Tooth Wear Guidelines for the BSRD

 Part 1: Aetiology, Diagnosis and Prevention (June Dental Update)

 Part 2: Fixed Management of Wear (July/August Dental Update)

 Part 3: Removeable Management of (September Dental Update) RestorativeDentistry

NEW

Moisture levels vary. Our bond won’t.

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Variations in moisture level can be di ffi cult to detect, especially in the depths of a class II proximal box. Thanks to the new, patented Active-Guard™ Technology, Prime&Bond active adhesive provides reliable performance on over-wet and over-dried , taking out some of the guess work and resulting in virtually no post-operative sensitivity*.

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2 DentalUpdate July/August 2018

Prime&Bond active Ad-A4_NEW Class II.indd 1 12.10.16 10:25 RestorativeDentistry

Ken Hemmings

Angharad Truman, Sachin Shah and Ravi Chauhan

NEW Tooth Wear Guidelines for the BSRD Part 1: Aetiology, Diagnosis Moisture levels vary. and Prevention Our bond won’t. Dent Update 2018; 45: 3–10

Tooth wear (TW) is a common condition selected literature review covers three loss (TSL), can be described simply as ‘the affecting patients who often require advice sections: pathological non-carious loss of tooth and treatment from dentists. Physiological 1. Aetiology, diagnosis and prevention of tissue’.1 TW is normal and accepted by most tooth wear; The distinction between 2. Fixed management of tooth wear; patients. Pathological TW, by virtue of pathological and physiological TW can 3. Removable management of tooth wear. symptoms or rapid wear, will prompt the be difficult to determine. Wearing of the Each section is concluded with need for dental care. It can range from teeth is a normal physiological process. The a summary of key points which can act mild sensitivity from an to estimated normal vertical loss of enamel as a quick reference checklist for the busy gross destruction of the dentition. Similarly, from physiological wear is thought to be practitioner. It is hoped that effective 2 treatment can range from simple operative approximately 20−38 μm per annum. It is treatment or advice given at the right important to remember that just because a care to full mouth reconstruction with time can reduce the amount of long-term tooth has some element of wear this does crowns or complex dentures. Too little or maintenance care required in the future. not always necessitate treatment. Tooth too much treatment can lead to However, it is acknowledged that some wear may be regarded as pathological if the and patient complaints. severe bruxist patients will always require rate of wear is greater than that expected These guidelines are designed Prime&Bond active™ regular repairs or replacement restorations. for the patient’s age, the patient has to help dentists manage tooth wear. A Guidelines become out of date Universal Adhesive concerns over the wear or the prognosis of immediately they are published. The society the tooth is compromised due to the wear. Data on fi le will review and update these guidelines on Ken Hemmings, BDS, MSc, DRD RCS, MRD Tooth wear is often multifactorial Variations in moisture level can be di ffi cult to detect, especially in the depths of a class II proximal box. a 3-yearly basis. The work that the authors RCS, FDS RCS, ILTM, FHEA, Consultant in in nature and can be difficult to distinguish Thanks to the new, patented Active-Guard™ Technology, Prime&Bond active adhesive provides reliable have put in to draft these guidelines is between, but it is often subdivided into: Restorative Dentistry, Eastman Dental Hospital gratefully received. The British Society of performance on over-wet and over-dried dentin, taking out some of the guess work and resulting in and Institute, UCLH Trust and private practice,  ; Restorative Dentistry (BSRD) Council and virtually no post-operative sensitivity*. Angharad Truman, BDS(Hons), MFDS RCPSG,  Erosion; members of the society are also thanked for PGCME, FHEA, Specialty Registrar in Restorative  Abrasion; and their comments in improving the document. For more information visit www.dentsplysirona.com/pbactiveuk Dentistry, Bristol Dental Hospital, Sachin Shah,  (abfraction is often

©2016 Dentsply Sirona. All rights reserved. * Effective treatment does exist and it is most BDS, MFDS RCS, MClin Dent(Pros), MRD RCS, described but, as yet, is not universally gratifying to make a dramatic difference to Specialist Prosthodontist in private practice/ accepted as a true form of tooth wear). patients with tooth wear when guidance is Clinical Teaching Fellow, Eastman Dental provided. Hospital and Institute, 256 Gray’s Inn Road, Attrition London, WC1X 8LD and Ravi Chauhan, MDDr, ‘The loss of tooth substance or MSc, MJDF RCS(Eng), MFDS RCS(Edin), Specialty Definition a restoration as a result of mastication or Registrar in Restorative Dentistry, King's College Tooth wear, or as it is also often contact between occluding surfaces of Dental Hospital, London, UK. referred to as non-carious tooth surface approximal surfaces’.1 July/August 2018 DentalUpdate 3

Prime&Bond active Ad-A4_NEW Class II.indd 1 12.10.16 10:25 RestorativeDentistry

Erosion 15%. Severe wear (exposing secondary to be the predominant pathological ‘The loss of tooth tissue by dentine) remained at 2%.9 cause of tooth wear in 11% of cases and chemical processes not involving bacterial Tooth wear in adults is a common reckoned that it accounted for two-thirds 3 action’. clinical finding, with an increase in of the combined aetiology of TW. It is prevalence with increased age. A systematic important to acknowledge that a level of Abrasion review showed 3% of 20-year-olds and TW is normal, physiologically increasing ‘The physical wear caused by 17% of 70-year-olds exhibited severe tooth with age, but may become pathologically materials other than tooth contact’.4 wear.10 Furthermore, it has been suggested secondary to a parafunctional habit.14 that males tend to experience greater TW The diagnosis of parafunctional activity Abfraction than females, possibly due to increased is difficult and patients themselves are ‘Tooth wear located in the cervical tooth retention and greater occlusal forces often not aware of the condition. In fact, it 11 area caused by flexural forces during in males. has been suggested that only half of the function and parafunction’.5 It is worth noting that prevalence population of bruxists are aware of the studies are somewhat lacking for adults and condition.15,16 Owing to this, the reported stricter guidelines are required for quality prevalence of varies between 5% Prevalence 10 control. This may be attributed to the and 96%.3 Two popular theories have been difficulties in recruiting participants and proposed, but not confirmed, as the cause maintaining them, the varied study designs Prevalence in children and adolescents of bruxism, including parafunctional activity and terminology making comparisons 17 Epidemiological research across as a manifestation of stress and as a result difficult. Europe has shown an increasing prevalence of premature contacts on mandibular 18 in tooth wear in children over the last ten movement. years. An increased level of TW is found Aetiology At present, there is little evidence to be associated with increasing age, Clinical presentation and to support the theory that a reduced especially in the deciduous dentition.6 Tooth aetiology is usually subdivided into the number of occluding teeth leads to wear was reported to be between 0% and previously mentioned terms of attrition, increased tooth wear. Studies have reported 80% for children under seven years of age. erosion, abrasion and abfraction. Diagnosis no significant correlation between the This significant relationship of level of TW is often based on the clinical findings, loss of posterior teeth and anterior TW, 19,20 to increase in age found in the deciduous which may suggest one causative factor. including the shortened dental arch. It is dentition did not appear to correspond to However, it is well known that the cause of suggested that the proprioceptive feedback the permanent dentition.6 tooth wear is multifactorial, making clinical mechanism and mutually protected 19,21 In the UK, the Child Dental Health diagnosis difficult. Thus it is suggested that contribute to this finding. Survey has been undertaken decennially these single terms, which can be useful since 1973. The most recent survey, in 2013, when considering and describing the Erosion showed an increased incidence of tooth aetiology, may only describe the outcome It has been well documented wear. In children aged five, 33% had some of a number of underlying events rather that demineralization of dental hard tissue evidence of TW on the buccal surfaces, than the cause or process involved in the leading to dental erosion occurs following with 4% involving the dentine or and wear. the drop in pH of the oral cavity below 57% on the lingual, with 16% involving It is important to acknowledge, critical pH, ie 5−5.5.22 Smith and Knight13 7 the dentine or pulp. In the permanent even if one single contributing factor found an erosive aetiology as part of the dentition, 31% of 15-year-olds showed signs appears to be involved, that other cause in almost 89% of patients referred for of TW on the occlusal surfaces of the first damaging factors may be present. Failure to severe wear. Erosion is often subcategorized permanent molars and 44% on the palatal acknowledge this may lead to insufficient into ‘extrinsic’ or ‘intrinsic’, depending on the 8 surfaces of the maxillary incisors. advice, failure of treatment and progression nature of the acidic causative agent.23 of the condition. A thorough patient history A wide range of diseases and is essential to help aid understanding of the Prevalence in adults syndromes are associated with erosion: causative factors. In the UK, NHS Information  Various medications, such as the frequent Occasionally, patients may have Centre commission surveys are undertaken use of asthma inhalers containing steroid inherited dental conditions that may decennially to assess the dental health or effervescent medication, which have a increase the severity of tooth wear, such status of adults to capture trends over time. pH value ranging from 4.3 (Bricanyl, powder as dentinogenesis imperfecta and dentine The most recent survey, in 2009, showed an form) to 9.3 (Ventolin, aerosol form);24 dysplasia, to name but two. It is important increased incident of tooth wear from 66%  Reduced quantity and quality of saliva to inform these patients of their increased to 76% since the 1998 survey. Tooth wear (including drug-induced, salivary gland risk of wear.12 into dentine was found to be higher than agenesis, Sjögren’s syndrome); and previously, at 77% in the anterior teeth.  Reduced motor function (including Moderate TW (extensive into dentine) also Attrition cerebral palsy), affecting the clearing of showed an increase from 11% in 1998 to Smith and Knight13 found attrition acidic food and drink from the teeth, may 4 DentalUpdate July/August 2018 RestorativeDentistry

enhance intrinsic and extrinsic factors chlorinated swimming pool water.35 Due anorexia nervosa. The most common sign leading to erosion.25 to this, improvements in health and safety of this condition is perimolysis , It has been noted that, for have been developed, such as wearing which are erosive lesions on the palatal children of all socio-economic backgrounds, protective airways masks, to reduce the surfaces of maxillary incisors.40 The effects tooth wear is most common on the effects of environmental erosion from the of such disorders leading to self-induced palatal surfaces of the maxillary incisors. work place.36 in the development of dental Furthermore, cross-sectional studies Chronic alcoholism is a source of erosion are well documented.41,42 The report a high prevalence of erosion, 53%26 both extrinsic and intrinsic dental erosion, incidence of bulimia has rapidly increased, and 77%27 in adolescents and adults, Extrinsically, the alcohol consumed has with 14 per 100,000 affected and respectively, in the UK. The prevalence of an acidic component, resulting in erosion approximately 7 per 100,000 individuals dental erosion in children and adolescents alongside the effects of regurgitation, in the population now thought to be is believed to be due to the increased vomiting and gastritis.4 affected by anorexia. This increase may be susceptibility of demineralization of the due to increased exposure to the media newly formed dentition, the time taken portraying the ‘ideal’ body shape and Intrinsic erosion for maturation and the reduced salivary size.43,44 It is worth noting that the male Intrinsic erosion results from the buffering capacity at night. to female ratio is approximately 1:10. gastric content entering the oral cavity.25 However, males are less likely to seek This can be from a variety of voluntary or medical attention so may be at equal risk Extrinsic erosion involuntary habits and diseases. Vomiting of eating disorders.45 Extrinsic sources of acid can be both voluntary and involuntary as Rumination predominately may include acidic food and drinks and a result of pregnancy, as a side-effect of affects patients with mental disabilities. medications, from the environment or some medications, through alcoholism, It involves GORD combined with industrial processes. Medications, such alimentary tract disorders, as well as voluntary or involuntary regurgitation of as Aspirin (a salicylic acid), iron tonics, psychosomatic conditions including eating swallowed food into the oral cavity, which chewable vitamin C and replacement disorders. is then re-chewed and re-swallowed. hydrochloric acid, may lead to erosive tooth Involuntary regurgitation of Unfortunately, this condition is poorly wear.3 gastric acids may be a result of gastro- understood and the prevalence of erosion Epidemiological studies have intestinal disturbances, such as during associated is not fully known.42 observed a correlation between acidic diets pregnancy, gastro-oesophageal reflux and the development of erosive TW.28,29 disease (GORD), vomiting, hiatus hernia or Acidic food and drink intake has increased rumination. Abrasion on a population level, furthermore, there Approximately half of patients The prevalence of abrasion has been an increase in population trends with localized anterior tooth wear report is reported in a range from 5%−85%, of leading a healthy lifestyle with increased having gastric reflux. GORD results in depending on the inclusion criteria.46 consumption of diet drinks and ‘juicing’, gastric content moving from the stomach Abrasion can often result from over leading to increased erosion. A strong link into the oesophagus due to a laxity in the enthusiastic toothbrushing with abrasive between the increased consumption of lower oesophageal sphincter.37 It is now , improper use of interdental carbonated drinks, citrus fruits, fruit juices, recognized as a more common condition cleaning aids, or patient habits such as herbal tea and erosion is well known.23,28,30 for children/adolescents than previously nail-biting, pen-chewing or having a Both carbonated and non-carbonated thought. Stomach acid has a pH of tongue piercing. It is also suggested that drinks exhibit a similar erosive potential.31,32 approximately 2, which is highly erosive to there is an occupational hazard associated The acids commonly found in these foods the dentition. The effect can be particularly with some jobs, such as dress-making, include phosphoric, citric and malic acid, damaging to the dentition, especially the glassblowers and musicians.14 Dental however, there are many other acids with palatal surfaces, when continual episodes treatment may cause attrition if improper erosive potential in food. It has been are involved.38 Silent reflux can occur materials are utilized, for example, accepted that titratable acidity, which is a whereby patients are unaware of having unpolished ceramic restorations against a measurement of the total acid content, is longstanding, asymptomatic GORD leading natural tooth.1 a more important indicator than actual pH to dental erosion. Referral to a general It has also been highlighted that value in determining erosive potential of medical practitioner to assess this may be the present day ‘healthy diets’ may be beverages.22 beneficial to the patient as repeated soft contributing to an increase in tooth wear,1 Exposure to acid in the work tissue harm can lead to strictures, ulceration especially if there is high erosive content place can lead to environmental erosion. of the oesophageal lining and, in some from ‘juicing’, alongside an increase in It has been reported in those working cases, malignant changes, in particular abrasive foods such as nuts and seeds. It in industries such as wine tasting33 and Barrett’s oesophagus.39 is important to take into consideration manufacturing battery acid.34 Leisure Voluntary regurgitation is dietary, social and demographic patterns activities, such as swimming, may also increasing due to increasing incidence associated with time to determine what be a causative agent due to low pH gas- of eating disorders, such as bulimia and is acceptable for physiological wear.47 This July/August 2018 DentalUpdate 5 RestorativeDentistry

