Full-mouth rehabilitation of a worn dentition with a reduced occlusal vertical dimension
A 58-year-old man presents for full-mouth rehabilitation. Twenty years of reflux and a five-a-day cola habit have left generalised erosion, with dentine exposed on the palatal surfaces of the upper anteriors and the occlusal surfaces of all posterior teeth; attrition has shortened the upper central incisors by about 4 mm. He has lost 36 and 46, the lower molars have drifted mesially, and there is no stable posterior stop on either side. His freeway space measures 1.5 mm and the lower facial third appears reduced compared with photographs from ten years ago. He reports a jaw click on opening that is painless, occasional morning jaw stiffness, and heavy nocturnal clenching; he has never worn a night guard. He has no relevant medical history, is a non-smoker, and takes no medication. He is a schoolteacher who talks a great deal and is worried about his speech. Radiographs show adequate bone support and no periapical pathology; the remaining teeth are vital and minimally restored.
1. Can the occlusal vertical dimension be increased in this patient, and if so, by how much? Describe the records you would use to decide.
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Yes, but the increase must be planned and tested rather than assumed. The 1.5 mm freeway space, the 4 mm shortening of the incisors and the loss of posterior stops all indicate that vertical dimension has been lost; a normal freeway space is roughly 2–4 mm. Gain is available, but the amount must be verified functionally.
Records: (1) freeway space, measured by getting a reproducible rest position through swallowing and relaxed pronunciation, compared with the intercuspal position; (2) the closest speaking space during "s" sounds, which should be about 1–2 mm and is a sensitive check in a patient whose speech matters; (3) facial proportions, comparing upper, middle and lower thirds, and profile photographs against old photographs; (4) mounted casts on a semi-adjustable articulator with a facebow record and a verified centric relation; (5) a diagnostic wax-up at the proposed vertical, transferred to provisionals; (6) phonetics, aesthetics and comfort assessed with the trial restoration in place.
A practical increase is 2–4 mm at the incisors in stages, with up to about 5 mm usually tolerated. The painless click and morning stiffness are not absolute contraindications but are a reason to trial the new vertical with a removable appliance or long-term provisionals for at least eight to twelve weeks before any tooth is prepared irreversibly. If symptoms, speech or comfort deteriorate, reduce the increase.
2. Sequence the rehabilitation and justify the order, the provisional phase and your material choices.
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Phase 1 - disease control. Caries, endodontics if needed, periodontal treatment, hygiene instruction, and a decision on the drifted and missing units. Refer him for management of reflux and dietary advice about the cola; without this, the erosion continues whatever is placed.
Phase 2 - planning. Diagnostic wax-up at the new vertical, cross-mounted casts, a trial in the mouth or a removable overlay appliance, and a written aesthetic and phonetic checklist.
Phase 3 - provisional phase. Provisionals or a removable overlay worn for eight to twelve weeks at the proposed vertical. This tests speech, comfort, aesthetics, the click and the patient's tolerance before irreversible preparation, and it protects the worn dentine. It also allows the hygienist to assess his cleaning around the margins.
Phase 4 - definitive restoration. Re-establish posterior support and centric stops first, because posterior contacts define the vertical and provide stability, then restore the anterior segment for aesthetics and guidance, checking that anterior guidance is shared and does not overload any single tooth. Where the posterior teeth are missing, decide between implants, a cantilever or a removable partial denture that restores the vertical, rather than simply replacing teeth at random.
Materials. Monolithic zirconia for posterior crowns and onlays for wear resistance and strength; lithium disilicate or bonded ceramic for anterior units; consider a bonded ceramic or composite for eroded palatal surfaces where space is limited. Provide a hard night guard and review the occlusion closely, given the nocturnal clenching.
3. He cannot afford the full plan. What is the minimum acceptable treatment, and what would you warn him about?
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The minimum acceptable plan must still protect the remaining tooth structure and leave him in a stable, comfortable occlusion. It would be: completion of disease control; dietary and reflux management; desensitising and fluoride therapy for exposed dentine; a hard acrylic stabilisation splint for the nocturnal clenching; and then the most strategic restorations, usually the posterior units that re-establish a stop on each side, plus the upper anteriors that affect speech and appearance.
A cheaper route is direct composite build-ups at an increased vertical, or a removable overlay appliance that restores vertical and posterior support without preparation. Both are legitimate, but both have limitations that must be stated plainly.
Warnings: composite in a heavy clencher has a finite life and will need repair or replacement, and repeated repairs can accumulate; a removable appliance depends entirely on compliance and may not be worn; and a piecemeal plan that raises the vertical on some teeth while leaving others untouched creates occlusal interference and overloads the unrestored units. Do not begin a partial rehabilitation that you know will leave him worse than before, and do not prepare the anterior teeth irreversibly before the new vertical has been tested. Offer staged treatment with a written priority list, review the splint and the provisionals at each stage, and document that he declined the comprehensive option so that the decision is shared and recorded.