Tooth wear | OPEN

CLINICAL

Rehabilitating a severely worn dentition with

removable prosthodontics
Stephanie Hackett,*1 Richard Newton1 and Rahat Ali2

Key points
Removable prostheses in severely worn The general design features of a removable Patients who are provided with removable
dentitions are of value when fixed approaches prosthesis include: metal backings on teeth of prostheses to manage their tooth wear need
are not indicated or have low prognosis for guarded long-term prognosis; metal or acrylic to be carefully monitored, with reduced recall
success, where there are missing teeth, or as part onlays on posterior teeth where the occlusion intervals of 3–4 months. Close attention
of a combined fixed-removable treatment plan. allows or vertical dimension is increased; anterior should be paid to preventative regimes and
bite platforms where required to gain functional identification of new disease.
tooth contacts; and minimal apron flanges over
teeth used as overdenture abutments.

Abstract
In the next part of this series on tooth wear management, we discuss the indications and clinical stages for the
provision of removable prostheses for the treatment of severely worn and depleted dentitions. The general design
features of a complex prosthesis are described for reorganised occlusal schemes and maintenance guidelines are
explained. In addition, the clinical stages for three different situations are described: removable-only approaches, and
combined fixed and removable in the same arch and separate arches. The value of providing removable prostheses
in worn dentitions allows the immediate rehabilitation of severely worn teeth taking a non-invasive and retrievable
approach when the remaining dentition is of poor quality or structure and/or there are missing teeth.

Introduction chrome-based dentures offer more rigidity • Removable partial dentures only
(particularly relevant to parafunctioning • Fixed restorations and a removable partial
In this paper, we will discuss the clinical patients), tooth support on retained worn teeth, denture in the same arch
indications for removable prostheses in the fit more accurately and are less bulky. • Fixed restorations in one arch and a
treatment of tooth wear. Removable prostheses In the treatment of tooth wear, removable removable prosthesis in the opposing arch.
provide an option for when fixed restorations partial dentures can replace teeth which have
are contraindicated or have a poor chance of been completely lost, or as overdentures when Studies have shown a high degree of patient
being successful. They can also be provided with teeth are severely worn. Retaining roots as satisfaction with overdenture treatment, with
fixed restorations as part of a more complex abutments improves proprioception,1 assists over 94% of patients being either mostly or
treatment plan. It is the authors’ preference to with tooth support for the denture, maintains fully satisfied with their prosthesis over several
provide definitive cobalt chromium prostheses local alveolar bone2 and prevents combination years.4,5 A recent review found that mandibular
for all patients, unless a transitional denture is syndrome from developing.3 canine-root-supported overdentures compared
required when acrylic is preferred, for example, Overdenture-type prostheses can be favourably with mandibular two-implant
in a growing patient, a failing dentition, or as subdivided in to three main categories (Fig. 1): supported overdentures.6 They found no
an interim prosthesis during a more protracted • Overdentures – where the denture covers statistically significant differences with patient
fixed-removable treatment plan. Overall, retained roots satisfaction, prosthodontic complications, or
• Onlay dentures – components of the denture patients’ ability to clean their prosthesis.
1
Speciality Registrar in Restorative Dentistry, Department
onlay posterior teeth, similar to a ‘table top’.
of Restorative Dentistry, Liverpool University Dental Can re-establish the occlusal plane and Indications for removable
Hospital, Pembroke Place, Liverpool, L3 5PS, UK;
restore contacts with the opposing arch prosthodontics
2
Consultant in Restorative Dentistry, Department of
Restorative Dentistry, Liverpool University Dental Hospital, • Overlay dentures – anterior flange and
Pembroke Place, Liverpool, L3 5PS, UK. prosthetic teeth cover the labial surfaces of Patients with tooth wear can be managed with
*Correspondence to: Stephanie Hackett
Email address: stephaniehackett@hotmail.com retained anterior teeth whose crowns remain fixed or removable treatment options. Should
Refereed Paper.
at least partially intact. the worn teeth lack adequate tooth structure for
Submitted 5 October 2022 bonding or to provide a ferrule effect for a crown,
Revised 8 January 2023 Furthermore, partial dentures for the it is not predictable to restore these teeth with
Accepted 14 January 2023 treatment of tooth wear may be provided in a fixed restoration. Also, a history of repeated
https://doi.org/10.1038/s41415-023-5583-5
any one of the following scenarios: failure of direct restorations might indicate

