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Altering occlusal vertical dimension in functional and esthetic rehabilitation of

severely worn dentition

Article · January 2010

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Review Article

Altering occlusal vertical dimension

in functional and esthetic
rehabilitation of severely worn
dentition
Vinay Chila Bachhav,* and Meena Ajay Aras†
*Post graduate student. †Professor and head, Department of Prosthodontics, Goa Dental
College and Hospital, Goa, India.

Abstract
Many situations requiring full mouth rehabilitation with severely worn
dentition present with the challenge of a lack of restorative space.
These patients often exhibit the loss of occlusal vertical dimension
(OVD).This may require an increase in OVD in functional and esthetic
rehabilitation of such cases. It may be difficult to determine if OVD has
been lost. Careful and comprehensive treatment planning is required
for each individual case and an assessment of the vertical dimension at
rest and in occlusion is essential. This paper overviews etiology of
tooth wear and its relation to OVD, various methods of evaluation of
OVD, whether to increase OVD or restore to existing vertical height
and techniques utilized to alter it.

Key words: Vertical dimension; Vertical dimension of occlusion;

Worn dentition; Rehabilitation

Introduction
Vertical dimension is the distance between two selected
anatomic or marked points (usually one on the tip of the nose and the
other upon the chin), one on a fixed and one on a movable member (1).
Occlusal Vertical Dimension (OVD) is the distance measured between
two points when the occluding members are in contact (1).

