R E S TO R AT I VR

E EDSE TN O
TRI SATTR IY V E D E N T I S T R Y

A Question of Space: Options for the

Restorative Management of Worn
Teeth
K. DYER, R. IBBETSON AND N. GREY

maxillarymandibular relationship on
Abstract: The prevalence of tooth surface loss has increased in recent years. The closure is accepted. It can be suitable
essence of management is an effective preventive regime; however, in many instances
for restoration of a single tooth or small
restoration may also be necessary. A number of strategies is available for creating
sufficient space to enable restoration and several techniques for restoration known. group of teeth. Examples are:
This article reviews the significance of the vertical dimension of occlusion and
describes the restorative management of a patient affected by severe toothwear. ! reducing the teeth in the same or
opposing arch;
Dent Update 2001; 28: 118-123 ! surgical lengthening of the crown.
Clinical Relevance: There is a variety of ways in which the restorative treatment
of worn teeth may be managed. The reader should understand the principles Reducing the Teeth in the Same Arch or the
underpinning the different approaches to restorative care.
Opposing Arch
This approach would be appropriate if
there were adequate tooth tissue to
allow for conventional preparation,
oothwear, defined as the preparations with adequate retention which is rarely the case. Making a crown
T pathological, non-carious loss of
tooth tissue, is becoming an
and resistance form and acceptable
aesthetics can be difficult.
preparation on short teeth leads to
broad, wide occlusal surfaces where
increasingly common problem in This article addresses some of the stability is hard to produce and the
restorative dentistry as more patients problems and presents a case to preparations beneath these restorations
retain their natural teeth. The aetiology demonstrate practical steps in generally have poor resistance form. It
is well known and there is rarely a single treatment. can make sense to follow this approach
cause; usually it is a combination of when making a solitary restoration; what
erosion, attrition and abrasion. When seems less appropriate is to do the same
damage to the dentition has been CREATING SPACE FOR thing repeatedly, ending up with a
significant and restoration is necessary, RESTORATIONS reconstruction done by degrees under
the main difficulties in providing A number of methods can be used to less than ideal occlusal relationships. If
treatment are the reduced clinical crown create space for restorations. These repeated restorations are necessary it is
height and the lack of interocclusal may be subdivided into methods based sensible to adopt some of the strategies
space for the restorations. If traditional on using: that allow restorations with better form
crowns are required, creating and mechanical properties to be made.
! a conformative occlusion, where the
existing position of mandibular Surgical Crown Lengthening
closure is maintained; or One way of exposing more tooth
K. Dyer, BDS, MFDS RCPS, Senior House Officer,
Edinburgh Dental Institute ,R. Ibbetson, BDS, MSc,
! a reorganized occlusion, where the structure is by surgical crown
FDS RCS (Eng.), FFGDP (UK), Professor of Primary position of closure is altered. lengthening. This is a significant
Dental Care, Edinburgh Postgraduate Dental undertaking for both the operator and
Institute, and N. Grey, BDS, MDSc, PhD, DRD, the patient. The procedure is carried out
MRD, FDS RCS (Edin.), Consultant in Restorative Conformative Approach on a number of teeth and generally
Dentistry, Edinburgh Dental Institute, Edinburgh.
This is the situation where the existing involves an apical repositioning of the

118 Dental Update April 2001


gingival tissues following removal of
crestal alveolar bone. The aim is to
provide increased tooth tissue for a
longer, more retentive crown
preparation. A period of healing, ideally
3 months for an anterior tooth, less for a
posterior tooth, is required to allow the
gingiva to stabilize at its new position.
A potential difficulty with the final
restoration of anterior teeth that have
been surgically crown lengthened is
poor aesthetics related to the dark
triangular spaces interproximally.1 This is
a consequence of the tapering form of
the roots resulting in an increase in size
of the embrasures between the teeth.
Additionally, localized crown
lengthening of a single tooth or several
teeth can leave a poor final appearance
due to the differential levels of the
gingival marginal tissues after surgery.
Reorganized Approach
This means changing the position of
closure. There are several ways in which
this can be achieved:
! altering the jaw relationship
(mandibular repositioning);
! localized minor axial tooth
movement;
! increasing the vertical dimension of
occlusion.
