Al-Quds University

Faculty of Dentistry
Prosthodontics
Lecturer: Dr. Ahed Kadamani

Literature review about tooth wear

Management of Tooth wear
Tasneem Saleem Rajabi

May, 2020
Table of Contents
Introduction .................................................................................................................................................................... 1
Prevalence tooth wear ................................................................................................................................................... 1
Classification of tooth wear ............................................................................................................................................ 1
1. Attrition .............................................................................................................................................................. 1
2. Abrasion .............................................................................................................................................................. 2
3. Erosion ................................................................................................................................................................ 2
4. Abfraction ........................................................................................................................................................... 3
Prevention of tooth wear ............................................................................................................................................... 4
1. Dietary ................................................................................................................................................................ 4
2. Adequate tooth brushing: technique, brushing time and frequency................................................................. 4
3. Fluoride addition ................................................................................................................................................ 4
4. Patient’s tress control ......................................................................................................................................... 4
Planning and Treating of tooth wear.............................................................................................................................. 5
1. Clinical Assessment............................................................................................................................................. 5
2. Diagnostic information and records ................................................................................................................... 5
3. Stabilisation ........................................................................................................................................................ 6
4. Planning Restorations ......................................................................................................................................... 6
5. Material Selection............................................................................................................................................... 8
6. Restoring the dentition....................................................................................................................................... 9
Discussion ..................................................................................................................................................................... 13
Conclusion .................................................................................................................................................................... 14
References: ................................................................................................................................................................... 15

a
Introduction
Non-Carious Tooth Surface Loss also termed Tooth Wear is a current issue of concern to dental
practitioners regarding the diagnosis, identification of the etiological factors, prevention, and execution of
an adequate treatment.1

Tooth surface loss can span from initial enamel loss, though cupping of the occlusal surfaces of posterior
teeth, exposure of large areas of dentine on anterior teeth, fractures of unsupported enamel and on until
much of the tooth tissue has been lost.3

Tooth wear is a multifactorial condition, leading to the loss of dental hard tissues, viz. enamel and
dentine. Tooth wear can be divided into the subtypes mechanical wear (attrition and abrasion) and
chemical wear (erosion). Because of its multifactorial aetiology, tooth wear can manifest itself in many
different representations, and therefore, it can be difficult to diagnose and manage the condition.9

Prevalence tooth wear

Although tooth wear is considered to be age dependent, an increasing number of both adult and young
patients is experiencing tooth wear, usually erosive in nature.4

For many years, tooth wear was a condition of little interest in daily clinical practice, nowadays this is
changed. Tooth wear is becoming increasingly significant in maintaining the long-term health of the
dentition. This becomes especially important when the dentition is kept relatively intact in the
contemporary ageing population, and edentulism is decreasing. There is also evidence that the prevalence
of tooth wear is growing, although data are scarce and contradictory.01

Tooth wear is increasing in severity and prevalence, partly because of an ageing population and partly
because of modern lifestyles.7 It was found that 15% of adults showed moderate wear and 2% severe
wear. And, it has been estimated that 17% of those aged 70 years will have severe tooth wear.3

Classification of tooth wear

According to Grippo classification established in 1991, four type of surface loss have been identified and
distinguished by the different causes.1

1. Attrition

Attrition is defined as the wearing away of tooth substance (or restoration) due to tooth to tooth
contact.1 It is intrinsic mechanical wear as a result of function and/or parafunction (e.g. bruxism).10

As all individuals chew and therefore have attrition,9 It can be mostly remarkable in patients with a
vegetarian diet.1

The wear from attrition may be localized on the occlusal surfaces of posterior teeth, the palatal surfaces
of maxillary anterior teeth, the labial surfaces of mandibular anterior teeth, and the incisal edges of
anterior teeth. The affected surfaces are usually hard, smooth, and shiny. In certain cases, they may be

1
sharp and jagged. The areas of attrition may be associated with a yellowish-brown discoloration if the
wear has penetrated the enamel. Wear may also concern interproximal surfaces leading to mesial drifting
and broadening of proximal contacts.1

2. Abrasion

Abrasion is extrinsic mechanical wear as a result of other factors than function and/or parafunction, 10
occurs when dental substance wears away due to friction between the tooth surface and external agent
other than an opposing tooth.1

