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Tooth wear: A systematic review

of treatment options
Erik-Jan Muts, MSc,a Hans van Pelt, DDS, PhD,b
Daniel Edelhoff, DMD, PhD, CDT,c Ivo Krejci, Prof Dr Med Dent,d
and Marco Cune, DDS, PhDe
Center for Dentistry and Oral Hygiene, University Medical Center
Groningen, University of Groningen, Groningen, The Netherlands;
Dental School, Ludwig-Maximilians-University, Munich, Germany;
School of Dentistry, University of Geneva, Geneva, Switzerland
Statement of problem. Treatment of tooth wear is increasing. Because no evidence-based guidelines are available, the
clinician may have difficulties deciding which treatment option to choose to resolve complex situations.

Purpose. The purpose of this systematic review was to identify similarities among treatment options for generalized tooth
wear and to develop an approach to rehabilitation based on the best evidence available.

Material and methods. A Medline and Cochrane search (for articles published from January 31, 2003, to January 31, 2013)
was conducted. Minimally invasive and fully described treatments for generalized tooth wear with esthetically satisfying results
were included. Five steps within the treatment procedures were analyzed: diagnostic waxing (DW), occlusal positioning (OP),
vertical dimension increase (VDI), restoration, and follow-up.

Results. Common threads were established within the 5 treatment steps. Nine studies used DW, and 6 performed diagnostic
tooth arrangement (DTA). Centric relation was used in 5 studies, and VDI was tested in 8 studies, 5 of which used a
removable appliance. Seven studies implemented a provisional stage, and 5 used composite resin at that time. For definitive
treatment, composite resin (6 studies) and glass ceramic (6 studies) were used. Seven studies applied a protective appliance,
and 5 scheduled regular posttreatment evaluation as means of aftercare.

Conclusions. Within the limitations of this systematic review, the present evidence is not strong enough to form conclusions,
and the presented similarities cannot be substantiated with evidence. Therefore, comprehensive clinical research into the
designated treatment of generalized tooth wear is recommended. (J Prosthet Dent 2014;112:752-759)

Clinical Implications
The available evidence advises the use of diagnostic waxing and
diagnostic tooth arrangement. The use of centric relation is advised
for the occlusal positioning for rehabilitation. Testing of the vertical
dimension increases with a removable appliance and the use of a
provisional stage before definitive treatment is recommended. Both
composite resin and glass ceramic are indicated, and a protective
appliance with regular posttreatment evaluation is advised for follow-up.

a
Assistant Professor, Department of Fixed and Removable Prosthodontics, Center for Dentistry and Oral Hygiene, University Medical
Center Groningen, University of Groningen.
b
Associate Professor, Department of Fixed and Removable Prosthodontics, Center for Dentistry and Oral Hygiene, University Medical
Center Groningen, University of Groningen.
c
Tenured Associate Professor, Department of Prosthodontics, Dental School, Ludwig-Maximilians-University.
d
Professor and Chairman, Division of Cariology and Endodontics, School of Dentistry, University of Geneva.
e
Professor and Chairman, Department of Fixed and Removable Prosthodontics, Center for Dentistry and Oral Hygiene, University
Medical Center Groningen, University of Groningen.