*Author for correspondence: Dr Vinay C.Bachhav, Post Graduate student,

Department of Prosthodontics, Goa Dental College and Hospital, Rajiv
Gandhi Medical Complex, Bambolim. Goa, India. 403202.
Tel: +91-9422783856
E-mail: vinaybachhav@gmail.com
Vertical dimension in rehabilitation of worn dentition
In order to get the necessary
restorative space and offer the patient a good
long term prognosis, it is sometimes
necessary to make changes to the OVD (2-5).
OVD and its alteration is one of the most
complex restorative challenges for a dentist.
Patients with severely worn dentition and
loss of posterior teeth may result in reduced
OVD (6, 7) and these patients often need
rehabilitative treatment (8).
Tooth surface loss may be purely
physiological and occurs as a natural
consequence of ageing (9, 10). However;
certain non-carious factors may lead to tooth
surface loss pathological. The etiology of
such non-carious tooth surface wear includes
abrasion, attrition, erosion and abfraction
(11). Attrition describes mechanical wear
resulting from mastication or parafunction,
and is limited to the contacting surfaces of
teeth (12), it is a process in which tooth
tissue is removed as a result of opposing
tooth surfaces contacting during function or
parafunction. Such direct contact occurs at
the proximal areas, on supporting cusps and
on guiding surfaces. Abrasion denotes the
wearing away of tooth structure through
some unusual or abnormal mechanical
process other than tooth-to-tooth contact
(12). External agents which have an abrasive
effect on the teeth include toothbrush
bristles and dietary factors. Erosion indicates
the progressive loss of tooth structure
through chemical processes that do not
involve bacterial action (13). Erosive factors
may be either extrinsic or intrinsic. Extrinsic
factors include drinks such as fresh fruit
juices, carbonated drinks, cordials and
alcoholic beverages etc. Intrinsic factors
include gastrointestinal reflux disease and
eating disorders. Abfraction connotes the
pathologic loss of tooth structure attributed
to mechanical loading and resulting in
wedge-shaped defects in the cervical areas
(14, 15). It has been suggested that the
abfraction is a consequence of eccentric
forces on the natural dentition (14, 16).
Journal of Oral Health Research, Volume 1, Issue 1, January 2010
Tooth wear and loss of OVD
Two theories exist whether loss of
tooth structure lead to loss of OVD (17). The
first as stated by Niswonger concluded that
nature conserves a constant interocclusal
distance of 3mm from birth to death (18).
This distance is maintained by dentoalveolar
compensation i.e., an extrusion of the dento-
alveolar complex to compensate for dental
wear. Tallgren (6) found that 80% of severe
tooth wear patients had a normal
interocclusal rest space. Proponents of this
theory (19, 20) feel that a change in the VD
can cause serious problems at the dental,
muscular and articular level. Another theory
supported by cephalometric studies is that of
the variability of facial proportions (6, 7).
This concept follows that there are
sometimes changes in the OVD, following
dental wear or the loss of posterior teeth.
The disciples of this theory feel that the
patient’s neuromuscular system can adapt to
changes to the dento-alveolar complex.
Evaluation of OVD
It is not necessary that loss of tooth
structure means there is loss of OVD (21, 22).
It may be difficult to determine if OVD has
been lost. There are many methods
described in the literature for evaluating
OVD (23). Assessment of the rest vertical
dimension is one way to clinically evaluate
the OVD. The drawback of this technique is
that interocclusal distance may be variable
(24). Other methods of assessing OVD
include evaluating posterior speaking space,
facial soft tissue contours (25), and
cephalometrics. However, there is no
absolute method to determine an acceptable
OVD. Amongst techniques mentioned,
speech and function can be used to clinically
evaluate an acceptable OVD (26). Various
soft tissue contours used in evaluating OVD
include the golden rule, profile, contour of
the lips and old photographs (27, 28). The
speaking method is a physiologic phonetic
method which measures vertical dimension
by means of the closest speaking space (29).
3
Vertical dimension in rehabilitation of worn dentition
This space can be measured before
the loss of the remaining natural teeth to
give us the patient’s natural vertical
dimension which can be recorded and used
at later dates. When a patient has lost
natural occlusal stops for recording the
vertical dimension, this technique has
provided consistently reliable results (30).
Cephlometrics can also be utilized in
evaluating OVD. Hard tissue cephalometric
analyses like McNamara’s analysis, Andrews’
analysis which determine lower anterior
facial height are used for this purpose (6, 7,
31). Other techniques to establish, OVD, such
as jaw tracking and electrical muscle
stimulation used by the proponents of the so
called “neuromuscular dentistry” concept,
have not been proved scientifically to be
superior to the traditional techniques (32).
Possible clinical problems associated
with altered OVD
Clinical problems associated with
altered OVD include joint or muscle pain,
instability of altered OVD, impaired muscle
activity and altered phonetics (33-36).
Altering VD does not produce pain of more
than one to two weeks which might be a
result of increased temporary muscle
Journal of Oral Health Research, Volume 1, Issue 1, January 2010
awareness by the patient (33). Response after
opening OVD may differ from patient to
patient. Some can remain stable while others
may relapse a lot. But this is not being a
problem usually as this may go unnoticed
dentally. Dawson stated that changes in the
true OVD are not permanent. The VDO will
return to its original dimension measurable
at the masseter muscle. Unnecessary
increases in the OVD are contraindicated as
they are not maintained (34). Clinical
experience has indicated that moderate
increases in the vertical dimension of
occlusion are well tolerated by patients as
