journalofdentistry39(2011)662–671

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Prosthetic rehabilitation and treatment outcome of partially edentulous

patients with severe tooth wear: 3-Years results

Joannis Katsoulis a, *, Senka Geissbu¨hler Nikitovic a, Sophie Spreng a,

Klaus Neuhaus b, Regina Mericske-Stern a
a Department of Prosthodontics, School of Dental Medicine, University of Bern, Switzerland
bDepartment of Preventive, Restorative and Pediatric Dentistry, School of Dental Medicine, University of Bern, Switzerland
article info abstract

Article history: Objectives: The purpose of this study was to report on the management and treatment outcomes of partially
Received 30 April 2011 edentulous elderly patients with severe tooth wear.
Received in revised form 22 Methods: Partially edentulous patients with severe tooth wear who underwent the same protocols for full
July 2011 prosthodontic rehabilitation were eligible for this observational study. Their clinical diagnoses were based on
Accepted 23 July 2011 a complete oral examination, photos, functional and cast analysis, general health conditions and behavioural
aspects, such as acidic diets and bruxism. A 6-month preliminary phase with splints and provisional
prostheses was main-tained prior to the final fabrication of fixed and removable prostheses. All patients com-
Keywords: pleted a follow-up period of 3 years. The outcomes were technical and biological complications with the
Tooth wear prosthesis (wear or fracture of anchorage, abutment, prosthesis core or veneering, and implants, plaque index,
Attrition caries, endodontic and periodontal lesions, tooth fractures and periimplantitis) and oral health-related quality
Bruxism of life (using the oral health impact profile questionnaire, German version of OHIP G-14).
Partial edentulism Prosthetic
rehabilitation Biological and
technical complications Results: Data from 42 patients (33 men, 9 women) with a mean age of 62 8 years were available. The
probability that a first, second or third technical complication occurred was 49%, 38% and 21%, respectively.
Quality of life About 50% of the patients remained without any complica-tion. The average OHIP-value was 5 7, which
represents high oral health-related quality of life. No statistically significant correlations between the OHIP
values and the type of prostheses or the occurrence of complications were observed.

Conclusions: From multiple perspectives, the rehabilitation of partially edentulous patients with severe tooth
wear is a complex task, and more information regarding treatment protocols, prosthetic indications and
treatment outcome is needed.
# 2011 Elsevier Ltd. All rights reserved.

1. Introduction skeletal class, the presence of reflux disease, eating disorder, strong biting,
coarse and acidic food, saliva, chewing patterns adapted to tooth loss and
Tooth wear simply means the loss of tooth substance without any clear prosthesis, and the absence of prosthetic maintenance. The pattern of wear
definition of its aetiology or pathology and some surface loss over the is based on the individual, while its aetiology and diagnosis are not always
1
years is considered physiological. Tooth wear is considered to have clear. As such, the treatment outcomes are not always
multiple factors, such as the type of

