Rest of lost vert dim/ academy general dentistry

INDIAN DENTAL ACADEMY
Leader in continuing dental education
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Introduction

Definitions: GPT 8
 Vertical Dimension of Occlusion :
The distance between any two points measured in the maxilla and
the mandible when the teeth are in maximum intercuspation
 Vertical Dimension of Rest :
The postural position of mandible when an individual is resting
comfortably in an upright position and the associated muscles are in a
state of minimal contractural activity
 Interocclusal Clearance :
The arrangement in which the opposing occlusal surfaces may
pass one another without any contact
The amount of reduction achieved during tooth preparation to
provide for an adequate thickness of restorative material
 Interocclusal Distance :
The distance between the occluding surfaces of the maxillary
and mandibular teeth when the mandible is in a specified positionwww.indiandentalacademy.comwww.indiandentalacademy.com

Peter E. Dawson:
The repetitive contracted length of the elevator
muscles determines the vertical dimension of
occlusion
i.e. The vertical space between the fixed maxilla
and muscle positioned mandible into which the
upper and lower teeth intercuspates at the most
closed position
What isVDO ?

VERTICAL DIMENSION
 Static relationship
 Initially determined by interaction
 Genetic Growth Potential
 Environmental factors
 Dynamics of Neuromuscular Function during
growth
 Maintenance of VD O
 Interaction of environmental factors
 Dynamics of neuromuscular function throughout
aging process

EruptiveForceVsTooth Wear
 Throughout life, eruptive force causes teeth to
move vertically with their alveolar bone
 Stopping force:
 Teeth of opp arch
 Tongue..Thumb …Lips
 Objects…. Pipes/ appliances
 Dentoalveloar Compensation: [Berry & Poole
1976]
 TSL compensated by alveolar growth which
maintains occlusal vertical height eg.: Bruxism
 Rate of wear > comp alveolar growth = Loss of VDO

Environmental Factors
 Particular role in the vertical dimension of facial
skeleton, ultimately the VDO
 Function of upper respiratory tract (Linder-
Aronson)
 Mandibular Retrognathism
 Increased vertical facial height
 Open bite
 Cross bite……chronic airway obstruction

Biologic Adaptation/Maintenance of VD
 Adaptive responses can occur within
 Temporomandibular joint (TMJ),
 Periodontium
 Dental Occlusion
 First Response : within TMJ
 Strain: Shift in the fluids within the disc and
retrodiscal tissues
 Strain is relieved: The fluid will return to its original
position and the morphology of the tissues is
maintained.
 Prolonged strain : Alteration of the architecture of
the collagen and non-collagen proteins and ultimately
a change in tissue morphology

 Stress beyond the levels of Adaptation :
Morphologic adaptive changes within the
cartilage and bone, that may be apparent
radiographically
 Stress beyond the adaptive capacity of the
tissues :
 Degeneration
 Loss in vertical support
 Structural changes that have the potential to
impact the vertical dimension of occlusion

Tooth Wear
Physiological Pathological/ Excessive
At a lower rate
Molar: 29 µ m/ year
Premolar: 15 µ m / year
At a Higher rate
Parafunction: 3 times of normal
oLoss of convexity on the cusps
oFlattening of cusp tips on posterior
tooth
oLoss of mammelons on anterior tooth
oWear facets with minimal length &
depth
oUnacceptable damage to
occluding surfaces
oDestroy anterior tooth structure
oLoss of anterior guidance
oNon Diagnostic
Diagnostic:
Dependably related to tooth surfaces
that are in direct interference with
functional / para functional
movements of mandible

Tooth Wear
 Attrition
 Normal Process
 Excessive occlusal wear
 Pulpal pathology
 Impaired function
 Occlusal disharmony
 Esthetic disfigurement
 Intracapsular disorder
 Decreased ramus ht. puts the molars into
interference
 Posterior tooth Wear:
 Interference with completely seated TMJ /
anterior guidance
 Worn surfaces can be contacted during centric
relation closure / during excursions to and from CR

Tooth Wear
 Abrasion of teeth
 Diet & chewing of abrasives
(tobacco)
 Environmental Factors
Dust & grit
 Unglazed porcelain restorations
 Erosion
 Chemical action
Citrus juices…Cola drinks… Vinegar…Pickled
foods
 Constant Regurgitation/ Projectile vomiting (GERD)
 Loss of Posterior Support
 Attrition of Ant. teeth ….
 Loss of posterior teeth
 Malposition of teeth
 Occlusal interference…. Drives mandible forward