makes the diagnosis between physiological and pathological a little more difficult to determine as it is ever changing.

Abfraction Abfraction has caused much debate as to whether it is an accepted form of tooth wear. Much research has developed from finite element studies with little clinical evidence.48,49,50 As TW is Figure 1. Tooth wear presenting as mainly Figure 2. Tooth wear mainly presenting as often multifactorial in nature, it is debated attrition. The lack of posterior support may have erosion from frequent vomiting in a patient with that abfraction is a manifestation of a contributed to this appearance. anorexia bulimia. Note how the has been combination of erosion, abrasion and spared from the erosive wear. attrition.46 Erosive processes may lead to subsurface mineral loss, which leads to a softening of the tooth surface. Abrasion and results in loss of the cusp tips or incisal attrition may lead to an acceleration of the edges which generally interdigitate with the tooth wear processes in the cervical region. occluding dentition.53 Initial presentation may involve localized occlusal cusp tips and Clinical presentation the palatal surfaces of the maxillary anterior Due to the multifactorial aetiology teeth showing loss of tooth structure. tooth wear can present in a variety of As the process progresses, dentine may clinical appearances, making a diagnosis become exposed, leading to flattening of may be difficult. Occasionally, one causative incisal edges and cusp tips. The matching Figure 3. Tooth wear mainly presenting as abrasion with the prominent teeth being affected factor may be dominant and indicative opposing surfaces wear at the same rate most. of the main cause, but often the clinical and so the teeth continue to interdigitate appearance is the result of cumulative (Figure 1). damage over a period of time. Tooth wear may present as localized or generalized Erosion observed on the buccal cervical surfaces of loss off tooth substance, depending on the Often, early erosive lesions are the maxillary teeth and the occlusal surfaces number of teeth affected. not noticed by the patient. The cause of the of the mandibular posterior dentition.13 Patients may be unaware of erosion can determine, to some extent, the It has been suggested that erosive and the presence of tooth wear, especially in clinical presentation as the location and abrasive TW can be differentiated, in the the early stages of the process. However, 5 severity may differ. If the erosive process is cervical region, as erosive wear tends to often patients present complaining of currently active, there is often no staining of create broader dished-out shallow lesions in reduced aesthetics. Occasionally, patients the teeth. If dentine is exposed and stained, complain of the appearance of reduced comparison to the sharply defined margins often the erosive element is no longer 55 lower facial height, however, due to alveolar associated with abrasion. occurring. In intrinsic erosion, TW tends compensation, this is not often a presenting In general, erosive lesions present feature. Dentists may note a reduced to present on the palatal surfaces of the clinically when in enamel only as rounded maxillary dentition. The lingual surfaces and interocclusal space for restorations. Enamel and smooth lesions with loss of surface may fracture and the teeth appear shorter.23 lower anterior teeth are often not affected contour. Once the enamel layer has been due to the protective nature of the tongue Loss or thinning of the enamel may lead lost, exposed dentine is more susceptible covering them from exposure to the acid to shine through or exposure of the to the acidic attack and the accumulation underlying dentine, changing the optical attack41 (Figure 2). of tooth wear factors, leading to a more properties and colour of the teeth.45 rapid loss of tooth substance. This can lead Patients may complain of symptoms to cupping or dished out lesions. Teeth Abrasion of dentine sensitivity and impaired may appear translucent, due to thinning of Clinical presentation is dependent function.51 Other reported symptoms of the enamel anteriorly, or darker due to the on the causative factor and will affect , oral ulceration exposed dentine. Anterior teeth may chip or the severity and distribution of the wear. and parotid gland enlargement may be fracture and restorations may stand proud Localized lesions may be the result of a provided.52 from the teeth. A chamfer margin of enamel habit such as pen-chewing, nail-biting, is often observed.54 pipe-smoking, or present as an occupational Attrition In extrinsic erosion, for example issue, such as builders holding screws Attrition, as previously defined, from dietary intake, tooth wear is often between their teeth. The tooth wear pattern 6 DentalUpdate July/August 2018 RestorativeDentistry

will fit the shape of the object causing the of oral hygiene should be recorded together suggestions have been proposed to wear. with the undertaking of a Basic Periodontal improve the TWI, including modifying Overenthusiastic toothbrushing Examination (BPE). An occlusal assessment the threshold values for pathological often presents as rounded grooves in may be required for moderate to severe wear, expanding the scoring criteria and the cervical region of teeth; again this wear. creating another scoring level for secondary can present as a localized problem, often dentine and pulpal exposure. Millward with the canines and premolars being Measuring and monitoring et al60 modified the TWI to study erosion most affected, or as a more generalized tooth wear in primary and secondary dentine by condition dependent on the patient’s grouping TWI scores into categories of A large number of indices have toothbrushing technique. Of note, right- ‘Mild’, ‘Moderate’ and ‘Severe’. Again, there is been developed over the years, including handed individuals tend to create more potential for overestimation of tooth wear. the more popular Tooth Wear Index (TWI)13 wear on the left side and vice versa (Figure Fares et al61 undertook the most recent and the Basic Erosive Wear Examination modification of the TWI to produce the 3). 58 (BEWE). However, at present, a single Exact Tooth Wear Index. This index scores universally accepted method of quantifying Abfraction wear for enamel and dentine separately. It and recording tooth wear is yet to be has the potential for scores to be converted 59 Abfraction lesions can present adopted. This can make recording and into the original TWI for research purposes similarly to toothbrushing abrasion cavities, documenting TW difficult. for comparison and review. but tend to be more angular and undercut Some indices record wear based The above indices tend to be at the coronal aspect where enamel on the aetiology; however, the majority quite comprehensive and often used for overhangs the defect. of indices that have been developed are research. Bartlett et al58 designed The Basic based on the diagnosis and monitoring of Erosive Wear Examination (BEWE). It is a the wear. These indices tend to distinguish simple index, based on the principles of Examination of the tooth wear severity of the wear and are often numerical patient the Basic Periodontal Examination (BPE) as in nature. Measuring wear in vivo is difficult a screening tool for tooth wear. The BEWE For patients presenting with for a clinician as indices can only provide is a partial scoring system recording the tooth wear, the extra-oral examination the prevalence of wear at the point of time most severely affected surface for each should include an assessment of their of recording as there is a lack of reliable sextant. This can then be utilized to guide temporomandibular joints and associated natural reference points for continuity. management of the condition, much like musculature. The presence of any clicking, The majority of indices rely subjectively the BPE for . This index crepitation, mandibular deviation on on visual assessment of the wear severity, has been found to be easy to use by general opening or closure, maximum jaw opening which can lead to a conflict of opinions dental practitioners and researchers alike. (less than 40 mm is considered restricted) from different clinicians. Furthermore, the Studies have found the BEWE to be an and any associated muscle tenderness/ vast number of indices available makes acceptable method for scoring erosion aches/pain should be recorded.56 It is also comparison and aggregation of data with good inter-examiner reliability when worth noting the presence of parotid gland challenging.6 scoring sound surfaces and TW into dentine, enlargement, which is often seen in bulimic The Tooth Wear Index, developed but more discrepancies were recorded patients. by Smith and Knight,13 is the most widely when scoring enamel lesions.62 Severe tooth wear patients utilized. It was designed to be of use in A new classification, proposed may present with a reduced lower facial research into the aetiology, prevention, by Vailati and Belser,63 the Anterior Clinical height due to over closure from loss of management and monitoring of tooth Erosive classification (ACE), aims to provide vertical tooth height. Due to this, the facial wear and epidemiology. It was the a tool that is easier to use than the BEWE vertical proportions should be noted. first index of its kind to measure and for clinicians. Patients are grouped into six This can be examined by assessing the monitor multifactorial tooth wear. It is a classes based on five parameters relevant to freeway space (FWS), by determining the comprehensive index whereby the four the treatment and the prognosis: patient's resting vertical dimension (RVD) surfaces of a tooth are scored according 1. The dentine exposure in the contact and occlusal vertical dimension (OVD). to clinical findings based on the level areas; Callipers or a Willis gauge can be used for of enamel lost, level of dentine lost and 2. The preservation of the incisal edges; this. Other simple techniques include the change of the contour of the surface. 3. The length of the remaining clinical use of phonetic assessments (particularly Smith and Knight13 proposed a distinction crown; the sibilant sounds) and facial soft tissue of pathological levels of wear based on a 4. The presence of enamel on the vestibular contour analysis.57 The patient’s smile patient’s age. surfaces; and aesthetics may also be examined looking at However, there are several 5. The pulp. the smile line and line. limitations to this index.11 The thresholds A dental treatment plan is A full intra-oral examination for each age group have been criticized suggested for each class.63 Much like the should be undertaken including a detailed with subsequent underestimation aforementioned BEWE and the well-known soft and hard tissue assessment. The level of pathological wear.59 A number of Basic Periodontal Examination (BPE) utilized July/August 2018 DentalUpdate 7 RestorativeDentistry