* Corresponding author at: Department of Prosthodontics, School of Dental Medicine, University of Bern, Freiburgstrasse 7, 3010 Bern, Switzerland. Tel.: +41 31
632 25 86, fax: +41 31 632 49 33.
E-mail address: joannis.katsoulis@zmk.unibe.ch
(J. Katsoulis). 0300-5712/$ – see front matter # 2011
Elsevier Ltd. All rights reserved. doi:
10.1016/j.jdent.2011.07.008
journalofdentistry39(2011)662–671 663
 developed to investigate the (FPP), but exhibiting non-
2 impact of dental/oral conditions on The hypothesis was that a restored gaps.
successful. Historically, extensive
19,20 - Removable partial dentures or
tooth wear has been identified quality of life. The presence purported correlation between the
based on evaluation of skulls, of a higher number of teeth leads oral health-related quality of life, overdentures (RPD, OD) with
probably as a result of coarse food to better scores than partial or the type of prosthesis and the rate insufficient occlusal support
intake, hard biting and prolonged complete tooth loss and the of complications rate exists. and instable occlusion,
3
mastication. In spite of wearing of removable dentures. including a complete denture
controversy and weak evidence Specific investigations by means (CD) in one jaw.
regarding many aspects of tooth of the OHIP in relation to severe - Partial tooth loss without any
2. Methods
wear, it appears that there is a tooth wear have not been prosthetic reconstruction.
consensus regarding the use of the conducted thus far.The aims of the
terminologies of erosion, abrasion 2.1. Patients
present longitudinal study were as 2.2. Diagnosis and
4–6
and attrition. Diagnostic criteria follows: treatment protocol
for erosion have been previ-ously Over a 2-year period, 48 partially
proposed.
7–9
Attrition is a term edentulous patients with severe
All patients completed the
used to describe tooth surface loss tooth wear were identified among
- To provide information on systemic health questionnaire
caused by occlusal or proximal all patients who were referred for (signed by the family physician)
clinical findings and prosthetic
contacts, while abrasion refers to comprehensive prosthetic and were allocated to an ASA
the loss of tooth substance due to indications, as well as an
rehabilitation. They eventually classification (American Society of
mechanical impact from materials assessment of quality of life, in received prosthetic treatment in the Anesthesiology, http://
others than teeth. partially edentulous patients same clinical setting and were 22
with severe tooth wear after www.asahq.org; accessed 2011).
followed regularly for at least 2
prosthetic treatment. A dietary protocol was recorded,
years to investigate technical
and each patient underwent the
Generalizing treatment complications, failures of same clinical examination and
concepts for severe tooth wear is - To assess the occurrence of reconstructions, implants or teeth diagnostic protocol as follows:
rather difficult. Some authors have technical complications with the and quality of life. All patients had
proposed classifications and new prostheses during the first 3 missing teeth, and
indices for the diagnosis of the years after prosthetic mostweremissingteethinboth jaws
7,10,11
amount of wear, while others rehabilitation, with the when theywere first examinedand
have discussed the occlusal wear assumption that parafunctional admittedfortreatment. Thissurvey
associated with restorative waspart of a quality control Dispensarizare; Înregistrare Chestionar
habits and bruxism were
4,12,13
materials as well as increases frequent causes of tooth wear in assessment of the dental
complicații OHIP
in vertical dimension, prosthetic the present study cohort. consultations and was approved by
14 Sfârșitul
reconstruction and occlu-sion. A the institutional ethical committee.
studiului
few studies have investigated the The patients gave their informed 36 luni
epidemiology of tooth wear consent for the use of their data,
involving the associations between including photographs, and were
Protocol studiu
aetiological factors and willing to answer a question-naire.
pathological effects on teeth, and Pacienți admiși
The protocol of the present
discussed restorations and Diagnostic
observational study is summarized
prosthetic reconstructions, Plan tratament
in Fig. 1. The following inclusion
particularly from the perspective
criteria for the analysis ofthe
of erosion and bruxism as major 24 luni
2,15,16 patientsinthe contextofthe
aetiological factors. To date,
presentsurveywere adapted from
the combined effect of severe Fig. 1 – Study protocol.
Hugoson et al.’s attrition index
tooth wear in patients with partial
21
tooth loss and instable occlusal from 1988 and Bartlett et al.’s
support has not been described in erosion index from 2008 :
7
relation to therapeutic
consequences.

Severe tooth wear on the tooth

substance or on the dental
The duration of functional material (localized or
tooth contact per day during
generalized), including wear that
mastication is short and, under
exhibits well-matching facets.
normal conditions, will not lead to
pathological wear. Currently, oral A loss of 50% of crown
parafunction (e.g., grind-ing, height of teeth in
clenching) isfrequently observed contact. Pronounced
among patients. Itislikely to be occlusal tooth wear with
associated with stress and anxiety visible dentin. Dental
17 status: partial
in some patients, and bruxism
appears to be a chief cause of edentulism.
18 - Natural teeth (including
severe attrition.
The Oral Health Impact Profile fillings and onlays) or a
questionnaire (OHIP) was combina-tion of natural teeth
and fixed partial prostheses
664 journalofdentistry39(2011)662–671