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October 2014 753
The prevalence of the pathological options for generalized tooth wear ac- Table I. Broad inclusion criteria
loss of calcified tooth substance in a cording to modern, and in particular
mechanical but particularly in a chem- minimally invasive, dentistry. Is there a 1. Generalized tooth wear.
2. Complete description of treatment.
ical way is globally perceived as an common thread in these treatment 3. Wear into dentin.
increasing problem.1,2 Tooth wear af- possibilities? In order to ensure a useful 4. Minimally invasive.
fects tooth anatomy, and all kinds of approach, the treatment should be 5. No removable dentures.
complications may arise if it is left un- simple, stepwise, adjustable, repairable, 6. Esthetically satisfying.
7. Minimal edentulous spaces prior to
treated. These complications result and cost-effective. Contemporary ad- treatment.
from the loss of mineralized tooth hesive techniques meet most re-
substance and include a higher risk of quirements. Remaining tooth structure
tooth sensitivity, pulpal complications, needs to be preserved, and less experi- restored.4,5,13 Treatments of wear that
and discoloration.3,4 Probably even enced dentists should be able to treat had progressed into the dentin were
more important is the loss of function the patient with satisfactory results.11 included.
and esthetics. The loss of occlusal ver- Important steps to look into are the After the broad selection, detailed
tical dimension may result in dentoal- need for diagnostic waxing (DW), inclusion criteria (Table II) were
veolar compensation or an increased chosen occlusal position (OP), vertical applied. Studies were included that
interocclusal rest space.5 This will affect dimension increase (VDI), restorations, described simple, stepwise, adjustable,
the neuromusculature, efficiency of and follow-up. Similarities or differ- repairable, and cost-effective treat-
masticatory function, and esthetics as ences in treatment options are estab- ments. Treatment was considered sim-
the position of the smile line, the hori- lished analyzing these 5 treatment ple when the procedures were clearly
zontal occlusal plane, and the incisal steps. Common similarities within explained and easy to execute, stepwise
edge position changes.4-6 Loss of different treatment options could be when treatment could be transferred
anterior guidance and canine protec- considered as the best available evi- step by step from a long-term interim
tion may increase horizontal stresses in dence for the choice of treatment for restoration to a definitive stage or when
the posterior occlusal surfaces and generalized tooth wear. a technique with direct composite resin
thereby cause loss and fracture of res- was used, adjustable and repairable
torations.4 Moreover, instability of the when adhesive techniques were used,
occlusion will decrease masticatory MATERIAL AND METHODS and cost-effective when a segmented
function and increase the incidence of transfer was possible or a direct com-
cheek and tongue biting.3,5,7 The Selection criteria posite resin was used.
described loss of tooth substance in- Furthermore, only English-language
fluences not only teeth and masticatory The purpose of the inclusion criteria articles concerning humans published
system but also quality of life.8 was to select articles that described in dental journals in the last 10 years
Dentists should therefore use modern adhesive techniques and prac- were included. Because only adhesive
adequate diagnostic tools and indices tical techniques for clinicians to use in techniques could meet the selection
to identify tooth wear while straight- the best interest of their patients. These criteria, the literature search was limited
forward treatment is still possible.5,7,8 criteria included fully described treat- to the past 10 years.4,14 This period was
Accurate monitoring and use of diag- ment for generalized tooth wear with expected to contain the best evidence
nostic casts, indices, and/or intraoral data related to the clinical outcome. available because the prevalence (and
photographs are recommended.7,9 At Both broad and detailed inclusion as a result probably the treatment) of
a certain stage, the restorative treat- criteria were used. According to the tooth wear is increasing.1,2 Studies
ment of tooth wear is necessary to broad inclusion criteria (Table I), the describing highly invasive, esthetically
prevent the negative effects previously treatment should be minimally invasive, disappointing, complicated, non-
described. esthetically satisfying, and performed adjustable, nonrepairable, or expensive
The restoration of teeth with severe without the use of long-term removable treatments were excluded. Studies
wear is complex. Several approaches dentures. Studies were considered describing the treatment of only poste-
that use different materials and tech- minimally invasive when restorative rior or anterior dentition or incomplete
niques to restore worn dentition have procedures were performed with as lit-
been described.3,4,9 Unfortunately, no tle removal of healthy tissue as
evidence-based guidelines are available reasonably possible.12 This implies the Table II. Detailed inclusion criteria
to help clinicians choose the most use of adhesive procedures. Treatments
appropriate therapy.10 At present, only were found to be esthetically satisfying 1. Simple.
when the original tooth proportions, 2. Stepwise treatment.
expert opinions guide the clinician.
3. Adjustable and repairable.
The objective of this systematic re- smile line, horizontal plane of occlu- 4. Cost-effective.
view was to identify different treatment sion, and incisal edge position were
Muts et al
754 Volume 112 Issue 4
Table III. Search conducted in Medline and Cochrane databases Citation mining was performed by
checking the reference lists of retrieved
Search No. of articles against the selection criteria; no
Database No. Search Terms Results new articles were found. All articles
recommended by experts had already
Medline (up to 1 “Tooth Wear/therapy”[MeSH] 1366
January 31, 2013)
been analyzed or included. Because
some studies consisted of multiple
2 #1 AND (“last 10 years”[PDat] AND Humans 518
[MeSH] AND English[lang] AND jsubsetd publications, those publications were
[text]) merged (Table IV, Fig. 1). A total of 11
studies, consisting of 16 publications,
Cochrane (up to 1 MeSH descriptor: [Tooth Wear] explode all 63
January 31, 2013) trees and with qualifier(s): [Therapy-TH]
were included in this review.
2 #1 AND “last 10 years” (manual) 32
Data analysis

