journal of dentistry 39 (2011) 662671

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journal homepage: www.intl.elsevierhealth.com/journals/jden

Prosthetic rehabilitation and treatment outcome of partially

edentulous patients with severe tooth wear: 3-Years results
Joannis Katsoulis a,*, Senka Geissbuhler Nikitovic a, Sophie Spreng a,
Klaus Neuhaus b, Regina Mericske-Stern a
a
b

Department of Prosthodontics, School of Dental Medicine, University of Bern, Switzerland

Department 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

Received 30 April 2011

outcomes of partially edentulous elderly patients with severe tooth wear.

Received in revised form

Methods: Partially edentulous patients with severe tooth wear who underwent the same

22 July 2011

protocols for full prosthodontic rehabilitation were eligible for this observational study.

Accepted 23 July 2011

Their clinical diagnoses were based on 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-

Keywords:

tained prior to the final fabrication of fixed and removable prostheses. All patients com-

Tooth wear

pleted a follow-up period of 3 years. The outcomes were technical and biological

Attrition

complications with the prosthesis (wear or fracture of anchorage, abutment, prosthesis

Bruxism

core or veneering, and implants, plaque index, caries, endodontic and periodontal lesions,

Partial edentulism

tooth fractures and periimplantitis) and oral health-related quality of life (using the oral

Prosthetic rehabilitation

health impact profile questionnaire, German version of OHIP G-14).

Biological and technical

Results: Data from 42 patients (33 men, 9 women) with a mean age of 62  8 years were

complications

available. The probability that a first, second or third technical complication occurred was

Quality of life

49%, 38% and 21%, respectively. About 50% of the patients remained without any complication. 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

Tooth wear simply means the loss of tooth substance without

any clear definition of its aetiology or pathology and some
surface loss over the years is considered physiological.1 Tooth
wear is considered to have multiple factors, such as the type of

skeletal class, the presence of reflux disease, eating disorder,

strong biting, coarse and acidic food, saliva, chewing patterns
adapted to tooth loss and prosthesis, and the absence of
prosthetic maintenance. The pattern of wear is based on the
individual, while its aetiology and diagnosis are not always
clear. As such, the treatment outcomes are not always

* 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

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journal of dentistry 39 (2011) 662671

successful.2 Historically, extensive tooth wear has been

identified based on evaluation of skulls, probably as a result
of coarse food intake, hard biting and prolonged mastication.3
In spite of controversy and weak evidence regarding many
aspects of tooth wear, it appears that there is a consensus
regarding the use of the terminologies of erosion, abrasion and
attrition.46 Diagnostic criteria for erosion have been previously proposed.79 Attrition is a term used to describe tooth
surface loss caused by occlusal or proximal contacts, while
abrasion refers to the loss of tooth substance due to
mechanical impact from materials others than teeth.
Generalizing treatment concepts for severe tooth wear is
rather difficult. Some authors have proposed classifications
and indices for the diagnosis of the amount of wear,7,10,11
while others have discussed the occlusal wear associated
with restorative materials4,12,13 as well as increases in
vertical dimension, prosthetic reconstruction and occlusion.14 A few studies have investigated the epidemiology of
tooth wear involving the associations between aetiological
factors and pathological effects on teeth, and discussed
restorations and prosthetic reconstructions, particularly
from the perspective of erosion and bruxism as major
aetiological factors.2,15,16 To date, the combined effect of
severe tooth wear in patients with partial tooth loss and
instable occlusal support has not been described in relation
to therapeutic consequences.
The duration of functional tooth contact per day during
mastication is short and, under normal conditions, will not lead
to pathological wear. Currently, oral parafunction (e.g., grinding, clenching) is frequently observed among patients. It is likely
to be associated with stress and anxiety in some patients,17 and
bruxism appears to be a chief cause of severe attrition.18
The Oral Health Impact Profile questionnaire (OHIP) was
developed to investigate the impact of dental/oral conditions
on quality of life.19,20 The presence of a higher number of teeth
leads to better scores than partial or complete tooth loss and
the wearing of removable dentures. Specific investigations by
means of the OHIP in relation to severe tooth wear have not
been conducted thus far.The aims of the present longitudinal
study were as follows:
- To provide information on clinical findings and prosthetic
indications, as well as an assessment of quality of life, in
partially edentulous patients with severe tooth wear after
prosthetic treatment.
- To assess the occurrence of technical complications with the
new prostheses during the first 3 years after prosthetic
rehabilitation, with the assumption that parafunctional
habits and bruxism were frequent causes of tooth wear in
the present study cohort.