Fig. 2 – (a–c) Atriție severă cu micșorarea spațiului interarcadic la un pacient de sex masculin edentat parțial de 56 ani, care nu și-a purtat proteza
mobilizabilă o perioadă îndelungată. Majoritatea diinților au pierdut >50% din țesutul dur.
 (both >5 mm), as well as a
An observation period of 4–6 deep bite with impingement
months was maintained with of the palatal soft tissue.
1. Extra- and intraoral photos This included also composite
and radiographs were
the provisional reconstructions
fillings and composite Awareness of bruxism
in situ. (self-reported or by
obtained, followed by buildups for worn teeth
5. The provisional period was the
identification of hopeless teeth without caries, e.g., short others).
basis on which to determine
and records of periodontal mandib-ular front teeth,
the final treatment plan.
status, caries, and mandibular endodontic treatment and
Treatment was performed with
jaw function. crown length-ening. If FPPs
fixed and removable
2. Casts were obtained and were fabricated, the
prostheses using teeth and
mounted on the articulator. reconstructions were designed
implants.
Bite registrations were in short segments (i.e., single
performed in two different crowns and short span FPPs).
positions: in the patient’s Adhesive luting for ceramic
current maximum materials, compos-ite fillings
intercuspidation and, if and buildups was used,
possible, in a retrusive contact phosphate cements for gold
position that corresponds to a copings and FPP. Implant
centric relation position of the supported single crowns and
jaw. The retrusive position FPP were screw retained.
was often unstable due to RPDs were planned whenever
severe premature contacts, possible with quadrangular
caused by tooth elongation supports. For implant support
into non-restored opposed of overdentures soldered gold
gaps, tooth migration and bars were fabricated, for tooth
eruption of jaw segments. support of overdentures gold
copings with Dalla Bona
3. A tooth set up using anchors were used. Splints and
prefabricated acrylic teeth that night-guards were deliv-ered
were adapted on the models to protect the new prostheses
served for further analysis of after final rehabilitation.
the inter-jaw relations. This
analysis, together with the
criteria for facial appearance
and physiognomy, offered the Six trained dentists working
background on which to re- in the same clinical setting
establish stable occlusion and followed the treatment protocol
vertical dimension. under supervision of one person
and had treated the patients.
4. The entire set of diagnostic Figs. 2a–c and 3a and b
measures enabled the planning represent two clinical cases
of provisional prostheses and exhibiting severe attrition.
combined splint therapy. The
preliminary treatment 2.3. Oral and prosthetic status
consisted of extractions of before and after prosthetic
hopeless teeth, hygiene rehabilitation
instructions and periodontal
treatment, provisional fillings, In the context of the present
removal of strong premature study, two trained examiners who
contacts had not been involved in the
and fabrication of provisional treatment of the patients
prostheses and splints in a
anonymously collected data based
23
reorganized approach. A on an abstraction of the oral
great variety of prostheses and examinations, radiographs and
splints were used, which
served: medical files.
To bring the mandible into a
stable position and to 1. Initial status:
stabilize occlusion. Presence and type of old
To increase the vertical prosthetic reconstruction in
dimension of occlusion the mandible and maxilla:
(VDO), if necessary. RPD, OD, CD, and FPP.
Overclosure and loss of VDO.
To consider the aesthetic
aspects of both tooth length Locked bite with premature
contacts.
and facial appearance.
Large overjet and overbite
 journalofdentistry39(2011)662–671 665

Fig. 3 – (a și b) Cazul unui pacient cu uzură severă a dinților frontali, migrări dentare spre breșele edentate opuse și blocarea ocluziei cauzată de
contactele premature existente. DVO este mult crescută în retruzie. Nu se poate reface planul de ocluzie din cauza poziției premolarului 4.5.

