Diagnosis and Management of Occlusal Wear: A Case Report
Diagnosis and Management of Occlusal Wear: A Case Report
DOI 10.1007/s13191-012-0173-2
CLINICAL REPORT
Received: 12 November 2011 / Accepted: 18 September 2012 / Published online: 4 October 2012
Indian Prosthodontic Society 2012
Abstract The rationale for doing full mouth rehabilita- introducing deflective occlusal interferences. Literature
tion are, when occlusal forces become traumatic hampering indicates stress combined with tooth interferences in cen-
the health of periodontal tissues, extensive occlusal dis- tric and eccentric occlusion as triggering factors of para-
eases, trauma, temporomandibular joint disease and con- functional activity. Glossary of Prosthodontic terms (GPT-
genital disorders with malformed dentition. Literature 8) defines Bruxism as ‘‘Parafunctional grinding of teeth or
exposes that full mouth fixed rehabilitation is one of the an oral habit consisting of involuntary rhythmic or spas-
taxing procedures in the field of Prosthodontics. A critical modic non functional gnashing, grinding or clenching of
aspect for successful occlusal rehabilitation is to determine teeth in other than chewing movements of the mandible
the aetiology, correct sequence of treatment and most which may lead to occlusal trauma’’ [2]. Bruxism can
importantly the occlusal vertical dimension and centric occur during wakefulness (Diurnal Bruxism) or during
relation in which to plan the treatment. A systematic sleep (Sleep Bruxism). The International Classification of
approach in managing these patients can lead to a pre- Sleep Disorders (AASM, 2005) categorizes Sleep Bruxism
dictable and favourable prognosis. This article presents the as a sleep-related movement disorder and defines it as ‘‘An
stages of prosthodontic rehabilitation, from diagnosis to oral activity characterized by grinding or clenching of the
final treatment and follow-up, of a bruxer patient with teeth during sleep’’ [3].
severely worn dentition. Restitution of mutilated dentitions, as a result of func-
tional and parafunctional occlusal wear is one of the
Keywords Occlusal disease Bruxism Extra capsular arduous trials in Prosthodontics [1, 4, 5]. Hesitations in
Load testing Adapted centric Sectional acrylic block attempting to reconstruct debilitated dentitions are height-
ened by widely divergent views concerning the appropriate
procedures for successful treatment. McCollum, D’Amico,
Introduction Stuart and Stallard, Christensen, Pankey-Mann-Schuyler
are the proponents whose concepts were debated, tried and
Occlusal wear of teeth due to attrition is the result of tested over the years by the practicing gnathologists. This
friction by functional and parafunctional activities [1]. led to the evolution of a more organized approach in
Frictional tooth wear alters the existing occlusal plane occlusal rehabilitation [1, 6, 7]. Occlusal rehabilitation is
the correlation of all indicated and required dental treat-
ment for a particular patient in order to restore his occlu-
sion to normal function, to improve esthetics, and to
preserve tooth and their supporting structures [8]. This case
report elucidates the stage by stage full mouth rehabilita-
V. R. Thirumurthy Y. A. Bindhoo (&) tion of a patient with bruxism who presented with gen-
S. J. Jacob A. Kurien K. S. Limson P. Vidhiyasagar
eralized attrition of his dentition. The importance of
Department of Prosthodontics, Sri Ramakrishna Dental College
& Hospital, Coimbatore, India diagnosis and treatment planning in this scenario is thor-
e-mail: [email protected] oughly discussed.
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Case Report
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Diagnostic Mounting Review was done after 24 h and patient reported a mild
reduction in symptoms. Further checkups, after a week and
Two sets of maxillary and mandibular diagnostic impres- a month, revealed that the patient was responding favour-
sions were made with irreversible hydrocolloid (Tulip– ably to the splint as the muscle and joint tenderness were
Cavex, RW Harlem, The Netherlands). The maxillary cast satisfactorily controlled. This confirmed the necessity to
was mounted on a semi adjustable articulator (Artex-NA, correct the occlusal contacts to relieve the patient’s
Amann Girrbach, Germany) using transfer bow. As the symptoms. Still more, the severely attrited teeth needed
patient had reduced VDO, a wax interocclusal record of CR protection from further damage, so prosthodontic inter-
position was made at a VDO that will allow a normal vention in the form of full mouth occlusal rehabilitation
freeway space of 3 mm. CR record was made after anterior was decided for the patient. After a permissive splint has
deprogramming. The mandibular cast (first set) was related been used, the challenge is to maintain this harmony in the
to the mounted maxillary cast using this CR record. This final rehabilitation. Designing of occlusal scheme in rela-
was removed and set aside and the second mandibular cast tion to the condyle/disk assembly is the most challenging
was mounted using this CR record again. The first man- part in full mouth rehabilitation. Mock preparations and
dibular cast was used for fabrication of occlusal splint and diagnostic wax ups were planned to decide the next phase
the second set was used for diagnostic evaluation. of treatment.