The hypothesis was that a purported correlation between

the oral health-related quality of life, the type of prosthesis
and the rate of complications rate exists.

2.

Methods

2.1.

Patients

Over a 2-year period, 48 partially edentulous patients with

severe tooth wear were identified among all patients who were
referred for comprehensive prosthetic rehabilitation. They
eventually received prosthetic treatment in the same clinical
setting and were followed regularly for at least 2 years to
investigate technical complications, failures of reconstructions,
implants or teeth and quality of life. All patients had missing
teeth, and most were missing teeth in both jaws when they were
first examined and admitted for treatment. This survey was part
of a quality control assessment of the dental consultations and
was approved by the institutional ethical committee. The
patients gave their informed consent for the use of their data,
including photographs, and were willing to answer a questionnaire. The protocol of the present observational study is
summarized in Fig. 1. The following inclusion criteria for the
analysis of the patients in the context of the present survey were
adapted from Hugoson et al.s attrition index from 198821 and
Bartlett et al.s erosion index from 20087:
 Severe tooth wear on the tooth substance or on the dental
material (localized or generalized), including wear that
exhibits well-matching facets.
 A loss of 50% of crown height of teeth in contact.
 Pronounced occlusal tooth wear with visible dentin.
 Dental status: partial edentulism.
- Natural teeth (including fillings and onlays) or a combination of natural teeth and fixed partial prostheses (FPP), but
exhibiting non-restored gaps.
- Removable partial dentures or overdentures (RPD, OD)
with insufficient occlusal support and instable occlusion,
including a complete denture (CD) in one jaw.
- Partial tooth loss without any prosthetic reconstruction.

2.2.

Diagnosis and treatment protocol

All patients completed the systemic health questionnaire

(signed by the family physician) and were allocated to an ASA
classification (American Society of Anesthesiology, http://
www.asahq.org; accessed 2011).22 A dietary protocol was
recorded, and each patient underwent the same clinical
examination and diagnostic protocol as follows:

Study protocol

Patients admitted
Diagnosis
Planning

Provisional
phase

24 months

6 months

Fig. 1 Study protocol.

Final
treatment

3-6 months

Follow up; Registering

complications

36 months

Questionnaire
OHIP
End of study

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journal of dentistry 39 (2011) 662671

Fig. 2 (ac) Severe tooth attrition with over-closure in a partially edentulous 56-year-old male patient who did not wear his
RPDs for a long period of time. Many teeth have lost >50% of the original tooth substance.

1. Extra- and intraoral photos and radiographs were obtained,

followed by identification of hopeless teeth and records of
periodontal status, caries, and mandibular jaw function.
2. Casts were obtained and mounted on the articulator. Bite
registrations were performed in two different positions: in
the patients current maximum intercuspidation and, if
possible, in a retrusive contact position that corresponds to
a centric relation position of the jaw. The retrusive position
was often unstable due to severe premature contacts,
caused by tooth elongation into non-restored opposed gaps,
tooth migration and eruption of jaw segments.
3. A tooth set up using prefabricated acrylic teeth that were
adapted on the models served for further analysis of the
inter-jaw relations. This analysis, together with the criteria
for facial appearance and physiognomy, offered the
background on which to re-establish stable occlusion and
vertical dimension.
4. The entire set of diagnostic measures enabled the planning
of provisional prostheses and combined splint therapy. The
preliminary treatment consisted of extractions of hopeless
teeth, hygiene instructions and periodontal treatment,
provisional fillings, removal of strong premature contacts
and fabrication of provisional prostheses and splints in a
reorganized approach.23 A great variety of prostheses and
splints were used, which served:
 To bring the mandible into a stable position and to
stabilize occlusion.
 To increase the vertical dimension of occlusion (VDO), if
necessary.
 To consider the aesthetic aspects of both tooth length and
facial appearance.
An observation period of 46 months was maintained with
the provisional reconstructions in situ.
5. The provisional period was the basis on which to determine
the final treatment plan. Treatment was performed with
fixed and removable prostheses using teeth and implants.