Functional assessment of the
mandibular jaw and joint,
including pain on muscle
palpation, internal derange-
ment (clicking sounds, disc
dislocation), reduced jaw
movements, self-reported
problems, and facial pain.
2. Preliminary treatment to
restore function and aesthetics:
Removable prostheses or
splints.
Increase in the vertical
dimension of occlusion.
Tooth extraction, endodontic
treatment, or crown length-
ening.
3. Final prosthetic therapy:
Type of final prosthesis in
both jaws, including the
placement of implants.
Materials in occlusal surface
restorations that are in
contact, such as the enamel
of the natural teeth (E),
adhesive composite
restorations (hybrid filled)
and acrylic denture teeth
(A), ceramic materials, i.e.,
onlays and full ceramic
crowns (press ceramics) or
veneering of porcelain fused
to metal (FPP) supported by
teeth or implants (C). No
metal occlusal surfaces were
present. The following
classification was used:
1. One type of material in
contact with occluding
surfaces: A/A or C/C.
2. Two types of materials in
contact: A/E or A/C or
C/E.
3. Three types of materials
in contact: A/C/E.
2.4. Treatment
complications
The primary outcome was the
incidence of technical and
biological complications as well
as survival of the prosthesis and
implants. The patients were
regularly followed during a
minimum of a 3-year period with
two scheduled visits per year. The
dental hygienist performed
hygiene procedures and checked
periodontal health and caries
under the supervision of the
dentist who also checked the untreatable periodontal lesions,
prostheses. - tooth extraction due to deep
tooth fracture (not caused by
- Wear and fracture of the trauma),
anchorage devices of the
2.4.1. Technical removable prosthesis - treatment of periimplant
24
complications (matrices and patrices of disease.
Technical complications with the attach-ments, clasps and
new prostheses and related solder joints of implant 2.5. Questionnaire (OHIP)
maintenance services were bars).
recorded for both scheduled and - Fracture of the retention The secondary outcome was the
screw for bars or implant quality of life after a 3-year period
non-scheduled visits. These
crowns and FPP. with the new reconstructions in
events required interventions by
situ. The German version of the
the dentist, mostly combined with
2. Complications and failures of Oral Health Impact Profile
repairs in the dental laboratory. prosthesis/implants:
questionnaire (OHIP
The technical complications were - Loss of FPP (fracture of
classified as follows: abutment teeth and posts or
fracture of framework).
- Need for re-cementation of
1. Complications with anchorage: FPP.
- Fracture of removable
prosthesis.
- Fracture of implants.
- Minor chipping of ceramic
materials, only polishing
needed.
- Extensive chipping and need
for a remake.
3. Repair due to wear:
- Visible and severe wear of
occlusal surfaces of
prostheses to such a degree
that repair and replacement
of worn teeth were advised.
2.4.2. Biological
complications
During the provisional treatment
phase, hygiene of the patients was
strictly monitored and the plaque
measured at 4 sites of the teeth
(mesial, buccal, distal, lingual).
The plaque index (PLI) was
expressed as percentage of sites
exhibiting plaque. The goal was to
reach a PLI of 20% or less. After
completion of the treatment and
during the 3 year follow-up period
plaque records were continuously
obtained.
Biological complications
during the maintenance phase
were recorded as follows:
- recurrent caries or new caries
lesions requiring fillings,
- apical lesion after endodontic
treatment,
- need of endodontic treatment,
- tooth extraction due to deep
caries, endodontic failure or
666 journalofdentistry39(2011)662–671
 20,25 Tabelul 1 – Rezultate clinice: diagnosticul functional și de
G-14) was administered to all patients who were told that they were
free to complete it or not. The rating scale was from 0 to 4 with low ocluzie
values representing good quality of life. The patients completed it without
any assistance from the dentist, dental hygienist or nurse. However, in the Criterii Număr
beginning, they received information about the structure and content of pacienți
the questionnaire. Uzură dentară Spațiul interarcadic, micșorare 32
și ocluzie DVO 3–7 mm
Ocluzie blocată 7

2.6. Statistical analysis Ocluzie adâncă, OB 5 mm 11

OJ mare 6 mm 6
Erupția segmentului 11
Descriptive statistics were used for the patient demographics and clinical frontal mandibular
findings as well as for the numbers and types of prosthetic indications. Ocluzie cap la cap 9
The estimated time that elapsed between delivery of the prosthesis and the ATM Durere, problem invocate de pacient 1
first, second or third event was calculated from the censored data by Durere musculară la palpare 6
means of a Kaplan Meier survival analysis. The correlations between the Cracmente 2
Limitarea miscărilor mandibulare 1
OHIP, the types of prostheses and failure rates were calculated via Conștientizare
Pearson correlation. Statistical analyses were performed with the SPSS parafuncții De către pacient 14
software (SPSS 17.0, Chicago, IL, USA).