The included studies were analyzed


treatment descriptions were also Data collection and described. The year, type of study,
excluded. number of patients, follow-up period of
All 550 identified titles were the definitive treatment stage, and
Search methodology assessed for subject relevance and publishing journal of the studies are
screened for inclusion. The abstracts listed in Table V. The 11 different
A literature search of the Medline were then obtained from 111 appro- treatments for generalized tooth wear
and Cochrane databases (from articles priate titles and assessed for inclusion were also assessed by analyzing the 5
published from January 31, 2003, according the broad inclusion criteria different treatment steps: DW, occlusal
to January 31, 2013) was performed (Table I). Then 36 full texts were ob- position (OP), VDI, restoration, and
to identify studies for inclusion. The tained and assessed according to the follow-up.
Medical Subject Heading (MeSH) broad and detailed inclusion criteria These steps were chosen because
“Tooth Wear” linked to the MeSH sub- (Table II). This selection process was they provide the basics of treatment
heading “therapy” was used (“Tooth chosen to prevent unjustified exclusion procedures, depend as little as possible
Wear/therapy” [MeSH]). The Cochrane at an early stage. Twenty publications on the preference of the practitioner,
database search was designed as a per- were excluded. and are probably well described in
mutation of the Medline search strategy To support the use of the inclusion most studies. More detailed procedures
by manually selecting the studies of the criteria, some excluded articles will be (such as, interocclusal record registra-
last 10 years. To ensure a highly sensitive explained. The study by Meyers15 was tion) depend more on practitioner
search strategy, only the MeSH term excluded because the esthetic result was preference. Each step was analyzed by
“Tooth Wear/therapy” [MeSH] was disappointing and the original tooth means of research questions, and
used. This MeSH term also covers tooth proportions were not restored. The the results were schematized on a chart.
abrasion, tooth attrition, and tooth study by Avinash16 was also excluded To determine a common thread in
erosion. because of the invasive treatment pro- different treatment steps, there should
The results of the search were cedures performed, even though be similarity in at least 5 studies.
extended by hand searching. Hand enough space was available for nonin- Seven research questions were asked
searching was performed by citation vasive restorative treatment. The study about each included study in accor-
mining and expert recommendations. by Fradeani et al17 was excluded dance with the 5 different treatment
The performed searches are shown in because the treatment was considered steps, as shown in Table VI.
Table III. to be neither stepwise nor cost-effective.

RESULTS
Table IV. Selection process used during data collection
Description of studies
Assessment Inclusion Criteria No. of Results
A total of 16 publications on the
Titles Relevant topic 111 treatment of generalized, complete-
Abstracts Broad inclusion criteria (Table I) 36 arch tooth wear met the inclusion
Full text Broad and detailed inclusion criteria (Table II) 16 criteria (Table IV). By merging sub-
Included studies Combining substudies 11 studies, a total of 11 studies were
included and analyzed.