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the lack of potential for bonding or retention experience, teeth which have lost more than 50% of direct resin composite build-up treatment.
on the worn teeth, which might be better used coronal tooth structure and have poor quality Sclerotic dentine caused by pathological tooth
as overdenture abutments. In the authors’ sclerotic dentine have more frequent failure wear has been shown to feature histological

Fig. 1 Three broad types of overdentures to treat tooth wear patients. a, b) Onlay denture covers labial surfaces of anterior teeth. c, d) Overdenture
covers retained roots of maxillary teeth. e, f) Onlay-overdenture prosthesis covering roots of anterior teeth and onlay rests on posterior teeth

Fig. 2 a, b, c, d, e, f) Patient with severe tooth wear and loss of occlusal vertical dimension. Rehabilitated with anterior tooth composites in the
mandibular arch, and maxillary and mandibular onlay/overlay partial dentures. Notice how the mandibular prosthesis has metal backings on the
lingual surface of the anterior teeth to facilitate easy addition to the denture should these teeth of dubious prognosis be extracted in the future

Fig. 3 a, b, c) A patient with significant overeruption and dentoalveolar compensation in to opposing edentulous spaces, on a background
of localised anterior tooth wear. This patient would benefit from extractions and subsequent resorption of the alveolus to allow prosthetic
rehabilitation. Photographs courtesy of Callum Cowan

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Fig. 4 Full coverage overlay-onlay denture to restore worn maxillary teeth. a, b) Old denture was frequently broken as patient was able to break
off the prosthetic teeth at the extremities of dynamic occlusion due to severe parafunctioning habits. c, d, e, f) New denture metal framework
lips over incisal edge to prevent fracture of the prosthetic teeth in a patient with severe parafunctional tendencies

obliteration of dentine tubules with intratubular removed during episodes of acute parafunction metal over incisal edges, metal backings on
sclerotic casts, in addition to an acid-resistant and replaced with a protective guard for sleep anterior teeth and occlusal onlay rests (Fig. 4).
hypermineralised layer, thus reducing the ability to maintain the abutment teeth. The skeletal
of adhesive systems from achieving the hybrid relationship may further guide the clinician Problems with removable
layer necessary for optimal dentine bonding.7 to either fixed or removable prostheses. A prosthodontics
In these cases, consideration could be given Class III incisor relationship (particularly
to rehabilitate these patients with removable with associated loss of posterior support) may Some patients may not tolerate a partial denture,
prosthetics. Retaining worn teeth as overdenture benefit from a maxillary denture, maintaining especially those who gag. We know from
abutments affords the benefit of bracing and the worn anterior teeth as overdenture existing research that one of the prognostic
support for the denture, particularly when there abutments and facilitating the prosthetic indictors for success are dentures which
are reduced features of denture bearing anatomy, incisors into a preferred Class I relationship. replace anterior teeth.10 Despite counselling
such as diminutive tuberosities, inadequate General reasons for providing removable a patient that their partial denture to replace
sulcus depth and a flat vaulted palate. over fixed restorations still apply, including missing posterior teeth will protect their newly
From an occlusal viewpoint, one should patient-related factors, such as a requirement provided anterior fixed restorations, it is easy
assess the lower face height and decide if the for reduced clinical time and large edentulous to understand why compliance to wearing a
patient is over-closed. If so, this can be restored spans not amenable to fixed rehabilitation. seemingly non-essential prosthesis is still one
with an onlay/overlay denture at an increased of the great challenges in the restoration of a
occlusal vertical dimension (OVD) or by using Benefits of removable worn dentition. Additionally, patients tend to
a retruded contact position that increases the prosthodontics seek a fixed solution over a removable prosthesis
vertical dimension to a suitable level (Fig. 2). for restoration of their worn teeth, as they often
Patients with severely worn roots and teeth that Treatment can be provided reversibly, since the associate wearing a denture with negative social
have compensated will have a correct lower prosthesis is removable and requires minimal stigma. It is down to the clinician to make a
face height. Such patients, who are unsuitable tooth preparation. Additionally, the worn balanced judgement on the predictability of
for surgical crown lengthening, may require dentition with multiple missing posterior fixed and removable treatment, and to guide
extraction and subsequent resorption of the teeth may present with reduced vertical facial patients, while attempting to remove some of the
alveolus to create interocclusal space followed proportions. A denture can immediately negative connotations of removable prostheses.
by prosthetic replacement of the spaces (Fig. 3). restore this, improving aesthetics, increasing A removable prosthesis may hinder plaque
Assessment and diagnosis of the aetiology the number of occlusal contacts and therefore control. 11 An onlay/overlay denture can
of tooth wear will aid in the clinician’s restoring function. have a more complicated design than usual.
determination of fixed restoration prognosis. For patients with primarily attritional tooth It is therefore imperative that patients can
A bruxist patient with primarily attritional wear, chrome dentures can be reinforced demonstrate optimal plaque control and are on
tooth wear will apply excessive force to the with additional metal-based features to resist a tailored supportive maintenance programme
teeth and therefore fixed restorations will be warpage or breakage of the framework, often to ensure that the dentures do not act as plaque
at much greater risk of failure.8,9 If a removable seen in severe bruxists (Fig. 2). Clinicians can traps and accelerate the loss of their remaining
alternative is provided, at least it can be be creative with these features, such as lipping dentition.12

