I love tooth wear. Sometimes worn teeth are the only reason that my patient decides to seek treatment. For most of these patients, the weakest link in their system is the teeth, showing the effect of strong muscle forces over time – well developed, powerful muscles combined with healthy joints that bear the load very well and have removed so much tooth structure that the teeth can sometimes be practically gone. My dilemma comes in trying to deal with those heavy forces as I try to give the patient back the teeth that he has worn away and will undoubtedly continue to wear away following my intervention.

I hate tooth wear. Worn teeth are a clear indication of what this patient is capable of doing to anything that I would put in position to be rubbed on, ground on and chewed with. Those powerful muscles rarely are uncomfortable and the TMJ is usually well within its adaptation limits. My dilemma comes in trying to deal with those heavy forces as I try to give the patient back the teeth that he has worn away and will undoubtedly continue to wear away following my intervention.

This love/hate relationship with tooth wear is one experienced by most of us throughout our dental career. The thrill of being able to restore function and esthetics to a grateful patient has been counter-balanced by the defeat of seeing that grateful patient crack, fracture and finally destroy all of our hard work. It doesn’t take too many of these experiences to create a neurally implanted “fear bomb” that erupts when gazing upon a severely worn dentition. Sometimes the fear is too much and they send those severely worn dentitions to their friendly prosthodontist, who immediately experiences pain and fear.

Throughout our Spear Continuum, beginning with the Facially Generated Treatment Planning workshop and continuing through Restoring the Edentulous Arch, we visit and revisit the observations and concerns about working with patients who present with severely worn teeth. Our differential diagnosis of the etiology of wear continues to evolve; the newest subject of consideration for me in that diagnostic process is the airway and the more I learn about etiology, the better I feel about addressing the consequences. That discussion is, however, the topic of another Digest commentary.

That these dentitions must be addressed is the common factor, and the factor that created and continues to create the fear that my dentistry will be destroyed. Because I am in the process of doing that right now, I thought it might be fun to share some of it with you. Perhaps it will help me manage the fear. This is an interim report of my work with one such patient.

The Worn Dentition Patient: Paul

I met Paul because he asked me to look at his teeth and discuss what, if anything, could be done to improve his smile and function. Here are his initial images and the plan that I put together based on Facially Generated Treatment Planning.

A tooth wear case - Figure 1
A tooth wear case - Figure 2

 

A tooth wear case - Figure 3
A tooth wear case - Figure 4

 

A tooth wear case - Figure 5
A tooth wear case - Figure 6

 

A tooth wear case - Figure 7
A tooth wear case - Figure 8

 

A tooth wear case - Figure 9
A tooth wear case - Figure 10

Wax-ups and Mock-ups

Here is the wax-up completed by WinterLab based on my design. I asked that it be an additive-only wax-up so I could mock-up things easily and see what my ideas looked like prior to removing tooth structure. This also made it easy for Paul to see the hoped-for result.

(Click here for an article on segmenting a full-mouth diagnostic wax-up.)

A tooth wear case - Figure 11
A tooth wear case - Figure 12

 

Here is the “mock-up” on one set of mounted casts so I could look at the case in another way using the guides I had created.

A tooth wear case - Figure 13

Here is the mock-up and the first set of provisionals in place. We’ll hope for the best and begin to work through the process of evaluating the impact that his function and parafunction will have on them. As he breaks the cement loose and knocks them off, cracks them, fractures them into pieces or wears through them, we will adjust, reshape, redesign and replace in the hope that we can minimize the rate at which he destroys them. IF the etiology that I suspected has been addressed, maybe he won’t destroy them too quickly. He’s in these now, so I’ll keep you posted with a follow-up as soon as we decide to move forward with ceramics.

A tooth wear case - Figure 14
A tooth wear case - Figure 15

 

A tooth wear case - Figure 16
A tooth wear case - Figure 17

 

A tooth wear case - Figure 18
A tooth wear case - Figure 19

 

A tooth wear case - Figure 20
A tooth wear case - Figure 21

 

A tooth wear case - Figure 22

(If you enjoyed this article, click here for more by Dr. Gary DeWood.)

Gary DeWood, D.D.S., M.S., Spear Faculty and Contributing Author


Comments

Commenter's Profile Image Cossette G.
January 7th, 2016
Amazing!
Commenter's Profile Image Daniel W.
January 8th, 2016
Great article! Your provisional look great! How long do you typically provisionalize for until you are comfortable transitioning into porcelain?
Commenter's Profile Image Gary D.
January 8th, 2016
Thanks Dan .... I'm planning on a 90 day time frame to see what happens. I've always found 3 months to be a good frame for evaluation. I see him for planned follow-ups that increase in time between. If things are stable we then begin with prep refinement, final impressions, and completing the ceramics.
Commenter's Profile Image Brittany C.
January 14th, 2016
Such an amazing transformation on his teeth! I'm sure he is very happy. I'm definitely curious to see what is the next step to making his smile more permanent! Awesome article!
Commenter's Profile Image Douglas M.
September 19th, 2016
Looking GREAT, Gary! A few questions if you don't mind sharing: 1) what technique did you use to determine the joint position for design/restoring? 2) what material are the restorations? 3) how did you attach those restorations ? Thanks Doug McMaster
Commenter's Profile Image Gary D.
September 19th, 2016
I seated the condyles at CR and mounted the models. VDO was determined by putting the incisal edges of maxillary and mandibular incisors at an appropriate position and closing the articulator. These are Bis-Acryl provisionals. I seated them with Rely-X luting cement (a resin modified glass ionomer). Thanks for asking Doug!
Commenter's Profile Image David H.
September 22nd, 2016
Rely-X luting cement? Doesn't that all but guarantee difficulty in managing the provisionals if he breaks them? Even if he doesn't break them and you proceed with final impressions, aren't you forced to destroy these provisionals and make new ones when you attempt to remove them? Great case and write up!
Commenter's Profile Image Gary D.
September 22nd, 2016
The plan was to cut them off and make another set after shaping these as required to accommodate his movement patterns. I wanted to mimic a final result as closely as possible. Most of them I was able to remove when we were ready to finish. I also remade several sections during our trial runs.