for assessing periodontal disease, the Prevention example, in cases of , avoidance most severely affected tooth is used The increase in incidence of tooth of further exposure of the tooth to acid is 66 to decide the classification. It is worth wear, especially in children, is concerning paramount. A reduction in the quantity noting that the classification is specifically as, without appropriate prevention, this and frequency of the consumption of for the anterior maxillary dentition, is likely to continue into adulthood.64 The acidic food/drinks would be beneficial. however, assessment and treatment of the correct diagnosis is essential for successful Patients should also be advised to limit posterior dentition must also be planned prevention and management. Even though their consumption of acidic foods/drinks as an integral part of the definitive oral prevention is of utmost importance, there to meal times. A change of habit, so that rehabilitation, which is a limitation of this is little high quality evidence about the when acidic drinks are consumed they classification. clinical effectiveness of most preventive are drunk through a wide bore straw, plus The difficulty with all the measures.65 Furthermore, it is difficult to avoidance of swishing beverages in the mouth, will help to reduce the rate of dental indices is that they are subjective and predict which individuals will be affected by erosion. It has been found that consuming potentially insensitive to small changes. TW, making primary prevention difficult to dairy products, including hard cheese or Some, such as the TWI, may be time achieve. chewing gum after the ingestion of an consuming in a general dental practice The decision to treat arises when acidic substances, is beneficial in promoting setting when compared with the BEWE the extent of the tooth wear and potential and ACE. However, both are good for the re-hardening of enamel, stimulating for progression may affect the prognosis of assessing the level of tooth wear and saliva flow and increasing the saliva pH and the tooth, or the patient expresses a want how best to manage the condition. reducing the effects of the erosive source.69 for treatment, or there is the presence of Alternative methods to measure TW Appropriate toothbrushing symptoms. In the absence of functional and include using intra-oral three-dimensional advice and habit avoidance or counselling aesthetic issues, monitoring and counselling laser scanners; sequential photographs; will also be of benefit to the patient, may be the preferred treatment option.66 periodic accurate study casts; sectional including the avoidance of overzealous It is reported that, once TW has silicone index and radiographs, which toothbrushing and the use of less abrasive been diagnosed, wear progression appears have all been utilized in clinical settings toothpastes such as those marketed for to occur at a relatively slow rate whilst with varying results. Furthermore, . Toothbrushing shortly the enamel is still present, particularly in assessing the patient clinically and for after acid exposure (commonly practised cases where preventive advice has been changes in reported symptoms, ie the after vomiting or after drinking citrus juice successfully implemented.66,67 However, patient begins to notice increased tooth in the morning) should be avoided. Studies a change in lifestyle and personal wear or sensitivity, should also be utilized have shown that remineralizing toothpastes circumstances, including an increase in for measuring TW. increase the surface hardness of teeth stress, may be associated with sporadic exposed to acidic substances and have a bursts of wear activity amongst these greater effect than conventional fluoride- Diagnosis patients, which may have the potential containing toothpastes alone.70 However, The difficulty in distinguishing to produce severe wear. Therefore, early topical fluoride application has been shown between the clinical presentations and preventive advice is paramount to success to protect against subsequent tooth wear often multifactorial nature of tooth in preventing ongoing wear leading to following an acid challenge. A neutral wear can make diagnosis difficult. It is possible highly restored dentitions with sodium fluoride mouthrinse or gel should important to take into consideration long-term management requirements. Most be recommended. whether the wear is physiological or research into the efficacy of preventive Furthermore, fluoride application pathological. A detailed history of the strategies has focused on the prevention of can also aid in prevention of symptoms chief complaint should be ascertained erosive wear. Preventive advice should be of sensitivity. Toothpastes containing and documented. Alongside this, also structured in relation to cause. potassium and Tooth Mousse ACP (GC) record an accurate and up-to-date medical Preventive advice may be centred are also considered to be appropriate for history assessment of the clinical signs and on medical management with referral to a the management of dentine sensitivity.56 symptoms and the location of the wear medical practitioner or psychiatrist.68 This Such agents may be applied with the aid (generalized or localized) when creating a is considered appropriate when an eating of a custom-fabricated tray (containing diagnosis. disorder or reflux disease is suspected. reservoirs akin to bleaching trays). For The diagnosis of a patient Medication, such as antacids, omeprazole patients experiencing sensitivity this may presenting with tooth wear should include and ranitidine can be used to reduce be prevented by the application of dentine- a description of the type(s) of lesions gastric reflux and acid production. Where bonding agents, and fissure sealant to observed, together with an account of xerostomia may have an underlying role, erosive lesions may be of some benefit. the extent/location (localized, anterior/ referral to a specialist in oral medicine However, studies have shown the longevity posterior or generalized) and severity may be considered; or discussing with of dentine-bonding agents applied to teeth (restricted to enamel only, into dentine or the medical practitioner an alternative displaying severe wear to be relatively severely affecting the teeth involving the medication if xerostomia is a side-effect short lived.71 Glass ionomer cements can pulp) of the condition. of a current medication regimen. For also be readily applied to worn surfaces for 8 DentalUpdate July/August 2018 RestorativeDentistry

a a may be aware or unaware of their tooth wear. If it is of concern and they have symptoms (pain, poor function or poor appearance) they may request treatment. If possible, the dentist should advise prevention or minimal intervention treatment to prevent symptoms from occurring. 5. The exposure of dentine and presentation of thin or unsupported enamel should b prompt a discussion with the patient about b the tooth wear. The rate of TW is likely to increase when dentine is exposed. 6. Preventive management of tooth wear may include any of the following: (a) Dietary advice; Figure 4. (a, b) Soft or bilaminar splints are cheap (b) Medical referral; to provide but not as durable as a hard acrylic (c) Oral hygiene instruction and correction splint. of damaging habits; (d) Fluoride application; Figure 5. (a, b) A maxillary hard acrylic splint involves more clinical and laboratory time to (e) Alkaline solutions; make. It can be more durable and effective when (f) Remineralizing solutions; the purposes of sensitivity and tooth wear treating severe tooth wear, TMJ dysfunction and (g) Desensitizing agents; prevention. reducing muscle dysfunction. (h) Occlusal splints; Advising patients to change (i) Composite or glass ionomer restorations habits, such as that of pen/pencil-biting, to cover dentine. nail-biting or holding or opening objects 7. In early or mild presentations of tooth with the teeth, such as bottle tops, hair on wear/usage must be precise, so that wear, in the absence of symptoms, grips, sewing needles, pipes, will also help the splint does not become a reservoir for monitoring and prevention may be most prevent ongoing wear. the acid produced. In erosive tooth wear appropriate. In cases of tooth wear, splint a soft vacuum-formed appliance modified 8. Occlusal splints may be soft, bilaminar therapy is beneficial in order to prevent to include reservoirs is beneficial. Neutral (hybrid) or hard and can be placed in either the loss of tooth structure from attrition. fluoride gels, desensitizing agents and also jaw. The selection will depend on the The use of a night guard is recommended acid neutralizers, ie sodium bicarbonate severity of tooth wear and cost involved. for nocturnal bruxists. This may be a soft solution, can be applied, respectively.56 Hard acrylic splints are expensive but are splint, but this will not be durable in the more effective in managing severe TW, long term. A bilaminar splint may be more Key points severe TMJ dysfunction and establishing cost-effective72 (Figure 4). However, for an a reproducible retruded contact position 1. Making a diagnosis in tooth wear established bruxist patient, a full coverage (RCP) in pre-restorative treatment. hard acrylic occlusal splint should be is a fundamental starting point for constructed (ie a Michigan splint or a Tanner managing TW. It should be expressed in terms of aetiology, severity, whether it is References appliance). The splint should be fabricated 1. Kelleher M, Bishop K. Tooth surface loss: tooth to provide an 'ideal occlusion' (Figure 5). physiological or pathological, localized surface loss: an overview. Br Dent J 1999; 186: It is important to take precautions when or generalized and compensated or non- 61−66. 2. Lambrechts P, Braem M, Vuylsteke-Wauters M, providing splints to patients with an erosive compensated. This should be explained to Vanherle G. Quantitative in vivo wear of human factor, in the cause of the tooth wear, patients in terms that they can understand. enamel. J Dent Res 1989; 68: 1752−1754. 2. Monitoring tooth wear is best carried 3. Bishop K, Kelleher M, Briggs P, Joshi R. Wear especially if night reflux is a causative factor. now? An update on the etiology of tooth wear. Advice should be given to the patient out with study casts or photographs. In the Quintessence Int 1997; 28: 305−313. future, digital scanning methods are likely 4. Smith BG, Robb ND. Dental erosion in patients accordingly, as the acidic substances may with chronic alcoholism. accumulate within the splint and further to be available in daily practice. The most J Dent 1989; 17: 219−221. exacerbate the rate of wear, and regular useful indices58,63 have not gained universal 5. Lee WC, Eakle WS. Possible role of tensile stress in the etiology of cervical erosive lesions of maintenance is required. Splints may be acceptance as yet. teeth. J Prosthet Dent 1984; 52: 374−380. used to protect teeth during episodes of 3. Tooth wear usually has a mixed aetiology 6. Kreulen CM, Van’t Spijker A, Rodriguez JM, Bronkhorst EM, Creugers NH, Bartlett DW. vomiting for the bulimic patient, which of attrition, erosion and abrasion. Abfraction Systematic review of the prevalence of tooth are worn during the vomiting period only is not a universally accepted entity. wear in children and adolescents. Caries Res and after vomiting should be removed and 4. Patients’ attitude will dictate whether 2010; 44: 151−159. 7. Pitts NB, Chadwick B, Anderson T. Children’s cleaned. Again precautions and instructions prevention or treatment is advised. They Dental Health Survey 2013 Report 2: Dental July/August 2018 DentalUpdate 9 RestorativeDentistry