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General design features

We will focus attention on specific denture

design principles, which the authors have
found to be beneficial when managing worn
dentitions. Dentures should be designed to
account for loss of further teeth in the future.
Teeth with a questionable prognosis should
have a (metal) palatal or lingual backing
adjacent to it when the denture is seated Fig. 8 a, b) A partial, or apron flange is useful to minimise overbulking lip support where there
(Fig. 2, Fig. 5). Should these teeth be lost are retained roots, whilst aiding in anterior retention of the denture
in the future, an in situ impression of the
denture can be taken, the backing can be provide a metal-wax-tooth trial for the patient and should be avoided for all patients who
perforated, and replacement acrylic teeth to approve before processing the denture. parafunction (Fig. 6).
can be added to the existing framework. Bruxist patients benefit from reinforcement When providing a removable denture for the
Backings also benefit from increased tooth of the denture to prevent warpage. In tooth wear patient, it is necessary to establish
support, indirect retention and bracing. Figure 4, a patient with a history of broken whether it is to conform to the existing
However, metal backings placed behind prosthetic teeth from their first denture was occlusal vertical dimension, or to be as part
denture teeth can cause grey discolouration provided with a metal bite platform which of a reorganised occlusal scheme. Generally
of the teeth and it is therefore important to lipped over the incisal edges. While this is speaking, the conformative denture is provided
not the most aesthetic of solutions, it is by following fixed restoration provision in the
far the most functional, and some patients same arch at a newly established OVD (see
may have to be guided towards this treatment later), but the majority of tooth wear patients
should other treatment fail. U-shaped major require reorganisation of the occlusion
connectors are prone to stress and warpage to account for collapse during tooth wear
pathology (Fig. 7). A new vertical dimension
is established by components of the denture
sitting on teeth or ridges.
The tooth preparation requirements for
overdenture abutments are straightforward:
removal of sharp edges, undercuts, and
Fig. 5 Maxillary partial denture framework unsupported enamel. There is little evidence
with onlay rests on posterior teeth and metal to support elective endodontic treatment
backings on anterior teeth to provide tooth of overdenture abutments,13,14 or coverage
support, indirect retention, and to safeguard of root dentine with glass ionomer cement
the denture against the loss of anterior
or other restorative material.15 Teeth which
teath in the future. The denture can be easily Fig. 6 Fracture of chrome denture framework
modified if an additional tooth is required from excessive occlusal forces will support onlay rests do not require
modification; however, should conventional

Fig. 7 a, b, c, d, e, f) An overclosed patient with loss of posterior occlusal support. On the retruded arc of closure, the first tooth contact offers
adequate restorative space to restore the worn anterior teeth