Factors related to patients include abnormal process or habits: 1

 Tooth brushing has been incriminated as to be the main etiological factor in dental abrasion. This has
been noted clinically, while observing a coincidence of smooth-surface and/or cervical abrasion as well
as an extensive oral hygiene. This causes cervical abrasion where the severity depends on the brushing
technique, time spent on brushing as well as the force applied on brushing.1

 Besides, the abrasion of interdental areas may be the result of extensive use of interdental brushes or
tooth picks.1

 Notching of incisal edges may be caused by pipe smoking, nuts and seed cracking, nail or thread
biting, and hairpin biting which are rarely seen today.1

 Material factors: they have been found to influence the prevalence of abrasion such as amount, pH
and abrasiveness of tooth pastes used for brushing or inserted within interdental brushes. Similarly,
tooth brush stiffness and their bristle design and flexibility -mainly when they are associated with
aggressive brushing techniques- explain this prevalence.1
As for restorations, unglazed porcelain causes abrasion of opposing natural teeth.1

 Environmental factors: they include exposure to dust and grit in some working places.1

As with attrition, the condition is rarely caused by a single factor with erosion being a common cofactor.1

3. Erosion

Erosion is chemical wear, not caused by caries, as a result of intrinsic or extrinsic acids.10 It may involve
the entire dentition or be localized as a single solitary lesion.1

According to the characteristic pattern, two forms of erosion are to be considered:1

 The first erosion pattern is characterized by evident concave depressions where enamel appears thin
and translucent. These are commonly exhibited on the palatal and occlusal surfaces of maxillary teeth
as well as buccal and occlusal surfaces of mandibular posterior teeth. This specific pattern is linked to
certain voluntary or involuntary medical conditions.1

Voluntary or self-induced endogenous regurgitation of stomach contents is due to anorexic or bulimia

nervosa. Involuntary regurgitation is explained by gastroesophageal reflux disease (GERD) or gastric
ulcers and hiatus hernias. It should be noted that lesions due to GERD are called perimolysis or
perimylolysis.1

2
 The second erosion pattern is specified by scooped out depressions present on labial surfaces of
maxillary anterior teeth.1
This is mainly caused by dietary factors, associated with slimness food and acidic drinks (fruit juices,
carbonated or cola drinks, vinegar…).1

 Other exogenous factors such as exposure to corrosive or acidic substances and fumes that have a
critical pH level of less than 5.5 (work in battery factories) have been reported. Some sports as
swimming in pools with low pH can also cause potential surface tooth loss.1

Both patterns are caused by saucerized defects where acid is in contact with the teeth which is different
from chemical dissolution not related to acid produced by dental plaque. These effects may be
aggravated by the reduction in salivary flow caused by dehydration and some drugs.1

Recently, it was stated that the role of erosion in the multifactorial tooth wear process is increasing. This
can be explained by the growing consumption of acidic drinks and food.01 In modern society, most
individuals have an erosive diet and therefore have erosion, it is virtually impossible to separate these
phenomena.9

4. Abfraction

Abfraction means the pathological loss of tooth structure resulting in wedge-shaped lesions with sharp
line angles which may be located completely beneath the marginal gingiva.1

Its existence or aetiology may be of debate.9 Numerous hypotheses were suggested to explain their exact
cause.1

Practitioners widely accept that abfraction is related to atypical occlusal loading.1

It is a consequence of eccentric forces on the natural dentition, which were theoretically said to have
been caused by tooth fatigue, flexure and deformation via biomechanical loading of the tooth structure.
Cusp flexure, due to lateral occlusal forces during mastication and parafunctions, causes tensile stress.
This disrupts the chemical bonds presented by induced cracks in the enamel and dentin in the region of
concentrated stress at the cervical region.1

While some authors have shown evidence that supports this hypothesis, suggested that such evidence is
not that solid. They suggested that cervical lesions are probably accelerated when they are combined to
erosion, abrasion, and attrition.1

Abrasion in the cervical region is usually distinguishable from abfraction by its smooth, rounded nature of
the lesion along with minimal to extreme gingival recession-with or without mucogingival defects.
Gingival recession may also be seen with abfraction but is not a hallmark of these defects.1

3
Prevention of tooth wear
The damage of tooth wear is irreversible and will thus compromise the dentition for the total lifetime.
This may require repeated and increasingly complex and expensive restorations. Therefore, it is important
that the diagnosis of tooth wear is made early, and adequate preventive measures are being taken. To
that end, dentists should explore the numerous factors that play a role in the onset, severity and
progression of tooth wear.10