Tooth Wear
 Congenital Anomalies
 Amelogenesis Imperfecta
Hypoplastic … . 1/8 – ¼
enamel thickness
Hypomaturation … . .softer
enamel
Hypocalcified … . friable
enamel
 Dentinogenesis Imperfecta
Weak enamel attachment
Rapid Attrition

Tooth Wear
 Bruxism /Parafunctional habits
 Occlusal interferences
Occlusal splints
Occlusal adjustments
 Chewing Tobacco
 Pipe smoking
 Pencil/ Pen biting
 Holding objects b/w teeth
 Emotional stress
Patient counseling &
periodic self-monitoringwww.indiandentalacademy.comwww.indiandentalacademy.com

Consequenceof Lossof VDO
 Appearance
 Masicatory
efficiency
 Neuromuscular
system
 TMJ
 Dental occlusio
 Functionsl surfaces of teeth: flatter and wider,
disrupting the occlusal plane
 Overclosure and deep bite
 Distalising effect on the condyles
 Overcontraction of muscles: are stressed and fatigued
 Thinning of lips
 Forward positioning of mandible causing chin
prominence and chin closer to nose
 Exaggeration of facial folds

Costen Syndrome
 In 1934, Costen described a symptom complex that included
 Loss of dental occlusal support
 Ear symptoms (such as pain and tinnitus)
 Sinus pain
 Agerberg has reported that the number of missing teeth was
directly correlated with increasing symptoms of mandibular
dysfunction

Classification

Clinical Classification of Tooth Wear
Pindborg's original classification of TSL
 Compensated TSL: Tooth surface loss without loss of OVD
 Complete or nearly complete dentition
 Free-way space remains within the normal range
 Non-compensated TSL: Tooth surface loss leading to the loss of
OVD.
 Confined to the anterior segments
 Associated with a lack of posterior occlusion
 Rate of wear, confined to a smaller number of teeth
 Lack of compensatory eruption


Clinical Classification of Tooth Wear
Turner & Missirlian
Category-1: Excessive wear with loss of VDO
Category-2: Excessive wear without loss of VDO but with space
available
Category-3: Excessive wear without loss of VDO but with
limited space
JPD, Year : 2005 | Volume : 5 | Issue : 2 | Page : 89-93

Evaluation of VDO
Phonetic evaluation (Pound & Silverman)
 Normal mandibular position during the 's' sound ….. incisal
edge of the mand incisors about 1 mm inferior and lingual
to the incisal edge of the maxillary incisors
Interocclusal Distance
 Supplemental diagnostic aids / guidelines.
 Interocclusal distance of 6 mm : is more capable of
tolerating a slight increase in OVD than the patient with an
interocclusal distance of 2 mm. (Turner KA, Missirlian DM)
Facial Measurements
 Vertical distance from the external corner of the eye (outer
canthus) or the pupil to the corner of the mouth7
 Vertical distance from the eyebrow to the ala of the nose
 Vertical length of the nose at the midline (from subnasion to
glabella)

Diagnosis& Trmt Planning
Orderly Sequence for occlusion based treatment planning :
I. Evaluation of CR position of the mandible
II. Evaluation of VDO to be raised -- Joints, muscles, & teeth
must be placed at an acceptable VDO in the final
restorations
III. Finally restoration with equilibrated occlusal scheme in
an appropriate occlusal plane
Initial Treatment:
I. Extraction of hopeless tooth
II. Periodontal assessment
III. Caries control
IV. Endodonticswww.indiandentalacademy.comwww.indiandentalacademy.com

VDO : Increase/ Decrease?
Michael D. Wise
 Assessment
 Diagnostic appliance
 Diagnostic wax up
 Provisional restorations
 Clinical assessment of response
 Mount casts of provisional restorations
 Mount working casts at the accepted VD
for final restorations

Diagnostic Appliance
 Assessment : Decrease in VD
 Acrylic overlay appliance is fabricated
 Either to the anticipated VD or if this appears
excessive, to an intermediate dimension with
additions being made periodically until the planned
VD is reached or until the pt experiences discomfort
 Tolerance of the clinical procedures by the patient
should not be exceeded
I. No reliable tests
II. Crude guide: inter occlusal clearance
III. Best Test : Time tested Trial & Error
IV. Stabilization splint : 3 months
V. Adaptation of the muscles

