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Journal of Oral Rehabilitation, 1975, Volume 2, pages 209-214

LIBRARY SCHOOL pf D [ N r f l L s-"-

An alternative treatment in cases AIJG 7 197c;with advanced localized attrition

'Mvmm OF PENriSVL

BJ0RN L. DAHL, OLAF KROGSTAD ami KJELL KARLSENDepartments of Prosthetic Detitistry atid Orthodontics, Dental faculty.University ofOslo

SummaryA combined orthodontic/prosthetic treatment of patients with advanced localizedattrition has been described. In one patient the effect of the orthodontic treatment uponthe morphological face height has been studied using an X-ray cephalographic tech-nique and the results have been discussed.IntroductionPhysiological attrition has been defined as the gradual and regular loss of toothsubstance as a result of natural mastication, whereas attrition confined to groups ofteeth or localized areas only, and caused by abnormal function or position of teeth, hasbeen termed pathological attrition (Pindborg, 1970). This type of attrition may pro-gress so rapidly that secondary dentine formation fails to keep up with it, and exposureof the pulp may occur even in adolescents.

Wear of teeth may be influenced by salivary factors (Carlsson, Hugoson & Persson,1965; 1966), by the consistency of the diet (Carlsson et al., 1967) and by occupationalfactors (Frykholm, 1963). Excessive wear of the palatal surfaces of the upper incisorshas been ascribed to involuntary bruxing movements (Krogh-Poulsen & Carlsen, 1973),V When advanced attrition is observed, steps must be taken to protect the teethagainst further loss of substance. This is usually done by covering the worn surfaces

with some sort ofa crown prosthesis. Additional removal of tooth substance or grind-ing of the opposing teeth to provide space for the crown material is usually undesir-able. Ageneral bite raising by means of crowns or bridges covering all the teeth in theinvolved jaw is therefore the solution most frequently resorted to. It may well beagreed that this procedure has the character of an emergency exit rather than that ofan ideal solution to the problem.

In an effort to avoid capping a great number of teeth, with its many jeopardizingconsequences, a technique has been developed by which the necessary space for thecrown material has been obtained by orthodontic measures. Such a treatment could

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210 B. L. Dahl, O. Krogaiad and K. Karlsen

Fig, I. Photograph showing advanced attrition of palatal surfaces of upper incisors (x 2/3).

Fig. 2. Photogrctph showing the chrome-cobalt splint

Materials and methodsThe patient was a male, 18 years of age, with heavy wear of the palatal surfaces of theupper incisors (Fig. 1). A pink hue from the underlying pulp was apparent, especiallyon the central incisors. None of the upper front teeth had interproximal contacts.Following alginate impressions casts were poured in Vel-Mix Stone *' (Kerr Europe,Scafati, Italy) and mounted on a Dentatus articulator (Type ARH, AB Dentatus,Stockholm, Sweden) according to a wax index with the lower jaw in the retvudedcontact position. A removable chrome-cobalt splint, approximately 2 mm thick, wasmade covering the palatal surfaces of the upper front teeth (Fig. 2). Retention was

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Alternative treatment in cases with adranced iocatizcd attrition 211

Fig. 3 . Photograph showing the distance between upper and lower premolars and molars when bitingon the splint at the beginning of the treatment (x 2/3).

Fig. 4. Photograph showing paiat; if pinlays after cementation f x 2/3),

To enable a detailed study of the changes in the vertical dinietision of the face atechnique worked out b> Bjork (1968) was appl ied. Tantuium needles were implantednear the midl ine of the basal port ions of the upper and lower jaw s. Imm ediately uponinser tion of the splint and after 2, 5 an d 8 m on ths lateral hea d plates were taken in anX-ray cephalostat with and without the spl int in situ and with the jaw s in the c losestrelat ion ship possible. Th e dis tance from the focus to the mid-sagi t tal plane w as 160 cm

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212 B. L. Dahl 0. Krogstad and K. Karlsen

F ^ . 5. Pholograph showing frontal view of piniays after cementation ( x 2/3).

Table 1. Distance (mm) between tantalum implants0 months 2 months 5 months 8 months 12 months

Chrome-cobaltsplint in situChrotne-cobaltsplint removedDitTerenceAfter cetnentationof pinlays

39-236-92 3

3S-737-80 9

38-738-2

0 - 5

38-838'60 2

ResultsAfter 4 weeks a space could clearly be observed clinically between the upper and lowerincisors when the splint was removed and the leeth brought together in the intercuspalposition. Visually this space seemed to increase gradually until after 8 months itappeared to be equal to the thickness of the splint.The results of the cephalometric measurements are presented in Table I. Thefigures are the mean of three measurements and the error is expected to be in therange of 0 2-0-3 mm (Krogstad & Kvam, 1971). h will be seen that after 2 monthsthere was a slight decrease in the distance between the implants with the splint in situwhereupon it. remained constant. The distance without the splint showed a steadyincrease which was greatest during the first 2 months. The increase in the distance

