Figure 11. Case 2: worn lower anterior teeth, provide even bilateral posterior support Figure 14. Case 2: frontal view showing the
frontal view. finished restorations.
(Figure 12). The use of two separate partial
dentures maintained posterior support
while the anterior teeth were undergoing
reconstruction. The lower onlay denture
also temporarily restored the appearance
of the worn teeth.
After 2 months, pin-retained core build
ups were placed on the worn lower
anterior teeth 1|12 at an increased OVD,
using a cermet material (Ketac Silver,
Figure 12. Case 2: overlay denture at increased ESPE, D-82229 Seefeld, Germany) (Figure Figure 15. Case 2: left buccal view, showing
OVD in place. 13). Ceramometal crowns were used as posterior separation in mandibular protrusion.

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should be regarded as having

predominantly anterior or posterior Generalized toothwear
toothwear. Our treatment philosophy is to
restore function and aesthetics by

Need restorative care?
preserving and protecting the remaining
tooth tissue, with minimal alteration of the
Yes No
supporting structures and occlusal
relationships. Extraction of the worn teeth

and their replacement with partial or Adequate coronal tissues for Review/monitor
complete dentures without first adhesive/conventional castings? ± preventive care
thoroughly exploring the possibility of
more conservative approaches is
unacceptable: extraction should be used Yes No (severe toothwear)
only in the last resort if the existing teeth
are unsalvageable, or if replacement of


such teeth is not essential. It may be more Existing OVD satisfactory? Teeth require endodontic treatment
appropriate to accept a sub-optimal
aesthetic outcome based on the existing Yes No Yes
worn teeth, such as partial restoration of
the crown length of the worn incisors with


Full arch restorations At increased OVD restore with No
resin composite or onlay denture, rather required? Yes
adhesive/conventional castings
than an ‘optimal’ aesthetic appearance OR post-crown
with acrylic denture teeth replacements. OR overdenture
Successful management of different No
degrees of toothwear requires early
diagnosis of the problem and an




understanding of the different treatment At existing OVD, restore At increased OVD, restore At increased OVD, restore
strategies and techniques available, and with adhesive/conventional with adhesive/conventional with adhesive/conventional
of the properties of dental materials. castings using ‘every other castings OR overlay casting after:
Close co-operation with dental tooth’ technique denture 1. core build-up
2. crown lengthening
specialists such as orthodontists, 3. post-crown after
periodontists and prosthodontists is elective endodontics
necessary when there are opportunities OR overlay denture
for improved treatment results. OR overdenture after
The restorative management of elective endodontics
generalized toothwear is outlined in Figure
Figure 16. Flowchart of management of generalized toothwear.
16. Successful maintenance requires
regular recall for monitoring and
preventive measures.
toothwear. Dent Update 1995; 22: 52–59. mandibular postural rest position. Int J Prosthodont
2. Tench RW. Dangers in dental reconstruction 1994; 7: 216–226.
involving increase in the vertical dimension of the 8. Hellsing G. Functional adaptation to changes in
lower third of the human face. J Am Dent Assoc vertical dimension. J Prosthet Dent 1984; 52: 867–
ACKNOWLEDGEMENTS 1938; 25: 566–570. 870.
We would like to express our gratitude to Mr Anthony 3. Schyler CH. Problems associated with opening the 9. Wassel RW, Steele JG,Welsh G. Considerations
C.K. Kam and Mr K.B.Wong at the Prince Philip bite which would contraindicate it as a common when planning occlusal rehabilitation:A review of
Dental Hospital for their excellent technical support. practice. J Am Dent Assoc 1939; 26: 734–740. the literature. Int Dent J 1998; 48: 571–581.
We would also like to thank Mr Michael Nesbit of 4. Carlsson GE, Ingervall B, Kocak G. Effect of 10. Williamson EH, Lundquist DO.Anterior guidance:
the Department of Conservative Dentistry, Eastman increasing vertical dimension on the masticatory Its effects on electromyographic activity of the
Dental Institute, for his assistance in laboratory system in subjects with natural teeth. J Prosthet Dent temporal and masseter muscles. J Prosthet Dent
work. Special thanks must be directed to Mr 1979; 41: 284–289. 1983; 49: 816–823.
Raymond Leung and Mr Tat M.Yim for their help in 5. Manns A, Miralles R, Gurreo F. The changes in 11. Calagna LJ. Influence of neuromuscular
clinical photography and professional drawings. This electrical activity of the postural muscles of the conditioning on centric relation registration.
study was funded by the Committee on Research mandible upon varying the vertical dimension. J Prosthet Dent 1973; 30: 598–604.
and Conference Grants, University of Hong Kong. J Prosthet Dent 1981; 45: 438–444. 12. Setchell DJ. Periodontal diagnosis and treatment
6. Carr AB, Christensen LV, Donegan ST et al. and occlusal analysis. In: Rowe AH,Alexander AG,
Postural contractile activities of human jaw muscles Johns RB, eds. A Companion to Dental Studies.
following use of an occlusal splint. J Oral Rehabil Oxford: Blackwell Scientific, 1986; pp.497–519.
REFERENCES 1991; 18: 185–191. 13. Wise MD. Occlusion and Restorative Dentistry for
1. Hemmings KW, Howlett JA, Woodley NJ, Griffiths 7. Gross MD, Ormianer Z. A preliminary study on the the General Dental Practitioner. London: British
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