Bite- raising Appliance
• Bite raising appliances increase the jaw-to-jaw
dimension & interfere with the repetitive
contracted length of the elevator muscle
• Occurs by intrusion of teeth covered, by an
amount approximately equal to the thickness of
the bite plane
• Restorative phase would utilize the space when
the intrusion has occurred and sufficient bite
opening has ocurred
• Extrusion of teeth occurs within 6-12 months
• Eruption of teeth can be stopped by habitual
tongue biting

Typesof Splints
• Anterior splint: Anterior tooth contact only on a flat surface
perpendicular to the long axis of the mandibular incisor teeth
• Stabilization splint : Uniform occlusal contact of the anterior and
posterior teeth
• Anterior repositioning splint : held the condyles
slightly (0.5 – 1 mm anterior & inferior to the intercuspal
position and had uniform occlusal contact of all teeth
• Bilateral pivot splint: had pivots placed bilaterally between the
second molars and had no other occlusal contacts
• Unilateral pivot splint: had a pivot placed between the second molar
one side of the dental arch

Philosophiesfor Condylar Position
 Bioaesthetics
 Fixed numerical value based on incisal
relationship
 Distance between gingival margins of
 18-20 mm in an unworn class I occlusion
 upper incisal length of 12 mm
 lower incisal length 10 mm,
 4 mm overbite & 1 mm overjet
 Gnathological
 Fully adjustable articulator to determine
condylar path from hinge axis
 5 degree increase to ensure no posterior
interferences

Philosophiesfor condylar position
when determining VD
 Centric Relation based
 Principles of P. Dawson
 CR is defined prior to change in VD
 Neuromuscular
 Based on the principles of muscle activity
determined by electromyography

Centric Relation VsVertical
Dimension
Dawson’s technique: Prior to VD corrections,
mandible has to be established in CR . The
importance of CR as told by Dawson
 Disk is properly aligned on both condyles
 Condyle-disk assemblies are at the highest point
possible against the posterior slopes of the
eminentiae
 Medial pole of each condyle-disk assembly is
braced by bone
 Superior lateral pterygoid muscle have released
contraction and are passive
 TMJs can accept firm compressive loading with
no sign of tenderness or tension

Centric Relation VsVertical
Dimension
 Condyles rotate in a fixed axis
 Bite record made at any point of opening on
correct centric relation arc is still in centric
 Vertical Dimension can increased / decreased
without introducing any error

Diagnostic Waxup
 Established VD
 Measure VD : record dist. bw. 2 suitable
gingival landmarks with calipers
 Transfer VD to mounted diagnostic casts
 Diagnostic waxup carried out

Provisional Restorations
- R.J. Ibbetson & D.J. Setchell 1989
Four Methods:
 Use of anterior provisonals along with modified
occlusal splint
 Use of composite resin with anterior provisionals in
place
 Placing provisionals on posteriors first with modified
anterior occlusal splint
 Provisionals place both in anterior and posterior teeth

Turner & Missirlian
Category - 1 : Excessive wear with loss of
VDO
 Closest speaking space is more than 1 mm
 Interocclusal space is more than 4 mm
 Loss of facial contour
 Drooping of the corners of the mouth
Reliable method… .
 Placement of trial restorations
 Removable splint/ partial denture……..6 – 8
weeks
 Fixed provisional restorations …. .. 2 – 3
months
 All teeth of one arch must be prepared in a single sitting… ..
 Less abrupt VDO
 Better control of estheticswww.indiandentalacademy.comwww.indiandentalacademy.com

Turner & Missirlian
Category - 2 : Excessive wear
without loss of VDO but with
space available
 History of gradual wear ….
 Bruxism
 Moderate oral habits
 Environmental factors
 OVD maintained by continuous
eruption
 Tooth prep to establish retention &
resistance form may be critical ….
 Gingivo;lasty ….CLP
 Enameloplasty of opposing posterior
teeth…

Turner & Missirlian
Category - 3 : Excessive wear
without loss of VDO but with
limited space
 Excessive wear of anterior teeth
 Minimal wear of posterior teeth
 CR = CO
 Closest speaking space = 1 mm
 Interocclusal distance = 2 -3 mm
 Vertical Space obtained by
 Orthodontic movement
 Restorative repositioning
 Surgical respositioning of segmentswww.indiandentalacademy.comwww.indiandentalacademy.com