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Alternative treatment in eases with advan ced iocalized attrition 213DiscussionClinically a reduction in the morphological face height is commonly observed as aresult of loss of teeth or heavy wear. Restitution of what is considered to be the 'norm al'face height of a patient by means offixedprosthetic restorations is therefore a widelyaccepted technique in clinical dentistry. In some patients restorations interfering withthe habitual occlusal relationships will cause dysfunctional problems (Posselt, 1968),while in others the teeth and muscles seemingly adjust themselves without the patientmaking complaints. In cases with adjustment it is an open question whether the inter-fering teeth are intruded or whether the remaining teeth erupt. Therefore it is difficultto ascertain whether a permanent change in the morphological face height has occurredin cases where the vertical dimension has been altered.In a review based on 50 years of experience in oral rehabilitation, Schweitzer (1974)has claimed that in most cases where the vertical dimension had been inereased in thetreatment, the original relationship usually returned after some time.Blichi (1950) and Tallgren (1957) have found that an increase in the morphologicalface height may take place even in adult age. It seems reasonable, therefore, that atleast in those patients a certain degree of permanent increase in the morphologicalface height by fixed appliances might be tolerated.The results of the present study indicate that an increase in the morphological faceheight has occurred after insertion of the splint. After 8 months the distance betweenthe tantalum needles without the splint in situ was 38-6 mm while at the beginningof the experiment it was 36-9 mm. The differenee. 1-7 mm, represents the increase inthe morphological face height and is not due to basic growth since the distance betweenthe upper implant and nasion has remained constant. Therefore the action of the splinthas been one of letting the posterior teeth erupt rather than causing intrusion of thefront teeth. Certainly, after 2 months the measurement with the splint in situ showed adecrease in the distance between the tantalum needles of 0-5 mm. Henceforth thisdistance remained constant (Table 1). This observation may indicate that the initialreaction is also one of intrusion of those teeth whieh carry the full load of the occlusalforces. This would be in agreement with the findin gs in monkeys (Breitner, 1941).However, the decrease in distanee was so small that it is not far from the combinederror of method and measurements (Krogstad & Kvam, 1971).To establish whether the morphological face height eontinues to undergo changes afollow-up will be made with lateral head plates approximately every 6 months.

A total of twelve patients from 17 to 60 years old have been treated aecording to thiscombined orthodontic/prosthetic technique with good results. However, this reportis based on the analysis of one case only, and definite conclusions or recommendationsare not justified. A study of a larger group of patients treated in the same way hastherefore been initiated.

ReferencesBJORK, A. (t96S) The use of metallic implants in the study of facial growlh in children: Method and

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214 B.L. Dahl, O. Krogstad and K. KarlsenC A R L S S O N , G.E., H U G O S O N , A. & P ERS S ON, G. (1966) Dental abrasion and alveolar bone loss in the

white rat. II. Effect of selective ligalion of the ducts of the major salivary glands. OdontologiskRevy, 17, 44.

C A R L S S O N , G.E., H U G O S O N , A. & P ERS S ON, G. (1967) Dental abrasion and alveolar bone loss in thewhite rat. IV. The importance of the consistency of the diet and its abrasive components.Odontologisk Revy, 18, 263.

F R Y K H O L M , K . O . (1963) Undensokning av tandforhailanden hos jarnverksarbetare inom ett sinterverkmed sarskild hansyn till abrasionsskador. Odontologi.^k Tidskrift, 71,199.

K R O G H - P O U L S O N , W. & C A R L S E N , O. R. (1973) BidfimktionjBettfysiohgi, p. 269. Munksgaard,Kobenhavn, Dan mark.

K R O G S T A D , O. & K V A M , E. (1971) Geometric errors in measurements on X-ray films. A methodologicstudy on lateral model exposures. Acta odontologica Scandinavica, 29, 185.

PiNDBORG^J.3.(\910)Pathologyof the dental hard tissues, p.294.Munksgaard,Copenhagen,DenmarkPOSSELT, U. (1968) Physiology of occlusion and rehabilitation, 2nd edn., p. 75. Blackwell ScientificPublications, Oxford.

S C H W E I T Z E R , J.M. (1974) Restorative dentistryA half century of reflections, .lournal of ProstheticDentistry, 31, 22.T A L L G R E N , A. (1957) Changes in adult face height due to ageing, wear and loss of teeth and prosthetictrealment. Acta odontohgica Scandinavica, 15,. Suppl, 24.

M anuscr ip t accepted 16 D e c e m b e r 1975

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