The second set of mandibular cast was secured back on
the articulator for evaluation. Customized Broadrick flag
Fabrication of Centric Stabilization Splint assembly was set for the articulator to determine the
Curve of Spee. Mock preparations of the anterior teeth
Occlusal splint therapy was planned to free the neuro- were done and diagnostic wax up of these teeth was
musculature from occlusal interferences and to assess completed. With distal incisal edge of mandibular canine
patient’s response to increased vertical dimension. Wax as the anterior survey point and articulator condylar ele-
pattern for occlusal splint was prepared on the mandibular ment as the posterior survey point, long arc and short arc
cast in the recorded VDO and was processed with heat of 4 inch radii were scribed on the flag respectively
polymerizing clear acrylic resin (Veracril, Mangalore (Fig. 4). The point of intersection of the arcs was used to
dental corporation, Karnataka, India). The fabricated draw a sagittal curve of 4 inch radius along the stone cast
diagnostic occlusal splint was assessed on the articulator of mandibular posterior teeth. The procedure helped to
mounting and refined to be free from interference in centric differentiate between tooth surfaces requiring considerable
and eccentric position. The universal flat plane appliance tooth reduction from tooth surfaces requiring minimal
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preventive and restorative point of view [5, 6]. Attrition is a teeth as the mandible moves from CR. The anterior guid-
tooth–tooth friction due to bruxism and empty mouth ance (lines in the front) assumes the responsibility of
parafunction [1]. A systematic approach for managing separating the posterior teeth during excursions providing
tooth wear can lead to a predictable and favorable prog- mutual protection for each other [8]. This harmony
nosis. This article presents the stages of prosthodontic between anterior and posterior teeth can be established by
rehabilitation, from diagnosis to final treatment and follow- identifying the correct occlusal plane. The curve of Spee,
up, of a bruxer patient with severely worn dentition. which exists in the ideal natural dentition, allows harmony
Inspite of the existence of conflicting philosophy, the to exist between the anterior tooth and condylar guidance
basis of successful full mouth rehabilitation is programmed [14–16].
treatment planning. All occlusal analysis should start with In the present case, the temporomandibular joints and
the examination of temporomandibular joint. In the pres- centric relation assessment revealed the cause of the
ence of joint disorder, the choice of treatment is clearly patient’s symptoms to be due to extracapsular reasons.
related to the category of the TMD. The second parameter Parafunctional wear due to psychological stress combined
to be considered is a properly aligned condyle-disk with occlusal interferences has triggered the muscular pain.
assembly in centric relation which directs forces through Psychological Counseling and use of occlusal splint
the avascular, noninnervated central portion of discs that relieved the symptoms of the patient. Decision was made to
are designed to accept loading. This is only possible in the increase the vertical dimension of occlusion. The contour
absence of deflective occlusal interferences to centric of anterior teeth and their guidance were refined to be in
relation. Assessment of these essential factors allows cre- compliance with the envelope of function. The customized
ating harmonious posterior determinants in developing Broadrick flag analyzer assisted in the reproduction of
functional occlusion. [1, 4, 11]. tooth morphology of posterior restorations, commensurate
The third important issue to be addressed in full mouth with the curve of Spee [17]. This method prevented pro-
rehabilitation is deciding the correct occlusal vertical trusive interferences. The use of sectional acrylic bite block
dimension in which full mouth rehabilitation can be plan- fabricated from the diagnostic mounting facilitated con-
ned [6, 11]. This is especially a confounding issue in trolled conservative tooth reduction. In the clinical report
dentitions showing extensive wear. Methods used to presented, the bite block was a vital tool for transferring the
determine vertical dimension are still considered unem- designed VDO from the diagnostic wax-up on the articu-
pirical due to the number of factors influencing the rest lator to the mouth. The bite block allowed accurate
position recording. In situations requiring alteration in reduction of the tooth structure to the level of the rede-
VDO, to overrule this difficulty, two or more methods are signed occlusal plane. This ensured adequate clearance for
always employed to decide vertical dimension and the prostheses fabrication in the laboratory. Due consideration
changes should be tried with provisional restorations [6, 8]. was given for patient compliance and the entire treatment
In this present case, physiologic method, esthetics and plan was tried first with provisional restorations and then
phonetics were used to assess the VDO which was later duplicated in the final restoration. Occlusal protection of
found satisfactory with the short term use of provisionals. the final restorations with soft splint served to protect
The anterior determinants of mandibular movement are dental/periodontal structures against adverse effects of
the contacting surfaces of maxillary and mandibular teeth. hyper-loading and parafunctional wear. [18].