This included also composite fillings and composite

buildups for worn teeth without caries, e.g., short mandibular front teeth, endodontic treatment and crown lengthening. If FPPs were fabricated, the reconstructions were
designed in short segments (i.e., single crowns and short
span FPPs). Adhesive luting for ceramic materials, composite fillings and buildups was used, phosphate cements for
gold copings and FPP. Implant supported single crowns and
FPP were screw retained. RPDs were planned whenever
possible with quadrangular supports. For implant support
of overdentures soldered gold bars were fabricated, for
tooth support of overdentures gold copings with Dalla Bona
anchors were used. Splints and night-guards were delivered to protect the new prostheses after final rehabilitation.
Six trained dentists working in the same clinical setting
followed the treatment protocol under supervision of one
person and had treated the patients.
Figs. 2ac and 3a and b represent two clinical cases
exhibiting severe attrition.

2.3.
Oral and prosthetic status before and after prosthetic
rehabilitation
In the context of the present study, two trained examiners
who had not been involved in the treatment of the patients
anonymously collected data based on an abstraction of the
oral examinations, radiographs and medical files.
1. Initial status:
 Presence and type of old prosthetic reconstruction in the
mandible and maxilla: RPD, OD, CD, and FPP.
 Overclosure and loss of VDO.
 Locked bite with premature contacts.
 Large overjet and overbite (both >5 mm), as well as a deep
bite with impingement of the palatal soft tissue.
 Awareness of bruxism (self-reported or by others).

journal of dentistry 39 (2011) 662671

665

Fig. 3 (a and b) Example of a patient with tooth wear on the front teeth, tooth elongation in the opposed gaps and
subsequently locked occlusion due to strong premature contacts. VDO in the retruded contact position exceeds the normal
height. A regular occlusal plane cannot be re-established when the mandibular premolar is maintained in its current position.

 Functional assessment of the mandibular jaw and joint,

including pain on muscle palpation, internal derangement (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 lengthening.
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 prostheses.

2.4.1.

Technical complications

Technical complications with the new prostheses and related

maintenance services were recorded for both scheduled and
non-scheduled visits. These events required interventions by
the dentist, mostly combined with repairs in the dental
laboratory. The technical complications were classified as
follows:
1. Complications with anchorage:

- Wear and fracture of the anchorage devices of the

removable prosthesis (matrices and patrices of attachments, clasps and solder joints of implant bars).
- Fracture of the retention screw for bars or implant crowns
and FPP.
2. Complications and failures of prosthesis/implants:
- Loss of FPP (fracture of abutment teeth and posts or
fracture of framework).
- Need for re-cementation of 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
untreatable periodontal lesions,
- tooth extraction due to deep tooth fracture (not caused by
trauma),
- treatment of periimplant disease.24
-

2.5.

Questionnaire (OHIP)

The secondary outcome was the quality of life after a 3-year

period with the new reconstructions in situ. The German
version of the Oral Health Impact Profile questionnaire (OHIP

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journal of dentistry 39 (2011) 662671

G-14)20,25 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 values representing good quality of life. The
patients completed it without any assistance from the dentist,
dental hygienist or nurse. However, in the beginning, they
received information about the structure and content of the
questionnaire.

2.6.

Tooth wear
and occlusion

Statistical analysis

Descriptive statistics were used for the patient demographics

and clinical findings as well as for the numbers and types of
prosthetic indications. The estimated time that elapsed
between delivery of the prosthesis and the first, second or
third event was calculated from the censored data by means of
a Kaplan Meier survival analysis. The correlations between the
OHIP, the types of prostheses and failure rates were calculated
via Pearson correlation. Statistical analyses were performed
with the SPSS software (SPSS 17.0, Chicago, IL, USA).

3.