Disease and Damage in Children England, Wales 29. Lussi A. Erosive tooth wear − a multifactorial 51. Addy M, Pearce N. Aetiological, predisposing and Northern Ireland. Health and Social Care condition of growing concern and increasing and environmental factors in dentine Information Centre, 2015. knowledge. Monogr Oral Sci 2006; 20: 1−8. hypersensitivity. Archiv Oral Biol 1994; 39: S33− 8. Murray JJ, Vernazza CR, Holmes RD. Forty years 30. Phelan J, Rees J. The erosive potential of some S38. of national surveys: an overview of children's herbal teas. J Dent 2003; 31: 241−246. 52. Milosevic A. Tooth wear: an aetiological and dental health from 1973−2013. Br Dent J 2015; 31. Kitchens M, Owens B. Effect of carbonated diagnostic problem. Eur J Prosthodont Rest Dent 219: 281−285. beverages, coffee, sports and high energy 1993; 1: 173−178. 9. White DA, Tsakos G, Pitts NB, Fuller E, Douglas drinks, and bottled water on the in vitro erosion 53. Mair LH. Wear in dentistry − current GV, Murray JJ, Steele JG. Adult Dental Health characteristics of dental enamel. terminology. J Dent 1992; 20: 140−144. Survey 2009: common oral health conditions J Clin Pediatr Dent 2007; 31: 153−159. 54. Bartlett DW. The role of erosion in tooth wear: and their impact on the population. Br Dent J 32. Al-Dlaigan Y, Shaw L, Smith A. Dental erosion in aetiology, prevention and management. Int Dent 2012; 213: 567−572. a group of British 14-year-old school children J 2005; 55: 277−284. 10. Spijker AV, Rodriguez JM, Kreulen CM, Part II: Influence of dietary intake. Br Dent J 55. Levitch LC, Bader JD, Shugars DA, Heymann HO. Bronkhorst EM, Bartlett DW, Creugers NH. 2001; 190: 258−261. Non-carious cervical lesions. J Dent 1994; 22: Prevalence of tooth wear in adults. Int J 33. Mulic A, Tveit AB, Hove LH, Skaare AB. Dental 195−207. Prosthodont 2009; 22. 35−42. erosive wear among Norwegian wine tasters. 56. Mehta SB, Banerji S, Millar BJ, Suarez-Feito JM. 11. Donachie MA, Walls AW. Assessment of tooth Acta Odont Scand 2011; 69: 21−26. Current concepts on the management of tooth wear in an ageing population. 34. Tuominen ML, Tuominen RJ, Fubusa F, Mgalula wear: part 1. Assessment, treatment planning J Dent 1995; 23: 157−164. N. Tooth surface loss and exposure to organic and strategies for the prevention and the 12. Barron MJ, McDonnell ST, MacKie I, Dixon MJ. and inorganic acid fumes in workplace air. passive management of tooth wear. Hereditary dentine disorders: dentinogenesis Community Dent Oral Epidemiol 1991; 19: Br Dent J 2012; 212: 17−27. imperfecta and dentine dysplasia. Orphanet J 217−220. 57. Rivera-Morales WC, Mohl ND. Restoration of the Rare Dis 2008; 3: 31. 35. Geurtsen W. Rapid general dental erosion by vertical dimension of occlusion in the severely 13. Smith BG, Knight JK. An index for measuring the gas-chlorinated swimming pool water. Review worn dentition. Dent Clin North Am 1992; 36: wear of teeth. Br Dent J 1984; 156: 435−438. of the literature and case report. Am J Dent 651−664. 14. Grippo JO, Simring M, Schreiner S. Attrition, 2000; 13: 291−293. 58. Bartlett D, Ganss C, Lussi A. Basic Erosive Wear abrasion, corrosion and abfraction revisited: a 36. Kim HD, Douglass CW. Associations Examination (BEWE): a new scoring system for new perspective on tooth surface lesions. J Am between occupational health behaviors and scientific and clinical needs. Clin Oral Investig Dent Assoc 2004; 135: 1109−1118. occupational dental erosion. 2008; 12: 65−68. 15. Agerberg G, Carlsson GE. Functional disorders J Public Health Dent 2003; 63: 244−249. 59. Bardsley PF. The evolution of tooth wear indices. of the masticatory system II. Symptoms in 37. Mahoney EK, Kilpatrick NM. Dental erosion: part Clin Oral Investig 2008; 12: 15−19. relation to impaired mobility of the 1. Aetiology and prevalence of dental erosion. 60. Millward A, Shaw L, Smith AJ, Rippin JW, as judged from investigation by questionnaire. NZ Dent J 2003; 99: 33−41. Harrington E. The distribution and severity Acta Odont Scand 1973; 31: 335−347. 38. Bartlett DW, Evans DF, Smith BG. The of tooth wear and the relationship between 16. Helkimo M. Studies on function and relationship between gastro‐oesophageal reflux erosion and dietary constituents in a group of dysfunction of the masticatory system: IV. disease and dental erosion. J Oral Rehabil 1996; children. Int J Paediatr Dent 1994; 4: 151−157. Age and sex distribution of symptoms of 23: 289−297. 61. Fares J, Shirodaria S, Chiu K, Ahmad N, Sherriff dysfunction of the masticatory system in Lapps 39. Reid BJ, Weinstein WM, Lewin KJ, Haggitt M, Bartlett D. A new index of tooth wear. Caries in the north of Finland. Acta Odont Scand 1974; RC, VanDeventer G, DenBesten L, Rubin CE. Res 2009; 43: 119−125. 32: 255−267. Endoscopic biopsy can detect high-grade 62. Mulic A, Tveit AB, Wang NJ, Hove LH, Espelid 17. Budtz‐Jørgensen EJ. Occlusal dysfunction and dysplasia or early in Barrett's I, Skaare AB. Reliability of two clinical scoring stress. J Oral Rehabil 1981; 8: 1−9. esophagus without grossly recognizable systems for dental erosive wear. Caries Res 2010; 18. Ramfjord SP. Bruxism, a clinical and neoplastic lesions. Gastroenterology 1988; 94: 44: 294−299. electromyographic study. J Am Dent Assoc 1961; 81−90. 63. Vailati F, Belser CU. Classification and treatment 62: 21−44. 40. Schmidt U, Treasure J. Eating disorders and the of the anterior maxillary dentition affected 19. Smith BG, Robb ND. The prevalence of dental practitioner. by dental erosion: the ACE classification. Int J toothwear in 1007 dental patients. Eur J Prosthodont Rest Dent 1997; 5: 161−167. Periodont Restor Dent 2010; 30: 559. J Oral Rehabil 1996; 23: 232−239. 41. Robb ND, Smith BG, Geidrys-Leeper E. The 64. Chadwick BL, White DA, Morris AJ, Evans D, Pitts 20. Witter DJ, Creugers NH, Kreulen CM, De Haan distribution of erosion in the dentitions of NB. Non-carious tooth conditions in children in AF. Occlusal stability in shortened dental arches. patients with eating disorders. Br Dent J 1995; J Dent Res 2001; 80: 432−436. 178: 171−175. the UK, 2003. Br Dent J 2006; 200: 379−384. 21. Bartlett D, Phillips K, Smith B. A difference 42. Milosevic A. Tooth surface loss: eating disorders 65. Kelleher MG, Bomfim DI, Austin RS. Biologically in perspective − the North American and and the dentist. Br Dent J 1999; 186: 109−113. based restorative management of tooth wear. European interpretations of tooth wear. Int J 43. Monteath SA, McCabe MP. The influence of Int J Dent 2012; 2012: 742509. Prosthodont 1999; 12: 401−408. societal factors on female body image. 66. Bartlett DW, Palmer I, Shah P. An audit of study 22. Singh S, Jindal R. Evaluating the buffering J Soc Psychol 1997; 137: 708−727. casts used to monitor tooth wear in general capacity of various soft drinks, fruit juices and 44. Hawkins N, Richards PS, Granley HM, Stein DM. practice. Br Dent J 2005; 199: 143−145. tea. J Conserv Dent 2010; 13: 129. The impact of exposure to the thin-ideal media 67. Bartlett DW. Retrospective long term monitoring 23. Eccles JD. Tooth surface loss from abrasion, image on women. Eat Disord 2004; 12: 35−50. of tooth wear using study models. Br Dent J attrition and erosion. Dent Update 1982; 9: 45. Bishop K, Briggs P, Kelleher M. The aetiology 2003; 194: 211−213. 373−374. and management of localized anterior tooth 68. Treasure J, Schmidt U, Troop N, Tiller J, Todd 24. O’Sullivan EA, Curzon ME. Drug treatments for wear in the young adult. Dent Update 1994; 21: G, Keilen M, Dodge E. First step in managing asthma may cause erosive tooth damage. 53−60. : controlled trial of therapeutic Br Med J 1998; 317(7161): 820. 46. Bartlett DW, Shah P. A critical review of non- manual. Br Med J 1994; 308(6930): 686−689. 25. Johansson AK, Omar R, Carlsson GE, Johansson carious cervical (wear) lesions and the role of 69. Imfeld T, Birkhed D, Lingström P. Effect of urea A. Dental erosion and its growing importance in abfraction, erosion, and abrasion. J Dent Res in sugar-free chewing on pH recovery clinical practice: from past to present. Int J Dent 2006; 85: 306−312. in human dental plaque evaluated with three 2012; 2012: 632907. 47. Crothers AJ. Tooth wear and facial morphology. different methods. Caries Res 1995; 29: 172−180. 26. Bardsley PF, Taylor S, Milosevic A. J Dent 1992; 20: 333−341. 70. Muňoz CA, Feller R, Haglund A, Triol CW, Epidemiological studies of tooth wear and 48. Rees JS. The role of cuspal flexure in the Winston AE. Strengthening of by dental erosion in 14-year-old children in North development of abfraction lesions, a finite a remineralizing after exposure to an West England. Part 1: The relationship with element study. Eur J Oral Sci 1998; 106: acidic soft drink. water fluoridation and social deprivation. Br 1028−1032. J Clin Dent 1999; 10(1 Spec No): 17−21. Dent J 2004; 197: 413−416. 49. Rees JS. The effect of variation in occlusal 71. Bartlett D, Sundaram G, Moazzez R. Trial of 27. Daly B, Newton TJ, Fares J, Chiu K, Ahmad N, loading on the development of abfraction protective effect of fissure sealants, in vivo, on Shirodaria S, Bartlett D. Dental tooth surface lesions: a finite element study. J Oral Rehabil the palatal surfaces of anterior teeth, in patients loss and quality of life in university students. 2002; 29: 188−193. suffering from erosion. Prim Dent Care 2011; 18: 31−35. 50. Rees JS, Hammadeh M. Undermining of enamel J Dent 2011; 39: 26−29. 28. Jarvinen VK, Rytomaa II, Heinonen OP. Risk as a mechanism of abfraction lesion formation: 72. Longridge NN, Milosevic A. The bilaminar (dual- factors in dental erosion. J Dent Res 1991; 70: a finite element study. Eur J Oral Sci 2004; 112: laminate) protective night guard. Dent Update 942−947. 347−352. 2017; 44: 648−654. 10 DentalUpdate July/August 2018 RestorativeDentistry

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20180724_AD_Synea_RingLED+_Oberfläche_A4-hoch.indd 1 24.07.2018 14:45:43 RestorativeDentistry

Ken Hemmings

Angharad Truman, Sachin Shah and Ravi Chauhan

Tooth Wear Guidelines for the BSRD Part 2: Fixed Management of Tooth Wear Dent Update 2018; 45: 11–19

The management of tooth wear (TW) of life. Significant tooth structure loss can life, affecting patients’ satisfaction with may often present a dilemma to the also lead to difficulties with any potential their dentition, in particular; aesthetics, clinician. The clinical decision-making rehabilitation.1 Patients often only become oral comfort and/or mastication.5 Correct process between monitoring and active aware of their TW when the appearance diagnosis is therefore critical for successful management can be difficult. Thorough of their teeth begins to deteriorate or they management of TW. The predominant history-taking and clinical assessment become symptomatic. Enamel may appear aetiology should be determined and the are essential parts of gathering sufficient thin or discoloured, begin to fracture and patient concerns identified.6 Although the information to allow the clinician and the the teeth may appear shorter.2 Exposure rehabilitation of worn teeth is common patient to make these treatment decisions. of dentine can lead to transient pain in clinical practice, there appears to be a Uncontrolled tooth wear response to chemical, thermal, tactile or can lead to poor aesthetics, dentine osmotic stimuli. This is commonly known stark absence of documented outcomes. hypersensitivity and functional problems, as dentine hypersensitivity and may occur It has been identified in numerous reviews ultimately resulting in a reduced quality following loss of enamel with dentinal that there is no strong published evidence exposure secondary to tooth wear.3 This on management strategies.6,7 To date, pain can often be unsettling for the patient most recommendations are based on and may lead to limitation of the types of published, evidence-based, expert opinion Ken Hemmings, BDS, MSc, DRD RCS, MRD food or beverage ingested. or observational studies, with a lack of RCS, FDS RCS, ILTM, FHEA, Consultant in Loss of tooth structure can high quality research supporting individual Restorative Dentistry, Eastman Dental Hospital have many restorative implications. The restorative measures for the replacement of and Institute, UCLH Trust and private practice, need to conserve tooth structure, in tooth tissue.7 Angharad Truman, BDS(Hons), MFDS RCPSG, particular enamel, remains vital to the The decision to treat arises when PGCME, FHEA, Specialty Registrar in Restorative predictability of adhesive restorations the patient’s needs, severity of the wear and Dentistry, Bristol Dental Hospital, Sachin Shah, which are indicated, where possible, to potential for progression are of concern. BDS, MFDS RCS, MClin Dent(Pros), MRD RCS, avoid removal of more tooth structure, as There is a lack of evidence to suggest that Specialist Prosthodontist in private practice/ is required with conventional crown and Clinical Teaching Fellow, Eastman Dental bridge work.4 Further restorative difficulties the presence of TW will predictably lead to 6 Hospital and Institute, 256 Gray’s Inn Road, can be encountered as TW causes loss of severe wear. In the absence of aesthetic London, WC1X 8LD and Ravi Chauhan, MDDr, interocclusal space, thereby leaving limited or functional issues, monitoring of the MSc, MJDF RCS(Eng), MFDS RCS(Edin), Specialty space for the restorative material. TW and preventive advice, including diet Registrar in Restorative Dentistry, King's College Uncontrolled tooth wear may counselling, may be preferable.8,9 Dental Hospital, London, UK. ultimately result in decreased quality of The preservation of tooth 12 DentalUpdate July/August 2018 RestorativeDentistry

structure is critical. In cases of intrinsic and removable restorative approach. wax-up can be carried out at the desired erosion, prevention of further exposure Disadvantages of restorative treatment vertical dimension. This diagnostic preview to the damaging gastric contents is of revolve around the patient entering forms the foundation for future treatment paramount importance.10 The management the restorative maintenance cycle, thus and can be transferred to the patient in strategy should be centred around medical rendering both the restorations and the order to assess proposed changes in the management, and psychiatric evaluation teeth susceptible to fracture or even failure. vertical dimension and aesthetics and 11 The consequences of failures and their if eating disorders are suspected. function. Parafunctional habits may exert highly subsequent management must all be taken destructive forces and are difficult to into consideration prior to embarking on a prevent in comparison to erosive wear.12 restorative management strategy. Occlusal splints Despite prevention being the foundation A hard heat-cured full coverage for successful management, there is a lack Preliminary investigations acrylic splint can be used in the diagnostic of high quality evidence about the clinical The initial investigations should phase. The ideal splint should provide effectiveness of most preventive measures.13 involve thorough assessment of the even contact along the retruded arc of patient in order to identify the cause of closure, with anterior guidance on anterior wear, if possible, and correlate the clinical teeth with posterior disclusion and canine Indications for fixed symptoms resulting from such wear. The guidance in lateral excursions with no management of tooth wear relevant aesthetic, restorative, periodontal interferences from the posterior dentition.15 Generalized/localized tooth and endodontic examinations should They can provide the following benefits: wear in dentate patients with associated: be carried out along with any necessary  Protect worn teeth from any further wear,  Pain/discomfort; radiographic investigations. This should be especially if the original cause is attrition;  Aesthetic concern; accompanied with a set of mounted study  Disrupt the habitual path of closure into  Functional disturbance; casts. intercuspal position (ICP) by separating the  Compromised structural integrity of On conclusion of the teeth; tooth/teeth; assessments, the clinician will be able to  Testing tolerance to the planned changes  Alveolar compensation with resulting lack draw conclusions on the overall state of the in occlusal vertical dimension.16-18 This is of interocclusal space for restoration. dentition, the complexity of the problem, probably unnecessary, since proprioception individual and general prognosis and makes tolerance highly likely when occlusal Contra-indications for fixed potential treatment options available. loads are directed through the periodontal management of tooth wear ligament (PDL), as with fixed restorations; Contra-indications include: Diagnostic phase  Pre-restorative stabilization to ensure a  Worn teeth compromising periodontal Mounted study casts reproducible jaw relationship is established disease and/or extensive caries; A set of articulated study prior to embarking on a re-organized  Unrestorable teeth − vertical root casts can be used to assess the overall approach. This is thought to be achieved by fractures, horizontal/oblique fractures dentition, occlusal relationship, contacts breaking the proprioceptive feedback from to bone crest, caries to bone crest, failed and interferences, and restorative space periodontal mechanoreceptors, resulting endodontics; available. The mounted casts can also in muscle relaxation that will facilitate the  Concurrent soft tissue defects; be used to assess the effect of changing accurate recording of the retruded axis  The additional time and cost involved occlusal contacts (trial equilibration), position (RAP);17 which may be prohibitive for some patients; diagnostic repositioning of teeth14 and to   Worn dentitions with extensive Protection of new restorations from create a diagnostic preview. edentulous spans or insufficient posterior occlusal forces in parafunction; If it is determined that support and dental implants are not  Management of temporomandibular reconstruction is required, treatment considered. dysfunction through a true therapeutic should aim to restore the worn dentition to effect or potential placebo effect.19,20 a determined occlusal vertical dimension Partial coverage splints should Aims of fixed management of needed to create space for restoration of be avoided due to potential selective tooth wear lost tooth tissue, avoiding sound tooth intrusion and extrusion of teeth. The Restorative management of destruction, whilst ensuring acceptable resulting can be difficult tooth wear may be necessary in order function and aesthetics. In most patients to correct and a potential source of to achieve the aims of restoring the who are fully or mostly dentate, where medicolegal litigation. appearance, function and/or speech of restorations will be tooth borne, such patients with worn dentitions, conserving changes are well tolerated. The occlusal remaining tooth structure and reducing vertical dimension should ideally be Planning strategies sensitivity or pain associated with captured with a jaw registration at or close Management strategies will be worn teeth. This may be by means of to the desired vertical dimension, which is influenced by the following factors that fixed, removable or a combined fixed then used to mount the casts. A diagnostic should all be considered during the July/August 2018 DentalUpdate 13 RestorativeDentistry