De alte persoane 5
DVO, dimensiunea vertical de ocluzie; OB, overbite; OJ, overjet.

removable denture in both jaws, while 32% had an RPD in one jaw. About
55% had natural teeth
3. Results

Based on the selection criteria, clinical data from 42 patients (33 males
and 9 females, with a mean age of 62.0 8.3 years) were used for the
present survey. They had been followed over a 3-year period, no dropout
was registered and all patients had followed regularly the maintenance
visits. Eighty-five percent of the patients were older than 55 years. Due to
partial tooth loss and missing posterior support, dento-alveolar morpho-
logical changes were frequent. The chief complaints when the patients
were first seen by the dentist were as follows: aesthetic impairment (69%)
due to short or partly missing front teeth, chewing problems for some
types of food (13%) and oral discomfort (8%). Ten percent of the
complaints were not clearly expressed, although some patients mentioned
that they hurt their lip and tongue on the sharp edges of their broken teeth.

The completion of a dietary protocol revealed overall physiological

eating habits. For seven male patients (five of them being farmers), a high
daily consumption of tough and acidic food was found. One female
patient was diagnosed with a reflux problem accompanied by a
Campylobacter infection. She underwent stomach surgery prior to
treatment by the dentist. One female patient had a history of bulimia
combined with clenching and grinding. She had successfully undergone
psychological therapy.

According to the ASA classification, 76% of the patients were healthy

(i.e., P-1), while 15% were allocated to P-2 and 9% to P-3. 30% of the
patients had medications and some of them, like antihypertensive, may
have caused dry mouth. However, the intake of specific medications was
not found to be explanatory for severe wear. Only one female patient was
a smoker, 2 male patients admitted heavy smoking (>10 cigarettes up to
on package per day), one was a pipe smoker, and two smoked
occasionally.

Table 1 shows the diagnostic findings regarding function and

occlusion at the time of initial patient examination. Thirteen percent had a
 Tabelul 2 – Tratamentul preliminar.
Criterii Nr.
pacienți
Reabilitare ocluzală PPM 22
Gutieră/ Șină 17
Ambele 3
Pre-tratament Extracții 34
Obturații 27
Alungiri coronare 7
Tratament endodontic 19

combined with some fixed restorations and non-restored gaps in both

jaws. Preliminary treatments are summarized in Table 2. The type of the
definitive reconstruction included fixed and removable dentures often
supported by implants ( Table 3). Accordingly, twelve patients received,
for the first time in their life, a removable prosthesis in one jaw and three
patients in both jaws. A total of 81 implants were placed in 27 patients for
overdenture anchorage and strategic support of RPD as well as for
fixation of FPP. Table 4 gives the dental and prosthetic status before and
after treatment. Depending on the types of tooth restorations and
prostheses, the occluding surfaces exhibited the same or different
materials. Table 5 exhibits the combination of materials in occluding
contact.

During a 3-year period, 17 patients remained

completely free of any complications and the
implants remained stable resulting in a survival
rate of 100%. Nineteen patients remained without
technical complications and 23 without
biological failures. Various types of technical
complications occurred in 12 patients, while 2
patients exclusively exhibited severe wear of the
acrylic denture teeth of the removable prosthesis.
A complete failure of FPP without a chance of
repair and requiring a remake was observed in
four prostheses in three patients. Table 6 shows
the complications and services that were
provided. The probability that a first, second and
third technical complication occurred within the
3-year observation period in the same patient was
49%, 38% and 21%, respectively ( Fig. 4).
 journalofdentistry39(2011)662–671 667

Table 3 – Protezele finale maxilare și mandibulare.

Maxilar Pacienți Mandibulă Pacienți

Mobilizabilă 24 Mobilizabilă 21
PT 9 PT 1
OD: dispozitive radiculare, PPM 8 OD: dispozitive radiculare, PPM 12
a b
OD: implanturi și bară 2 OD: implanturi /bară 8
OD: dinți și implanturia 5
Fixă 18 Fixă 21
PPF: dinți 6 PPF: dinți 3
a b
PPF: implanturi 2 PPF: implanturi 1
PPF: dinți și implanturia 5 PPF: dinți și implanturib 12
SDA: dinți, coroane 5 SDA: dinți, coroane 5
a Total 37 implanturi.
b Total 44 implanturi.

Tabelul 4 – Status dentar și protetic înainte și după tratament. The PLI remained low but raised slightly during the mainte-nance period.

