RESTORING ESTHETICS AND ANTERIOR

GUIDANCE IN WORN ANTERIOR TEETH:

A CONSERVATIVE
MULTIDISCIPLINARY APPROACH
FREDERICK MCINTYRE
J Am Dent Assoc 2000;131;1279-1283

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 C O V E R S T O R Y

RESTORING ESTHETICS AND ANTERIOR

GUIDANCE IN WORN ANTERIOR TEETH
A CONSERVATIVE MULTIDISCIPLINARY APPROACH
FREDERICK MCINTYRE, D.D.S.

Downloaded from jada.ada.org on December 5, 2008

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

JADA, Vol. 131, September 2000 1279

Copyright 1998-2001 American Dental Association. All rights reserved.
COVER STORY
Figure 1. A patient with worn anterior dentition. Figure 2. The stereographic tracing technique.
teeth at night.
Bruxism
was classified
by Ramfjord
and Ash1 into
two categories:
centric (verti-
cal loading
during waking
hours) and
eccentric
(grinding into
lateral excur-
sion while
sleeping).
There are a
number of rea-
sons why peo-
Figure 3. The Behren Hanau Clinometer (Waterpik
Technologies). ple clench and
grind their
teeth, and
success is the recognition of they generally fall into one of
the causative factors and nec- two categories: psychological
essary restorative corrections. and odontogenic. A number of
The case presented in this studies discuss the etiology of
article is that of a 24-year-old bruxism and the controversial
man who was seeking esthetic role that teeth play in the
dental treatment because he process.1-4,10,12-14
was unhappy with the appear- Whatever the cause of
ance of his maxillary anterior occlusal instability, it is impor-
teeth. He was unaware of the tant that the restorative dentist
causal relationships between be able to recognize its signs. It
the severe wear of his anterior is these signs that give the
teeth and the alteration of his clues to the location and extent
smile. His concerns were of damage to the teeth and the
esthetic, not functional. During corrections that are necessary
the review of his dental history, to reduce the wear caused by
he related that he ground his the patients bruxism. By recog-
1280 JADA, Vol. 131, September 2000
Copyright 1998-2001 American Dental Association. All rights reserved.
nizing signs of instability such
Downloaded from jada.ada.org on December 5, 2008
as tooth hypermobility, tooth
wear, abfractions, periodontal
breakdown, occlusal dimpling,
stress fractures, exostosis, mus-
cle enlargement and loss of pos-
terior disclusion, the restorative
dentist can interpret the wear
patterns and design a treat-
ment that will protect the teeth
or at least reduce the rate of
wear.5 A dentist can recognize
the signs of instability only by
taking a thorough medical and
dental history; conducting a
complete head, neck and oral
examination; and reviewing
accurate diagnostic casts
mounted on a semiadjustable
articulator in centric relation.
To develop the functional
stability necessary for the suc-
cess of the treatment, the den-
tist must evaluate the determi-
nants of occlusion. The muscles
of mastication must be exam-
ined and palpated for tender-
ness. The condition of the tem-
poromandibular joints, or TMJs,
should be evaluated. A determi-
nation of the relationship of the
condylar guidance to the anteri-
or guidance has to be evaluated
in cases associated with severe
anterior wear.5 For the results
of the patients treatment to be
stable, the following criteria
must be satisfied:

Figure 4. Tooth-size indicator (Trubyte, Dentsply).
dthe patient can function from
centric relation without occlusal
interferences;
dthe TMJ can be loaded with-
out tenderness;
dthere are centric stops ante-
riorly between the maxillary
and mandibular anterior teeth;
danterior coupling allows for
disclusion of the posterior teeth;
dthe teeth are positioned in
balance with the tongue and
facial muscles.5
DEVELOPING ESTHETICS
AND ANTERIOR
GUIDANCE: DIAGNOSTIC
PREVIEW
Once the restorative dentist has
a thorough understanding of
the causal factors related to the
damage of the patients teeth,
he or she then can begin gath-
ering the information necessary
to create a diagnostic preview of
Copyright 1998-2001 American Dental Association. All rights reserved.
Figure 5. Cephalometric tracing of the patient.
the final restorations. The diag-
nostic preview will be used to
develop the relationship between
the condylar and anterior guid-
ance; to establish the esthetic
In many cases,
dentists overlook
or misunderstand
the importance of
establishing anterior
guidance.
requirements for the final
restorations; to create templates
for periodontal surgery, tooth
preparation and temporization;
and to set up the incisal guide
table on the articulator.
COVER STORY
Downloaded from jada.ada.org on December 5, 2008
I created the diagnostic pre-
view for this patient on the
Denar Combi articulator (Water-
pik Technologies). I used this
articulator because it allowed for
a more precise mapping of the
condylar movements by means
of a stereographic tracing tech-
nique (Figure 2). The maxillary
cast was mounted on the articu-
lator using a spring bow, and to
ensure that the technician
would have an accurate repre-
sentation of the incisal edges to
the pupillary line, I used the
Behren Hanau Clinometer
(Waterpik Technologies) to
transfer the relationship to the
articulator (Figure 3). To deter-
mine the size and shape of the
maxillary central incisor, and
develop the relationship of
tooth size and shape for the
lateral aspect and canine from
JADA, Vol. 131, September 2000 1281
COVER STORY
Figure 6. Developing a diagnostic preview.
Figure 8. Final restorations.
a denture mold guide, I used a
tooth-size indicator (Trubyte,
Dentsply) (Figure 4).6
In many cases, dentists
overlook or misunderstand the
importance of establishing
anterior guidance. With this
particular patient, establish-
ing anterior guidance was
paramount to the success of
the treatment. In cases in
which the anterior teeth exhib-
it stability, anterior guidance
can be developed using the
existing guidance. However, in
this case, the instability dic-
tated an alternate approach.
(As a point of interest, it has
been suggested that anterior
guidance can be developed
using phonetics, computer gen-
erated axiography or cephalo-
metric tracing.5)
1282 JADA, Vol. 131, September 2000
Copyright 1998-2001 American Dental Association. All rights reserved.
Figure 7. Preparation design.
For this
patient, I used
information
gathered from
the tooth size
indicator and
the cephalo-
metric tracing
to determine
the maxillary
incisal edge
position of the
central incisor
(Figure 5).
The cephalo-
metric tracing is valuable for
determining the interincisal
angle, the position of the
upper central incisors and the
position of the lower central
incisors and for facilitating a
profile analysis.7 By transpos-
ing the length of the central
incisor on the cephalometric in
relation to the NA line, I estab-
lished the position of the max-
illary incisal edge and meas-
ured the overjet and overbite
on the cephalometric tracing.
I used information gathered
from intraoral photographs to
establish gingival symmetry at
the proper height on the diag-
nostic casts. Then, on the basis
of information from the cephalo-
metric tracing, I developed the
diagnostic preview of the final
restorations (Figure 6).
CLINICAL TREATMENT
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The clinical treatment began
after completion of the diagnos-
tic preview, which allowed me
to visualize the final restoration
and to fabricate the templates
for perioesthetic recontouring,
tooth preparation and
temporization.
The initial stage in the clini-
cal treatment of the patient was
periodontal recontouring. The
severe wear of the anterior
teeth had created eruption of
the anterior teeth. The eruption
patterns were varied owing to
the unequal wear of the teeth,
leaving gingival asymmetry.
Using information gathered
from intraoral photographs and
from the diagnostic preview, I
fabricated clear plastic tem-
plates for the periodontist, so
that the gingival asymmetry
could be corrected and the max-
illary premolar could be
exposed to improve the buccal
corridor.
After healing, the patient
was scheduled for tooth prepa-
ration. The design of the tooth
preparation should encompass
necessary reduction relative to
tooth position and the require-
ments of the restorative materi-
al. The review of the cephalo-
metric tracing indicated the

need for a modification in
preparation design that result-
ed in the conservation of tooth
enamel. Because of the position
of the teeth in the arch, facial
reduction was reduced, while
lingual incisal reduction was
increased to accommodate the
more labial position of the final
restorations (Figure 7). Reduc-
tion of the labial surface of the
tooth accommodated the manu-
facturers requirements for the
material to circumvent the
porcelain veneers propensity to
crack,8 while conserving labial
enamel. The lingual-incisal
reduction satisfied the manu-
facturers requirements for the
restorative material to prevent
fracture as a result of occlusal
loads. The use of the diagnostic
preview and of the cephalomet-
ric tracing allowed for addition-
al contour of the porcelain
veneers, which is a key element
in enamel preservation.9 After
preparing the teeth, I took an
impression and, using an ante-
rior jig, a new centric relation
record.
Temporization was accom-
plished by means of a template
fabricated from the diagnostic
preview and a resin-based com-
posite material (Provipont DC,
Ivoclar). The composite tempo-
rary restorations were placed
with spot etching and allowed to
remain in place for three
months as a test of the vitality
of the diagnostic workup. I pro-
vided the patient with a soft
mouthguard at the time of tem-
porization to protect the restora-
tions during his bruxing
episodes.
Photographs, the diagnostic
preview and the articulator
with the custom anterior guide
Copyright 1998-2001 American Dental Association. All rights reserved.
were sent to the laboratory for
use in fabricating the final
restorations (Figure 8). Brux-
ism may continue even after
the teeth have been reposi-
tioned to reduce wear and to
establish esthetics and a new
anterior guidance.11 Therefore,
after placing the final restora-
tions, I provided the patient
with a hard acrylic occlusal
guard to protect the restora-
tions during his bruxing
episodes.
Many steps are involved in
The use of the
diagnostic preview
and of the
cephalometric tracing
allowed for additional
contour of the
porcelain veneers,
which is a key
element in enamel
preservation.
creating restorative excellence
in a case such as this. When
restoring the worn dentition,
the clinician should bear in
mind the five Ps: proper plan-
ning prevents poor performance.
CONCLUSION
Advances in dental materials
and technology have given prac-
ticing dentists the ability to cre-
ate beautiful smiles for their
patients. In doing so, dentists
have the responsibility of devel-
oping proper form and function
to protect the integrity of the
COVER STORY
masticatory system. Dentists
must blend the new materials
and technology with traditional
functional concepts to be suc-
cessful. As the case presented
here demonstrates, this combi-
nation of innovation and tradi-
tion is achievable with careful
planning.
Dr. McIntyre is a clinical associate profes-
sor of restorative dentistry; the director,
Postgraduate Prosthodontics; and the direc-
tor, Esthetic Dentistry Education Center,
University at Buffalo, State University of
New York, School of Dental Medicine, 222
Squire Hall, Buffalo, N.Y. 14214. Address
reprint requests to Dr. McIntyre.
Downloaded from jada.ada.org on December 5, 2008
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