material is of far less importance by way of shown to perform better than the older comparison to survival of the tooth and the microfilled resins. dentino-pulpal complex.13 In a series of studies assessing Modern resin-based restorative direct and indirect composite resin materials have risen in popularity due restorations in predominantly erosive to their use being less destructive to the cases, Gow and Hemmings found an remaining tooth tissue whilst serving the annual failure rate of 6.9% in a relatively functional requirements, bringing into short follow-up of two years for indirect question traditional fixed prosthodontic palatal ceromer veneers.26 The indirect 9 restorations did not offer any advantages Figure 1. Adhesive metal backings and onlays are approaches. durable but can have poor aesthetics. over direct composites. Gulamali et al found Localized tooth wear a similar annual failure rate when assessing indirect and direct hybrid composites in The vast majority of studies the management of localized TW, with are centred around management of median survival times of 7 years for major planning phase: localized tooth wear. Huge variations in 1. The aetiology and pattern of failures and 5.8 years when assessing all outcomes exist in the reported success and 27 tooth wear; failures. Despite more than 50% of all survival of direct and indirect restorations. restorations suffering some form of failure, 2. Occlusal vertical dimension, There has been a gradual evolution dento-alveolar compensation the authors concluded that composite resin in restorative methods when it comes restorations offer a viable medium-term and available restorative space; to the management of TW. Traditional 3. The remaining available tooth management strategy for TW, in view of the methods revolved around full coverage fact that they are non-destructive of tooth tissue; cast restorations. Rochette’s introduction 4. Space requirements of the tissue when compared with conventional of a method for cementation of metal indirect restorations and treatment can proposed restorative materials; alloy castings to enamel without relying be repeated. Despite the huge variation in 5. The patient expectations primarily on macromechanical resistance clinical situations posed and the variety of

and retention resulted in significant approaches used to rehabilitate dentitions, Aetiology and pattern of tooth wear 22 advances within restorative dentistry. The which limits comparison among different The aetiology of tooth wear adhesive techniques proposed allowed studies, annual failure rates of composite and wear resistance of restored and natural for a more conservative approach to be resin restorations appear to be within an teeth should be considered. Although adopted, whereby individual cast-metal acceptable range. some aetiologies can be controlled, some veneers cemented to the palatal surfaces of may be beyond the control of the patient anterior maxillary teeth. Further advances or the clinician. It is essential to establish in the physical properties of resin-based Generalized tooth wear whether the restored dentition is likely to restorations have resulted in a further Traditional treatment methods be exposed to such causes of wear prior to development of management techniques for patients with severe generalized tooth making material choices. Behaviour under involving the sole use of composite resin- wear involved full mouth rehabilitation with normal and excessive loads will have an based restorations. cast indirect restorations, However, there influence on decision-making, especially The success and survival rates is a lack of well-designed clinical studies in parafunctional patients. Given the of the newer adhesive techniques have assessing performance and outcomes for complex nature of the oral environment, gradually improved with the evolution of this method.6,7 This, combined with high both mechanical and biological failures materials. Nohl et al, reported an overall cost and an invasive technique, rendered are possible. Biological failures have been success rate of 89% in a retrospective survey this approach less favourable when shown to be primary or secondary (often of 48 patients treated with 210 metal palatal compared to the newer more conservative following a mechanical failure), and are veneers for anterior palatal TW for periods treatment strategies. Despite rehabilitation more probable.21 Laboratory-based trials of up to 5 years.23 They recommended the of severely worn teeth being common have shown the wear resistance of gold and combination of metal palatal veneers with practice, there appear to be deficiencies ceramic materials to be similar, whereas resin composite luting agent restoring the in the evidence in support of specific resin-based materials have demonstrated functional surfaces of maxillary anterior techniques or materials.28 three to four times more material wear teeth affected by acid erosion (Figure 1). The limited data shows that than gold or ceramics. In cases of high Direct composite resin rehabilitation of TW with direct composite load conditions, traditionally, metal or restorations have been extensively studied resin can offer good clinical results, whilst metal-ceramic restorations have been and vary significantly in annual failure being less invasive than preparations for an recommended as the material of choice,6 rates from 0.7%24 to 26.3%.25 Variations in indirect approach. Direct hybrid composite however, under extreme conditions material properties have been suggested as restorations have been reported to perform there is no material that is likely to last. contributory factors to this wide variation. well, even in larger posterior restorations. A Nevertheless, survival of the restorative Microhybrid composite resins have been number of studies have suggested that 14 DentalUpdate July/August 2018 RestorativeDentistry

a 1010 restorations in 164 patients, Milosevic results. Parafunctional activity can result and Burnside suggested that direct in devastating forces resulting in the hybrid composite resin restorations offer increased risk of mechanical failure at both a predictable option in the management the restoration and tooth level. Numerous of generalized TW, with relatively low clinical studies on the management of failure rates.31 The study highlighted the severe TW exclude high risk subjects such detrimental impact of attrition and the lack as bruxists.28 As such, interpretations of posterior support on survival outcomes. of these studies should be carried out Within the current literature, with caution. Research into the use of very few studies are available assessing composite resin in such cases have shown b the management of generalized TW, with mixed results. A few studies have shown even fewer comparing the use of direct and good outcomes supporting its use,31,34 indirect restorative techniques. however, these were over a relatively short Vailati assessed the observational period, whilst others have management of severely eroded dentitions shown poorer outcomes.25,35 It is clear that with a combination of indirect palatal further high-quality research is required to composite restorations and labial porcelain aide material choice in such cases. veneers.32 The study concentrated upon observations on the restored anterior teeth, whilst the posterior teeth were restored Assessing the occlusal vertical but not assessed. The authors used USPHS dimension and available assessment criteria, with most restorations restorative space c receiving alpha or bravo scores, however, no In the absence of tooth wear statistical analysis of the results were carried the free-way space remains constant due out, with findings being purely descriptive. to the continued growth and increase in Despite positive findings in the use of anterior facial height into middle age.36,37 ceramic in erosive cases, the risk of chipping Localized TW often presents with the under heavy load, coupled with difficulty in occlusal vertical dimension within normal repairing ceramic restorations, may prove to limits. be a significant deterrent for its use in wear Generalized tooth wear cases when aetiology might involve some can often present one of two distinct form of parafunction.33 outcomes: Figure 2. (a, b) Full mouth reconstruction with Only one study compared 1. Compensated TW: Tooth conventional crowns and bridges at fit and at 14 the use of composite resin restorations wear with continued eruption of teeth, year review. The long span bridge has failed and and traditional metal-ceramic and allowing free-way space and facial the UR3 abutment is unrestorable. (c) Lower arch gold restorations in the severely worn proportions to remain constant without at 14 years with no failures. dentitions.34 This study found cumulative loss of occlusal vertical dimension.38,39 survival estimates of 74.5% for indirect 2. Non-compensated TW: Tooth restorations and 62% for direct restorations, wear when the rate of the TW exceeds that over 10 years. Over the study period the of the physiological mechanisms of tooth material properties may not be as relevant authors found a strong trend for lower eruption.40 This will result in an increased as originally thought when considering survival of the composite resin restorations free-way space and loss of occlusal vertical longevity of the restorations.29,30 A in comparison to the indirect restoration. dimension. retrospective case series by Hamburger et al However, these results were not statistically The list below can be used in assessed the use of direct composite resin significant. The least failures were noticed combination to determine the correct in the management of severe TW caused with full gold crowns, whilst the metal- OVD: by erosion, bruxism or a combination of ceramic crowns experienced 25.2% failures. 1. The point of first contact 12 the two. A total of 332 restorations were Modes of failure with indirect restorations along the retruded arc of closure (RAP) placed in 18 patients over a period of 6 were mostly biological complications. if there are unworn teeth posterior to months to 12 years following completion of Composite resin restoration, in comparison, the worn anterior teeth. This will be the treatment. Findings were again descriptive, suffered more fractures, the management retruded contact position (RCP) and may with a total of 23 failures, predominantly of which was identified as being provide the required space to restore the in the maxilla, 8 of which were major straightforward (Figure 2). worn anterior dentition; failures. The authors concluded that the The aetiology of wear can have 2. Ideal tooth dimensions; direct hybrid composites offer good clinical a significant impact on the subsequent 3. Occlusal plane and tooth performance in cases of severe TW. management. Incorrect diagnosis can display at rest and on smiling; In a prospective study assessing prove to have a confounding effect on 4. Amount of posterior July/August 2018 DentalUpdate 15 RestorativeDentistry

a a d

b e b

c f c

Figure 4. (a, b) Anterior tooth wear showing loss of incisal height and palatal erosion in a male patient with excessive intake of carbonated drinks. (c, d) Post-operative view of first documented case of composite ‘Dahl’ approach.49 (e, f) Posterior disclusion at time of placement of composite ‘Dahl’ restorations. Posterior occlusion restored in 4 months. d

to changes in the vertical dimension is the following factors have an impact on thought to be down to the the nature of the restorative material choice: dento-alveolar structures and associated  Remaining enamel and dentine − Despite neuro-musculature proprioception through improvements in dentine bonding the the supporting periodontal ligament. presence of a complete ‘ring’ of enamel may The occlusal vertical dimension influence the clinician towards adhesive can theoretically be increased to anywhere restorations; Figure 3. (a) Anterior erosive tooth wear. (b) along the retruded arc of closure in a  Remaining clinical crown height − If Metal Dahl appliance in place. (c) Dahl appliance dentate patient. Dahl et al used a removable sufficient tooth structure is remaining removed after 4 months of use. (d) Conventional appliances to increase the vertical to provide sufficient resistance form for crowns in place. Case completed in 1993. dimension from 1.8 mm to 4.7 mm (mean of conventional restorations. For conventional Adhesive restorations would be considered more 2.84 mm).41 Hemmings et al25 and Gow and appropriate today. Hemmings26 placed anterior restorations at restorations, tooth restorability should be an increased vertical dimension allowing for assessed without any existing restorations separation of posterior teeth of up to 4 mm. allowing evaluation of the amount and prosthetic space required for contribution of remaining coronal dentine to restoration of teeth; Assessing severely worn teeth resistance and retention form.42 Less critical 5. Assessing phonetics; for remaining available tooth for adhesive restorations. 6. Photographs of the patient’s tissue  Pulpal status of tooth − Reducing a tooth teeth prior to being worn. Severely worn teeth can still be will expose more dentinal tubules and less Generally, dentate patients restored by means of traditional or adhesive calcified dentine, making the pulp more will be able to tolerate even significant techniques. The tooth must be assessed by vulnerable to cariogenic bacteria.43,44 The changes in the occlusal vertical dimension. the following normal parameters in order physical and thermal insult of conventional The ability of the dentate patient to adapt to determine its restorability. Additionally, preparation techniques can result in 16 DentalUpdate July/August 2018 RestorativeDentistry

a a restorations require a minimum thickness of 1−2 mm, depending on manufacturer guidelines and functional load.