Admittedly, prevention of tooth surface loss is preferable to restoration. To prevent tooth wear
aggravation, etiological factors must be determined along with early recognition of signs and symptoms.
Thus, Prevention of further tooth wear ideally includes elimination of the causative agent. This simple
action is often impossible, though.1

Several researchers agree that wear progression can be reduced by patient education. This is based on
preventive advice tailored to the cause and severity of the non-carious tooth surface loss. It focuses on: 1

1. Dietary

Patients are required to confine acidic drinks to meal times in favour of neutral drinks like milk and water
along the day.1

As for fruit juice consumption, it is preferable to be consumed once a day. The use of wide-bore drinking
straws is highly recommended when consuming acidic beverages which helps to reduce the tooth-acid
contact time.1

2. Adequate tooth brushing: technique, brushing time and frequency

It has been proved that dental tissues take 60 minutes to be reestablished after contact to acid, tooth
brushing should not be performed soon after vomiting or after acidic drinking.1

3. Fluoride addition

It has been proved to reduce the damage of acid drinks to teeth. Whereas it’s application, via mouth
rinses gels is recommended to fight acid damage, requiring thus, the use of 0.7% fluoride solution
followed by home application of 0.4% fluoride. Other authors report that tooth pastes containing
potassium are also considered to be appropriate for the management of sensitive dentine.0

When it comes to parafunctional activity, patients with GERD are advised to wear a protective occlusal
splint. However, specific attention and rigorous hygiene instructions are recommended as acidic
substances may accumulate within the splints which may further exacerbate the rate of tooth wear.1

Reference to other medical specialities is recommended in case of voluntary vomiting and suspected
gastro-esophageal reflux.1

4. Patient’s tress control

It is key to tooth wear progression management. The previous methods based on advice and life style
management are crucial to preserve the remaining tooth structure and to enhance the longevity of

4
restorative treatment. Removing the etiological factors highly determines the treatment success.
Whereas, failure can be early predicted if culprit factors couldn’t be managed.1

The exact aetiology of wear in an individual case may or may not be ascertainable but the quality of life
for a patient with tooth surface loss may be impeded to such an extent that they will require us to
intervene not only preventively but also restoratively.3

Planning and Treating of tooth wear

Planning and treating a TSL case is divided into six stages as listed: 9

1. Clinical Assessment

For each presenting clinical case, a thorough medical, dental and social history (including diet assessment)
should be taken.9

Appropriate clinical assessments:

1) Extra-oral examination should assess, the smile line, lip support, gingival show, tooth proportion
and display, occlusal planes and centre lines, TMJ and associated orofacial musculature.9

2) Intra-oral examination should assess, periodontal, endodontic,9 the static occlusal and incisal
relationship, the presence or absence of inter-incisal space in ICP and whether or not the patient is
overclosed, measurement of the freeway space (FWS) with a Willis gauge is required, although
often overclosure is clinically obvious, the extent of wear should be noted in terms of surfaces
involved, whether or not dentine is exposed and the degree of dentine exposed on the surface,
estimate the area of dentine exposed on the surface and state whether the wear facet is flat or
cupped/grooved, finally, the lip or smile line should be assessed.7

The assessment for patients with tooth wear is fundamentally the same as for all patients. Gingival health
is usually acceptable and teeth worn by attrition are firm otherwise the high loads would lead to
increased mobility and drifting in periodontally compromised teeth.

2. Diagnostic information and records

Appropriate diagnostic records:

1) Relating diagnostic study casts in an anatomical relationship (retruded axis position or intercuspal
postion) useful for diagnostic procedures.9

2) A jaw registration record facilitates the mounting of the mandibular cast to the maxillary cast. 9

3) Radiographic examinations are also undertaken to aid the formation of a diagnosis.9

5
 4) Indexing should be applied to rate worn dentition,1 Recording of wear has received greater
attention of late.7

Flat facets with mating or matching of the upper and lower facets in ICP and lateral excursions indicates
attrition, whereas as a rule, cupped occlusal cusps indicates erosion or abrasion.7
When dento-alveolar compensation has occurred, the zone of attached gingivae is wide and often
unsightly, particularly when short worn teeth are present.7

Clinical diagnosis of severe tooth wear is not easy and the etiology seems to be always multi-factorial.6

