First, and most important, there is no evidence based treatment for this patient. You also asked how to rehabilitate the patient and this cannot be done without attending to the anterior teeth. If you just do the posteriors you are doing conformative dentistry.

Without diagnostic casts mounted in centric relation and a full intra and extra oral clinical and TMJ exam one should always be hesitant to make clinical decisions. Obviously, caries and periodontal disease should be a priority.

We have seen numerous patients with this scenario and have had success in treating them. As the anterior teeth wear down the mandible rotates to accommodate incising and unfortunately, in most cases, bruxing. This as opposed to the patient who has all of their teeth worn down evenly. The inter-occlusal gap is key with these patients. If the opening is minimal, you have to move slowly with caution in restoring the lost VD and in the senior patient this may not be possible.

You can test the hypothesis by making an overlay RPD that restores the proper anterior tooth length and arch form, establishing an incisal guide angle that satisfies the esthetic and phonetic needs of the patient. We have done enough of these that we often go directly to fixed provisionals. Once the incisal guide angle is fine tuned you will see that the condyle has rotated, and perhaps translated, back in to a more ”normal” position and the rehabilitation becomes easier and more predictable. I would not do any RCTs on the posterior teeth until the mandibular position is stabilized, as it may not be needed.

I know this is a difficult concept to grasp, so try the non-invasive overlay RPD first and see how you do.

A similar patient:

The Use of a Diagnostic Matrix in the

Management of the Severely Worn Dentition

Phuong D. Doan, DDS; and Gary R. Goldstein, DDS

J Prosthodont 2007;16:277-281.

Sorry, copyright laws prevent me from uploading the article.

if this patient come to my dental clinic i will take history if there is any psychiatric problems  and if i doubt  presence of such problems  i will her to psychiatrist.  then step two i will make full clinical examination   including TmJ and checking partial denture not annoying her no sharp edge  no sharp or incorrectly positioned clasp  and if present  adjust  also i will ask if there any para functional habits

as clenching or bruxism  then i will check that and if that present i will make splint in centric occlusion for clenching and stent for bruxism and iwill give muscle relaxent cyclopenzabrin 10 mg/day  mention BURKIT oral medicine.

then third step i will check the occlusion and i thought that is the major problem in this case and prematurity in occlusion can lead to serious problems so coronoplasty is mandatory. so i will begin make coronoplasty using wax of occlusal analysis  and marker and begin to corectt occlusion in centic relatio then from centric relation to centric occlusion and check posterior touch in protrusive and correct any prematurity in non working side during lateral movements following rules of coronoplasty with using muscle relaxant to decrease musticatory overwork and anti-inflamatory and make physiotherapy asking patient to make tongue touch palate and making closing and opening slowly to make both sides work evenly as should done in normal with follow up case after one week to check patient problem solved or not and i hope my answer  would be helpful to you.

I agree with dr. Goldstein, there is no evidence based treatment for this patient. Furthermore, it is nigh impossible to give considered advice as no information is given regarding the occlusal state, which may or may not need interventions. In order to decide this matter, the diagnostic methods suggested by Dr. Goldstein are required.

If the occlusion is without occlusal disturbances or these can easily be rectified by occlusal grinding adjustments, two questions remain:

1.       Does the degree of attrition merit a restorative procedure?

In this context it is usually wise to observe over time to see if the attrition increases. If it does not, do not treat unless there are other specific reasons for intervening. My strongest advice is therefore to be reluctant to undertake lengthy and usually very expensive procedures necessary to restore tooth substance lost to attrition unless one is absolutely certain that this is the only option.

2.       What can be done to avoid repeated fractures of the partial denture in the 24, 25 region?

In many cases the reason for this mishap is an insufficient quantity of acrylic to withstand the forces of occlusion due to large retention pegs etc. If the occlusal surfaces of the denture teeth are in supra-contact in centric occlusion or during lateral excursions the problem is even more likely to occur. Once the teeth have broken no repair is likely to succeed in the long run because the repair (usually with autopolymerising acrylic) is always weaker that the original base material.

Instead, construct the partial denture with the framework material continuing from the palatal major connector on to the occlusal surface, and polymerise the facings of 24 and 25 underneath. This construction prevents further fractures as it is immeasurably stronger than the traditional method. The only disadvantage is that a precise occlusal index is a must, as adjusting the cobalt-chromium occlusal surface in centric occlusion and during lateral excursions is a tedious task.

Dear Ankur Sharma,

Pls check the link it may be helpful to you.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3774953/#!po=3.84615