long as they are accompanied by a stable
position of mandibular closure together with
anterior guidance that provides separation of
the posterior teeth on mandibular
movement (35). When closing VD there is
very little relapse; it may open by up to 1 mm
within the first year and will then remain
stable (36). The postural muscle tone (i.e.,
the rest position) reduces when VD is
increased but is also back to normal within
three months (37). Phonetics can sometimes
be a problem for the ‘S’ sounds (38). Patients
usually get adapted otherwise need
correction by creating space.
To restore at ‘increased” or “existing”
OVD?
Occlusal vertical dimension (OVD)
determines facial proportions at maximum
intercuspation and influences facial
dimension at rest. Underdevelopment of
alveolar bone may result in loss of lower
facial height and could lead to signs of
premature ageing. Increasing the vertical
dimension of occlusion can have far reaching
effects on facial aesthetics, not just on the
peri-oral areas but on the whole face (39).
Rationale for altering OVD comprise
of aesthetics, altering the occlusal
relationship and for prosthetic convenience
to allow space for restorations (40). It is
important to establish the cause of wear
before intervention to help improve the
effectiveness of any preventive and
4
Vertical dimension in rehabilitation of worn dentition
restorative care (41). Management of these
patients using fixed or removable prostheses
is complex and are among the most difficult
to restore (35, 42). Without knowing the
initial position of the stable bony points of
reference before the dental changes, it is
difficult to determine with certainty if there
is a loss of OVD. Clinicians may decide to
increase OVD based on the amount of
interocclusal space required to restore the
dentition to proper esthetics, form, and
function. The decision whether to restore at
increased or existing OVD is made by
assessing free way space (FWS) and
dentoalveolar compensation. (Fig.1). If an
increase is indicated and performed, it
should be followed up for several months.
Techniques utilized in altering OVD
Conventionally, increase in OVD is
achieved either with a removable acrylic
resin occlusal splint or with the use of
provisional restorations, for example, direct
bonded composite resin or provisional fixed
restorations (43). The OVD can also be
altered during splint therapy (44).
Disadvantages of removable occlusal splints
include patient compliance and speech
interference.
Dahl in 1975 gave a concept to create
space in the treatment of anterior localized
tooth wear (45). It involved the wearing of a
removable chrome cobalt appliance with an
anterior bite plane that separated the
posterior teeth. Initially the posteriors were
disoccluded, but rather than using
restorative means to reestablish the posterior
occlusion, it was allowed to reestablish by
itself over time. Dahl stated that this
reestablishment of posterior occlusion was
due to a combination of both intrusion of
anterior teeth and eruption of posterior
teeth, which usually occurred over a period
of about 4 to 6 months (46). Limitation of
this appliance is that it is used only for
localized severe attrition.
A conventional fixed provisional
restoration can be modified in the mouth
Journal of Oral Health Research, Volume 1, Issue 1, January 2010
until all guidelines have been precisely
followed and the patient completely happy.
A diagnostic wax-up will aid in such
treatment planning. Even when heat
polymerized, these restorations may wear
during the evaluation period or over the
span of treatment, and, therefore, may make
long-term management of OVD difficult.
Loss of cement seal and irreversible tooth
preparation are additional problems
associated with fixed provisional
restorations.
Base metal (BM) onlays provide a
fairly reversible approach (47). The onlays
can be bonded to unprepared or restored
tooth surfaces so that an increase in OVD
can be evaluated (48). The altered OVD is
maintained throughout the evaluation
period as these onlays show wear resistance,
permitting complete mouth rehabilitation to
be accomplished in segments over a long
period of time. Other advantages of using
BM onlays include minimal or no tooth
preparation required and no issue of patient
compliance. However, disadvantages are
increase in laboratory procedures and cost,
difficulty in adjusting due to the hardness of
BMs; and are unaesthetic (47). Use of
porcelain onlays to treat patients with tooth
wear has been described (49, 50), but long-
term follow-up has not been reported.
Direct composite restorations are
relatively simple to place, esthetic, and
predictable provided moisture control is
maintained. Their use in treating patients
with tooth wear has been described (51, 52);
however, clinical studies have not been
reported. Direct composite restorations
placed at an increased occlusal vertical
dimension can provide a simple, short-term
restorative solution to patients with localized
anterior tooth wear and loss of interocclusal
space. Hybrid composites were shown to
perform better than the microfill composites
in such cases (53).
5
Vertical dimension in rehabilitation of worn dentition
Conclusions
Full mouth rehabilitation of a patient
with severely worn dentition may require
alteration in occlusal vertical dimension
(OVD) to restore the dentition to an ideal
form and function. Increasing the OVD
becomes necessary in those cases where
interocclusal space problems or aesthetic
considerations are especially critical. In such
instances, there need not be undue
hesitation in increasing the OVD. Loss of
tooth structure does not necessarily mean
loss of OVD. It may be difficult to determine
if OVD has been lost. The decision to change
the occlusal vertical dimension should not
be taken lightly as a change in a patient’s
OVD automatically necessitates the
restoration of complete arch and even both.
Therefore, it is necessary to evaluate whether
the proposed alteration in OVD is
restoratively acceptable, if it needs to be
altered.
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