Mandibular Repositioning
In this situation a new intercuspal
position is created that coincides with
the retruded axis position. This can
provide the opportunity for creating
space for anterior restorations. However,
it is useful only for people who have
significant mandibular translation
between their retruded axis and
intercuspal positions.
Localized Minor Axial Tooth Movement
There is a variety of methods that
combine differential intrusion and
eruption of teeth to create interocclusal
space. It can be produced by several
different approaches, including:
! direct composite restorations;
! orthodontics;
Dental Update April 2001
R E S TO R AT I V E
! fixed or removable bite planes; or
! the definitive restorations
themselves.
A significant amount of space can be
created in a reasonable period of time
without destroying tooth tissue. The
procedure is generally well tolerated2
and patients seem to adapt to the altered
mandibular position. The space is
created by a combination of intrusion
and dentoalveolar compensation.
This method was originally described
by Dahl et al.3 to create space to restore
worn front teeth where there was little
indication for restoration of the
posterior dentition. They used a
removable bite-raising appliance made
of cobalt chrome as an anterior bite
plane in the maxillary arch. Intrusion of
the incisors and over-eruption of the
posterior molars created a space that
could then be used for the placement of
definitive restorations. The need to
increase the vertical dimension of
occlusion, to create the space anteriorly
necessary for restoration, was avoided
and consequently the posterior teeth
could be spared from restoration.
The conservative nature of treatment
employing relative axial tooth movement
frequently lends itself to combination
with adhesive restorative techniques.
The increasing reliability of dentine
bonding has made the direct placement
of composite resin an acceptable method
for restoration following toothwear,
especially for replacing incisal edges
and palatal surfaces of anterior teeth.4
Increasing the Vertical Dimension of
Occlusion
This is the placement of restorations
that encroach on the interocclusal
space. Traditionally it has been
approached with caution as it was
uncertain whether patients could
tolerate the increase in their occlusal
vertical dimension, which becomes
manifest as discomfort from the
muscles of mastication and pain in the
teeth. However, this does not appear to
be the case.
In 1946 Thompson5 suggested that the
rest position was constant throughout
life, and therefore toothwear was
D E N T I S T RY
compensated for by further growth of
the alveolar process (dentoalveolar
compensation). Thompsons
suggestion was supported by research
carried out on Anglo-Saxon skulls,6
which found that the distance between
the occlusal surface and the alveolar
bone crest remains constant throughout
life; therefore a constant clinical crown
height is maintained. The distance
between the alveolar bone crest and the
cementoenamel junction was found to
increase, indicating that there is further
eruption of the teeth throughout life.
Another study used radiographs of
women aged between 20 and 81 years.7
Throughout life the lower face height
increases, which could be attributed to
an increase in anterior dentoalveolar
height, of equal proportion in the maxilla
and the mandible. In the mandible,
approximately one-third of the increase
in height is due to an increase in incisor
length, which the researchers attributed
to either extrusion of the tooth or
recession of the anterior bone margin.
Knowing that the effects of slowly
progressive toothwear are overcome by
dentoalveolar compensation indicates
that the lower face height does not
reduce. Consequently, placing
restorations at an increased vertical
dimension would result in encroachment
on the freeway space. Researchers have
therefore concentrated on what happens
when the occlusal vertical dimension is
increased and whether damage occurs
as a consequence. In a widely quoted
article on this subject,8 patients were
given acrylic resin splints to wear; these
increased the vertical dimension of
occlusion by 4 mm and produced a
balanced occlusion. Patients were
assessed for subjective symptoms,
radiographically (to measure the
change in interocclusal space) and
electromyographically (assessing
changes in the muscles of mastication).
The conclusion drawn was that all the
subjects created a new postural
position of the mandible. There was no
evidence of disorder of the muscles of
mastication, such as tenderness to
palpation. Electromyography (EMG)
showed decreased postural activity
with the splint inserted. The article
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 R E S TO R AT I V E
Figure 1. Labial view of the teeth in occlusion
before treatment.
emphasized that these results were
achieved because occlusal stability was
maintained and this should therefore
also be established in patients where
the vertical dimension of occlusion was
altered.
