Aetiology and Management of tooth wear

Contents
Introduction, Aetiology, Diagnosis and treatment planning, Management Strategies
Conclusion, References
Introduction
The term tooth wear (TW) is a general term that can be used to describe the surface loss of
dental hard tissues. It is a normal physiological process that is macroscopically irreversible
and is cumulative with age. The normal physiologic wear of enamel is approximately 2038m per annum (Lambrechts et al, 1989).
Physiologic wear results in both shortening the vertical length of teeth and narrowing the
horizontal width of teeth. The vertical dimension of occlusion is maintained even when rapid
abrasive wear occurs. As the occlusal surfaces of the teeth wear, the dento alveolar process
elongates by progressive remodelling of the alveolar bone. The increase in vertical length of
alveolar process matches the loss of occlusal height, and so the vertical dimension of lower
facial height is maintained at a constant dimension. The horizontal dimension of length
around the arch is shortened by several millimetres during life. The proximal wear is
compensated by a constant forward pressure that keeps the contacts together. These adaptive
process continue to function throughout life and helps to maintain the dentition intact.
Pathologic/ excessive wear refers to any level of occlusal wear that can be expected to require
corrective interventions in order to preserve the dentition. This results in unacceptable
damage to occluding surfaces, and destroys anterior tooth structure that is necessary for
acceptable anterior guidance.
Aetiology
The process of tooth wear has a multi-factorial aetiology. The term tooth surface loss (TSL)
was suggested by Eccles in 1982 to embrace all of the aetiological factors regardless of
whether the exact cause of wear has been identified.
There are four sub-classifications of tooth wear lesions:
Attrition
Erosion
Abrasion
Abfraction.
1. Attrition
It is defined as wearing away of one tooth surface by another tooth surface. Excessive
wear can result in pulpal pathology, impaired function, occlusal disharmony and
aesthetic disfigurement. Lesions due to attrition are most commonly observed to occur
on the incisal and occlusal contacting surfaces. The early clinical manifestation of
attrition is the appearance of a small polished facet on the cusp or ridge, or the slight
flattening of an incisal edge. As the lesion progresses, there is a tendency towards the

reduction of the cusp height and flattening of the occlusal inclined planes, with
concomitant dentine exposure. In severe cases there may be a marked shortening of
the clinical crown height of the affected tooth/teeth respectively.
2. Erosion.
It has been defined as the loss of tooth surface by a chemical process that does not
involve bacterial action. It is caused by the chronic exposure of dental hard tissues to
acidic substrates which may be of an intrinsic or extrinsic source.
The consumption of soft drinks in the UK has increased seven fold between the 1950s
and 1990s (Shaw and Smith, 1999), with adolescents and children accounting for 65%
of all purchases. The pH of these carbonated drinks fall in the range of 2.5-3.8
The presence of a gastro-oesophageal reflux as seen in patients diagnosed with
anorexia nervosa, bulimia nervosa or those with hiatus hernia, sphincter
incompetence, oesophagitis, or increased gastric pressure (and volume) may also be
associated with considerable erosive wear. It has been reported that female patients
are affected by eating disorders more frequently than males at a ratio of 10:1.5.
Cyclical vomiting syndrome and voluntary regurgitation (rumination) have also been
reported as aetiological conditions respectively. Pregnancy may also increase the risk
of developing tooth wear, as it has been suggested that an increase in abdominal
pressure may predispose the patient to regurgitation, whilst morning sickness may be
associated with frequent episodes of vomiting, which may further exacerbate the wear
pattern seen. A history of heartburn or reflux is a key factor to note, although in
subclinical cases there may be a lack of patient awareness. Gastric reflux may also be
associated with oesophageal carcinoma.
Medication, such as the frequent use of asthma inhalers containing steroid or
effervescent medication, may contribute to dental erosion. It has been suggested that
the pH values of common asthma medications range from 4.31 (Bricanyl, powder
form), to 9.30 (Ventolin, aerosol form). Medications in tablet form such as aspirin
(salicylic acid) and chewable vitamin C preparations (ascorbic acid) as well as various
iron preparations have also been associated with dental erosion. Other drugs through
inducing xerostomia may also be causative (by virtue of reducing the protective effect
offered by saliva) such as diuretic agents and antidepressant drugs.
Erosive tooth wear has also been reported to occur amongst frequent swimmers as a
consequence of being exposed to chlorine in swimming pools; erosive wear affecting
the labial surfaces of maxillary anterior teeth has also been described to occur
amongst copper mine workers, who may be exposed to ambient sulphuric acid used in
the mining of this metal.
Other factors contributing to the development of xerostomia are sometimes indirectly
causative.
Erosive lesions typically manifest as bilateral concave defects without the chalkiness
or roughness normally associated with bacterial acid decalcification. In its early
stages, erosion affects the enamel layer, resulting in a shallow, smooth, glazed surface
that usually lacks developmental ridges and stain lines and are usually free from

