Bite from the side with lips retracted. More than any other, the dilemmas presented by the wear patient cause confusion and fear in dentists. Understanding the wear patient is the first step in successful treatment of these patients.

What makes managing the worn dentition so difficult? Fear of failure: Dentists don't want to do anything that's not going to work. You don't want the patient angry with you if treatments fail.

Number of teeth needing treatment: In severe wear cases, you almost have to treat every tooth, which in turn creates a huge financial consideration for the patient. Additionally, it may not be apparent how to do the case in segments, making it more manageable for the patient.

Complexity: Wear cases tend to bring up a lot of uncertainty because some dentists aren't exactly sure what to do. “Should I or shouldn't I open up the bite?” “Should I or shouldn't I crown lengthen the teeth?”

Inadequate tooth structure to restore: What do you do if you prep the tooth, and there's no tooth left?

No space for the restoration: You may have to open the patient's bite, but this is not always the case.

Need to alter vertical dimension.

A few items that contribute to the fear factor:

  • Fractured porcelain
  • Fractured preps
  • Fractured implants
  • Fractured solder joints

The biggest reason of all: The unknown. Treating someone when the outcome is uncertain is really unsettling.


Commenter's Profile Image Bern Slota
April 4th, 2012
Neuromuscular concepts make these cases seem very simple
Commenter's Profile Image Doug Lott
April 5th, 2012
Steve, I love the sacramento Spear study club meetings. I am keenly interested in what Spear teaches about worn dentitions. So far we have not heard a discussion about why people wear their teeth. I'm not sure I would get specific answers to my questions about wear if I took more Spear courses. Doug Lott.
Commenter's Profile Image Steve
April 5th, 2012
Hey Doug, Glad you are loving your club! YES, coming to more Spear courses will help you learn more about wear. In fact, Frank does a 2 1/2 day seminar called Treating the Worn Dentition and we also do a 3 day hands-on workshop with the same title. In both courses there is extensive discussion about wear, etiology of wear, wear patterns, bruxing, sleep disordered breathing and bruxing, erosion vs. attrition, treatment modalities, provisionalization and implants in the wear patient. There is a bunch to learn! Steve
Commenter's Profile Image Dan O'Rourke
April 13th, 2012
Wear is a sign of pathology. I have cases come to my laboratory where a 20 year old has severe wear, and other case where an 80 year old has none. I don't consider it opening the bite, we are really replacing what once was there. Without 1st verifying stable condylar position and making a diagnosis, I wouldn't recommend attempting these cases.
Commenter's Profile Image Steven Roth
April 14th, 2012
I can honestly say that until I became involved with Dr. Spear I was searching for the holy Grail of how to treat Wear Cases. Years of Dawson, Strupp, et al never quite got me where I needed to go. I am no longer intimidated by these cases. I feel completely comfortable treating them because of FS's ability to simplify the explanation of what to do and how to diagnose them. Thanks Dr Spear and friends!
Commenter's Profile Image Doug Lott
April 16th, 2012
Don Rinchuse (University of Pittsburg) is telling us (dentists) that mal-occlusions and c.r./c.o. discrepancies are not a primary cause of TMD and that psychosocial factors can be more to blame for worn out teeth than malocclusions. He teaches that you can finish an ortho case just about any way you want to, and that the finished malocclusions do not cause TMD or wear. He teaches that splints work but that seeing a shrink works better long term! That these TMD patients need to learn how to manage their stress! He teaches that parafunctional habits are basically c.n.s. phenomen and not of occlusal origin. He basically teaches that you should throw your articulators away (almost!) except for vertical measurements and smile planning. His views are in sharp contrast to the Bioesthetics camp and the Gnathologists, and of course Dawson. I don’t know for sure what Kois is teaching. The conversations I have had with Kois graduates make me think Kois would not agree with most of what Don Rinchuse is preaching. I am not the expert, just interested, but I listen and look and learn and so far I think Don Rinchuse has it mostly wrong. I learned most of my occlusal ideas from Tom Basta, who is in the Gnathologist camp. I don’t now use a fully adjustable articulator. Has anyone gone through the Kois occlusion courses and also the Spear occlusion courses? Do Kois and Spear agree mostly on occlusions as causative for wear? I’m beginning to think that the Spear occlusion courses are influenced by this Rinchuse religion. Am I wrong?
Commenter's Profile Image Steve
April 16th, 2012
Doug, I don't know Don nor am I personally familiar with his philosophy so I won't comment on what he is teaching. I am, however, an expert on what we teach! Occlusion is interesting in that every occlusal philosophy least some of the time. And some of the time, TMD is pyschosocial or has a pychosocial component. Occlusal schemes are usually not the reason for wear, teeth wear because of what people do with them. Some occlusal schemes make wear more likely when people parafunction. We base what we teach on the evidence in the literature and for the most part we have similar philosophies to Kois, Dawson, Pankey, and we've been influenced by gnathologists as well--that was Frank's training. The way we see it, each patient's individual circumstances have to be evaluated and the dentist needs to understand the way muscles and the joints work. I disagree that ortho cases can be finished anyway and not cause TMD, the literature is pretty clear that impeding the pathways of movement can lead to muscle dysfunction and pain or wear. That doesn't mean that they will brux, likewise, correcting a bite doesn't mean a bruxer will stop bruxing. There is no question that stress can be part of parafunction and who doesn't need to learn to manage stress? So, bottom out for zealots who have the one right answer. Seek people who will teach you how to think and evaluate what your patient needs.