Tipul Înainte de tratament După tratament The OHIP-14 questionnaire was completed 3 years after delivery of
restaurării (număr (număr the prostheses. A total of 36 out of the 42 patients returned the
pacienți) pacienți) questionnaire properly completed. Two patients did not complete it
Dinți, PPF, 24a 12b because the OHIP was not available in their native language, and four
la ambele maxilare patients did not return it for unknown reasons. The mean score for the
PPM, OD, PT 13c 13 questionnaire was 5 7. Fig. 5 shows that 80% of the patients gave a rating
la un singur maxilar
of 0 (never) or 1 (seldom) for all 14 questions. Few patients gave a rating
PPM, OD, PT 5c 17
la ambele maxilare
of 4 (very often) for four items, namely item 2 (bad taste) and items 4, 5,
and 8, which are related to stress and tension. The total mean rating of
Implanturi 1 27
seven patients was >10 up to 23. The Pearson correlations did not reveal
a Toate cu pierderi de țesut nerestaurate.
b Include SDA (arcul dentar scurtat). any clear tendencies between the OHIP values and the types of prosthesis
c Proteze mobilizabile purtate puțin, sprijin ocluzal insuficient. (r = 0.013) or the numbers of failures (r = 0.207). Patients who received
removable prostheses or experienced technical complications at various
instances did not give statistically significant higher ratings. Thus, the
hypothesis was not confirmed.
Biological failures were mostly related to minor carious lesions,
endodontic problems and tooth fracture, but not to periodontal problems.
Some extracted teeth being molars and wisdom teeth were not replaced by
implants. Only one implant exhibited a periimplant lesion that did not lead
to the loss of the implant. Table 7 gives an overview on biological
complications that occurred in 19 patients. The records of PLI at the Table 6 – Eșecuri după tratament.
beginning, at the end of the treatment and after 3 years of maintenance Tipul complicației Număr
were: 61.2 14.4% (range 14–100%), 19.5 5.03% (range 9–33%) and 27.0 pacienți
a
7.2% (range 15–50%). During the treatment phase the hygiene
Ancorare: uzura și fractură followed urmată de reparația
instructions were successful and the goal of an average PLI of 20% was OD, PPM: schimbări ale matricei 12
reached. Uzura system Dalla Bona: refacere 1
Fractură bare : reparație 1
Fractura PPF (implanturi) 0
Proteze: eșec, pierderea protezei și implanturilor
Fractura, pierderea PPF: refacere 2
Tabelul 5 – Materiale de la nivelul suprafețelor ocluzale. Nevoia de recimentare (PPF, cape aur OD) 8
Fractura OD, PPM, PT: urmată de reparație 1
Materiale Per pacient Număr pacienți Fractura dinți posteriori: extracție 1
A/A 8 Fractura implant 0
C/C 1 Material 1 Fisuri ceramica: lustruire 17
E/E 0 Fractura ceramică: refacere 2
A/C 6 Suprafața ocluzală: Uzura severă
A/E 2 Materiale 5 Dinții artificiali acrilici ai PT, OD, PPM 7
C/E 5 Obturații compozit 2
A/C/E 3 Materiale 17 Pierderea sau fracturarea obturațiilor din compozit (necauzate
de carii) 6
A, dinți acrilici, restaurări din rășini adezive și compozite; C, ceramică; E, smalț. O altă gutieră din cauza uzurii severe 8
a
Numărul nu s-a putut înregistra din moment ce unii pacienți au prezentat
multiple eșecuri
668 journalofdentistry39(2011)662–671

