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Show Your Work: Minimally Restoring Severe Tooth Surface Loss by Dr. Joe Whitehouse

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Categories: Orthodontics; Restorative Dentistry;
Show Your Work: Minimally Restoring Severe Tooth Surface Loss 

by Dr. Joe Whitehouse

Tooth surface loss is a common diagnosis in our patients—often unnoticed by them but restorable and preventable going forward with the correct diagnosis and treatment. The most common causes of this physical loss of tooth structure are erosion (usually chemical), abrasion (toothbrush, habits, certain foods) and nighttime grinding (bruxism).

Regardless of the cause, the choice to restore this loss starts with observation of such loss; sadly and too often, these surface losses are not diagnosed, so patients may continue to have worsening outcomes. Many new patients who entered my practice were surprised when I showed them evidence of such loss, especially with images from an intraoral camera.

This case was different because I’d pointed out the patient’s issue for seven years before he agreed to start treatment. This can be common if patients have certain issues such as poorly aligned, discolored or missing teeth, or other conditions they’re not quite ready to address.

With his long-term goals in mind as documented at the initial examination and the review of those goals periodically during recall hygiene appointments, the patient finally decided to have the care that would address this issue. At age 42, he realized that his anterior teeth were only going to get shorter and shorter, even though he’d been wearing a night guard for several years. (His budget also now allowed for the care to be rendered, knowing his dental insurance would pay for only a portion of the treatment.)

The patient presented showing severe tooth surface loss on Teeth #8, 9 and 22–27 from bruxism (Figs. 1–10). Dr. John Kois’ diagnosis for this case would be a “grazer,” or movement of the mandible left to right and backward and forward (as opposed to a “rat,” which involves pure clenching). With the decapitation of the incisal edge enamel, the surface loss of such a large exposed dentinal area would accelerate with more and more dentin exposed. Placing the patient in a night guard would not impede the chemical or abrasiveness of certain foods to further dentin loss, because of its softer makeup than enamel.

 Show Your Work: Severe Tooth Surface Loss
Fig. 1
Show Your Work: Severe Tooth Surface Loss
Fig. 2
Show Your Work: Severe Tooth Surface Loss
Fig. 3
Show Your Work: Severe Tooth Surface Loss
Fig. 4
Show Your Work: Severe Tooth Surface Loss
Fig. 5
Show Your Work: Severe Tooth Surface Loss
Fig. 6
Show Your Work: Severe Tooth Surface Loss
Fig. 7

Show Your Work: Severe Tooth Surface Loss
Fig. 8
Show Your Work: Severe Tooth Surface Loss
Fig. 9
Show Your Work: Severe Tooth Surface Loss
Fig. 10

Treatment options

When one wishes to present a treatment plan for a case like this, the remaining tooth structure can dictate what that entails. One choice would have been to place composite in the incisal area, but would have required incisal reduction that was questionable and retention/longevity would be indeterminate.

When the patient was asked, “How long would you like the treatment to last?” he replied, “As long as possible,” so composite was not an option.

Crown placement alone would leave such small abutments that retention would always be an issue as well as cosmetic concerns, because the patient would show a lower incisal view with aging and the crowns would look very short—no longer than the teeth looked in the beginning. Crown lengthening would be an option by some dentists, but that would be more invasive and still leave the possibility of endodontic concern with 2 mm of incisal reduction for crowns.

Because tooth intrusion is orthodontically possible, the patient was asked if he would mind wearing braces for around six months. He was open to that, so a treatment plan and fees were presented with case acceptance.

Treatment progress

The basic procedure for orthodontic intrusion is to leverage the teeth to be intruded with a nickel-titanium (NiTi) wire attached to enough posterior teeth to serve as anchorage (Fig. 11).

In this case, the Roth brackets on the posterior teeth were bonded at an elevation below the teeth intended to be intruded. The 0.018-inch round Bio-Force NiTi wire is then active and wanting to straighten out, thus intruding the anterior incisors.

Once intrusion took place on the lateral incisors (Fig. 12), the second wire (0.018-by-0.21-inch NiTi) was placed on top of those brackets to further intrude the teeth. The treatment time to this point was fi ve months. Fig. 13 shows the same technique to intrude teeth #24 and 25.

The intrusion depth was calculated to avoid any incisal reduction for the to-be-made three-quarter veneers. This is an important outcome, because this treatment was intended to be a minimally invasive tactic to get the best outcome. At the end of six months, the teeth were in the desired position.

Fig. 14 presents the incisor preparation with no incisal reduction and contacts opened for a three-quarter wrap, thus affording as much retention as possible. There was, in my mind, no need to reduce the lingual surfaces of Teeth #22–27.
Show Your Work: Severe Tooth Surface Loss
Fig. 11
Show Your Work: Don’t Slight Senior Care!
Fig. 12
Show Your Work: Severe Tooth Surface Loss
Fig. 13
Show Your Work: Don’t Slight Senior Care!
Fig. 14


Retraction was via Waterlase laser, because I do not pack cord, and impressions were with Impregum from a Pentamix. This case was done with BruxZir restorations from Glidewell, so strength was not an issue. The case was designed with cuspid rise and anterior disclusion.

Fig. 15 shows the use of Triad rope composite to mock up the final restorations and to allow for an impression (Fig. 16) to make a temporary “splint” to maintain the intrusion until the final restorations can be installed. Fig. 17 shows the cuspid rise that would be used to keep the incisors protected on lateral excursion. Fig. 18 shows the polished temporaries.
Show Your Work: Severe Tooth Surface Loss!
Fig. 15
Show Your Work: Severe Tooth Surface Loss!
Fig. 16
Show Your Work: Severe Tooth Surface Loss!
Fig. 17
Show Your Work: Severe Tooth Surface Loss!
Fig. 18


Fig. 19 shows the temporary bleaching tray material to protect the temporary restorations at night like a night guard, and Fig. 20 shows that tray installed.

Figs. 21–23 show the three-quarter crowns installed with lower anteriors; incisal edges were deliberately mismatched because the patient had asked me to “not make it too perfect.” (At any time he could ask that they be leveled or incisal angles be rounded more, which I like to do). Fig. 24 shows the same type of prepared three-quarter wrapped restorations on Teeth #8 and 9, and a pleased patient.
Show Your Work: Severe Tooth Surface Loss!
Fig. 19
Show Your Work: Severe Tooth Surface Loss!
Fig. 20
Show Your Work: Severe Tooth Surface Loss!
Fig. 21
Show Your Work: Severe Tooth Surface Loss!
Fig. 22
Show Your Work: Severe Tooth Surface Loss!
Fig. 23

 Show Your Work: Severe Tooth Surface Loss
Fig. 24

Author Bio
Dr. Joe Whitehouse Dr. Joe Whitehouse graduated from the University of Iowa Dental School in 1970. During his career, Whitehouse brought three other practices into his own and adopted a totally minimally invasive approach to dental care. He was a co-founder of the World Congress of Minimally Invasive Dentistry, serving as president for two terms.
Whitehouse also earned a master’s degree in counseling, enabling him to treat many fearful/apprehensive patients without drugs. He has written about dealing with fearful patients and authored articles on minimally invasive dentistry and clinical issues dentists face.


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