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Altering occlusal vertical dimension in functional and esthetic rehabilitation of

severely worn dentition

Article · January 2010

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Review Article

Altering occlusal vertical dimension

in functional and esthetic
rehabilitation of severely worn
dentition
Vinay Chila Bachhav,* and Meena Ajay Aras†
*Post graduate student. †Professor and head, Department of Prosthodontics, Goa Dental
College and Hospital, Goa, India.

Abstract
Many situations requiring full mouth rehabilitation with severely worn
dentition present with the challenge of a lack of restorative space.
These patients often exhibit the loss of occlusal vertical dimension
(OVD).This may require an increase in OVD in functional and esthetic
rehabilitation of such cases. It may be difficult to determine if OVD has
been lost. Careful and comprehensive treatment planning is required
for each individual case and an assessment of the vertical dimension at
rest and in occlusion is essential. This paper overviews etiology of
tooth wear and its relation to OVD, various methods of evaluation of
OVD, whether to increase OVD or restore to existing vertical height
and techniques utilized to alter it.

Key words: Vertical dimension; Vertical dimension of occlusion;

Worn dentition; Rehabilitation

Introduction
Vertical dimension is the distance between two selected
anatomic or marked points (usually one on the tip of the nose and the
other upon the chin), one on a fixed and one on a movable member (1).
Occlusal Vertical Dimension (OVD) is the distance measured between
two points when the occluding members are in contact (1).

*Author for correspondence: Dr Vinay C.Bachhav, Post Graduate student,

Department of Prosthodontics, Goa Dental College and Hospital, Rajiv
Gandhi Medical Complex, Bambolim. Goa, India. 403202.
Tel: +91-9422783856
E-mail: [email protected]
Vertical dimension in rehabilitation of worn dentition

In order to get the necessary Tooth wear and loss of OVD

restorative space and offer the patient a good Two theories exist whether loss of
long term prognosis, it is sometimes tooth structure lead to loss of OVD (17). The
necessary to make changes to the OVD (2-5). first as stated by Niswonger concluded that
OVD and its alteration is one of the most nature conserves a constant interocclusal
complex restorative challenges for a dentist. distance of 3mm from birth to death (18).
Patients with severely worn dentition and This distance is maintained by dentoalveolar
loss of posterior teeth may result in reduced compensation i.e., an extrusion of the dento-
OVD (6, 7) and these patients often need alveolar complex to compensate for dental
rehabilitative treatment (8). wear. Tallgren (6) found that 80% of severe
Tooth surface loss may be purely tooth wear patients had a normal
physiological and occurs as a natural interocclusal rest space. Proponents of this
consequence of ageing (9, 10). However; theory (19, 20) feel that a change in the VD
certain non-carious factors may lead to tooth can cause serious problems at the dental,
surface loss pathological. The etiology of muscular and articular level. Another theory
such non-carious tooth surface wear includes supported by cephalometric studies is that of
abrasion, attrition, erosion and abfraction the variability of facial proportions (6, 7).
(11). Attrition describes mechanical wear This concept follows that there are
resulting from mastication or parafunction, sometimes changes in the OVD, following
and is limited to the contacting surfaces of dental wear or the loss of posterior teeth.
teeth (12), it is a process in which tooth The disciples of this theory feel that the
tissue is removed as a result of opposing patient’s neuromuscular system can adapt to
tooth surfaces contacting during function or changes to the dento-alveolar complex.
parafunction. Such direct contact occurs at
the proximal areas, on supporting cusps and Evaluation of OVD
on guiding surfaces. Abrasion denotes the It is not necessary that loss of tooth
wearing away of tooth structure through structure means there is loss of OVD (21, 22).
some unusual or abnormal mechanical It may be difficult to determine if OVD has
process other than tooth-to-tooth contact been lost. There are many methods
(12). External agents which have an abrasive described in the literature for evaluating
effect on the teeth include toothbrush OVD (23). Assessment of the rest vertical
bristles and dietary factors. Erosion indicates dimension is one way to clinically evaluate
the progressive loss of tooth structure the OVD. The drawback of this technique is
through chemical processes that do not that interocclusal distance may be variable
involve bacterial action (13). Erosive factors (24). Other methods of assessing OVD
may be either extrinsic or intrinsic. Extrinsic include evaluating posterior speaking space,
factors include drinks such as fresh fruit facial soft tissue contours (25), and
juices, carbonated drinks, cordials and cephalometrics. However, there is no
alcoholic beverages etc. Intrinsic factors absolute method to determine an acceptable
include gastrointestinal reflux disease and OVD. Amongst techniques mentioned,
eating disorders. Abfraction connotes the speech and function can be used to clinically
pathologic loss of tooth structure attributed evaluate an acceptable OVD (26). Various
to mechanical loading and resulting in soft tissue contours used in evaluating OVD
wedge-shaped defects in the cervical areas include the golden rule, profile, contour of
(14, 15). It has been suggested that the the lips and old photographs (27, 28). The
abfraction is a consequence of eccentric speaking method is a physiologic phonetic
forces on the natural dentition (14, 16). method which measures vertical dimension
by means of the closest speaking space (29).