Table 7 – Complicații biologice.
Tipul complicațiilor
Noi leziuni carioase sau recidive care necesită obturații
Leziuni apicale
Dinți tratați (fără intervenție)
Necesitatea tratamentului endodontic
după apariția complicației.
Extracții dentare: din cauza
Cariilor profunde (molarii maxilari)
Eșecurilor tratamentului endodontic (molari
mandibulari)
Furcații deschise molari de minte
Fractura profunda a dinților neacoperiți de coroane
Periimplantite
Sensibilitate la colet
Durere la palparea muschilor masticatori who have
a au fost exprimate în procente
Numărul nu s-a putut înregistra
din moment ce unii pacienți au
prezentat mai mult de o
complicație
.
Fig. 4 – Probability of a
complication-free
maintenance phase and
occurrence of a first, second
or third event during a 3-
year period (Kaplan–
Meyer).
4. Discussion
A diligent review article on tooth
wear confirms that there is little
scientific information available on
the rehabilitation of this type of
6
damage. The clinical illustrations
given in that article reveal the oral
situation of patients with a mostly
complete dentition. This finding
is different from the present
observational study, which reports
on the diagnosis, treat-ment
concepts and short-term outcomes
of exclusively partially dentate
patients with severe tooth wear.
Because this severe status has
developed over many years, a
strict distinction between erosion,
attrition and abrasion could not be
made. Abfraction was neither a
factor investigated the present
study because many teeth
displayed attrition up to the
gingival border. Controversy
remains regarding the clinical
26
significance of abfraction. Tooth
wear is more often investigated in
young patients with erosive wear,
relation and question of space
were a major concern,
7,23,32,33
and
in the present study an increase in
the VDO became usually
necessary. The newly established
dimension was tested with
provisional prostheses and
27
splints. A zone of comfort was
aimed at establishing rather than
adopting specific measures. The
reorganized approach, which
brings the mandible into the
normal position, is not a scientific
methodology but a practical
clinical technique common in the
23
treatment process ; this appeared
Fig. 5 – Scoruri ale to be helpful in the current
chestionarului 14OHIP. Punctele treatment approach. By means of
crown lengthening for teeth
exhibiting extreme wear, suffi-
cient abutment heights were
obtained and space was
simultaneously created.
full dentition and therefore
present with different sequelae.
Case reports frequently show the
treatment of localized tooth wear
of the front teeth
27,28
or the build-
The overuse of teeth
up of worn posterior teeth.
29 in occlusal contact
Tooth erosion was reported to be was aggravated by the
present in 30–44% in children
30
presence of different
younger than 15 years. Children
from a low socio-economic opposing materials in
background showed significantly the occusal contact
more tooth ero-sion. The
incidence of new tooth surfaces
zone. While the wear
exhibiting erosion, in erosion-free mechanism of gold
children, decreased significantly
with age, while the progression in
against porcelain is
children with erosion did not abrasive, porcelain
change. In adult subjects,
itself has a fatigue
however, the presence of different
restora-tions makes it difficult to fracture type of wear.10
analyze and compare purely an From a reconstructive
erosive process. Controlled
studies on treatment modalities of point of view, the
cases with complete rehabilitation optimum solution
were not available for
comparisons with the present would be a fully fixed
cohort, although advanced and reconstruction made
severe wear are quite frequently
16,31
from the same
identified in elderly patients.
material in all contact
areas,34 in both jaws,
to avoid future
In this study a treatment
methodology and well-estab- irregular wear.
lished protocol for partially However, this was not
dentate patients with tooth wear
was described. However, the final achieved in
prosthetic reconstructions had to
be planned and designed
individually. Economic
considerations also determined
the type of prosthesis that the
patients received. The inter-jaw
 journalofdentistry39(2011)662–671
most cases. In patients with removable dentures, a combina-tion of
various materials was found, such as enamel, composite, natural teeth or
application of veneers to ceramic crowns, where continued irregular wear
can be expected. Most in vitro studies investigated the quantity of tooth
surface loss during a certain period of time. Surface quality was less often
reported, but would have the potential to account for particular surface
35
characteristics that determine how future loss might progress.
Some studies have reported that TMJ problems are not an indicator of
16,31
bruxism and that many bruxing patients do not exhibit TMJ problems.
In the present study, no overt signs of TMJ problems were detected.
36
Bruxism can be considered a dyskinesia that appears to be controlled by
37
the central nervous system. Various cofactors play important roles, such
as stress, coping strategies, genetics and behavioural characteristics.
Interestingly, the results from the OHIP questionnaire revealed that the
most negative ratings were given for the items concerning stress and
physical tension. Currently, no simple method exists that can assess
38
bruxism, and the subjective and normative assessments of treatment
need may be different. Prosthetic treatment is not a causal therapy for
strong biting and bruxism habits, although prosthetic rehabilitation was