PossibleClinical Concernsbehind
changing VD
 Joint / muscle Pain
 < 1-2 weeks
 Pain due to increased temporary muscle awareness
 Stability
 Relapse of restored VD variable without any fixed parameters
 Muscle activity
 VD increases EMG activity .. . Short lived
 Postural muscle tone reduces with increased VD … normal
within 3 months
 Phonetics : ‘S’ sound
 Increased VD shortens the lower incisors .. .ht has to restored
 Also improved by restoring the palatal surface of the upper
incisors www.indiandentalacademy.comwww.indiandentalacademy.com

ContraindicationsFor BiteRaising
 Dense sclerotic bone
 Hypertrophic Masticatory muscles

Criteriafor Success!!!
1. Loading test
2. Clenching test
3. Grinding test
4. Fremitus
5. Stability test
6. Comfort test
7. Aesthetic test

Loading Test
 TMJ cant accept firm loading .. ..
Condyles are braced by lateral
pterygoid muscles / intracapsular
disorder .. .. Instability of the TMJ
 Trmt . not complete.. .. TMJ does not
end up with complete comfort ….
Maximal loading

Clench Test
 Perfected occlusion… . no sign of
discomfort in any tooth / joint
 Discomfort in any tooth .. . . Sure sign of
premature / deflective contact
 Clench test produces discomfort.. .
Masticatory musculature…… occluso
muscular disorder

Grinding Test
 Test…Posterior Interferences
 Lack of posterior Disclusion
 Post. Interference … hyperactivates
elevator muscles
 Occlusions with no anterior contacts in
CR.. .. test modified to check the group
function on the working side

Fremitus Test
 Light contact on the labial
surfaces ….edge of fingernail….taps the teeth
 Movement of any ant teeth …. tooth is in
interference
 Interference …. restrictive envelope of function/
failure to provide a needed “long centric”
 Commonest cause: deflective posterior incline that
forces the man forward into hard contact with the
anterior teethwww.indiandentalacademy.comwww.indiandentalacademy.com

Stability Test
 Refers to stable TMJ and stable dentition… . at
least 3 months
 Manageable stability
 Joint Instability: Bone-to-bone TMJ contact in
osteoarthritic breakdown of condyle/ eminence
 Instable dentition:
 Excessive wear of teeth
 Hypermobility
 Shifting of tooth position

Comfort Test
Complete Comfort of :
 Teeth
 Lips
 Face
Speech:
 Comfortable
 Cause no tiredness in facial &
masticatory muscles
Perfected Occlusion :
 Peaceful neuromuscular system
 Goal of all occlusal therapy

Esthetic Test
Patient should be happy with the appearance
of the smile
Functional harmony = Anatomic harmony
Comfort test :
Comfortable & unstrained speech
Correctly placed incisal edges
Harmony with the neutral zone

CASE REPORTS – Bruxism
 45-year-old male patient with a habit of bruxism
 Attrition :
 Marginally less in the posteriors as compared to the anterior teeth
 Total collapse of the vertical dimension
 Lower anterior teeth were totally razed to the gingival level
 Upper lateral incisors & canines were also very badly destroyed

CASE REPORTS
 Second molars : Intercuspating occlusion
 First molars : > 40% attrition on the occlusal
surfaces with no intercuspation
 Upper right lateral incisor & canine : attrided
to the gingival level
 Lower Anterior : Right first premolar - left
canine were totally razed to gingival level
 Remaining teeth : > 40% of loss of crown
structure

CASE REPORTS
 Phase I
 Endontic
 Reestablishment of Vertical dimension
 Occlusal equilibration
 Phase II
 CLP
Upper and lower incisors
Endodontics
Glass fiber posts + Adhesive
restorations
 Post & core on upper right canine &
lower canine

CASE REPORTS

AmelogenesisImperfecta
 Incisal aspects …completely worn away exposing
the pulp chambers
 Occlusal aspects of all the posterior teeth were also
severely worn
 Cervical & proximal enamel was found to be normal
 Attrition of the molars resulted in a decrease of the
vertical dimension of occlusion
 Interocclusal distance : At physiologic rest position
= 7.3 mm
 Centric Occlusion = Maximum intercuspal position
 Gingival status: Good and well maintained
 Oral hygiene : satisfactory www.indiandentalacademy.comwww.indiandentalacademy.com