Methods of achieving space for restorative materials  Occlusal reduction of those teeth to be restored − This can be particularly b destructive to compromised teeth with b short clinical crowns and reduced amount of tooth tissue.  Reduction of opposing teeth − An option if opposing teeth are unaffected but preservation of dental tissue is vital in cases of tooth wear.  Occlusal equilibration − If there is a c significant horizontal discrepancy between retruded contact position (RCP) and intercuspal position (ICP) space may be c generated. This alone rarely provides a solution in cases of advanced wear, since it is difficult to establish a definite ICP in a more distal relationship. It is difficult to achieve and involves preparation of already Figure 6. (a) Anterior tooth wear pre- compromised teeth which warrants a operative appearance. (b) Appearance after careful assessment and execution. It is more surgery. (c) Post-operative often used as a pre-restorative measure appearance with composite restorations. before extensive restoration.47  Conventional orthodontics − This d provides a controlled and predictable method of creating localized interocclusal an increased risk of pulpal pathology.45 clearance. Conventional orthodontic appliances are indicated when tooth Space requirements of the movements in addition to minor axial proposed restorative materials movements are required.  Localized minor axial tooth movement The survival and success of (‘Dahl’ approach) − There is a variety of restorations is heavily influenced by the methods that combine differential intrusion physical properties of what material the and eruption of teeth to create interocclusal techniques use and the environment space, as originally described by Anderson48 within which it is placed. Conventional and subsequently Dahl41 (Figures 3−5 ). This cast metal ceramic restorations have the e well-described approach can be adapted to largest footprint, requiring up to 2 mm modern adhesive materials and techniques. occlusal reduction and can result in up  Crown lengthening surgery − Although 46 to 72% loss of tooth tissue (by weight). this does not create space in itself, increased All-ceramic monoblock crowns can be less axial wall height aids in retention and destructive, with the reduction guides for resistance form for restoration. Gingival newer full contour zirconia crowns being re-contouring may also modify the gingival comparable to conventional full metal architecture and improve aesthetics (Figure crown preparations. Space requirements 6). for adhesive restorations vary depending  Elective devitalization of pulps in order on the material properties and function. to utilize the root canal for retention of Figure 5. (a) Posterior occlusal wear. (b) Posterior Adhesive metal onlays require a minimum cast retention − A destructive option composite onlays. (c) Posterior onlays in situ. (d) of 1 mm occlusal clearance, whilst adhesive that worsens the prognosis for the tooth Anterior and posterior disclusion created. (e) metal palatal veneers require a minimum as compared with other methods of Occlusion re-established at 6 months. thickness of 0.7 mm. Composite resin restoration described. July/August 2018 DentalUpdate 17 RestorativeDentistry

a e With careful planning following a ‘tooth by tooth’ assessment, a combination of technologies may provide an extensive but conservative treatment plan (Figure 8).

Managing patient expectations b It is important for patients to have realistic expectations of any future reconstruction. They must be informed of their limitations and potential clinical and f financial implications of failure from the outset so that they do not attribute this to inadequate clinical work. The patient will need to be motivated and have a positive outlook if treatment is to provide a c successful outcome.

Key points 1. Consider adhesive methods of repair first g when treating tooth wear. Good moisture control and attention to detail with bonding procedures are required. 2. The prognosis for teeth can be difficult to d ascertain. In severe wear and in teeth which have been heavily restored the prognosis may be poor. When investigating such teeth, the patient should be told of the risk of removal if the prognosis becomes clear that they are uneconomic to repair or Figure 7. (a) Generalized tooth wear with erosion predominating. (b, c) Occlusal views of maxillary and hopeless. mandibular arches. (d) Full arch reconstruction with composite restorations. There are no long-term 3. If space exists and restorations conform studies on the survival of this type of management of tooth wear. (e, f) Occlusal views of dental arches. to the current occlusion, treatment may be (g) Review at 6 years. Composite repairs have been carried out on LL3 and UL7. relatively straightforward. 4. If a re-organized approach is undertaken and the occlusion is to be changed, careful planning is required. Mounted study casts  Increasing the OVD, re-organizing the  Cast metal palatal veneers; are required to produce a diagnostic wax- occlusal scheme in retruded axis position  Indirect ceramic veneers; up or wax try-in. An aesthetic composite (RAP) at a pre-determined vertical relation  Indirect resin restorations; or acrylic mock try-in can be tried in the − This may involve fixed, removable, or a  Direct resin restorations; combination of these options to reconstruct  Combination. patient’s mouth for approval. Digital one or both dental arches. This entails The choice of material to be simulations are also possible. a complex, expensive and extensive used for the restoration is critical. 5. Fixed adhesive or conventional repair treatment with long-term maintenance Unfortunately, the vast majority of with crowns are usually possible if there is (Figure 7). research on the physical properties of at least 50% of the original tooth structure  A combination of the above. restorative materials are laboratory-based remaining. If more tooth tissue is missing, trials. Extrapolation of results to the repair will be more difficult and may variable clinical environment is fraught require crown lengthening surgery. Material choice with difficulty.50 With such uncertainty 6. Interocclusal space for restoration can be Material options available: concerning the likely prognosis of different generated in the following ways:  Cast metal restorations; treatment options, it is reasonable to delay (a) Tooth reduction;  Cast metal ceramic restorations; treatment for as long as possible and (b) Orthodontic movement including the  All-ceramic restorations; provide a conservative approach initially. use of Dahl appliances; 18 DentalUpdate July/August 2018 RestorativeDentistry

a d should be explained to patients.

References 1. Kelleher M, Bishop K. Tooth surface loss: an overview. Br Dent J 1999; 186: 61−66. 2. Eccles JD. Tooth surface loss from b e abrasion, attrition and erosion. Dent Update 1982; 9: 373−381. 3. Addy M, Pearce N. Aetiological, predisposing and environmental factors in dentine hypersensitivity. Archiv Oral Biol 1994; 39: S33-−S38. 4. Mehta SB, Banerji S, Millar BJ, Suarez- Feito JM. Current concepts on the management of tooth wear: part 4. An overview of the restorative techniques and dental materials commonly applied c f for the management of tooth wear. Br Dent J 2012; 212: 169−177. 5. Al-Omiri MK, Lamey PJ, Clifford T. Impact of tooth wear on daily living. Int J Prosthodont 2006; 19: 601−605. 6. Johansson A, Johansson AK, Omar R, Carlsson GE. Rehabilitation of the worn dentition. J Oral Rehabil 2008; 35: 548−566. Figure 8. (a) Generalized tooth wear. (b, c) Occlusal views showing anterior teeth with significant wear 7. Hurst D. What is the best way to restore and more heavily restored posterior teeth. (d) Anterior teeth and premolars have been restored with the worn dentition? Evid Based Dent composite restorations. The heavily restored posterior teeth have been restored with adhesive and 2011; 12: 55−56. conventional cast restorations. (e, f) Occlusal views. The composite restorations would be expected to 8. Bartlett DW, Palmer I, Shah P. An audit of have a median survival of 6−7 years and the conventional crowns of 10−15 years. study casts used to monitor tooth wear in general practice. Br Dent J 2005; 199: 143−145. 9. Loomans B, Opdam N, Attin T, Bartlett D, Edelhoff D, Frankenberger R, et al. (c) Crown lengthening surgery (followed by this cannot be confirmed for full mouth Severe tooth wear: European Consensus further tooth reduction); reconstructions. Statement on Management Guidelines. (d) Increase in occlusal vertical dimension; 9. Conventional crowns have a high J Adhes Dent 2017; 19: 111−119. (e) Occlusal adjustment; biological and financial cost for the 10. Bartlett D. The Relationship between (f) Subapical osteotomy (only for severe patient. They are destructive of tooth Gastro-Oesophageal Reflux and Dental ). tissue, but are successful if planned and Erosion. PhD thesis, United Medical and 7. There is not an ideal material to treat provided carefully. The principles of Dental Schools of Guy’s And St Thomas’ tooth wear. There is a compromise between preservation of tooth structure, retention Hospitals, University of London, London, aesthetic considerations and durability. and resistance form, marginal integrity UK: 1995. Composite and porcelain are brittle and structural durability should be 11. Treasure J, Schmidt U, Troop N, Tiller materials and metals are unaesthetic. observed. J, Todd G, Keilen M et al. First step in Composite, acrylic and type III gold alloys Core materials should be managing bulimia nervosa: controlled do not worsen tooth wear on opposing viewed as ‘space fillers’ rather than adding trial of therapeutic manual. Br Med J 1994; teeth whereas other materials do. Similar strength to the tooth. 308(6930): 686−689. materials should be used if opposing 10. Full mouth reconstructions whereby 12. Hamburger JT, Opdam NJ, Bronkhorst restorations are provided. one or both dental arches are restored are EM, Kreulen CM, Roeters JJ, Huysmans 8. Composite restorations used to particularly demanding of the patient and MC. Clinical performance of direct treat localized anterior tooth wear, the the operator and require postgraduate composite restorations for treatment of ‘Composite Dahl’ technique, have been training. severe tooth wear. J Adhes Dent 2011; 13: shown to be effective over a 10-year 11. The maintenance requirements and 585−593. period with some maintenance. At present uncertain survival of extensive treatment 13. Kelleher MG, Bomfim DI, Austin July/August 2018 DentalUpdate 19 RestorativeDentistry

RS. Biologically based restorative localised anterior tooth wear (ten year 209−213. management of tooth wear. Int J Dent follow-up). Br Dent J 2011; 211: E9. 38. Berry D, Poole D. Attrition: possible 2012; 2012: 742509. 28. Mesko ME, Sarkis-Onofre R, Cenci MS, mechanisms of compensation. J Oral 14. Kesling HD. The diagnostic setup with Opdam NJ, Loomans B, Pereira-Cenci T. Rehabil 1976; 3: 201−206. consideration of the third dimension. Am Rehabilitation of severely worn teeth: a 39. Murphy T. Compensatory mechanisms J Orthod 1956; 42: 740−748. systematic review. J Dent 2016; 48: 9−15. in facial height adjustment to functional 15. Wise MD. Occlusion and restorative 29. Opdam NJ, van de Sande FH, Bronkhorst tooth attrition. Aust Dent J 1959; 4: dentistry for the general practitioner. Br E, Cenci MS, Bottenberg P, Pallesen U Dent J 1982; 152: 316−322. et al. Longevity of posterior composite 312−323. 16. Ramfjord S, Ash M. Occlusion 2nd edn. restorations: a systematic review and 40. Russell M. The distinction between Philadelphia: WB Saunders, 1983. meta-analysis. J Dent Res 2014; 93: physiological and pathological attrition: a 17. Ramfjord S, Ash M. Reflections on the 943−949. review. J Irish Dent Assoc 1986; 33: 23−31. Michigan occlusal splint. J Oral Rehabil 30. van de Sande FH, Rodolpho PA, Basso GR, 41. Dahl BL, Krogstad O, Karlsen K. An 1994; 21: 491−500. Patias R, da Rosa QF, Demarco FF et al. alternative treatment in cases with 18. Capp NJ. Occlusion and splint therapy. Br 18-year survival of posterior composite advanced localized attrition. J Oral Dent J 1999; 186: 217−222. resin restorations with and without glass Rehabil 1975; 2: 209−214. 19. Forssell H, Kirveskari P, Kangasniemi P. ionomer cement as base. Dent Mater: 42. McDonald A, Setchell D. Developing a Changes in headache after treatment official publication of the Academy of tooth restorability index. Dent Update of mandibular dysfunction. Cephalalgia Dental Materials 2015; 31: 669−675. 1985; 5: 229−236. 31. Milosevic A, Burnside G. The survival 2005; 32: 343−348. 20. Forssell H, Kirveskari P, Kangasniemi of direct composite restorations in 43. Ponce EH, Sahli CC, Fernandez JAV. P. Response to occlusal treatment in the management of severe tooth Study of dentinal tubule architecture of headache patients previously treated by wear including attrition and erosion: a permanent upper premolars: evaluation mock occlusal adjustment. Acta Odont prospective 8-year study. J Dent 2016; 44: by SEM. Aust Endod J 2001; 27: 66−72. Scand 1987; 45: 77−80. 13−19. 44. Zaslansky P, Zabler S, Fratzl P. 3D 21. Yip KH-K, Smales RJ, Kaidonis JA. 32. Vailati F. Adhesively restored anterior variations in human crown dentin Differential wear of teeth and restorative maxillary dentitions affected by severe tubule orientation: a phase-contrast materials: clinical implications. erosion: up to 6-year results of a microtomography study. Dent Mater Int J Prosthodont 2004; 17: 350−356. prospective clinical study: Department 2010; 26: e1−e10. 22. Rochette AL. Attachment of a splint to of Fixed Prosthodontics and Occlusion, enamel of lower anterior teeth. J Prosthet School of Dental Medicine, University of 45. Saunders W, Saunders E. Prevalence of Dent 1973; 30: 418−423. Geneva, Switzerland: 2013. periradicular periodontitis associated 23. Nohl FS, King PA, Harley KE, Ibbetson RJ. 33. Kimmich M, Stappert CF. Intraoral with crowned teeth in an adult Scottish Retrospective survey of resin-retained treatment of veneering porcelain subpopulation. Br Dent J 1998; 185: cast-metal palatal veneers for the chipping of fixed dental restorations: a 137−140. treatment of anterior palatal tooth wear. review and clinical application. J Am Dent 46. Edelhoff D, Sorensen JA. Tooth structure Quintessence Int (Berlin, Germany: 1985) Assoc 2013; 144: 31−44. removal associated with various 1997; 28: 7−14. 34. Smales RJ, Berekally TL. Long-term preparation designs for anterior teeth 24. Schmidlin PR, Filli T, Imfeld C, Tepper S, survival of direct and indirect restorations J Prosthet Dent 2002; 87: 503−509. Attin T. Three-year evaluation of posterior placed for the treatment of advanced 47. Ibbetson R, Setchell D. Treatment of the vertical bite reconstruction using direct tooth wear. Eur J Prosthodont Rest Dent resin composite − a case series. Oper Dent 2007; 15: 2−6. worn dentition: 2. Dent Update 1989; 16: 2009; 34: 102−108. 35. Bartlett D Sundaram G. An up to 3-year 300−307. 25. Hemmings KW, Darbar UR, Vaughan S. randomized clinical study comparing 48. Anderson DJ. Tooth movement in Tooth wear treated with direct composite indirect and direct resin composites used experimental malocclusion. Archiv Oral restorations at an increased vertical to restore worn posterior teeth. Biol 1962; 7: 7−15. dimension: results at 30 months. Int J Prosthodont 2006; 19: 613−617. 49. Hemmings KW, Darbar UR. Treatment J Prosthet Dent 2000; 83: 287−293. 36. Tallgren A. Changes in adult face height of tooth wear with direct composite 26. Gow AM, Hemmings KW. The treatment due to ageing, wear and loss of teeth, resin restorations at an increased of localised anterior tooth wear with and prosthetic treatment. A roentgen vertical dimension. J Dent Res 75: 1146 indirect Artglass restorations at an cephalometric study mainly on finnish (Abstract 134). increased occlusal vertical dimension. women. Acta Odont Scand 1957; 15: 50. Bayne S. Dental restorations for oral Results after two years. Eur J Prosthodont 1–122. Rest Dent 2002; 10: 101−105. 37. Thompson JL, Kendrick GS. Changes in rehabilitation–testing of laboratory 27. Gulamali AB, Hemmings KW, Tredwin CJ, the vertical dimensions of the human properties versus clinical performance for Petrie A. Survival analysis of composite male skull during the third and fourth clinical decision making. Dahl restorations provided to manage decades of life. Anat Rec 1964; 150: J Oral Rehabil 2007; 34: 921−932. 20 DentalUpdate July/August 2018 RestorativeDentistry