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Fig. 9 Case photographs for a separate arch fixed-removable case with severe erosive and attritional tooth wear. a) Pre-operative retracted
view. b, c) Jaw registration completed with maxillary wax rim, temporary composite mock-up of 41, 43, 31 at desired OVD, followed by
segmental removal of composite for silicone registration material. d, e) Wax-tooth try-in to verify tooth position and lip support. f) Metal
framework try-in of maxillary partial denture. Retention tags to support prosthetic teeth. g, h) Completed maxillary denture ready to fit. Note
acrylic anterior bite platform, which was essential to provide anterior tooth contact in this Class II division 1 incisor relationship. i, j) Completed
mandibular direct composite build-up restorations. k, l) Completion photographs, with maxillary denture in situ

rests be designed, standard protocols for would be tolerated and suitable. Features such remembered that when increasing the vertical
cutting of rest seats is recommended to provide as an apron flange (Fig. 8) not only reduce an dimension, the overjet is also increased and
positive seating of the framework. Clinicians excessive lip support but disguise a striking this sometimes comes with loss of anterior
should avoid placing rest seats into direct acrylic-soft tissue junction. By surveying the tooth contact. The choice of material for this
restorations, since repair and maintenance of soft tissue undercut on the cast, the flange is clinician- and patient-driven. Acrylic bite
these restorations in the future is complicated can be placed just 1 mm beyond the survey platforms, for the majority, are acceptable
by the metal framework being cast into line.16 This allows future reline or repair of the and benefit from ease of adjustment at the
these areas. denture should a root be lost subsequently. chairside and reduced technical challenges.
Lip support is a challenging concept when When increasing the vertical dimension, it However, if there is insufficient interocclusal
retaining anterior roots as overdenture is sometimes necessary to provide an anterior space for acrylic, or the patient requires a
abutments. Assessment of the required lip bite platform to ensure functional anterior more robust bite platform, then metal may be
support should be evaluated at the wax-tooth tooth contact, especially in Class I and II a more predictable option. This principle also
try-in stage to see if increased lip support incisor relationships (Fig. 9g). It should be applies to the choice of material for occlusal

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onlays (Fig. 10). Where space is limited,

metal occlusal onlays on posterior teeth are
preferred, since acrylic requires a minimum
of 2 mm interocclusal space to be sufficiently
rigid, versus 1 mm cobalt-chrome. Acrylic
onlays are more prone to fracture and should
be avoided in a patient with parafunction.
Metal is more resistant to wear than acrylic
and will hold the newly established vertical
dimension more predictably. It is the only
material of choice for a parafunctioning
patient.
Fig. 10 a, b) Metal occlusal onlay rests 25, 26. Hybrid metal-acrylic occlusal onlay rests 27, 28 in
Overlay prostheses often suffer from lack more aesthetic zone and where increased interocclusal space
of bucco-lingual space when balancing lip
support and functional tooth positions. For
this reason, the space required for the metal Prior to metal framework construction, the Table 1 Treatment sequence for sole
framework to cover the natural teeth, followed vertical dimension, occlusion, lip support, tooth removable chrome denture cases in the
by the prosthetic teeth overlying this, is often position and mould should be verified with a management of tooth wear
challenging and the prosthetic teeth are at risk wax-tooth try-in. Once these features have been No. Step
of being unsupported and lacking retention. To established and accepted, the metal framework
1 Primary impressions
counteract this issue, retention tags or loops can be reverse-engineered by taking a putty index
(Fig. 9f) within the metal framework can be of the tooth position and locating this back to Tooth preparation (if required) and master
2
impressions
of benefit. However, in some circumstances, the master model. In this way, features such as
Jaw registration at desired occlusal vertical
the space allowances do not accommodate metal backings, retention tags and loops can be 3
dimension
even these features and they need to be accurately positioned to the final tooth position.
4 Wax-tooth try-in
omitted. 4-methacryloxyethyl trimellitate After the metal work has been tried in, a
anhydride metal adhesive monomer offers penultimate wax/tooth/metal try-in appointment 5 Metal framework try-in
predictable bonding of acrylic to cobalt- is recommended. There may be ‘greying out’ 6 Definitive metal-wax-tooth try-in
chrome frameworks and reduces the need for of the denture teeth due to the metal backing
micromechanical retentive features. shining through and the patient should have an 7 Fit
Major connectors for maxillary dentures opportunity to check this and request a more
can be ring connectors, plates or mid-palatal opaque shade for their acrylic teeth, if needed. Table 2 Treatment sequence for same
straps. All designs are rigid and avoid the risk arch fixed and removable prostheses in
of deformation under excessive occlusal loads. the management of tooth wear
Clinical stages: combined fixed and
For mandibular dentures, lingual plates provide removable cases No. Step
the effect of metal backings against compromised
1 Primary impressions
anterior teeth, even when these teeth are restored Teeth which have been less severely affected
with direct composite restorations (Fig. 2). by wear may be predictably restored with fixed Master impressions in a special tray to
2
optimise the denture bearing anatomy
restorations, while there might be a need to
replace missing or severely worn teeth with 3 Jaw registration at desired increase in OVD
Clinical stages: provision of only
removable dentures a removable denture. This section is further Aesthetic preview14,15 of fixed restorations
subdivided in to: (using stent over wax-up and bis-acrylic
4 material) and removable dentures (as a
Table 1 describes the treatment sequence of • Provision of fixed and removable wax-tooth try-in). Ensure OVD and occlusal
such cases. restorations in the same arch contacts are correct
The authors favour alginate or a hybrid • Provision of a removable denture in Deliver fixed restorations (either direct
of light/medium-viscosity silicone in a one arch and fixed restorations in the or indirect) and interim acrylic partial
5 dentures. Likely to be delivered over
custom-spaced (2–3 mm) tray for the master opposing arch. multiple appointments. Dentures to be
impression. fitted at last appointment
A registration of the desired occlusal vertical Provision of fixed and removable Construct new cobalt-chrome removable
dimension is performed by using a wax rim restorations in the same arch 6 partial dentures if required at new OVD set
by fixed restorations
over the teeth to be used as overdenture When providing a combination of fixed
abutments and the patient is carefully guided restorations and removable dentures in the
into centric relation. Registration pastes allow same arch, it is impossible to avoid a transitional this reason, a transitional acrylic denture should
accurate recording of the jaw relationships and acrylic denture phase. This is due to the inability be made to be delivered at the time of fit of fixed
the wax rims should be checked back on the to accurately predict the final contour and restorations, which can be altered easily at the
master models to establish reproducibility in margins of fixed restorations while constructing a chairside, to provide (often) posterior occlusal
the laboratory. precisely fitting metal removable framework. For support. See Table 2 for treatment delivery stages.