3. Stabilisation

The initial step for any tooth wear case is to identify and control the risk factors, which requires in depth
and sensitive questioning of the patient. In an ideal world, restorative treatment should be postponed
until the dentist has established that the wear is not progressing and that the patient has been compliant
with advice. In the real world, this is not always possible nor indeed is it desirable. A pragmatic approach
should be adopted to manage the patient’s concerns. An example would be a patient with bulimia
nervosa or an adolescent who has eroded teeth and seeks treatment. Any patient, but particularly a
vulnerable one, must be managed sympathetically and with empathy.8

Stabilisation of presenting primary disease and the investigation and stabilisation of the aetiology of the
TSL is paramount before any reconstruction treatment is commenced.9

Stabilisation splint therapy could be considered at this stage if it is deemed that the recording of the
retruded axis position (RAP) is challenging by way of the patient’s resistance to manipulation of the
mandible. A hard acrylic maxillary splint of Michigan design may be used which provides an aid to a
prolonged period of muscle relaxation in order to assist in mandibular repositioning to RAP.9

It is important that any prevailing aetiology is addressed before the splint appliance is provided especially
if the TSL is primarily erosive in nature, where it has been suggested that acid can be retained under the
splint and make the erosion worse.9

4. Planning Restorations

All these informations are needed to indicate whether it is necessary to restore or not. 1

Clearly, identifying aetiological factors associated with wear in individual patients is the first step in
management, followed by lifestyle change on the part of the patient and monitoring by the dentist. Most
patients do not complain of pain or functional problems as the main driver for treatment is a desire for
aesthetic improvement.7

Management decisions are multifactorial, depending principally on the severity and effects of the wear
and the wishes of the patient. Restorative intervention is typically best delayed as long as possible. When
such intervention is indicated and agreed upon with the patient, a conservative, minimally invasive
approach is recommended, complemented by supportive preventive measures. 5

Generally, when patients do not show any interest in the treatment and in the absence of symptoms, a
preventive approach seems to be more efficient-mainly when the patient doesn’t present a dynamic wear
process.1

6
However, for some other cases, restorative treatment may be required. Nevertheless, prosthetic
rehabilitation in such patients is risky and prone to problems because of the complex structure of the
stomatognathic system.1

For those who show a high sensitivity and need to improve function, mastication and esthetic, restorative
procedures become highly beneficial.1

Some authors stress the benefit of delaying restorative treatment to an older age to avoid recycling the
restoration procedure in case of failure.1

The approach to management of wear may be dictated by its position in the arch and whether it is
anterior or posterior, localised or generalised.8
When treating the anterior worn dentition, the clinician must be aware of how these cases may be
planned for effective management and provision of adequate functional and aesthetic restorations. 9

In the absence of functional or esthetical problems, monitoring and counseling of the tooth wear may be
a good option. This would include making of study casts and providing information on the condition and
recommendations for prevention. Bruxing patients can be advised to wear an occlusal acrylic splint when
there is indication that bruxism is a main etiological factor. When functional or esthetical problems exist,
a restorative treatment would be advised, that may be conservative and minimally invasive.6 A restorative
rehabilitation of the entire dentition when bruxism is one of the main etiological factors can be
considered a clinical challenge for any restorative material.6

Attrition is more difficult to restore as the loads are very high during bruxism and space is not available.
Thus one approach to restoration is to categorise according to whether space is present or absent.7

The decision to change teeth position and gingival margin positions via orthodontics, Dahl occlusion
devices or periodontal surgery is dictated by the patient’s smile line, the extra-oral display of the gingiva
in the aesthetic zone and presenting dentoalveolar compensation that may influence the desired occlusal
outcome.9 In the latter scenario, elective crown lengthening is indicated in order to not only gain crown
height for conventional crowns or build-ups but also reduce the amount of gum displayed.7

The treatment of tooth surface loss is becoming more common in primary health care and a diverse
variety of patients are presenting with this condition are often being treated by general dental
practitioners,9 a dentist is unlikely to carry out periodontal surgery, but some cases can be managed in
primary care.7

7
 5. Material Selection

See the Table 1 below, Materials available to restore worn dentition with its indications, advantages and
disadvantages.(As mentioned in article 9)

