Almost every restorative dentist I know has a set of models sitting on their desk they have looked at multiple times and yet they still don't know what to do. A number of these models belong to patients with significant tooth wear, like the ones in these photos, and they all have requested treatment to improve the appearance of their anterior teeth.

For every patient who presents with tooth wear, it's important to know how to approach the planning process properly. Most of the time dentists are inclined to think about occlusion when starting to treatment plan wear patients, but the reality is that the reason the dentist doesn't know what to do is not simply an occlusal issue, but rather a tooth position issue.

The approach that makes the most sense is the concept of Facially Generated Treatment Planning. This approach is treatment planning from the outside in using the face and lips to first establish maxillary tooth position esthetically, then looking at how the mandibular teeth need to be altered to create an occlusion that functions correctly with the esthetically correct maxillary teeth.

The reason looking at models alone isn't helping you develop a treatment plan in these patient's is because models don't have a reference for how the teeth moved as they wore, nor do they have a reference for where the teeth need to be positioned to correct the changes that occurred. For a reference you need photographs of the patients face both at rest and in a full smile, and close ups of the patients lips and teeth both at rest and in a full smile. Looking at the worn teeth in the patient will give you the first piece of the puzzle as to how to start the treatment plan to correct tooth position.

Another difficulty in planning these patients is the fact that we were all taught to treatment plan based on the urgency of a problem. That is, we sequence our treatment planning based upon which problems we think need to be treated first. This concept is a great way to treat tooth problems if there are no tooth position issues, but is not the best way to treatment plan complex patients with tooth wear.

What we need to do as restorative dentists is differentiate between treatment planning and treatment sequencing. Treatment planning needs to be systematic and linear starting with maxillary tooth position, then developing the occlusion, followed by how teeth need to be restored or replaced, and finally what endo, perio, or oral surgery is necessary. This allows us to see and plan the whole mouth. After we have clarity on the plan then we can develop the sequence of how we will perform treatment, and of course the most urgent issues will be treated first, but they didn't limit how we see the mouth.