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October 2014 755
Seven studies used an interim stage
First electronic search (MEDLINE and Cochrane) before the definitive treatment. Com-
550 titles
posite resin was the most used restor-
ative material for this stage and was
used in 5 studies; 2 studies used it with
a direct technique and 2 studies with an
550 titles scanned 439 titles were not relevant
indirect technique, and 1 study com-
111 titles selected to the subject or duplicated
111 abstracts obtained during search process bined both the direct and indirect
techniques. Furthermore CAD/CAM-
fabricated high density polymethyl
methacrylate (PMMA) was used in 2
studies. One study used interim metal
111 abstracts
75 abstracts did not meet and acrylic resin restorative materials.
assessed
the broad inclusion criteria For the definitive treatment proce-
36 abstracts selected
(Table I)
36 full-texts obtained dure, composite resin and glass ce-
ramics were the most commonly used
restorative materials. Six studies used
composite resin; 2 studies used it
36 full-texts assessed directly, 2 studies used it indirectly, and
20 full-texts did not meet
16 publications 2 studies combined both techniques.
the broad and detailed
selected Glass ceramics were used in 6 studies, 3
inclusion criteria
16 publications
(Tables I and II) of which explicitly used lithium dis-
analyzed
ilicate. Furthermore, 4 studies used
gold, 2 studies used metal ceramic, 1
study used metal resin, and 1 study
used zirconia ceramic.
16 publications contained 11 different studies (Table IV)
A total 11 studies final included Seven studies prescribed a protective
appliance (hard acrylic resin), and 2
1 Schematic representation of searching process. studies specifically advised a Michigan-
type protective appliance. Five studies
All included studies were case (CAD) waxing. Both diagnostic and advised regular evaluations to modify
reports (8 studies) or case series anatomic waxings were used. Six the occlusion. In 4 studies, a (partial)
(3 studies) that studied between 1 and studies performed a DTA with tem- provisional state was accomplished,
4 patients and were published between plates and (temporary) composite resin and a step-by-step replacement of the
2007 and 2012 (Table V). The follow- to evaluate the treatment outcome and, interim restorations with definitive res-
up period after the definitive treatment if needed, to make adjustments. torations was recommended; 3 studies
stage ranged from 0 to 20 months. The Centric relation (CR) was the clearly explained their 2-phase tech-
follow-up of the interim stage was not occlusal position of choice for rehabili- nique (interim and definitive stage) and
included. tation in 5 studies, and maximum inter- the restorative materials used for
cuspation (MI) was used in 2 studies. definitive restoration; 1 study recom-
Results of analysis The remaining studies did not mention mended the transfer only when neces-
the use of the occlusal position. sary. Which restorative material was
The 5 treatment steps and potential The VDI was tested before treatment recommended was unclear; therefore,
similarities between the treatment op- in 8 of 11 studies. Five studies used a the presented treatment was considered
tions were analyzed by following the removable appliance, one of which to be the definitive treatment.
specific research questions. The results combined it with anterior composite
of the analysis are described below and resin. Four studies used a fixed method DISCUSSION
are shown in Table VII. with different materials, including (in)
DW was used in 9 studies for direct composite resin and metal Key findings
communication with both the patient interim restorations. The overall period
and the dental laboratory, for the of testing ranged from 1 to 3 months, The objective of this systematic re-
fabrication of templates, for diagnostic but 1 study used an extended period of view was to identify recent treatment
tooth arrangements (DTA), and for 6 months. When using a removable options for generalized tooth wear and
interim and definitive restorations. One device, the study authors recommended to identify within these treatment op-
study used computer-aided design 24 hours of use a day. tions a common thread of 5 important

Muts et al
756 Volume 112 Issue 4
Table V. Overview of included studies
No. of Follow-up
Study Year Type of Study Patients Period (mo) Journal

Dietschi18 2011 Case report * * Eur J Esthet Dent


19
Edelhoff 2012 Case report 1 0 Quintessence Int
23
Mizrahi 2008 Case report 1 0 Eur J Esthet Dent
Spreafico27 2010 Case report 1 9 Eur J Esthet Dent
22
Mehta 2012 Case series 2 0 Br Dent J
26
Schwarz 2011 Case report 1 6 J Prosthet Dent
29-32
Vailati 2008, 2011, 2012 Case series 4 0-12 Eur J Esthet Dent, J Adhes Dent
Reston24,25 2010, 2012 Case series 2 0 Oper Dent
28
Stumbaum 2010 Case report 1 0 Int J Comput Dent
20
Garcia 2009 Case report 1 20 Bull Tokyo Dent Coll
Hayashi21 2007 Case report 1 12 Oper Dent
*No result could be established.