Table 1, Materials available to restore worn dentition with its indications, advantages and disadvantages
Material Indication Advantages Disadvantages
- Mandibular incisor & canines - Less appointments - Durability
- Maxillary incisor and - Economic - Regular maintenance
Composite canine palatal and buccal surfaces - Easy to adjust and polish
Resin – Direct - Aesthetic
- Repairable
- No tooth prep required
- Mandibular incisor & canines - Durability - More appointments
Composite
- Maxillary incisor and - Easy to adjust and polish - Bond strength
Resin –
canine palatal and buccal surfaces - Aesthetic - Tooth preparation may be
Indirect - Repairable required
- Maxillary incisor and - Durability - More appointments
canine palatal surfaces - Expensive
- Difficult to adjust and polish
Metal Alloy –
- Unaesthetic
Type III
- Difficult to mask
Gold alloy
- Unrepairable
- Tooth preparation may be
required
- Maxillary incisor and - Durability - More appointments
canine palatal surfaces - Difficult to adjust and polish
- Unaesthetic
Metal Alloy – - Difficult to mask
Nickel - Aggressive wear to opposing
Chrome Alloy teeth
- Unrepairable
- Tooth preparation may be
required
Hybrid – Resin - Mandibular incisor & canines - Durability - More appointments
- Maxillary incisor and - Aesthetic - Expensive
Nano-
canine palatal surfaces - Repairable - Tooth preparation may be
Ceramic required
Ceramic – - Mandibular incisor & canines - Durability - More appointments
Lithium - Maxillary incisor and - Aesthetic - Expensive
Disilicate canine palatal surfaces - Repairable - Tooth preparation required
- Mandibular incisor & canines - Durability - More appointments
- Maxillary incisor and - Expensive
canine palatal surfaces - Tooth preparation required
Ceramic –
- Unaesthetic without layering
Zirconia - Difficult to adjust and polish
- Bond strength
- Unrepairable

8
 6. Restoring the dentition

The restorative treatment options available to restore the worn dentition:

1) Adhesive techniques:

Currently adhesive dentistry shows a considerable progress allowing advanced restoration techniques.
Thus, many treatment options were proposed such as: direct/ indirect composite resin restorations, cast
adhesive alloy (metal palatal veneers and onlays, and bonded ceramic restorations). 1

Adhesive restorations are minimally invasive, there is no need for tooth preparation to guarantee the
retention and the mechanical resistance will be offered using reliable materials where the resistance is
increased by bonding.1

2) Conventional fixed prosthesis:

It would still be the treatment of choice for rehabilitating extremely worn teeth. However, such treatment
is complex and is still considered to be invasive, require removal of sound dental hard tissue.1

Indeed, splinting to compensate short primary poorly retentive abutments is contra-indicated. Full
coverage crown usually requires provisional restorations that should be seated for enough time to refine
and validate functionality of the occlusal design.1

Besides, conventional full coverage crowns may lead to the loss of tooth vitality where pulpal exposure is
more likely to happen with teeth affected by wear process. Thus, adhesive additive approach might be
primarily considered, when attempting to actively manage TW.1

The restorative treatment procedures available to restore the worn dentition:

1) Direct composite resin – Free hand technique:

This technique enables to conduct a purely additive treatment without affecting the sound hard tooth
tissue. A highly skilled practitioner, being aware of the biomechanics principles, the concept of functional
occlusion and esthetics, is more likely to conduct a treatment as such.1

The resin is applied in bulk over the tooth surfaces. In a single visit, this technique is cost-effective.1

It may be reliable in case of small number of worn dentition. However, when full arch rehabilitation is
needed, the procedure is time consuming and totally depends on the operator’s skills.1

It could be expected that direct composite restorations would show high failure rates when used to
rehabilitate bruxing patients, but the good clinical behavior found in some studies, supports the
indication of this material to restore severely worn teeth even in these high risk patients. 6

2) Hemi direct composite resin using a polyvinylsiloxane matrix guide:

This technique involves the use of duplicated waxed casts modified according to the desirable esthetic /
function outcome. The matrix performed is used for direct composite layering.1

9
This technique is criticized for involving major voids which end up to the need for copious adjustments.
Hence, transparent silicones were suggested. They ensure the application of adequate quantities of
material. Nevertheless, these silicones lack rigidity which may compromise their positioning and
manipulation.1

3) Hemi direct composite resin using thermoplastic vacuum formed matrix guide:

The last described technique is using a customized vacuum formed matrix guide where a duplicate stone
cast of the diagnosis waxed model is used to perform a translucent matrix of one mm thick, from a rigid
material for accurate seating.1

Relief holes to avoid air incrimination can be pierced. It is also recommended to place wedges to avoid
bonding of resin material to interproximal surfaces.1

Worn teeth must be conditioned and then resin is applied into the matrix precisely positioned and
photopolymerized through the matrix.1