Journal of Oral Health Research, Volume 1, Issue 1, January 2010 3

Vertical dimension in rehabilitation of worn dentition

This space can be measured before awareness by the patient (33). Response after
the loss of the remaining natural teeth to opening OVD may differ from patient to
give us the patient’s natural vertical patient. Some can remain stable while others
dimension which can be recorded and used may relapse a lot. But this is not being a
at later dates. When a patient has lost problem usually as this may go unnoticed
natural occlusal stops for recording the dentally. Dawson stated that changes in the
vertical dimension, this technique has true OVD are not permanent. The VDO will
provided consistently reliable results (30). return to its original dimension measurable
Cephlometrics can also be utilized in at the masseter muscle. Unnecessary
evaluating OVD. Hard tissue cephalometric increases in the OVD are contraindicated as
analyses like McNamara’s analysis, Andrews’ they are not maintained (34). Clinical
analysis which determine lower anterior experience has indicated that moderate
facial height are used for this purpose (6, 7, increases in the vertical dimension of
31). Other techniques to establish, OVD, such occlusion are well tolerated by patients as
as jaw tracking and electrical muscle long as they are accompanied by a stable
stimulation used by the proponents of the so position of mandibular closure together with
called “neuromuscular dentistry” concept, anterior guidance that provides separation of
have not been proved scientifically to be the posterior teeth on mandibular
superior to the traditional techniques (32). movement (35). When closing VD there is
very little relapse; it may open by up to 1 mm
within the first year and will then remain
stable (36). The postural muscle tone (i.e.,
the rest position) reduces when VD is
increased but is also back to normal within
three months (37). Phonetics can sometimes
be a problem for the ‘S’ sounds (38). Patients
usually get adapted otherwise need
correction by creating space.

To restore at ‘increased” or “existing”

OVD?
Occlusal vertical dimension (OVD)
determines facial proportions at maximum
intercuspation and influences facial
dimension at rest. Underdevelopment of
alveolar bone may result in loss of lower
facial height and could lead to signs of
premature ageing. Increasing the vertical
dimension of occlusion can have far reaching
Possible clinical problems associated effects on facial aesthetics, not just on the
with altered OVD peri-oral areas but on the whole face (39).
Clinical problems associated with Rationale for altering OVD comprise
altered OVD include joint or muscle pain, of aesthetics, altering the occlusal
instability of altered OVD, impaired muscle relationship and for prosthetic convenience
activity and altered phonetics (33-36). to allow space for restorations (40). It is
Altering VD does not produce pain of more important to establish the cause of wear
than one to two weeks which might be a before intervention to help improve the
result of increased temporary muscle effectiveness of any preventive and

Journal of Oral Health Research, Volume 1, Issue 1, January 2010 4

Vertical dimension in rehabilitation of worn dentition

restorative care (41). Management of these until all guidelines have been precisely
patients using fixed or removable prostheses followed and the patient completely happy.
is complex and are among the most difficult A diagnostic wax-up will aid in such
to restore (35, 42). Without knowing the treatment planning. Even when heat
initial position of the stable bony points of polymerized, these restorations may wear
reference before the dental changes, it is during the evaluation period or over the
difficult to determine with certainty if there span of treatment, and, therefore, may make
is a loss of OVD. Clinicians may decide to long-term management of OVD difficult.
increase OVD based on the amount of Loss of cement seal and irreversible tooth
interocclusal space required to restore the preparation are additional problems
dentition to proper esthetics, form, and associated with fixed provisional
function. The decision whether to restore at restorations.
increased or existing OVD is made by Base metal (BM) onlays provide a
assessing free way space (FWS) and fairly reversible approach (47). The onlays
dentoalveolar compensation. (Fig.1). If an can be bonded to unprepared or restored
increase is indicated and performed, it tooth surfaces so that an increase in OVD
should be followed up for several months. can be evaluated (48). The altered OVD is
maintained throughout the evaluation
Techniques utilized in altering OVD period as these onlays show wear resistance,
Conventionally, increase in OVD is permitting complete mouth rehabilitation to
achieved either with a removable acrylic be accomplished in segments over a long
resin occlusal splint or with the use of period of time. Other advantages of using
provisional restorations, for example, direct BM onlays include minimal or no tooth
bonded composite resin or provisional fixed preparation required and no issue of patient
restorations (43). The OVD can also be compliance. However, disadvantages are
altered during splint therapy (44). increase in laboratory procedures and cost,
Disadvantages of removable occlusal splints difficulty in adjusting due to the hardness of
include patient compliance and speech BMs; and are unaesthetic (47). Use of
interference. porcelain onlays to treat patients with tooth
Dahl in 1975 gave a concept to create wear has been described (49, 50), but long-
space in the treatment of anterior localized term follow-up has not been reported.
tooth wear (45). It involved the wearing of a Direct composite restorations are
removable chrome cobalt appliance with an relatively simple to place, esthetic, and
anterior bite plane that separated the predictable provided moisture control is
posterior teeth. Initially the posteriors were maintained. Their use in treating patients
disoccluded, but rather than using with tooth wear has been described (51, 52);
restorative means to reestablish the posterior however, clinical studies have not been
occlusion, it was allowed to reestablish by reported. Direct composite restorations
itself over time. Dahl stated that this placed at an increased occlusal vertical
reestablishment of posterior occlusion was dimension can provide a simple, short-term
due to a combination of both intrusion of restorative solution to patients with localized
anterior teeth and eruption of posterior anterior tooth wear and loss of interocclusal
teeth, which usually occurred over a period space. Hybrid composites were shown to
of about 4 to 6 months (46). Limitation of perform better than the microfill composites
this appliance is that it is used only for in such cases (53).
localized severe attrition.
A conventional fixed provisional
restoration can be modified in the mouth

Journal of Oral Health Research, Volume 1, Issue 1, January 2010 5

Vertical dimension in rehabilitation of worn dentition

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