CASE REPORTS
Panoramic Radiographic Examination
Enamel of the teeth appeared to have the same radiodensity as dentin
Morphology of the roots were normal
Pulp chambers were normal with no evidence of calcification
Cementum, lamina dura, & bony trabeculations were within normal limits

CASE REPORTS
 Inadequate crown height for the fabrication of the
prosthesis
 Apically positioned flap
 Crown lengthening
 Increase of crown height by approximately 2 mm
was achieved
 Caries excavation was done for all carious teeth
 Endodontic therapy was carried out as required
 Bite registration using Type II modeling wax
 Increased vertical dimension of 5 mm with 3 mm of
freeway space
 Splint fabricated with heat-cured Polymethyl methacrylate
acrylic resin
 Patient used the splint for three monthswww.indiandentalacademy.comwww.indiandentalacademy.com

CASE REPORTS
 Full-mouth, heat-cured provisional restorations were fabricated at the
desired vertical dimension (with 3 mm freeway space) using methyl
methacrylate acrylic resin & were temporarily cemented

CASE REPORTS
 Maxillary anterior teeth: cast post cores
 Mandibular anterior teeth : prefabricated
posts
 Premolars & right first molar : Composite
core build-ups to increase the crown height
Crown preparation:
Porcelain-fused-to-metal (PFM) : Maxillary
& mandibular anteriors, premolars, and
maxillary first molars
All-metal restorations: remaining teeth

Conclusion!!!
Most patients with severe wear of teeth can be
managed by restoring the occlusion and without increasing
the vertical dimension. If the VDO has to be increased, such
as in Turner and Missirlian class-III situation, it has to be
done cautiously. According to literature, a limited increase in
vertical height can be tolerated and well adapted. The
amount of vertical height to be increased is best judged by
placing removable splint/denture and fixed provisional
restorations. The final restoration should mimic the OVD,
function, and esthetics that have been developed in the fixed
provisional restoration.

“ You cannot successfully treat
dysfunction unless you understand
function”

References : D. R. Bloom 1 and J . N. Padayachy , Increasing occlusal vertical
dimension
— Why, when and how , BDJ, 2006,200:251-256
 B. H. Smith, Changes in occlusal face height with removable partial
prostheses, JPD 1975; 34(3) : 279-285
 Turner KA, Missirlian DM. Restoration of the extremely worn dentition. J
Prosthet Dent 1985;52:467-74.
 Krishna MG, Rao KS, Goyal K, Prosthodontic management of severely
worn dentition: including review of literature related to physiology and
pathology of increased vertical dimension of occlusion. J Prosthet Dent
2005 ; 5(2): 89-93
 Dawson PE. Evaluation, Diagnosis, and Treatment of Occlusal Problems,
ed 2. St Louis: Mosby, 1989.

References :
 Okeson JP, Management of Temporomandibular Disorders and
Occlusion, ed 4. St Louis: Mosby, 1998:160.
 Araki A, Yokoyama T, Murakamu H, Ito Y, Maeda H, Kameyama Y.
Effect of decreased vertical occlusion on mandibular condyle of
senescence-accelerated mouseP8 [abstract 706]. J Dent Res 1999;78:194.
 Richard P. Harper, Clinical Indications for Altering Vertical Dimension
of Occlusion , Quintessence International, Vol 31, No 4 (April 2000)

THANK YOUTHANK YOU www.indiandentalacademy.comwww.indiandentalacademy.com

Journal Club
14th
June 2008
by
Dr. abhilasha
next !!!www.indiandentalacademy.comwww.indiandentalacademy.com

Guidemand to centric relation in dentulous
situation
A. Operator guided methods: manual guidance
 Chin Point guidance – Guichet (1970): thumb & forefinger
positions the condyle in RUM position
 Bimanual method – Peter Dawson (1974): guides the
mandible in most superior anterior position
 Three Finger method – Peter Thomas 1980: Positions
condyle in anterior superior position
A. Anterior Deprogrammer
 Uses of Leaf Gauge:
 Helps to deprogram the muscles and tripodizes the mandible for obtaining
centric interocclusal record by assisting the patient’s neuromusculature to seat
the condyles in anterior superior position
 Useful to detect centric prematurities in dentulous subjects
 Useful in TMJ dysfunction to eliminate muscle memory or engram. It helps to
identify occlusal prematurities and also to indicate the optimum vertical height

Rest of lost vert dim/ academy general dentistry

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