A Confident Smile After Years of Grinding

The Patient's Journey

This patient had worn his teeth down through severe bruxism. Bruxism is the involuntary grinding and clenching that most people do in their sleep, and that a few do with this much force. The attrition ran across his whole dentition rather than concentrating on the front teeth. Several upper incisors had shortened until they sat almost level with the gingival margin. He was embarrassed by them. He wanted a smile he could be confident about for a career change he had already decided on.

Wear of this severity is a bite problem before it is a cosmetic one. Treating it in the other order is how these cases fail. The teeth are short because the opposing arch has been abrading them for years, and lengthening them without first establishing where the bite should sit simply hands the same destructive forces a new set of surfaces to remove.

Two separate problems had to be solved before any ceramic was made. The first was structural. A restoration needs a collar of sound tooth structure to grip, called a ferrule, and teeth worn nearly to the gingival margin do not present one. Without a ferrule a restoration is held by adhesive alone against a patient whose parafunctional forces had already destroyed his own enamel, which is a poor arrangement. There was no room to prepare these teeth, because the preparation would have consumed everything that remained.

The second problem was the vertical dimension of occlusion, meaning the height at which the jaws close when the teeth meet. Decades of attrition had lowered his. The restorations had to reopen it, and reopening it is not a matter of simply building the teeth taller: the elevator musculature and the temporomandibular joints have accommodated the collapsed position over many years, and they have to tolerate the new one comfortably before it is committed to in ceramic. A vertical dimension the patient cannot function at produces muscle pain, joint symptoms and fractured restorations, in roughly that order.

The second problem was the vertical dimension, meaning the height at which the jaws close when the teeth meet. Decades of attrition had lowered his, and the restorations had to reopen it. Reopening the vertical dimension is not simply a matter of building the teeth taller. The muscles and the temporomandibular joints have accommodated the collapsed position over years, and they have to tolerate the new one before it is committed to in ceramic.

How Dr. Mehdizadeh Approached Treatment

Provisional restorations were then placed across both arches at the intended vertical dimension. This is the step patients most often want to skip. It is also the one that decides whether the case succeeds, because it converts a proposed occlusion into a tested one. He wore the provisionals and ate on them, and the restored bite was assessed in function rather than on an articulator alone. Only once his musculature and joints had accommodated the new position without complaint was the definitive work begun.

Twenty-eight individual ceramic restorations were then fabricated, fourteen in each arch, as a combination of inlays and crowns according to how much structure each tooth had retained. Individual units matter here. A splinted arch is simpler to make and simpler to fit, but it cannot be repaired one tooth at a time, and it removes the interproximal access a patient with his history will need for the rest of his life.

Twenty-eight individual ceramic restorations were then fabricated, fourteen in each arch, as a combination of inlays and crowns according to how much structure each tooth had retained. Individual units matter here. A splinted arch is simpler to make and simpler to fit, but it cannot be repaired tooth by tooth, and it removes the interproximal access that a patient with his history will need for the rest of his life.

The reconstruction restored the appearance of the dentition and the vertical dimension it had lost. He functions on the new bite. The worn edges are gone, the anterior teeth have proportions appropriate to his face rather than the stumps attrition had left, and the teeth are no longer the first thing anyone notices about him.

The parafunction itself has not been cured. Bruxism is a neuromuscular habit, not a dental one, and no restoration alters it. What changes is what absorbs the force. Ceramic is considerably harder than the enamel it replaced, and a night guard takes the load during the hours when the grinding actually occurs.

The parafunction itself has not been cured, because bruxism is a neuromuscular habit rather than a dental one, and no restoration alters it. What changes is what absorbs the force. Ceramic is considerably harder than the enamel it replaced, and a night guard protects the restorations during the hours when the grinding actually occurs.