In this video, Dr. Brian Mills talks about diagnosing Vertical Dimension of Occlusion when treating patients with severely damaged or worn dentition. You can also watch our video about diagnosing vertical dimension of occlusion on YouTube and subscribe to our channel!
Dr. Mills: Hi, Dr. Brian Mills from Mountain View, California. Today I’d like to share a case with you that I think demonstrates a lot of the thought process and diagnostic steps involved when diagnosing the vertical dimension of occlusion when you’re trying to restore a patient with badly damaged dentition.
Here’s our patient, a middle-aged man with generalized erosion, abrasion, and fracturing of all his dentition. I’m sure we all have patients like this in our practice. On initial clinical exam, what we can see is that his interpupillary line is asymmetrical and that midfacially he’s demonstrating some significant asymmetries. His midline is deviated. We look at the teeth, and what we see is generalized erosion, abrasion, and fracturing of all his dentition. We can see that he has significant passive eruption and that his closed vertical dimension of occlusion is 8 mm. Occlusally we see that he’s damaged all his anterior teeth down into the dentin. Posteriorly we can see that he’s worn through most of the posterior crowns into the underlying tooth structure.
Functionally, in protrusive, right, and left lateral, we see that he has inadequate anterior guidance. We know the genetic tooth form of a maxillary central incisor. The length will be about 12 mm, and the mandibular incisor will be about 10 mm. With proper overlap and overjet, the vertical dimension of occlusion is about 18 mm. Why don’t we start there and add back on the form that he’s lost. We recreate the proper form on his maxillary central and on his mandibular central, creating an 18-mm vertical dimension of occlusion. What we see is that it’s a non-restorable case without doing ortho and orthognathic surgery, which the patient isn’t interested in doing.
Another approach might be to intrude the maxillary and mandibular teeth, creating adequate room for your restorative materials and just treat to the existing plane of occlusion. If we look posteriorly, we can see that he’s worn through the crowns into the underlying tooth structure. It’s going to require an additional 1.5 mm of reduction to create the adequate room for your restorative materials here, leaving less than ideal tooth preparation for him, and in all likelihood many of these posterior teeth will require intentional endodontics.
Why don’t we look at it from a different approach? We know that in a healthy dentition, without passive eruption or damage to the anterior teeth, the maxillary anterior segment will be 12 mm and the mandibular anterior segment will be 10 mm. Let’s apply that approach to this case and create a 12-mm maxillary anterior segment compensating for the passive eruption, a 10-mm mandibular anterior segment once again compensating for the passive eruption, and a vertical dimension of occlusion of the two segments of 18mm. We can see posteriorly on the right side, he has 15 mm of vertical dimension, adequate room for your restorative materials, and on the left side, there’s 12 mm of vertical dimension. Not ideal, but treatable.
We go ahead and recreate the proper form. In his case, we wanted to verify the aesthetic plane of occlusion, so we do the preview guide. What we can see is that his anterior teeth are horizontal to the earth in repose and smiling. He demonstrates adequate tooth display, and “eee,” we see that the gingival display is acceptable. Here’s where we started, with the severely damaged dentition, recreating the proper form, and we transfer that to the mouth.
Now we can see he has adequate tooth display, acceptable gingival display. Functionally, in protrusive, right, and left lateral, he’s showing that he has adequate anterior guidance. Occlusally, we can see that he has adequate anterior guidance also. Here’s where we started, with our patient with badly damaged dentition, and here’s where we ended. And here’s our happy patient.
As with all complex cases, there is going to be more than one solution. I hope this stimulated your thinking in evaluating the vertical dimension of occlusion when you’re evaluating and diagnosing and treatment planning your complex cases when your patients have severely damaged dentition.