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Fig. 11 Moderate generalised erosive tooth wear treated with same arch maxillary direct composite build-ups, resin-bonded bridge 22, 23 to
replace 22 and definitive cobalt-chrome partial denture, and mandibular direct composite build-up restorations. The patient required an interim
phase with acrylic partial denture before the definitive cobalt-chrome denture was constructed. a, b, c) Pre-operative views demonstrating
erosive tooth wear in both arches, chipped existing composite restorations and failing Resin bonded bridge 22,23. d, e) Diagnostic wax-ups
and maxillary partial denture wax-tooth try-in made on articulated study models mounted at the desired OVD on a semi-adjustable articulator.
Note how the wax-tooth try-in has acrylic onlay rests on 26, 27 a to provide tooth support at the increased OVD. f, g, h) Aesthetic preview
appointment with temporary crown and bridge material (Integrity, Dentsply Sirona) on teeth to have composite restorations, and wax-tooth
try-in maxillary partial denture. i) Addition cured silicone (Memosil 2, Kulzer) full coverage indices made from diagnostic wax-ups. j) Palatal
addition cured silicone guide used for direct composite build-up restorations, based on the confirmed diagnostic wax-up. k, l, m, n) Post-
operative photographs following provision of definitive maxillary cobalt-chrome partial denture. The completed restorations were direct
composite build-up restorations on 11, 12, 13, 21, 23, 31, ,32, 33, 41, 42, 43, resin-bonded bridge 22, 23, maxillary partial cobalt-chrome denture

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In order to time the clinical events

Table 3 Treatment delivery sequence for separate arch fixed and removable prostheses in
accurately, a preview appointment is required the management of tooth wear
to try in both the planned fixed restorations
and a wax-tooth try-in of the denture (Fig. 11f- No. Step

h). This allows confirmation of the planned 1 Primary impressions

increase in vertical dimension and tooth
2 Master impressions
display. The denture can then be processed
to fit at the delivery of the fixed restorations 3 Jaw registration at desired OVD
to avoid delay in receiving posterior support Aesthetic preview try-in of fixed restorations14,15 (using stent over wax-up and bis-acrylic material) and
4
for the new anterior restorations. Following removable dentures (as a wax-tooth try-in)
an adaptation phase, which is often short, the 5 Removable metal framework try-in
transitional denture can then be replaced by a
6 Definitive metal-wax-tooth try-in
definitive cobalt-chrome denture, conforming
to the newly established OVD. 7 Fit removable denture