Ken Hemmings

Angharad Truman, Sachin Shah and Ravi Chauhan

Tooth Wear Guidelines for the BSRD Part 3: Removable Management of Tooth Wear Dent Update 2018; 45: 20–26

Removable prostheses can be used alone cost associated with fixed prosthodontic root fractures, horizontal/oblique fractures or in combination with fixed prosthodontic treatment is taken into account. The to bone crest, caries to bone crest, failed treatment to manage tooth wear (TW). It remaining coronal tooth tissue can be endodontics; is an accepted mode of treatment that can used to support, retain and/or stabilize a -Concurrent soft tissue defects; fulfill the aims of restoring the appearance, removable prosthesis. A partially dentate -The additional time and cost function and/or speech of patients with patient with advanced tooth wear may add involved. worn dentitions.1,2 more credence to this form of treatment. The lack of coronal tooth tissue Patients will need to be made in cases of severe tooth surface loss can aware of the limitations associated Contra-indications for make fixed prosthodontic treatment with removable appliances, the added removable management of more challenging and less predictable. maintenance and potential risks to the tooth surface loss Removable prosthodontic treatment remaining dentition. Patient compliance, Patients unable to tolerate a may be more appropriate in these cases, adaptation and managing expectations removable prosthesis. especially when the additional time and will also be key to providing a successful outcome. Aims of removable management Ken Hemmings, BDS, MSc, DRD RCS, MRD Indications for removable management of tooth surface  Restore appearance; RCS, FDS RCS, ILTM, FHEA, Consultant in  Restore function; Restorative Dentistry, Eastman Dental Hospital loss  Protect the remaining dentition;  Severe generalized tooth surface loss; and Institute, UCLH Trust and private practice,  Re-establish the occlusal vertical  Severe generalized tooth surface loss Angharad Truman, BDS(Hons), MFDS RCPSG, dimension if this has been reduced. PGCME, FHEA, Specialty Registrar in Restorative in a partially dentate patient with long Dentistry, Bristol Dental Hospital, Sachin Shah, edentulous spans and/or distal extensions; BDS, MFDS RCS, MClin Dent(Pros), MRD RCS,  Tooth surface loss in a patient well Definitions Specialist Prosthodontist in private practice/ adapted to wearing removable prostheses; The following terms will be Clinical Teaching Fellow, Eastman Dental  Patients who may not be suitable for used to describe the various removable Hospital and Institute, 256 Gray’s Inn Road, fixed prosthodontic treatment due to the appliances: London, WC1X 8LD and Ravi Chauhan, MDDr, following reasons: 1. Overdenture: a denture that MSc, MJDF RCS(Eng), MFDS RCS(Edin), Specialty - Worn teeth compromised by replaces the worn or missing teeth with Registrar in Restorative Dentistry, King's College periodontal disease and/or extensive caries; prosthetic teeth and an acrylic flange3 Dental Hospital, London, UK. - Unrestorable teeth − vertical (Figure 1). July/August 2018 DentalUpdate 21 RestorativeDentistry

a a a

b b b

Figure 1. (a, b) Overdenture abutments can be Figure 2. (a, b) Onlay provisional denture to test vital or non-vital teeth. Ideally, they should be an increase in the OVD. The onlays have to be Figure 3. (a, b) Anterior overlays on a metal 2mm supra-gingival. Re-inforced acrylic has been refined in the mouth for an accurate fit. A low framework partial denture. Refinement in the used. Often a metal strengthener is needed for lip line made this appearance acceptable for this mouth is usually necessary for accuracy of fit and durability. patient. a good appearance.

2. Overlay denture: a denture increased levels of plaque accumulation dentures at an advanced age. Extracting that covers the worn teeth with a full labial when oral hygiene is inadequate.7 It is the remaining teeth, no matter how heavily veneer facing3 (Figure 2). therefore even more critical that patients restored or worn, has therefore become 3. Onlay denture: a denture that are given clear instructions on maintaining a less frequently practised option. It can, covers the occlusal or incisal surfaces of the excellent oral hygiene and advised to leave however, still be a pragmatic option if abutment teeth3 (Figure 3). their removable prostheses out at night. there are only a few teeth remaining that Combinations of the above can be Failure to do so may quickly lead to failure are beyond saving, and if the patient is not used on the same prosthesis. of strategic abutment teeth and further suitable for complex treatment. Anecdotally, challenges for the patient and clinician. it is thought that many bruxist patients Removable management transform into maladaptive denture- Severely worn teeth cannot wearing patients. The high occlusal loads always be restored through fixed Managing patient expectations lead to early mucosal trauma and ridge prosthodontic means. They may be present It is important for patients to resorption. Careful planning and care at in combination with long edentulous spans have realistic expectations of removable every stage during the process of making that also require soft tissue replacement. prostheses. They must be informed of their complete dentures will be required. An Removable prostheses can help to replace limitations from the outset so that they implant-supported mandibular overdenture soft tissues and provide lip support. They do not attribute this to inadequate clinical can be considered as a further treatment can also be designed to have further teeth work. option in this cohort of patients to facilitate added to them in the future. and improve this transition.9,10 These will still Not all teeth necessarily require be subjected to high occlusal load in bruxist replacing. Patients can function well with Treatment options patients. 10 pairs of occluding units or a second Extracting the remaining teeth and providing premolar to second premolar occlusion.4,5 complete dentures Complete or partial overdentures Patients presenting with severe tooth Patients are retaining more It can be more appropriate to wear often do so because it affects their teeth for a longer period of time due to reduce the teeth further when they are anterior teeth. Compliance with removable the increase in life expectancy, fluoride severely worn and provide either complete prostheses has been shown to be better availability and improved oral hygiene or partial overdentures. These appliances when they replace and/or restore the practices.8 The increase in age, together replace the worn teeth with prosthetic anterior dentition.6 with increasing expectations, means that teeth and an acrylic flange. The following Despite the benefits of patients often have a lower adaptive advantages can be gained from doing this: removable prostheses, they can lead to capacity and ability to manage complete  Provide the psychological benefit of 22 DentalUpdate July/August 2018 RestorativeDentistry

tooth retention, creating a more positive and when smiling. An onlay type design will occurs when the rate of the tooth wear is attitude to dentures;11 not be aesthetic if the butt joint is visible in too fast for the physiological mechanisms  Maintain continued proprioceptive function and on smiling. An acrylic veneer of tooth eruption to keep up. There is feedback with the preservation of terminating at the will be therefore a resultant increase in free- 12,13 periodontal mechanoreceptors; more attractive in these situations. way space and loss of occlusal vertical  Decrease the rate of residual ridge  The path of insertion of the denture. dimension. resorption and therefore maintain added Gaining a favourable path of insertion Patients with compensated tooth support and stability.14,15 They can also for acrylic veneer facings may eliminate wear will usually have a complete dentition provide lip support if located anteriorly; favourable undercuts for clasping and treatment with removable prostheses  Can provide added retention, improved posteriorly and needs to be considered will rarely be indicated.1 Partially dentate masticatory efficiency and better control of when designing the denture. patients with loss of the posterior dentition mandibular movements;16  Further retention can be gained from the and wear affecting the anterior teeth will Partial dentures in combination with adhesive addition of precision attachments such as usually present with non-compensated or conventional fixed prosthodontics magnets or stud attachments; tooth wear and a loss of OVD, making Teeth that have not been  Replace soft tissue through the use of a it necessary to provide treatment with affected by wear can be modified so flange; removable prostheses. These patients will that they can help to retain, support and  Improve the crown-root ratio and often have an unacceptable occlusal plane stabilize a removable prosthesis. The therefore limit damaging lateral forces. and the following can be used to determine following features can be considered when There are, however, disadvantages the correct occlusal vertical dimension: designing the denture: associated with this treatment option that 1. The point of first contact along  Preparation of guide planes on abutment include: the retruded arc of closure (RAP) if there teeth to limit the ways in which the denture  A reduction in the space available for are unworn teeth posterior to the worn can be displaced and provide added the prosthetic teeth and denture base. This anterior teeth. This will be the retruded reduction can lead to weakness and the stability;  Additions can be made to teeth with contact position (RCP) and may provide the increased likelihood of developing a fatigue required space to restore the worn anterior fracture;17 composite resin to alter their contour and dentition;  Caries affecting the overdenture provide favourable undercuts for clasping;  2. Photographs of the patient’s abutments can be a problem due to plaque Consider restoring teeth that have large teeth prior to being worn; accumulation under the denture base if the plastic restorations with milled extra- 3. Tooth display at rest and on patient does not have a good preventive coronal restorations that have guide planes, regimen;11,18-21 ledges and/or rest seats. smiling;  Similarly, poor plaque control can lead to Damaging occlusal forces on worn 4. Amount of posterior prosthetic periodontal breakdown;18 anterior teeth restored with adhesive or space required, if necessary;  Severely worn teeth do not always conventional crowns should be considered 5. Phonetics; require root canal treatment due to the if the partial dentures only replace posterior 6. Use of a provisional denture for continued deposition of secondary dentine. teeth. Compliance with wearing dentures is between 6 weeks and 6 months. 22,23 However, there is always a risk of pulp reduced in this cohort of patients. The recording of the OVD exposure when reducing teeth. is usually carried out using occlusal Preliminary investigations registration rims. Edentulous patients will The following should be Complete or partial onlay or be less tolerant to changes in the occlusal investigated in relation to providing overlay dentures vertical dimension than dentate patients removable prostheses for tooth wear. The occlusal or incisal surfaces (Figure 4). of worn teeth can be restored with an onlay or overlay type appliance without a flange. Assessing the occlusal vertical dimension Assessing severely worn Onlay type appliances can be useful for Restoring the worn dentition to abutment teeth moderately worn posterior teeth to restore the correct occlusal vertical dimension will As mentioned earlier, a severely the surfaces of these teeth and re-establish form the basis of treatment. In the absence worn tooth does not necessarily need the correct occlusal vertical dimension. The of tooth wear the free-way space remains to be condemned. It can be retained as occlusal surfaces can be made of a cobalt- constant due to the continued growth chromium alloy and can be made to be an and increase in anterior facial height into an overdenture abutment. The following integral part of the denture framework to middle age.24,25 Tooth wear, however, leads factors need to be considered if a tooth is to increase their durability. to the continued eruption of teeth so that be retained as an overdenture abutment: The choice between an onlay the free-way space remains constant and  The periodontal health of the abutment or overlay design for anterior teeth will so do the proportions of the face. This is tooth. At least five millimetres of alveolar depend on the following factors: commonly known as compensated tooth bone support has been recommended,28,29  The height of the upper lip in function wear.26,27 Non-compensated tooth wear together with an adequate band off July/August 2018 DentalUpdate 23 RestorativeDentistry

a d especially if the original cause is attrition;  Break the proprioceptive feedback from periodontal mechanoreceptors resulting in muscle relaxation that will facilitate the accurate recording of the retruded axis position;37  Useful for testing tolerance to the planned changes in occlusal vertical b dimension.38,39 e Partial coverage splints should be avoided due to selective intrusion and extrusion of teeth. The resulting malocclusion can be difficult to correct.