Table 1 Clinical findings: occlusion and functional

diagnosis.

TMJ

Awareness of
parafunctional
habits

Criteria

Number of
patients

Overclosure, loss of
VDO 37 mm
Locked bite
Deep bite, OB 5 mm
Large OJ 6 mm
Eruption of mandibular
front segment
Incisal edge bite
Pain, problems self-reported
Muscle tenderness on palpation
Clicking joint
Limited jaw movements
Self-reported

32

By others

7
11
6
11
9
1
6
2
1
14

VDO, vertical dimension of occlusion; OB, overbite; OJ, overjet.

Results
Table 2 Preliminary treatment.

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

Occlusal rehabilitation

Pre-treatment

Criteria

No. of
patients

RPD
Splint
Both
Extractions
Fillings
Crown lengthening
Endodontic treatment

22
17
3
34
27
7
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).

667

journal of dentistry 39 (2011) 662671

Table 3 Final maxillary and mandibular prostheses.

Maxilla

Patients

Removable
CD
OD: root copings, RPD
OD: implants and bara
OD: teeth and implantsa
Fixed
FPP: teeth
FPP: implantsa
FPP: teeth and implantsa
SDA: Natural teeth, crowns
a
b

24
9
8
2
5
18
6
2
5
5

Mandible

Patients

Removable
CD
OD: root copings, RPD
OD: implantsb/bar

21
1
12
8

Fixed
FPP: teeth
FPP: implantsb
FPP: teeth and implantsb
SDA: Natural teeth, crowns

21
3
1
12
5

Total 37 implants.
Total 44 implants.

Table 4 Dental and prosthetic status before and after

treatment.
Type of
reconstruction
Natural teeth, FPP,
in both jaws
RPD, OD, CD
in one jaw
RPD, OD, CD
in both jaws
Implants

Before treatment
(number of
patients)

After treatment
(number
of patients)

24a

12b

13c

13

5c

17

27

All with non-restored gaps.

b
Including SDA.
c
Removable dentures not always worn, insufficient occlusal
support and gaps.

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 beginning, at the end of the treatment and after 3 years
of maintenance were: 61.2  14.4% (range 14100%),
19.5  5.03% (range 933%) and 27.0  7.2% (range 1550%).
During the treatment phase the hygiene instructions were
successful and the goal of an average PLI of 20% was reached.

Table 5 Materials in the occluding surfaces.

Occluding materials
A/A
C/C
E/E
A/C
A/E
C/E
A/C/E

Per patient
1 Material

2 Materials
3 Materials

Number of patients
8
1
0
6
5
5
17

A, acrylic denture teeth, adhesive resin and composite reconstructions; C, ceramic material; E, enamel of teeth.

The PLI remained low but raised slightly during the maintenance period.
The OHIP-14 questionnaire was completed 3 years after
delivery of the prostheses. A total of 36 out of the 42 patients
returned the questionnaire properly completed. Two patients
did not complete it because the OHIP was not available in their
native language, and four patients did not return it for
unknown reasons. The mean score for the questionnaire was
5  7. Fig. 5 shows that 80% of the patients gave a rating of 0
(never) or 1 (seldom) for all 14 questions. Few patients gave a
rating 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 seven patients was >10 up to 23. The
Pearson correlations did not reveal any clear tendencies
between the OHIP values and the types of prosthesis (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.

Table 6 Technical complications.

Type of complication
Anchorage: wear and fracture followed by repair
Anchorage of OD, RPD: changes of matrices
Wear of Dalla Bona anchor: remake of coping
Fracture of bars (extension): repair of extension
Fracture of occlusal screws of bars, FPP (implants)
Prosthesis: failure, loss of prostheses and implants
Fracture, loss of FPP: remake
Need for recementation (FPP, gold coping of OD)
Fracture of OD, RPD, CD: followed by repair
Fracture of post: tooth removed
Fracture of implant
Minor ceramic chipping: polishing
Major ceramic chipping: remake
Occlusal surface: Severe wear
Acrylic teeth of CD, OD, RPD
Composite filling
Broken and lost fillings (not due to caries)
New nightguard due to excessive wear

Number of
patientsa
12
1
1
0
2
8
1
1
0
17
2
7
2
6
8

a
The numbers cannot be added since some patients experienced
more than one technical complications.