8 Deliver fixed restorations (either direct or indirect)

Provision of a removable denture in
one arch and fixed restorations in the
opposing arch fluoride toothpaste for use twice daily Conclusion
For separate arch fixed/removable cases, the for brushing and once daily inside of the
clinician can again work the patient through denture, removal of the prostheses at night, A severely worn dentition is difficult to treat. If
to an aesthetic preview stage to trial the fixed and three-monthly recalls, with focused there are already a number of missing teeth and
and removable restorations. 17,18 However, oral hygiene instruction for all overdenture the remaining dentition is very worn, with only
they can omit the need for a transitional patients. sclerotic dentine remaining and short roots, then
acrylic denture. This means that a cobalt- The incidence of endodontic failure of an overdenture/overlay denture may represent
chrome denture can be made as the first overdenture abutment teeth is generally a more predictable, biologically conservative
denture. See Table 3 for the treatment low.15 Inadequate oral hygiene resulting in and quick means of rehabilitation. Retention of
sequence and Figure 9. caries and restoration failure is the most roots/teeth maintains proprioception, alveolar
The authors tend to provide the removable common cause for endodontic complications bone and soft tissue undercuts. These can
denture first in order to maximise the in these patients. Endodontic therapy to be used to optimise retention by prescribing
adaptation time and to assess patient teeth with short clinical crown heights can minimal, scalloped flanges, 1 mm above any soft
tolerance to an increased vertical dimension. be challenging and sometimes, extraction of tissue undercuts around any remaining roots.
Use of acrylic bite platforms are imperative the teeth is more predictable. Annual dentine Chrome-based frameworks are the material of
in these cases to enable adjustment of the bonding sealant of overdenture abutment choice, especially in cases where parafunction
acrylic component of the denture, rather than teeth may reduce endodontic complications is an issue or interocclusal space is minimal.
the fixed restorations, when harmonising the with vital abutments.15 Metal onlays can be used on posterior teeth to
occlusion at the end of treatment. Overdenture abutment teeth in the maxilla limit maintenance issues and backings should
opposed by natural teeth are at an increased be prescribed around any teeth of guarded
Maintenance issues risk of vertical root fractures.19 This is likely prognosis. Patients should be prescribed a
especially true while the dentures are not in mouthguard for nocturnal wear, as they will help
As with all complex restorative dentistry, place at night. For this reason, and to protect to preserve the fit of the overlay/onlay denture
maintenance is key for the survival and concurrent fixed restorations, provision of in the long term. Patients should be advised to
success of restorations. Multiple studies nocturnal splints are advised. The choice of see their practitioners on a 3–4-monthly basis
have shown an increased incidence of splint is dependent on the aetiology of tooth to ensure that they are maintaining optimal
complications and loss of overdenture wear, with most patients suiting a soft bite plaque control around the denture and should
abutment teeth if they are not regularly raising appliance, but patients with severe be advised to load their prosthesis with fluoride
reviewed and maintained.15,19,20,21,22 Frequent parafunction may benefit from a heat-cured toothpaste to minimise the development of
complications of overdenture abutments are acrylic splint. future carious lesions.
periodontal disease, caries and periapical O verdentures f re quent ly re quire
pathology. Despite this, high abutment maintenance, such as base adjustments Ethics declaration
tooth survival rates have been shown over and relines. 23 In tooth wear patients, the The authors declare no conflicts of interest.
several years.19,20,21 Factors associated with most frequent failures are occlusal surface All patients whose photographs are featured in this
increased abutment tooth loss are infrequent fractures. 24 In order to reduce this, the article have given full written consent for the use of
recalls (less than annually), infrequent use authors recommend the use of metal on the their photographs for this purpose.
of high fluoride toothpaste (5,000 ppm occlusal surfaces and minimal acrylic flanges
fluoride),19 24 hour wear of dentures22 and to facilitate future chairside relines should Author contributions
medically compromised patients. Therefore, overdenture abutments require extraction in The article was written and reviewed by Stephanie
the authors suggest the prescription of high the future. Hackett, Richard Newton and Rahat Ali.

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