plaque deposit. With progression, dentine exposure will occur and the lesion may take
on a rather dulled appearance. In more severe cases there may be evidence of
cupping of both the occlusal surface of posterior teeth and the incisal edges of
anterior teeth. Extrinsic erosion is often seen to occur on the labial surfaces of
maxillary anterior teeth, typically in the form of scooped out depressions, whilst
lesions initiated by intrinsic acid sources are most often seen on the palatal surfaces of
the maxillary anterior teeth, resulting in a concave depression of the entire palatal
surface. The term perimolysis has been used to describe the classical lesions seen as a
result of chronic vomiting, localised to the palatal surfaces of the maxillary anterior
teeth.
Hattab et al. suggest that erosion seems to be the most common cause of tooth surface
loss, with regurgitation erosion causing the most severe damage.
3. Abrasion
It is the physical wear of tooth surface through an abnormal mechanical process
independent of occlusion. It involves a foreign object or substance repeatedly
contacting the tooth (Shafer et al). The site and pattern of lesion is usually determined
by the offending object. A common cause of abrasion is the habit of overzealous tooth
brushing. Factors such as the type of toothbrush used, the intensity, the frequency and
timing of tooth brushing as well as the abrasivity of the dentifrice being used should
be analysed.
Lesions are typically rounded or V shaped ditches seen on the buccal/labial surfaces
in the region of the cement-enamel junction Canine and premolar teeth seem to be
most commonly affected. Notching of the incisal edges on maxillary central incisor
teeth is often seen as a result of habits such as the biting of tacks, nails, pins, threads,
a pipe stem, hair pins or a wind instrument.
4. Abfraction
It has been defined by Imfeld as the loss of hard tissue from eccentric occlusal loads
leading to compressive and tensile stresses at the cervical fulcrum area of the tooth.
Tensile stresses weaken the cervical hydroxyl-apatite, which has the effect of
producing classical wedge shaped defects with sharp rims at the cement-enamel
junction. Lesions are less commonly seen amongst teeth which may display signs of
mobility, but are often typified by the presence of recurrently failing cervical
restorations. The extent of the lesions is dependent on the size, duration, direction,
frequency and location of the forces concerned. Lesions due to abfraction have also
been described in the literature as cervical stress lesions.
Other causes of tooth wear are
Congenital Abnormalities
Among the congenital abnormalities, amelogenesis imperfect and dentinogenesis
imperfecta are important conditions that may cause accelerated wear of teeth because
of softness of enamel or dentine.
Amelogenesis imperfecta is of three types; hypoplastic, hypomaturation and
hypocalcified. In the hypoplastic type, the enamel has one-eight to one-forth of the

normal thickness. The enamel thickness in hypomaturation and hypocalcified type is