Some authors suggested the use of preheated injected resin. Despite the satisfying esthetic result it
offers; this technique has numerous drawbacks ranging from poorly fitting matrices to overfilling ones
which might culminate in gross excess along with air entrapment and potential post-operative sensitivity.1

4) Indirect composite resin:

They are currently based on mechanically resistant hybrid resin when compared to micro fitted resins.
They show an improvement of provisional surfaces wear while offering a better control of occlusal
contour and vertical dimension, especially in the case of multiple restorations. In fact, dry heating
treatment permits to eliminate internal porosities and evade oxygen incorporated in the resin which
jeopardize polymerization. Also, it gives specific hardness and abrasion resistance to resin. Nevertheless,
the indirect resin composite technique has numerous drawbacks. In fact, it requires at least two
appointments. The hard tissue undercuts must be priorly removed, restorations might be bulky and
inadequate wear resistance for posterior use may occur. Furthermore, the material used –resin
composite- may have inferior marginal fit when compared to metal and ceramic. Add to that, the resin
bonded luting agent may be exposed to wear and leakage.1

5) Conventional fixed restorations:

Conventional crown restorations, being an invasive procedure, require adequate interocclusal space
which is usually lost as a result of compensatory eruption of opposing teeth during the process of tooth
wear. Conventional restorative techniques to overcome the reduced crown height and lack of
interocclusal space are: 4
• Opposing tooth reduction.
• Elective endodontic treatment and post retention.
• Occlusal adjustment (retruded arc of mandibular closure).
• Periodontal surgical crown lengthening.
• Localized orthodontic tooth movement (conventional fixed appliance or ‘Dahl’ appliance).
• Overall increase in occlusal vertical dimension.

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 6) Removable onlay/overlay prosthesis:

It is recommended to construct a provisional acrylic resin removable prosthesis so that the shape,
position, occlusal relationship of the prosthetic teeth and soft tissues as well as the patient’s tolerance of
a removable prosthesis can be assessed.4

The available space determines whether or not an anterior labial flange can be used or alternatively
gingival fitting and/or butt-fitting tooth facings. The space demands are usually greatest in the anterior
region both in the vertical and labiolingual dimensions.4

7) Minimal preparation adhesive restorations:

~ Cervical tooth wear:

Depending on the type of the lesion, different materials can be used see Tale 2.
Table 2 Adhesive materials available for restoring cervical tooth wear 4
Lesions with margins that are still confined to Microfine or polishable densified composite resin,
enamel in conjunction with acid-etched enamel

Lesions that usually involve root cementum Form of dentin bonding agent in combination with
and dentin along with enamel a composite resin or a self-adhesive composite
resin formulation
OR
Glass ionomer cement

Higher aesthetic demand Polishable composite resin combined with some

form of adhesive bonding agent

Lesions are not visually prominent and involve Glass ionomer cement
more of the root surface, partly below the
gingival margin

Deeper cervical lesions Glass ionomer cement and polishable composite

resin

~ Anterior tooth wear:

Palatal tooth wear: To manage this form of tooth wear resin-bonded palatal metal alloy veneers can be
considered. The incisal and palatal peripheral enamel margins are smoothened and laboratory fabrication
of the metal alloy veneers is either done directly on a refractory working cast or by a wax/resin ‘lift-off’
technique.4

Incisal/palatal tooth wear: The incisal portion of the tooth can be built with direct acid-etch retained
composite resin and then a resin-bonded metal alloy palatal veneer can be constructed to cover both the
palatal tooth tissue and composite resin by which the appearance of lost incisal and labial tooth tissue can
be improved.4

11
The incisal and palatal tooth surfaces can be restored conservatively with direct acid-etch retained
composite resin at an increase in occlusal vertical dimension to accommodate the thickness of the
restorative material.4

Diagnostic wax-up is done on stone casts of planned restorations. Then rubber dam isolation of teeth is
done prior to adhesive restorations. Silicone putty index and interproximal tape are used to aid
restoration.4

A number of clinicians use modified porcelain laminate veneer restorations for the incisal and palatal
worn tissue.4

Indirect densified composite resins are the alternatives to using direct composite resins, with the
potential advantages of improved physical properties and better control regarding occlusal and
interproximal contouring.4

Labial/incisal/palatal tooth wear: All tooth surfaces can be restored with direct composite resin at an
increased occlusal vertical dimension in an attempt to initially recreate lost interocclusal space. After that
a decision can be taken either to continue with ongoing maintenance of the composite resin restorations
or alternatively to consider proceeding to conventional crowns conforming to the newly established
occlusion.4

