JCDA • www.cda-adc.ca/jcda • May 2006, Vol. 72, No. 4 • 301

Clinical S H O W C A S E

The treatment of tooth wear caused byerosion, abrasion and attrition iscomplex and demanding in terms of

both the dentist’s time and cost to thepatient. The main complication is that teethwith severe wear have short clinical crownheight, which makes conventional treatmentextremely challenging. In general practice,using restorations to increase the verticaldimension of worn teeth is both reliable andpredictable.1 Considerable research andclinical evidence exist to support the use ofcomposites to restore worn anterior teeth.2–4

After stable occlusion has been achieved, thecomposite can be maintained by polishingand repairing, or it can be replaced withcrowns.

This article illustrates the steps inrestoring worn dentition.

Wear on Palatal Surface of UpperIncisors

In this series of 3 clinical cases, thewear was limited to the palatal (lingual)surfaces of the upper incisors and thecomposites were used for the definitiverestorations.

In the first case, the cause of toothwear was a combination of erosion andattrition (Figs. 1a and 1b). This typicalappearance was caused by the patientholding acidic drinks in the palatal vault.The exposed dentin was not sensitive.Composite restorations were placed onthe palatal surfaces to replace the worn

Using Composites to Restore Worn Teeth David Bartlett, BDS, MRD, PhD, FDSRCS (Rest Dent), FDS RCS (Ed)

Figure 1a: Worn anterior teeth havetranslucent incisal edges.

Figure 1b: Tooth wear was caused by a combination of erosion and attrition. Cariouslesions are also apparent; they were treatedconventionally.

Figure 1c: Composites were placed on thepalatal surfaces to replace the worn toothtissue.

Figure 1d: The composites haverestored the appearance of the anteriorteeth.

This month’s “ClinicalShowcase” article waswritten by Dr. David

Bartlett, a speaker at the2006 FDI Congress.Dr. Bartlett will be

participating in a symposium on tooth

wear and abrasion sponsored by

GlaxoSmithKline onSeptember 24. His session

is titled “The role oferosion in toothwear:

etiology, prevention and management.”

tooth tissue (Fig. 1c).This increased the verticaldimension and sepa-rated the posterior teeth.Reversal of alveolarcompensation resultedin overeruption of theposterior segment andsome intrusion of theanterior teeth. About 3months later, however,the occlusion had stabi-lized, and the inter-cuspal position on theanterior teeth had

returned to normal (Fig. 1d).In a second patient, severe wear of the

upper anterior teeth (Fig. 2a) was related toregurgitation of gastric contents into themouth secondary to gastroesophageal refluxdisease. In patients with this condition, thegastric juices (which have a pH of about 1)may cause severe erosive wear of the palatalsurfaces of the upper anterior teeth.Microhybrid composites were added to thebuccal and palatal surfaces of these teeth toincrease the vertical dimension (Figs. 2b and2c). The carious upper bicuspid was extractedat a later time and replaced with an implant.Because the erosion was localized to the palatalsurfaces of the upper anterior teeth, there was no need to restore the occlusal surfaces ofthe posterior teeth. The initial increase inocclusal vertical dimension led to separation ofthe posterior teeth; as in the previous case,alveolar compensation was reversed, and theocclusion stabilized. Normally, reversal of alve-olar compensation occurs over 3 or 4 months,more quickly in younger people.

As seen in the third case, compositerestorations placed on the upper anterior seg-ment can be maintained by polishing andrepairing as required (Fig. 3) and may last formany years.

Generalized WearSometimes, the dentition exhibits more

generalized wear (Fig. 4a). In the case illus-trated here, the wear was classified as regurgi-tation erosion caused by gastroesophagealreflux.5 Regurgitation of the gastric contentshad resulted in erosion of both enamel anddentin on the palatal surfaces of the upperteeth6 (Fig. 4b); the wear on the lower arch wasless severe (Fig. 4c). The significant loss oftooth structure meant that, without electiveendodontics, there would be insufficient sup-port for conventional crowns. However, thedentist determined that an increase in verticaldimension would produce sufficient interoc-clusal space for restorations without furtherneed for occlusal reduction; as such, this pro-cedure would conserve tooth tissue.

Since the tooth wear was generalized,restorations were needed on both the anteriorand the posterior teeth. The increase in verticaldimension was planned using a diagnosticwax-up mounted on a semiadjustable articu-lator (Fig. 4d). There was enough height of thepalatal tooth tissue that crown lengthening wasnot required. The planned shape of the ante-rior teeth (on the basis of esthetic considera-tions) determined the increase in height of theposterior teeth. Patients with tooth wear typi-cally adapt to the change in tooth shape overtime, so increases in vertical dimension duringrestoration pose a further adaptive challenge.In this case, as in the others presented here, it

302 JCDA • www.cda-adc.ca/jcda • May 2006, Vol. 72, No. 4 •

–––– Clinical Showcase –––––––– Clinical Showcase –––––––– Clinical Showcase –––––––– Clinical Showcase –––––––– Clinical Showcase –––––––– Clinical Showcase –––––––– Clinical Showcase –––––––– Clinical Showcase –––––––– Clinical Showcase ––––

Figure 2c: Palatal view shows micro-hybrid composites bonded directlyonto the eroded anterior teeth.

Figure 3: Composites on the upper anteriorsegment, shown 5 years after initial place-ment, have been maintained by polishing andrepair.

Figure 2b: Microhybrid composites havebeen added to the buccal and palatal sur-faces of the upper anterior teeth to increasethe vertical dimension.

