“I’m not sure where to start when vertical dimension is over closed and the teeth are all severely worn.”
If you’ve ever thought something along these lines, there are a few things that need to be cleared up.
One of the things that Dr. Dawson teaches us is that if patients have all their teeth and the teeth are worn, they have not lost vertical dimension even if the teeth are halfway gone. We know that as teeth wear there is an elongation of the alveolar process and eruption occurs. So the distance between the chin and the nose does not in fact change even in the case of extreme wear.
But we still have to restore this mouth.
Where we’re going to start is on properly mounted cast in centric relation and with a really good series of clinical photos, which are the 21 pictures that we recommend. At that point, we could then make a very, very educated guess on where these teeth need to reside in space. Rather than guess, though, we will follow our protocol and do the two-dimensional and three-dimensional work-up so that we can determine where these teeth need to go.
What’s important to remember is even when we do this type of analysis we can’t be 100 percent sure that it’s right. But we will be close enough that we can proceed with our restorative care and put provisional restorations in the patient’s mouth.
In the provisional phase we will finish the determination process and make sure of a few things:
- Every contour of every tooth is precisely where we want it.
- We’ve got good stable stops.
- We’ve got anterior guidance that’s in harmony with the envelope of function.
- We’ve got aesthetics and great phonetics.
From that point, we can make impressions of those provisionals the laboratory can use to create final crowns that will fulfill the requirements of occlusal stability and provide ideal esthetics.
There’s no question of whether the worn dentition case challenges us more than anything; There is definitely a path for treating these types of cases predictably, though.
Initially, all we may know when we look in the patient’s mouth is a part of the occlusal scheme is not working. What we have to do is find the specific contours where the teeth need to go so that we will have predictability in this case.