Provisional appliances Fully acrylic provisional appliances that have an overdenture, onlay and/or c overlay design can be provided to test f changes in occlusal vertical dimension, aesthetics, phonetics and function. They can also be used to test the patient’s tolerance and adaptive capacity to removable appliances. They should be designed and made with the same care as a definitive denture. They can be modified, ie relined or adjusted, whilst abutment Figure 4. (a, b) Non-compensated tooth wear in a depleted dentition. Clinical appearance reproduced teeth are being prepared to receive in mounted study casts. (c, d) Increase in OVD determined in the laboratory. Upper and lower wax try- extracoronal restorations or being built-up ins made. (e, f) Provisional upper and lower partial overdentures in place for patient approval. with composite resin prior to making the definitive dentures.

attached gingival tissues.30 the space: Definitive dentures  The height of the overdenture abutment  The site and extent of spaces. Are the The ideal features of the should be one and a half to two millimetres spaces bounded or free end saddles?; provisional appliance should be carried above the gingival margin and dome-  Have any teeth drifted, tilted or over- forward to the definitive denture. These shaped.31 The reduction in crown root ratio erupted into the resulted space? This can be include the proposed changes to the will reduce the mobility of the tooth.32 more readily assessed on a set of accurately occlusal vertical dimension and aesthetics.  Reducing a tooth will expose more mounted casts; A wax try-in will be required if any further dentinal tubules and less calcified dentine,  What is the condition of the soft tissues changes are proposed. making the pulp more vulnerable to overlying the ridge? The definitive denture should fulfil the cariogenic bacteria.33,34 A good level of oral following aims: hygiene is therefore paramount. It has been Diagnostic phase  Increased durability; shown that overdenture abutments can be Occlusal splints  Reduced bulk; maintained in older patients with a history An upper, hard, heat-cured, full  Improved cleansability; of primary dental disease by four to five coverage acrylic splint with (provisional  Decreased maintenance. recall visits per year.35 denture) or without teeth can be used in The definitive denture should be designed the diagnostic phase. They should provide prior to considering any irreversible changes Assessing spaces even contact along the retruded arc of Spaces should be assessed in closure with anterior guidance on anterior to the abutment teeth. The changes to the three dimensions that should include inter- teeth with posterior disclusion and canine abutment teeth can then be made taking occlusal, mesio-distal and bucco-palatal guidance in lateral excursions.36 They can into account the materials to be used to measurements. The following should be provide the following benefits: construct the definitive denture. considered when making an assessment of  Protect worn teeth from any further wear, The stability of dentures and patients’ 24 DentalUpdate July/August 2018 RestorativeDentistry

a  Potential for future relining; without thin or sharp edges and can  Low initial cost. be chemically bonded to the acrylic Denture bases can be metal- or resin-based resin base or attached to a metal base Acrylic resin bases need be at through mechanical retention or chemical least two to three millimetres thick, can be bonding. An adhesive containing aesthetic and easily adjusted and relined. 4-methacryloxyethyltrimellitic anhydride They can, however, release internal strains (4-meta) can be used to bond acrylic that may lead to distortions and can be resin to metal-based dentures. A chemical more prone to accumulate deposits, be union can make the junction more bulky and less abrasion resistant.40 If this is hygienic. The low abrasion resistance b not possible, some form of strengthening of can make this material easy to adjust but the denture base should be considered. prone to accelerated wear in patients Metal-based dentures that can with parafunctional habits. Acrylic resin be cast in either gold, chrome or titanium prosthetic teeth can provide a natural alloys are more difficult to reline and adjust. appearance and are the kindest material for They do, however, have the following opposing teeth. advantages:  Can be cast more accurately than acrylic Chrome alloy resins, resulting in better adaptation to the Chrome alloy prosthetic teeth underlying tissues; can be cast in thin section and are therefore Figure 5. (a) Macromechanical and  Are more abrasion resistant; useful when space is limited. They still micromechanical retention needs to be applied  Cleanliness, due to the bacteriostatic provide good strength and rigidity in thin to the partial denture design, in this case with nature of metal bases; section. They can be cast as part of the beads and struts to retain anterior overlay  Transmission of temperature changes to overall framework but their appearance veneers. (b) Further protection of acrylic the underlying tissues; will limit their use to posterior sections of components with palatal backings, in this case  Can be cast in thin section, limiting their mouth and as palatal backings on anterior extended up to the incisal edge. bulk without compromising on strength teeth. They can, however, be difficult to and rigidity. adjust and also abrasive to opposing natural teeth when they lose their surface polish. Chrome alloy prosthetic teeth can be useful adaptation to them will be increased if Prosthetic teeth for covering the worn occlusal surfaces of guidance in excursions is maintained on The material used for replacing posterior teeth with an onlay type design in the natural teeth. In the depleted dentition missing tooth tissue will be influenced by patients with parafunctional habits. it is more likely that a bilateral balanced the following factors: occlusion should be provided.  The amount of prosthetic space available; Gold alloy  The material used for the denture base; Gold alloy prosthetic teeth will Materials  The presence of parafunctional habits; cause the least abrasion to natural teeth Denture base  Aesthetics, ie is the material visible on and can be more easily adjusted. Cast gold The retention of teeth as smiling and in function; occlusal surfaces can be attached to acrylic overdenture abutments will limit the  The position of the tooth in the arch, ie resin teeth and can be useful in patients amount of space available for the denture anterior or posterior; who parafunction. base and prosthetic teeth. This can  The surface of the tooth to be covered, ie therefore pose challenges when managing occlusal, labial, palatal; Ceramic patients with wear.  The opposing material. Tooth-coloured veneering The ideal denture base should materials can be the weak link in the meet the following requirements:40 Materials durability of partial and complete dentures  Accuracy of adaptation to the tissues Materials commonly available made for patients with tooth wear. with minimal volume change; include: Macromechanical and micromechanical  Dense, non-irritating surface capable of  Acrylic resin; retention needs to be applied to the receiving and maintaining a good finish;  Chrome alloy; denture design. Retentive beads, ‘nail heads’  Thermal conductivity;  Gold alloy; and struts can be combined with palatal  Low specific gravity;  Ceramic. metal backings to protect acrylic, composite  Lightweight in the mouth; or porcelain components. On occasion,  Sufficient strength; Acrylic resin these backings or onlays need to be  Easily kept clean; Acrylic resin prosthetic teeth extended up to the incisal edge or occlusal  Aesthetic acceptability; need to be provided in sufficient bulk contacting surfaces (Figure 5). July/August 2018 DentalUpdate 25 RestorativeDentistry

a a this. If their teeth have been worn down or fractured, patients will exert the same forces on their restorations. If a patient is prepared to use an occlusal splint on a regular basis adverse events can be reduced. Furthermore, well designed and executed prosthodontics can give these patients a welcome break from the restorative spiral downwards with the loss of restorations and teeth. b b Concluding remarks Dentists will be treating more patients with tooth wear as the population ages. There are many challenges ahead for the dental team in providing high quality dentistry for these patients. There have been many technological improvements over the years to help with providing care. Figure 7. (a, b) A precision retainer complete Figure 6. (a) Failure of an acrylic complete over- overdenture requiring considerable clinical and As a profession we will need to continue denture. (b) Failure in a partial metal framework laboratory skill. An enthusiastic patient following to develop new techniques to deliver cost- denture. A more robust design could avoid early a strict maintenance regimen will be required to effective and successful treatments for our failure in the future. prevent early failure. patients.

Key points 1. Removable or fixed and removable Maintenance to the overdenture abutment in the management of tooth wear may be The cohort of patients treated morning.42 The patient should not eat for indicated in the following circumstances: with removable prostheses for worn teeth 30 minutes following this to maximize (a) Severe wear; are usually older and have a number of other effectiveness;43 (b) Multiple missing teeth and tooth wear; missing teeth. These have often been lost  Clean the dentures after meals. (c) Soft tissue defects; as a result of plaque-associated disease and An occlusal splint with or without (d) Long spans or distal extension; so these patients are often at high risk of replacement teeth can be made for the (f) Primary disease or uncertainty with the caries and periodontal disease. This is often patient to be worn at night to protect the prognosis of some teeth; compounded by diminished fine motor abutment teeth from parafunction. If the (g) Cost. skills so that cleaning may still be ineffective, denture design has not been robust, early even if patients are motivated. Plaque failures should be expected (Figure 6). 2. If a re-organized approach is undertaken accumulation will also tend to increase in the All of the above should be supplemented and the occlusion is to be changed, careful presence of removable prostheses.7 These with regular recall as appropriate to review planning is required. Mounted study casts patients must therefore be managed similarly the abutment teeth, soft tissues and are required to produce a diagnostic wax- to patients with a high caries risk.41 removable prostheses (Figure 7). up or wax try-in. An aesthetic composite It is therefore of utmost importance or acrylic mock try-in can be tried into that patients change their behaviours to the patient’s mouth for approval. Digital prolong the survival of their abutment teeth. Maintenance care simulations are also possible. Patients should be instructed to do the By definition patients treated for 3. A diagnosis of compensated or non- following: tooth wear are heavily restored and need compensated wear should be made early in  Brushing the abutment teeth including more frequent review and maintenance care. treatment planning. overdenture abutments with a high fluoride Dental caries and periodontal disease can 4. Planning follows conventional concentration toothpaste; be worsened by the placement of multiple prosthodontic protocols with consideration  Use a daily fluoride mouthrinse at a restorations or by using an overdenture. for: different time from brushing; Preventive and periodontal care with (a) Saddles;  Leave the dentures out at night and soak a reliable recall system will help with (b) Support; these in a denture-cleansing solution; preventing primary disease. (c) Retention;  Apply a high fluoride concentration gel to Biomechanical failures should (d) Bracing and reciprocation; the fit surface of the denture corresponding also be expected and the patient informed of (e) Major connectors; 26 DentalUpdate July/August 2018 RestorativeDentistry

(f) Indirect retention. 2. Packer ME, Davis DM. The long-term denture. A clinical survey. Br Dent J 1959; 107: management of patients with tooth surface 57−62. 5. Partial or complete dentures for tooth loss treated using removable appliances. Dent 23. Witter DJ, Van Elteren P, Kayser AF. Oral wear patients may have one or more special Update 2000; 27: 454−458. comfort in shortened dental arches. J Oral components: 3. Hemmings KW, Howlett JA, Woodley NJ, Griffiths Rehabil 1990; 17: 137−143. BM. Partial dentures for patients with advanced 24. Tallgren A. Changes in adult face height due to (a) Overdenture; tooth wear. Dent Update 1995; 22: 52−59. ageing, wear and loss of teeth and prosthetic (b) Onlay; 4. Kayser AF. Shortened dental arches and oral treatment. Acta Odont Scand 1957; 15(Suppl (c) Overlay. function. J Oral Rehabil 1981; 8: 457−462. 24): 73. 5. Kanno T, Carlsson GE. A review of the shortened 25. Thompson JL, Kendrick GS. Changes in the 6. An increase in the occlusal vertical dental arch concept focusing on the work by the vertical dimension of the human skull during dimension (OVD) can often be guided by: Kayser/Nijmegan group. J Oral Rehabil 2006; 33: the third and fourth decades of life. Anat Rec (a) The former appearance; 850−862. 1964; 27: 209. 6. Jepson NJA, Thomason JM, Steele JG. The 26. Murphy T. Compensatory mechanisms in (b) Mandibular rest position and assessment influence of denture design on patient facial height adjustment to functional tooth of the free-way space; acceptance of partial dentures. Br Dent J 1995; attrition. Aust Dent J 1959; 4: 312−323. (c) Former crown height; 178: 296−300. 27. Berry DC, Poole DFG. Attrition: possible 7. Addy M, Bates JF. Plaque accumulation following mechanisms of compensation. J Oral Rehabil (d) OVD at the RCP; the wearing of different types of removable 1976; 3: 201−206. (e) Acceptance using a provisional denture for partial dentures. 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Zaslansky P, Zabler S, Fratzl P. 3D Variations good denture design and be used in thick Overdentures in General Dental Practice 3rd edn. in human crown dentin tubule orientation: a section of at least 2 mm to be durable. Cobalt London: British Dental Association, 1993. phase-contrast microtomography study. Dent chrome is strong in thin section. Advances 13. Kay WD, Abes MS. Sensory perception in Mater 2010; 26: e1−10. overdenture patients. J Prosthet Dent 1976; 35: 35. Budtz-Jørgensen E. Prognosis of overdenture in metal primers and treatments have 615−619. abutments in elderly patients with controlled increased the bond between these materials. 14. Crum RJ, Rooney GE Jr. Alveolar bone loss in oral hygiene. A 5-year study. J Oral Rehabil Composite, porcelain, gold alloys and flexible overdentures: a 5-year study. J Prosthet Dent 1995; 22: 3−8. 1978; 40: 610−613. 36. Wise MD. ln: Occlusion and Restorative Dentistry rubbers are alternative materials. 15. 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