normal. However, the enamel in hypomaturation is softer, whereas the enamel in
hypocalcified type is friable. It may show autosomal dominant, autosomal recessive,
sex-linked and sporadic inheritance patterns. Mutations in the amelogenin, enamelin,
and kallikrein-4 genes have been demonstrated to result in different types of AI.
Dentinogenesis imperfecta is a hereditary developmental disturbance of the dentin
originating during the histodifferentiation stage of tooth development. DI may be seen
alone or in conjunction with the systemic hereditary disorder of the bone,
osteogenesis imperfecta. In all three DI types, the teeth have a variable blue-gray to
yellow-brown discoloration that appears opalescent due to the defective, abnormallycolored dentin shining through the translucent enamel. Due to the lack of support of
the poorly mineralized dentin, enamel frequently fractures from the teeth leading to
rapid wear and attrition of the teeth.
Bruxism and other Parafunctional habits
Both diurnal and nocturnal bruxism have been found to be related to
extensive tooth wear. Careful questioning of patient and family
members is will reveal the cause. Bruxism may be triggered by
occlusal interferences.
Other parafunctional habits include chewing tobacco, pipe smoking,
pencil or pen biting, and holding objects between teeth. These
habits are usually associated with emotional stress.
Loss of posterior support.
Extensive attrition of anterior teeth often occurs when posterior
support has been compromised by loss of teeth, malposition of
teeth, or occlusal interference that drives the mandible forward and
excerts undue force on the anterior teeth.
Iatrogenic
Unglazd porcelain restorations cause abrasion of opposing natural
teeth.
Management
Diagnosis and treatment Planning
The successful management of any case of tooth wear is based on deriving an accurate diagnosis, having a clear understanding of the basic principles of occlusion, and a
good working knowledge of available materials and techniques to treat such cases
using both active and passive means. Treatment planning for cases displaying tooth
wear can often be fairly complex.
Common complaints associated with dentitions displaying tooth wear include concerns relating to:
Aesthetic impairment (fractured, unattractive teeth/restorations or tooth
discoloration)
Difficulties with function, such as the efficiency of mastication or lip/cheek or
tongue biting
Less commonly, comfort (pain and sensitivity).

A detailed history of the chief complaint should be ascertained and documented.

Accurate and up-to-date medical history must be obtained. The medical history may
reveal underlying conditions which preclude the provision of complex treatment
plans, and may also provide a valuable insight into the aetiology of the wear pattern
observed to be present.
The patients social history can reveal further insight into the aetiology, such as
lifestyle stresses or occupational details
Habits such as smoking, alcohol consumption or dietary trends should be documented. A detailed dietary analysis is often advocated. The frequency and quantity of
daily intake, the duration of consumption and the method of eating/drinking should be
established. Watson and Burke have suggested that patients affected by tooth wear
should undertake a three day consecutive comprehensive diet diary.
Extra-oral examination must include a meticulous assessment of their temporomandibular joints and associated musculature. The presence of any joint or muscle
tenderness, clicking, crepitation, mandibular deviation on opening or closure or any
associated aches/ pain should be noted. The maximum jaw opening should be
recorded (that less than 40 mm between incisal edges is considered to be restricted).
The presence of parotid gland enlargement is often seen in bulimic patients and may
be an important feature to note.
The facial vertical proportions should also be carefully examined. This should include
an assessment of the freeway space (FWS), by determining the patients resting
vertical dimension (RVD) and occlusal vertical dimension (OVD), with the aid of
callipers or by the use of a Willis gauge.
Other techniques that can be used for the evaluation of vertical dimension include the
use of phonetic assessments (particularly the sibilant sounds), facial soft tissue
contour analysis, jaw tracking and the use of electrical muscle stimulation techniques
(Rivera-Morales and Mohl). The smile line and lip line should also be noted, as well
as any midline discrepancies.
The intra-oral examination must include a detailed soft tissue assessment. The presence of buccal keratoses, scalloping of the tongue or signs of xerostomia may give
clues to the possible aetiology. Saliva has a vital role in the protection of enamel from
erosion by acid, both by supplying the components of the acquired pellicle that coats
the enamel surface and thereby conferring some level of protection, and also by virtue
of its buffering capacity, promoting the remineralisation of the enamel surface
following acid attack.
The level of oral hygiene should be recorded together with the undertaking of a Basic
Periodontal Assessment (BPE). The latter may indicate the undertaking of a full depth
six point periodontal chart.
A dental chart should be completed, detailing the presence or absence of teeth, dental
caries, restorations, failed restorations, fractures, abrasions and erosive lesions.