Of the teeth contact mentioned, the incisal guidance
formed by the anterior teeth, has the most profound influ-
ence upon the mandibular movement [1, 11–13]. So the Conclusion
fourth step in oral rehabilitation soon after deciding VDO
is to check for the presence of favourable incisal guidance Full mouth rehabilitation entails the performance of all
and in its absence to develop the contours of anterior teeth the procedures necessary to produce a healthy, esthetic,
in compliance with aesthetic and phonetic demands of the well-functioning, self maintaining masticatory mechanism
patient. The incisal guidance then controls the necessary [19]. This clinical report illustrates the value of thorough
steepness of all posterior tooth inclines. diagnosis of the condyle/disk assembly in relation to the
Summarizing all the above, the salient features of opti- occlusion in treating a patient with severe parafunctional
mum occlusion was stated by Peter Dawson [1] as ‘‘Dots in occlusal wear. Greater care was taken in diagnosing the
the back, lines in the front’’, clinically visualized in an cause before treating the effect. Without properly com-
ideal occlusion, when occlusal contacts are assessed in paring and classifying the joint position to the occlusion,
centric and eccentric relations, with articulating paper the development of neuromuscular harmony and con-
interposed. This formula represents contact in centric comitant pain resolution would have been virtually
relation (Dots in the back) and disclusion of all posterior impossible.
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The patient’s response to change in vertical dimension 8. Hotta TH, de Jesus L, Nunes AH, Quatrini CB, Nonaka O,
of occlusion was assessed first with occlusal stent, followed Bezzon O (2000) Tooth wear and loss: symptomatological and
rehabilitating treatments. Braz Dent J 11:147–152
by provisionals and then implemented in the final restora- 9. Beohar G, Shrivastava S, Agarwal S, Katare U (2011) A concise
tions. Sectional acrylic bite blocks employed ensured that overview of various options of TMJ deprogrammers: part II. Arch
the required amount of occlusal clearance was attained Dent sci 2:8–11
during tooth preparation procedure. This is simple less time 10. Dawson PE (1989) Evaluation, diagnosis and treatment of
occlusal problems, 2nd edn. Mosby, St. Louis
consuming procedure saved clinical chair time. 11. Mccullock AJ (2003) Making occlusion work: practical consid-
erations. Dent Update 30:211–219
12. Schuyler CH (2001) The function and importance of incisal
guidance in oral rehabilitation. J Prosthet Dent 86:219–231
13. Steele JG, Nohl FSA, Wassell RW (2002) Crowns and other
References extra-coronal restorations: occlusal considerations and articulator
selection. Br Dent J 192:377–387
1. Dawson PE (2007) Functional occlusion: from TMJ to smile 14. Craddock HL, Lynch CD, Franklin P, Youngson CC, Manogue M
design. Mosby, Canada (2005) A study of the proximity of the Broadrick ideal occlusal
2. The Academy of Prosthodontics (2005) The glossary of prosth- curve to the existing occlusal curve in dentate patients. J Oral
odontic terms. J Prosthet Dent 94:10–92 Rehabil 32:895–900
3. Ferini-Strambi L, Pozzi P, Manconni M, Zuconni M, Oldani A 15. Small BW (2005) Occlusal plane analysis using the Broadrick
(2011) Bruxism and nocturnal groaning. Arch Ital Biol 149:1–11 flag. Gen Dent 53:250–252
4. Dylina TJ (1999) Phase II therapy for a chronic pain patient: a 16. Lynch CD, McConnell RJ (2002) Prosthodontic management of
clinical report. Cranio 17:126–131 the curve of Spee: use of the Broadrick flag. J Prosthet Dent
5. Song M-Y, Park J-M, Park E-J (2010) Full mouth rehabilitation 87:593–597
of the patient with severely worn dentition: a case report. J Adv 17. Bedia SV, Dange SP, Khalikar AN (2007) Determination of the
Prosthodont 2:106–110 occlusal plane using a custom-made occlusal plane analyzer: a
6. Pokorny PH, Wiens JP, Litvak H (2008) Occlusion for fixed clinical report. J Prosthet Dent 98:348–352
prosthodontics: a historical perspective of the gnathological 18. Dao TTT, Lavingne GJ (1998) Oral splints: the crutches for
influence. J Prosthet Dent 99:299–313 temporomandibular disorders and bruxism. Crit Rev Oral Biol
7. Charles Becker S (1966) Clinical procedures in occlusal reha- Med 9:345–361
bilitation, 2nd edn. W. B. Saunders/ The University of Michigan, 19. Lucia VO (1983) Modern gnathological concepts—updated.
Philadelphia Quintessence Pub Co./ The University of Michigan, Ann Arbor
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