Figure 2a: Severe wear of the upper anteriorteeth was caused by regurgitation of gastriccontents into the mouth secondary to gastroesophageal reflux.

–––– Clinical Showcase –––––––– Clinical Showcase ––––

JCDA • www.cda-adc.ca/jcda • May 2006, Vol. 72, No. 4 • 303

–––– Clinical Showcase –––––––– Clinical Showcase –––––––– Clinical Showcase –––––––– Clinical Showcase –––––––– Clinical Showcase –––––––– Clinical Showcase –––––––– Clinical Showcase –––––––– Clinical Showcase –––––––– Clinical Showcase –––––––– Clinical Showcase ––––

Figure 4a: Preoperative appearance ofanterior teeth with generalized wear.There is some loss of the incisal edgeof the upper anterior teeth.

Figure 4b: Significant erosion of the palatal(lingual) surfaces, caused by regurgitation ofgastric contents, is evident. The shape and pat-tern of this wear is typical of dental erosion.

Figure 4c: The wear on the lower arch is notas severe as that on the upper arch.

Figure 4e: Composites are placed on theanterior and posterior maxillary teeth. Thecontacts on the teeth are adjusted to ensureeven contact in the new intercuspal position.

Figure 4f: Clinical photograph taken 3 yearslater shows several fractures. It was decidedto convert the restorations to metal ceramiccrowns.

Figure 4d: The increase in verticaldimension is planned with a diagnosticwax-up mounted on a semiadjustablearticulator. The shape of the anteriorteeth (which will determine the increasein height on the posterior teeth) wasplanned at the same time.

Figure 4h: Clinical photograph taken 4 yearsafter the patient’s initial presentation withtooth wear.

Figure 4i: Final result of restoration of theupper arch.

Figure 4g: The anterior teeth werecrowned first, to establish anterior guid-ance; the posterior teeth were prepareda few weeks later.

was anticipated that the planned increase invertical dimension would be well tolerated bythe patient. There are no reports of loss oftooth vitality or mandibular dysfunction as aresult of increase in vertical dimension.

Composite restorations were placed on theanterior and posterior maxillary teeth (Fig. 4e)to establish the vertical dimension and reshape

the worn teeth. The increase in tooth heightincreased the occlusal vertical dimension. Theocclusion was adjusted until the posterior con-tacts in the new intercuspal position were even.Adjustments were made to the composites atchairside. If such restorations prove durable,they can be considered long-term restorations,as described above.

destructive procedure); furthermore, the basicsof the occlusion will be established by the time adecision is made to convert from composites tocrowns. C

References1. Gough MB, Setchell D. A retrospective study of 50 treatmentsusing an appliance to produce localised occlusal space by rela-tive axial tooth movement. Br Dent J 1999; 187(3):134–9.

2. Redman CD, Hemmings KW, Good JA. The survival and clinical performance of resin-based composite restorations usedto treat localised anterior tooth wear. Br Dent J 2003;194(10):566–72.

3. Hemmings KW, Darbar UR, Vaughan S. Tooth wear treatedwith direct composite restorations at an increased verticaldimension: results at 30 months. J Prosthet Dent 2000;83(3):287–93.

4. Gow AM, Hemmings KW. The treatment of localised anteriortooth wear with indirect Artglass restorations at an increasedocclusal vertical dimension. Results after two years. Eur J Prosthodont Restor Dent 2002; 10(3):101–5.

5. Bartlett DW, Evans DF, Anggiansah A, Smith BG. A study of the association between gastro-oesophageal reflux andpalatal dental erosion. Br Dent J 1996; 181(4):125–31.

6. Bartlett DW. The role of erosion in tooth wear: aetiology, prevention and management. Int Dent J 2005; 55(4 Suppl 1):277–84.

304 JCDA • www.cda-adc.ca/jcda • May 2006, Vol. 72, No. 4 •

In this patient, the composite restorationsremained functional for about 3 years. Oncethey started to deteriorate (Fig. 4f), the teethwere prepared for conventional restorations(Figs. 4g to 4i) according to the occlusal schemedefined by the composites.

ConclusionsThese cases show that composite restorations

can be used to restore worn dentition. In somecases, such as the first 3 cases illustrated here, thecomposites produce the definitive restoration andcan be polished and repaired over a period ofmany years. However, if the composites fracture,the teeth can be restored with conventional metalceramic crowns. The advantages of compositerestorations are conservation of tooth tissue anddelay in the placement of crowns (which is a

–––– Clinical Showcase –––––––– Clinical Showcase ––––

Dr. David Bartlett is a reader and head ofspecialist training in prosthodontics at King’s College London Dental Institute,London, United Kingdom. Email: david.bartlett@kcl.ac.uk.

THE AUTHOR

The following tips are offered to assist inthe restoration of worn or eroded teeth.

1. Use the dentin bonding agent care-fully. Always follow the manufacturer’sguidelines to maximize bond strength.Because tooth wear exposes signifi-cant amounts of dentin, the bond tothis tissue is an important aspect ofthe restoration procedure.

2. Increase the occlusal vertical dimen-sion by the amount of tooth lost. Usediagnostic wax-ups to determinetooth shape and then increase theamount of tooth tissue accordingly.

3. Before starting the treatment, warnthe patient that his or her “bite” willchange. This is particularly importantwhen restoring anterior teeth withlocalized wear or erosion.

4. When adjusting the occlusion, ensurethat there is even occlusal contact onthe new restorations. The anteriorguidance will be shared by more thanone tooth.

5. If the teeth are worn to below 50% oforiginal tooth height, consider crownsrather than composites.

Practice Tips