In some cases with minimal tooth structure, localized crown lengthening surgery can be advantageous
which will help to capture all remaining tooth enamel. If for any reason surgical crown lengthening is not
available, then indirect splinted composite resin restorations can be considered to aid retention and
durability.4

~ Posterior and generalized tooth wear:

Resin-bonded heat-treated gold alloy restoration can be used in cases where aesthetics is not
paramount.4

If aesthetics is a primary concern then a resin-bonded ceramic or indirect composite resin onlay can be
considered.4

In situations where retention and resistance form for conventional crowns are particularly compromised
these techniques are helpful.4

In cases of generalized tooth wear, where a full mouth reconstruction of the dentition is indicated, the
use of adhesive onlay restorations in the posterior quadrants can be considered in certain circumstances.
If space is at a premium, the selection of a gold alloy instead of porcelain will be advantageous. In some
cases a full mouth reconstruction of the worn dentition using resin-bonded ceramic or indirect composite
resin restorations is possible.4

12
Discussion
Azouzi et al.1 proved that despite the recommendations outlined for managing tooth wear, a lack of
evidence is remaining.1 Also Hurst,3 Loomans et al.5 agree with Azouzi et al.1 in this point.

Azouzi et al.1 proved that a rigorous clinical examination as well as a well rationalized diagnosis are keys
to treatment success. Planification must be based on treatment goals, which are initiated by preventive
approaches and finalized by restorative treatment in cases of extensive tooth wear or esthetic demand.
Minimally invasive procedures are invading the field of restorative management essentially based on the
performance of adhesive agents. However, ultimate need for full coverage crowns is still imposed in
specific situations of generalized severe tooth wear.1

Patel.9 proved that the management of the worn dentition requires detailed treatment planning and
functional design of planned restorations within the anterior aesthetic zone. This is mandatory for their
appropriate management and treatment execution. The outcome of a predictable aesthetic and
functional result can only be preceded by detailed planning using diagnostic adjunctive instruments such
as facebows and articulators in the first instance. The clinical techniques described differ in their
approach of principally treating the same disease. A number of patient and tooth-related factors should
be carefully considered before any definitive decisions are made as to the technique employed by which
the worn teeth are restored. With the advent of modern materials and adhesive techniques, indirect
restorations may also be employed as the preferred treatment where the worn teeth are extensively
damaged and the restorative correction is extensive. Appropriate tailored monitoring and maintenance
regimes for each patient must be prescribed post-operatively so that long-term maintenance and care is
carried out to decrease the likelihood of restoration failure.9

Loomans et al.5 suggested the following guidelines for the treatment of patients with severe tooth wear
to help practitioners best manage severe tooth wear:

 Priority should be given to the diagnosis of the etiology of the wear and instigating appropriate
preventive measures.
 Patients with moderate or severe tooth wear but without (functional or esthetical) complaints should
be advised to monitor the situation first to determine whether the tooth wear is progressive or not.
 Restorative treatment should be as conservative as possible, employing minimally invasive treatment
strategies according to a dynamic restorative treatment concept.
 Direct and indirect minimally invasive techniques can be employed using adhesive materials.
Traditional, invasive restorations remain an option in selected cases and under certain circumstances.
 Explanation of the possible treatment options and expected complications should be included in the
informed consent.

Milosevic. (2016).7 completed a large study on survival of composite restorations in tooth wear with good
results. Overall, worn teeth are relatively easy to restore with composite. The material has excellent
aesthetics, does not require expert skill, is repairable and above all does not demand high maintenance
on the part of the patient. Patients should be warned that composite will stain from cigarette smoke and
dietary foodstuffs such as tea, coffee, red wine and turmeric in curry. Stains can be removed by
appropriate polishing. Composite is an additive restorative approach, conserving and protecting the
remaining tooth structure, while also preventing wear of the opposing teeth. 7 Also, the same auther in
another study Milosevic. (2018).8 proved that direct composite restoration of the worn dentition has
many advantages over a conventional, older approach using indirect PFM or all ceramic crowns and for

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localised anterior wear palatal gold or palatal ceramic with or without orthodontics. An additive approach
conserves remaining tooth which often is unable to provide adequate retention and resistance form for
conventional crowns. Dentists need to know which composites to use and how best to optimise survival
and performance in a challenging oral environment with persistent attrition, erosion and abrasion. Direct
composite restoration will meet patients’ expectations for improved appearance of a disordered, worn
dentition and precisely because it is not complex and is relatively low maintenance it will be more
acceptable and successful than traditional methods of restoration. 8