treatment steps. These findings could Nevertheless, the present evidence is foundations and preparation; and it
guide the clinician through the complex not strong enough to form conclusions provides better communication be-
treatment of generalized tooth wear. (low level of evidence).10 tween dentist, patient, and dental
technician.4,14,23,29,30 The disadvan-
Level of evidence Interpretation of results tages are the costs and time associated
with DW and DTA.33
All included studies were case re- DW and DTA were frequently used CR was most frequently used and
ports or case series with small numbers (in more than 5 studies) so a common was determined to be a common
of patients and short or no follow-up thread was determined. During the thread. Although the use of CR may
treatment. Assessing the included treatment of severe tooth wear, the use help the clinician during treatment,
studies on the rating of the publishing of DW and DTA may benefit the considering the molar occlusion in the
journals is not possible, and therefore clinician in the following ways: it al- decision whether to choose MI or CR is
no study quality rating was performed. lows the treatment outcome to be probably wise.29,34 Moreover, deter-
The case reports and case series should previewed while adaptations are still mining CR may be difficult, and com-
be accepted as proof of principles possible; it informs the patient; it bined with an unfavorable molar
and provide the best evidence to aids the fabrication of templates that occlusion, it may lead to an unnec-
guide the clinician during treatment. are advantageous during adhesive essary increase in the horizontal over-
lap.29 In contrast, CR is often
recommended because of its repro-
Table VI. Research questions ducibility.34 Changes in the occlusal
Treatment scheme appear not to cause temporo-
Step Research Question mandibular disorder-related problems
when absent before treatment.35
1 DW 1 Was DTA performed? The VDI was tested before treatment
2 Was DW used for treatment or treatment planning? in most studies; this step was deter-
mined to be a common thread. In most
2 DW 3 Was CR or MI used as occlusal position before treatment? patients, testing was performed with a
3 VDI 4 Was VDI tested before treatment? removable occlusal appliance. The
5 If so, how and for how long? similarity was sufficient to use this
treatment step as a useful direction.
4 Restoration 6 Which restorative materials were used, including possible provisional
According to previous studies, testing
and definitive restoration?
the VDI is only needed when the
5 Follow-up 7 How was follow-up performed? remaining interocclusal rest space
CR, centric relation; DTA, diagnostic tooth arrangement; DW, diagnostic waxing; MI, maximum after rehabilitation will be less than 2
intercuspation; VDI, vertical dimension increase. to 3 mm.6,22 Increasing the occlusal
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October 2014 757
Table VII. Overview of analyzed treatment steps
DW VDI Restoratives
Study DW DTA OP VDI Method Wk Interim Definitive Follow-up

Dietschi18 Yes * MI * * * None Composite resin Protective


(direct/indirect), device regular
lithium check-ups
disilicate

Edelhoff 19 Yes Yes CR Yes Occlusal device 12 High-density Lithium disilicate Clinical evaluation
PMMA and modification,
(CAD/CAM) segmented transfer

Garcia20 Yes * CR Yes Occlusal device * None Composite resin Protective device
(direct),
metal resin,
gold

Hayashi21 Yes * * Yes Acrylic resin 26 Acrylic Gold, glass Protective device,
(anterior), metal resin, metal ceramic 3 mo recall
(posterior)

Mehta22 Yes Yes CR Yes Occlusal device 4 Composite Gold, metal Protective device
resin (indirect) ceramic, (Michigan type)
composite
resin (indirect)

Mizrahi23 Yes Yes CR Yes Direct composite 8 Composite Glass ceramic, Protective device
resin (anterior), resin gold, (Michigan type)
occlusal device (direct/indirect) metal ceramic
(posterior)

Reston24,25 * * * * * * None Composite Protective device,


resin (direct) segmented transfer
(when necessary)

Schwarz26 Yes Yes * Yes Direct 12 Composite Lithium Evaluation of


composite resin disilicate occlusion,
resin (direct) oral hygiene
instruction

Spreafico27 Yes Yes * * * * None Composite resin Evaluation of


(direct/indirect) occlusion

Stumbaum28 * * CR Yes Occlusal 4-8 High-density Zirconia Protective device,


device PMMA ceramic segmented transfer
(CAD/CAM), to zirconia
composite ceramic
resin (indirect)

Vailati29-32 Yes Yes MI Yes Direct 4 Composite Composite resin Segmented


composite resin (indirect), glass final restoration
resin (posterior) (direct) ceramic posterior

CR, centric relation; DTA, diagnostic tooth arrangement; DW, diagnostic waxing; MI, maximum intercuspation; OP, occlusal positioning;
PMMA, polymethyl methacrylate; VDI, vertical dimension increase.
*No result could be established.

vertical dimension seems to be a safe testing patient acceptance or adapta- implementation of an interim stage
procedure (signs and symptoms tend to tion with a removable method is less during the treatment of generalized
be self-limiting) and well accepted up predictable than with a fixed method. tooth wear was established to be a
to 5 mm.34,36 The testing periods varied In this review, 4 studies used a fixed parallel within 7 studies and could be
in this study. If necessary, testing the method; therefore, this method was not used as guidance. The implementation
VDI for a period of at least 1 month for considered to be a common thread. of this stage is performed to evaluate
24 hours a day is probably advised.5,22 The majority used an interim treatment outcome and patient accep-
In addition, Abduo34 concluded that stage before definitive treatment. The tance.14,19 Changes in esthetics and
Muts et al
758 Volume 112 Issue 4
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