In an earlier study,9 clinical
examination and the EMG activity of
elevator and depressor muscles were
used to investigate the rest position. It
was found that a resting range, rather
than a mandibular rest position,
existed. The average resting range was
11 mm, as determined by assessment of
the temporal and digastric muscles. It is
therefore thought that if restorations
are placed within this resting range and
occlusal harmony maintained, the
patient will adapt without experiencing
problems, such as pain or discomfort. A
further paper considered that jaw
muscle motor behaviour was more
dynamic and adaptable than had been
believed.10 A report on a number of
patients whose treatment had involved
increasing the occlusal vertical
dimension confirmed the acceptability
of this approach.11
The evidence thus indicates that the
vertical dimension of occlusion is not
constant throughout life and that
alterations are well tolerated. There
does, however, appear to be a general
consensus that such changes should
be accompanied by ensuring occlusal
stability at the new vertical dimension.
CASE PRESENTATION
This describes the integrated use of a
number of the strategies available for
the restorative management of
toothwear.
120
D E N T I S T RY
A 42-year-old man presented
requesting treatment to improve the
appearance of his short upper anterior
teeth and the dark maxillary right central
incisor (Figure 1). He reported that the
wear had been progressing over several
years. Five years previously he had
experienced trauma to his face leading to
the maxillary right central incisor
becoming non-vital. This had been root
treated, was asymptomatic and had a
satisfactory radiographic appearance.
The treatment plan integrated routine
care with management of the worn teeth.
Examination
Examination revealed toothwear affecting
the palatal surfaces and incisal edges of
the maxillary teeth. This was most severe
on the incisors and canines (Figure 2).
The tooth surfaces appeared smooth and
shiny. There was a cupped appearance,
with the enamel appearing slightly proud
of the dentine due to the preferential loss
of dentine. Approximately half the clinical
crown height had been lost and
dentoalveolar compensation had taken
place to maintain contact with the lower
incisors: there was an edge-to-edge
incisor relationship. The incisal edges of
the maxillary teeth were level with the
upper lip at rest, suggesting that the
crowns required lengthening cervically
and incisally to produce an acceptable
appearance. The molars had been
restored with large amalgam
restorations.
Investigations were carried out using
mounted study casts, radiographs and
dietary analysis. The toothwear was
attributed predominantly to erosion with
some secondary wear due to tooth-to-
tooth contact. The maxillary arch was
mainly affected.
Treatment
Aims
The aims of treatment were:
1. To address the issues surrounding
the cause of toothwear and prevent
further destruction of the teeth. Of
concern was that further toothwear
might make provision of crowns
more difficult or not feasible.
2. To improve the aesthetics.
3. To preserve tooth tissue remaining,
allowing function to be maintained.
The options for treatment were
discussed with the patient, as:
! A period of monitoring, having
established a preventive regime, if
he did not want any further
treatment at this time. The dietary
analysis had shown a high intake of
carbonated drink and fruit juice and
the preventive regime included
dietary advice and instruction.
! Provision of a simple partial
overdenture.
! Fixed cast restorations in the upper
arch.
The patient was keen to have the
appearance of his teeth improved and
requested the fixed option. Study
casts were articulated and a diagnostic
wax-up of the proposed treatment
made. Owing to the severity of the
toothwear and the need to reconstruct
a number of posterior teeth in the
maxilla, fixed indirect restorations were
deemed to be the most appropriate
treatment.
In order to help communication with
the patient, a vacuum-formed matrix was
made on a stone cast prepared from the
diagnostic wax-up. This was filled with
temporary crown and bridge resin and
placed in the patients mouth. It was
then removed, trimmed and replaced in
the mouth to allow the patient to assess
the likely outcome of treatment.
Figure 2. Palatal view of the maxillary arch
showing the results of erosion.
Dental Update April 2001
 R E S TO R AT I V E D E N T I S T RY
Figure 3. The palatal incision at the time of
surgical crown lengthening of the anterior teeth.
Treatment plan
The definitive treatment plan was:
1. Provision of an occlusal splint to
allow a stable mandibularmaxillary
jaw relationship to be established.
2. Surgical crown lengthening 3| to |3.
3. Ceramometal crowns 3| to |3.
4. Gold onlays 6|, 5|, 4| and |4 as these
teeth had large amalgam
restorations.
This would result in the remaining molar
teeth being deprived of their occlusal
contacts. The last component of the
plan was:
5. To allow the remaining molars to
Figure 4. Labial view of the teeth in occlusion
immediately following placement of the crowns.
Figure 5. Palatal view of the maxillary arch
following treatment.
122
erupt into occlusion following Outcome
completion of the restorative The patient was pleased with the result
treatment. (Figure 6) and experienced no
discomfort following placement of the
Procedure
restorations.