Edelhoff et al.2 proved that the occlusal onlays made of high strength glass-ceramics represent an
interesting contemporary form of restoration for reconstructing the occlusion in patients with
pronounced deficiencies of the dental hard tissue. Combined with a supragingival preparation margin,
these onlays offer numerous advantages: 2

Reduced loss of dental hard tissue

Increased availability of enamel

Unobstructed view of the site during preparation

Simpler conventional and digital impressions

Less or no traumatic interference with the marginal gingiva

Well-controlled adhesive cementation.
A prerequisite for success, however, is meticulous adherence to the procedure described. 2

Mesko et al.6 proved that there is no strong evidence supporting a specific material and technique to
restore teeth with severe tooth wear. Although resin composite appears to be a feasible option to restore
teeth with severe wear, clinical studies are necessary to produce more definitive conclusions. 6

Conclusion
The patient must be informed and educated as to primary disease control and placed on a stabilisation
and maintenance regime tailored to their specific treatment needs,9 Careful comprehensive treatment
plan is required for each individual case.1

Clearly, identifying aetiological factors associated with wear in individual patients is the first step in
management, followed by lifestyle change on the part of the patient and monitoring by the dentist. Most
patients do not complain of pain or functional problems as the main driver for treatment is a desire for
aesthetic improvement.7

Prevention of further tooth wear should form the basis of care but in severe cases interventive restorative
treatment may be necessary in order to protect vulnerable tooth surfaces and re-establish satisfactory
appearance and function. Indications for interventive restorative treatment are: unacceptable
appearance of the teeth, loss of normal function and progressive tooth wear resulting in pulp necrosis
and/or difficulty in teeth restoration.4

Restoration of severe tooth wear should ideally be delayed as long as possible,1 the conservative
minimally invasive restoration, should first be considered.1

The restorative treatment options possible with today’s materials and techniques include: conventional
fixed restorations, removable onlay/overlay prostheses and minimal preparation adhesive restoration.4

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References:

1. Azouzi, I., Kalghoum, I., Hadyaoui, D., Harzallah, B., & Cherif, M. (2018). Principles and guidelines
for managing tooth wear: a Review. Internal Medicine and Care. 2(1), 1-9.

2. Edelhoff, D., & Ahlers, M., O. (2018). Occlusal onlays as a modern treatment concept for the
reconstruction of severely worn occlusal surfaces. Quintessence international (Berlin, Germany :
1985). 49(7), 521-533.

3. Hurst, D. (2011). What is the best way to restore the worn dentition?. Evidence-based dentistry,
12(2), 55–56.

4. King, P. (2017). Restoration of the worn dentition. Clinical Dentistry Reviewed. 1(1), 4.

5. Loomans, B., Opdam, N., Attin, T., Bartlett, D., Edelhoff, D., Frankenberger, R., Benic, G.,
Ramseyer, S., Wetselaar, P., Sterenborg, B., Hickel, R., Pallesen, U., Mehta, S., Banerji, S., Lussi, A.,
Wilson, N. (2017). Severe Tooth Wear: European Consensus Statement on Management
Guidelines. The journal of adhesive dentistry. 19(2), 111-119.

6. Mesko, M., Sarkis-Onofre, R., Cenci, M., Opdam, N., Pereira-Cenci, T., & Loomans, B. (2016).
Rehabilitation of severely worn teeth: A systematic review. Journal of Dentistry. 48, 9-15.

7. Milosevic, A. (2016). Direct Placement Composite: the Treatment Modality of Choice to Restore
the Worn or Eroded Dentition in Primary Dental Care. Primary Dental Journal. 5(3), 25-29.

8. Milosevic, A. (2018). Clinical guidance and an evidence-based approach for restoration of worn
dentition by direct composite resin. British Dental Journal. 244(5), 301-310.

9. Patel, M. (2016). Treating Tooth Surface Loss: Adhesive Restoration of the Worn Anterior
Dentition. Primary dental journal. 5(3), 43-57.

10. Wetselaar, P., & Lobbezoo, F. (2016). The Tooth Wear Evaluation System: a modular clinical
guideline for the diagnosis and management planning of worn dentitions. Journal of Oral
Rehabilitation, 43(1), 69– 80.

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