Occlusal Vertical Dimension Increase in a Patient with Severe Attrition and TMD History
A 61-year-old man presents with generalized severe attrition, loss of posterior occlusal stops, and a reduced occlusal vertical dimension. He reports a history of jaw clicking and occasional morning jaw soreness, but no locking and no pain at rest. He has a 4 mm freeway space at rest. He wants his teeth 'built back up.' He is a reformed bruxer who now wears a splint inconsistently. Cephalometric and clinical assessment suggests he could tolerate a 3–4 mm increase in OVD. He has no medical contraindications.
1. Outline a staged approach to increasing his occlusal vertical dimension, and state the criteria you would use to decide whether to proceed to definitive restorations.
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Staged approach:
- Stabilize and diagnose - confirm the TMD history is quiescent (no locking, no pain at rest). Treat any active TMD before elective reconstruction. Record the current OVD and the planned OVD (3–4 mm increase).
- Trial with a removable appliance - fabricate a full-arch occlusal splint or a provisional overlay at the proposed OVD and have the patient wear it for several weeks. This tests whether the patient tolerates the new vertical and whether the muscles and joints adapt.
- Provisional restorations - if the trial is tolerated, convert to fixed provisionals at the new OVD with a mutually protected or group-function occlusal scheme. Use these to refine esthetics, phonetics, and the occlusal scheme.
- Definitive restorations - only after the provisionals have been stable and comfortable for an adequate period.
Criteria to proceed to definitive:
- No pain, clicking that is unchanged or improved, no locking.
- Comfortable phonetics and swallowing.
- Stable provisionals with no fracture or debonding.
- Patient compliance with the splint.
If any criterion fails, do not proceed; revise the provisionals or reconsider the OVD.
2. He wears his splint inconsistently. How does this affect the prognosis and what is your recommendation?
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Inconsistent splint wear in a patient with a history of bruxism and a planned OVD increase is a significant risk factor. The reconstruction is being built to a new vertical and a new occlusal scheme; parafunctional loads during the adaptation period can fracture provisionals, loosen restorations, and destabilize the joints and muscles.
Recommendation:
- Do not proceed to definitive restorations until splint compliance is established. Use the provisional phase as a compliance test.
- Explain the link between compliance and the longevity of the work, and set a clear expectation that the splint is part of the treatment, not an optional extra.
- Consider a hard, full-coverage splint with a flat occlusal plane and even contacts, and review it at each visit.
- Document the discussion and the patient's agreement.
If compliance cannot be achieved, consider a more conservative plan (e.g., limited reconstruction of the most worn teeth) rather than a full-mouth reconstruction, because the prognosis of extensive work in an uncontrolled bruxer is poor.