Surgical crown lengthening of the
maxillary canines and incisors was DISCUSSION
necessary to increase the clinical crown
This case has illustrated a number of
length. This allowed more retentive
issues surrounding the treatment of the
crown preparations to be made, and the
worn dentition. Toothwear has certainly
production of crowns of an aesthetically
become a common problem, with more
acceptable length. Crown lengthening
patients needing restorative treatment.
was carried out under local anaesthesia
The latest Childrens Dental Health
and the patient then left for 3 months to
Survey12 found that 32% of 14-year-
allow healing to take place (Figure 3).
olds had evidence of erosion on the
First, the upper anterior teeth were
palatal surfaces of their maxillary
prepared for ceramometallic crowns. Full
incisors. As many patients retain their
labial reduction was made but the only
teeth, with ever-increasing
palatal preparation necessary was a
expectations, treatment is being
chamfer finish line. The incisal edges
demanded more frequently. The
were smooth and rounded. Provisional
extensive nature of the work
restorations were made from the matrix
undertaken in this instance reinforces
of the diagnostic wax-up and cemented
the need for early diagnosis that offers
at the increased vertical dimension of
the opportunity for simpler forms of
occlusion. The posterior teeth that were
management.
to be restored in their original position
In this case, a moderately complex
were stabilized with glass-ionomer
approach was required. The occlusion
cement. The provisional restorations
has been reorganized. The teeth needed
allowed assessment of the aesthetic and
crowns but first they required surgical
functional shape of the teeth before the
crown lengthening to make available
final crowns were made.
adequate tooth structure for reasonable
At a subsequent visit, the anterior
retention and resistance form. It was
crowns were tried in, adjusted and
also necessary to increase the length of
cemented with glass-ionomer luting
the clinical crowns in a gingival
cement.
direction to improve the aesthetics. The
The 6|, 5|, 4| and |4 were then prepared
surgery provided approximately 2 mm
for gold onlays. At a subsequent fit
additional crown length.
appointment, the onlays were heat-
The crowns were placed at an
treated and cemented with a surface-
increased occlusal vertical dimension
active composite resin-luting agent
and an effort was made to ensure that
(Panavia 21, Kuraray, Osaka, Japan).
occlusal stability was retained around
The gold margins were finished with
the arch. However, this was not entirely
impregnated rubber cones and zinc
possible. The decision was made to
oxide powder.
restore only a limited number of teeth
Those teeth not restored were left to
re-establish their occlusal contacts. It
was anticipated that relative axial tooth
movement would occur, with intrusion of
the teeth that had occlusal contacts and
eruption of those without (Figures 4 and
5). Within 1 month this had taken place
and full occlusion of all the teeth was re-
established.
Figure 6. Labial view of the mouth following
completion of restorative treatment.
Dental Update April 2001

and consequently the 8|, |6 and |7 were
not brought into occlusion: rather, the
principal of relative axial tooth
movement was employed so that teeth
with occlusal contacts were intruded
and those without erupted. This
approach does call into question some
previous statements discussed in the
review of the literaturethat moderate
increases in the occlusal vertical
distance are well tolerated as long as the
criteria for an ideal occlusion were
achieved. This was not the case in the
treatment of the patient discussed here;
at least not in the month after the last
crowns were placed. Where relative axial
tooth movement is employed, the
stability of the occlusion and the
desirability of the occlusal contacts
should be re-assessed once the teeth are
fully in contact.
BOOK REVIEW
Prosthodontics for the Elderly:
Diagnosis and Treatment. By Ejvind
Budtz-Jorgensen.
Quintessence Books, New Malden, 1999
(266pp., 59). ISBN 0-86715-368-7.
Twenty years ago a book on
Prosthodontics for the Elderly would
have majored on the construction of
complete dentures. In this book, only 15
of the 266 pages are devoted to the
subject. This is not because the
edentulous no longer exist, far from it, it is
just that a whole new set of problems
associated with tooth retention have
become, numerically, much more of an
issue. Furthermore, the options for
treating them have evolved to a level
which were a distant dream just a couple
of decades ago.
In so far as it sets out to address the
major issues which currently affect the
prosthodontic treatment of older adults,
this book succeeds. There are 10
chapters: 4 of them cover treatment
delivery and associated practical issues,
such as the mechanics of providing fixed
and removable prostheses; the rest cover
background information on epidemiology,
age changes and function, as well as
treatment planning and maintenance.