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journal of dentistry 39 (2011) 662671

Table 7 Biological complications.

Type of complication
Recurrent or new caries requiring fillings
Apical lesion of endodontically
treated tooth (no intervention)
Need of endodontic treatment after
complication with prosth.
Tooth extraction: due to
Deep caries (maxillary molars)
Endodontic failure (mandibular molar)
Open furcation of wisdom tooth
Due to deep fracture of uncrowned teeth
Periimplant lesion
Sensitivity of tooth neck
Myofascial pain of masticatory muscles

Number of
patientsa
4
1
2

2
1
1
4
1
4
1

a
The numbers cannot be added since some patients experienced
more than one biological complication.

Fig. 4 Probability of a complication-free maintenance

phase and occurrence of a first, second or third event
during a 3-year period (KaplanMeyer).

4.

Discussion

A diligent review article on tooth wear confirms that there is

little scientific information available on the rehabilitation of
this type of damage.6 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, treatment 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
significance of abfraction.26 Tooth wear is more often
investigated in young patients with erosive wear, who have

Fig. 5 Ratings of the 14 OHIP items in terms of percentages

of patients.

full dentition and therefore present with different sequelae.

Case reports frequently show the treatment of localized tooth
wear of the front teeth27,28 or the build-up of worn posterior
teeth.29 Tooth erosion was reported to be present in 3044% in
children younger than 15 years.30 Children from a low socioeconomic background showed significantly more tooth erosion. The incidence of new tooth surfaces exhibiting erosion,
in erosion-free children, decreased significantly with age,
while the progression in children with erosion did not change.
In adult subjects, however, the presence of different restorations makes it difficult to analyze and compare purely an
erosive process. Controlled studies on treatment modalities of
cases with complete rehabilitation were not available for
comparisons with the present cohort, although advanced and
severe wear are quite frequently identified in elderly
patients.16,31
In this study a treatment methodology and well-established protocol for partially dentate patients with tooth wear
was described. However, the final prosthetic reconstructions
had to be planned and designed individually. Economic
considerations also determined the type of prosthesis that
the patients received. The inter-jaw 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 splints.27 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 treatment process23; this appeared
to be helpful in the current treatment approach. By means of
crown lengthening for teeth exhibiting extreme wear, sufficient abutment heights were obtained and space was
simultaneously created.
The overuse of teeth in occlusal contact was aggravated by
the presence of different opposing materials in the occusal
contact zone. While the wear mechanism of gold against
porcelain is abrasive, porcelain itself has a fatigue fracture
type of wear.10 From a reconstructive point of view, the
optimum solution would be a fully fixed reconstruction made
from the same material in all contact areas,34 in both jaws, to
avoid future irregular wear. However, this was not achieved in

journal of dentistry 39 (2011) 662671

most cases. In patients with removable dentures, a combination 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 characteristics that determine how future
loss might progress.35
Some studies have reported that TMJ problems are not an
indicator of bruxism16,31 and that many bruxing patients do
not exhibit TMJ problems. In the present study, no overt signs
of TMJ problems were detected. Bruxism can be considered a
dyskinesia36 that appears to be controlled by the central
nervous system.37 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 bruxism,38
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.39
The 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 was reported in studies of fixed prostheses.4042
Minor ceramic chipping required the polishing and recementation 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-symptomatic patients.4345 Twenty
patients in all (48%) experienced various technical problems

669

within the 3-year observation period. Controversy exists

whether implants should be placed in patients with bruxism.46
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 German was available.20,25 Preliminary reference values
for patient groups of various ages, with different oral/dental
conditions and different types of prostheses, were provided.25,47 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
completion of treatment.47 The investigators expected that
types of reconstruction or experiences with complications
would influence the OHIP-ratings. However, a strong correlation 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
associated with the General Health Questionnaire status.48
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 life as reported in a
recent study.49 Some considerations and concerns on what the
OHIP really measures were also expressed.50

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 rehabilitation 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

journal of dentistry 39 (2011) 662671

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