indicated for all patients in the present study. Thus the probability of
encountering a problem after a short time was relatively high. The type of
technical complications and fractured natural teeth indicates that strong
biting and parafunctional habits were a major cause of complications. This
was also confirmed by the fact that night-guards hat to be remade after a
short time. Ioannidis et al. investigated the possible influence of age on
the longevity of tooth supported fixed prosthetic restorations. The
39
results of this systematic review showed that increased patients’ age
should not be considered as a risk factor for the survival of fixed
prostheses. Although the majority of studies did not show any effect of
age on the survival of fixed prostheses, there was some evidence that
middle-aged patients may present with higher failure rates.
The patients had 2 scheduled visits per year and were fully compliant.
Thus, biological problems such as development of periodontitis,
insufficient oral hygiene and periimplantitis were well under control. The
experience was that in these patients with severe tooth wear and bruxing
habits the periodontal and periimplant tissues are healthy, remain stable
and bone was of good quality and quantity for implant placement.
Biological complications were related to minor carious lesions but not in
first line to periodontal problems and only one implant exhibited a
periimplant lesion that was successfully treated. A rather good level of
hygiene was maintained during the follow up time and only a few patients
fell back in spite of the regular recall.
Altogether, technical complications occurred with a higher rate than
40–42
was reported in studies of fixed prostheses. Minor ceramic chipping
required the polishing and re-cementation of crowns, while short-span
bridges were required for FPPs. Problems with the anchorage system of
removable prostheses supported by implants were typical for this type of
reconstruction and were comparable with results associated with non-
43–45
symptomatic patients. Twenty patients in all (48%) experienced
various technical problems
669
within the 3-year observation period. Controversy exists whether implants
46
should be placed in patients with bruxism. While an increased risk for
overload resulting in the loss of osseointegration or implant fracture may
be expected, scientific evidence has not been definitive to date. In the
present study, implants were used in various prosthetic indications with
fixed and removable prostheses. During the observation time of 3 years,
no implants were fractured or lost for any reason. In some patients who
lost teeth due to biological complications, particularly tooth fractures,
implants were placed to compensate for the extracted teeth.
An abbreviated version of the OHIP that has been translated into
20,25
German was available. Preliminary reference values for patient
groups of various ages, with different oral/dental conditions and different
25,47
types of prostheses, were provid-ed. The overall mean value of the
OHIP was 5.5, which represents a good oral health-related quality of life.
Patients with fixed prostheses in both jaws gave slightly better ratings.
The highest mean value (7.0) was calculated for the group having an FPP
in one jaw and an RPD in the other. Some of these patients had received a
removable prosthesis for the first time, which might have influenced some
negative ratings of the OHIP. A treatment effect was not reported in the
present study because the OHIP was administered only after the
47
completion of treatment. The investigators expected that types of
reconstruction or experiences with complications would influence the
OHIP-ratings. However, a strong correla-tion was not found. Some
patients expressed high satisfaction with the treatment by adding personal
comments on the OHIP form despite experiencing complications.
Furthermore in the majority of the cases (69%) the initial chief complaint
was an aesthetic impairment of front teeth and less often chewing
problems (13%) or oral discomfort (8%). One can assume that given the
individual life circumstances of certain patients, stressful situations or
other related elements may have a greater impact on the OHIP than the
oral situation itself. The influence of oral health on the life quality of
patients seeking dental implant treatment was reported to be strongly
48
associated with the General Health Questionnaire status. Psychological
conditions of elder edentulous subjects, in contrast, did not mediate the
effect of the type of prosthetic treatment on oral health related quality of
49
life as reported in a recent study. Some considerations and concerns on
50
what the OHIP really measures were also expressed.
5. Conclusions
Partially edentulous patients with severe tooth wear appeared to be
satisfied with the prosthetic treatment outcomes. However, the provision
of new prostheses did not eliminate the risk of technical complications in
patients with tooth wear and bruxism. Regardless of the type of prosthesis
and the occurrence of technical complications, quality of life as expressed
by the OHIP appears to be good. From multiple perspectives, the
management of tooth wear and the rehabili-tation of bruxism remain
complex tasks for patients. Therefore, it is important to gather more
information about treatment protocols, prosthetic indications and
treatment outcomes for partially edentulous patients with severe tooth
wear.
670 journalofdentistry39(2011)662–671

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