There are plenty of illustrations, though
Dental Update April 2001
R E S TO R AT I V E
CONCLUSIONS
A case report has been used to describe
aspects of restorative management of
worn teeth. It illustrates that a number of
strategies can be combined to produce a
satisfactory restorative result. It further
reflects on the processes of increasing
the vertical dimension of occlusion and
relative axial tooth movement.
R EFERENCES
1. Ward VJ. Tooth surface loss. 11. Surgical crown
lengthening. Br Dent J 1999; 187: 2124.
2. Gough MB, Setchell DJ. A retrospective study of
50 treatments using an appliance to produce
localised occlusal space by relative axial tooth
movement. Br Dent J 1999; 187: 134139.
3. Dahl BL, Krogstad OK, Karlsen K. An alternative
treatment in cases with localized attrition. J Oral
Rehabil 1975; 2: 209214.
4. Briggs P, Djemal S, Chana H, Kelleher M. Young adult
patients with established dental erosion what
these are rather small (fewer larger ones
may have been more helpful). Whilst it is
successful in raising the issues, it is less
successful in the aims expressed in the
preface to try to base it on the best
evidence available. The lack of really
good evidence for a lot of what we do in
prosthodontics means there is a
tendency, as in this book, to fall back on
clinical experience. The literature is
widely, though not comprehensively,
cited, but the clinical conclusions could
not be said to be evidence-based.
With such a heterogeneous pool of
patients and clinical conditions to deal
with, it is impossible for a book like this to
be comprehensive. Rather than attempt
this, the author uses clinical cases to
illustrate various points. In some chapters
this works; the material on overdentures
was particularly good. There are important
areas though which are not covered in the
sort of detail they merit. Adhesive
techniques are barely mentioned,
shortened dental arch philosophy is not
discussed fully and the approach to
treatment planning is rather old fashioned.
Overall though, this is an honest attempt
to deal with a diverse clinical subject and
will prove valuable to clinicians or
postgraduate students with a special
interest in the oral health of the elderly.
Jimmy Steele
University of Newcastle Dental School
D E N T I S T RY
should be done? Dent Update 1998; 25: 166170.
5. Thompson JR. The rest position of the mandible
and its significance to dental science . J Am Dent
Assoc 1946; 33: 151180.
6. Newman HN, Levers BG. Tooth eruption and
function in an early Anglo-Saxon population. J R
Soc Med 1979; 72: 341350.
7. Tallgren A, Solow B. Age differences in
dentoalveolar heights. Eur J Orthod 1991; 13: 149
156.
8. Carlsson GE, Ingervall B, Kocak G. Effect of
increasing vertical dimension on the masticatory
system in subjects with natural teeth. J Prosthet
Dent 1979; 41: 284289.
9. Garnick JJ, Ramfjord SP. Rest position. J Prosthet
Dent 1962; 12: 895911.
10. Hellsing G. Functional adaptation to changes in
vertical dimension. J Prosthet Dent 1984; 52: 867
870.
11. Rivera-Morales WC, Mohl ND. Relationship of
occlusal vertical dimension to the health of the
masticatory system. J Prosthet Dent 1991; 65: 547
553.
12. Childrens Dental Health in the United Kingdom
1993. London: Office of Population Censuses and
Surveys, 1993; p.74.
ABSTRACT
CAN YOUR DENTAL NURSE TEACH
YOU ORAL MEDICINE?
Hepatitis Which Letters Pose a
Threat? I. Douglas. The British Dental
Nurses Journal 2000; Winter: 89.
This article, intended for an audience
of dental nurses, clearly and concisely
sets out the current situation
regarding the many variants of
Hepatitis. I am quite certain, however,
that most dental practitioners would
also find the article extremely useful!
It is suggested that:
! Hepatitis B virus poses a much
reduced risk for the dental team
because of successful vaccines.
! The escape mutants which have
caused so many problems may be
limited by the impact of a new
generation of vaccines.
! Hepatitis C poses a far more serious
risk to the team, and the prospects for
a successful vaccine are still remote.
! On current evidence, the latest
hepatitis virus, HGV, seems to pose
little cross-infection risk to the team or
patients.
Peter Carrotte
Glasgow Dental School
123