Once diagnosed the location of tooth wear (localised, anterior/posterior or generalised) and severity of the tooth surface loss should be recorded (as being restricted
to enamel only, into dentine or severely affecting the teeth or series of teeth).
A number of indices have been proposed for the above purpose. The Tooth Wear
Index of Smith and Knight is most commonly described in literature.
A comprehensive occlusal assessment is mandatory. The overbite and overjet should
also be measured and recorded.
The presence of a stable centric occlusion (CO) should be determined, and tooth
contacts in the intercuspal position (ICP) described. The ease with which the patient
can be manipulated into their retruded arc of closure should also be established.
Where a patient cannot be readily manipulated into centric relation (CR), due to protective neuromuscular reflexes, the use of deprogramming devices should be considered; commonly used examples of such deprogramming devices range from the use of
cotton wool rolls and wood spatulas, to more elaborate appliances such as anterior
bite planes (Lucia jig) or full coverage stabilisation splints.
The first point of tooth contact in CR, hence the retruded contact point (RCP) should
be identified and the presence of any slides (and the direction of the latter) from CR
to CO established.
Tooth contacts during lateral excursive (canine guidance or group function) and
protrusive movements of the mandible should be determined. If present, any working
side/non-working side occlusal interferences should be described.
Where the patient may be partially dentate, an evaluation of the denture bearing areas
must be undertaken, as well as the fit of any removable prostheses.
The first consideration is to identify and try to eliminate or reduce the factors that may
contribute to excessive wear of teeth.

SEVERITY OF TOOTH WEAR

It is also important to establish the severity of tooth wear seen. Subdividing cases into those
where the severity of tooth wear may be considered to be normal or physiological for that
persons age, or excessive, unacceptable or pathological in relation to what is considered to
be acceptable for an individual of a certain age grouping. For cases of physiological wear,
particularly where there may be no aesthetic or functional detriment, or any associated
symptoms of discomfort, management strategies as discussed below may be limited to
prevention and monitoring only. In contrast, those with pathological tooth wear may, in
addition to preventive protocols and regimes, be in need of active restorative/operative
intervention.
A number of indices have been proposed to grade the severity of tooth wear seen, by
recording the surface characteristics of teeth with a numerical score.
The most popular is that of the Tooth Wear Index, by Smith and Knight.

Other indices applied less commonly to assist with the diagnosis and monitoring of tooth
wear include: tooth wear index, index for grading severity of occlusal wear and the index for
grading severity of dental erosion.1vdental erosion.1
In 2010, Bartlett presented a paper describing an index based on the BPE to record the
severity of tooth wear for patients seen in the primary care setting. The index known as
BEWE (Basic Erosive Wear Examination) was formed in collaboration with European
colleagues. Their objective was to construct an index for the recording of tooth wear, which
would be simple to use, easy to record, and would provide the dental practitioner with the
opportunity to record that tooth wear had been examined and considered. BEWE records the
severity of wear on a scale from 0 to 3 for each sextant, hence 0 (no wear), 1 (initial loss of
surface texture), 2 (less than 50% loss of surface) and 3 (greater than 50% loss of surface).
Vailati and Belser have introduced the anterior clinical erosive classification (ACE) based on
their clinical observation of the upper anterior teeth. This classification system has been proposed to not only assess the severity of hard tissue loss but also to provide a guide to the
treating clinician on how to appropriately restore the affected teeth.

LOCALISED MAXILLARY ANTERIOR TOOTH WEAR

Maxillary anterior teeth are most commonly involved in localised tooth wear,
1. Tooth wear limited to the palatal surfaces only
2. Tooth wear involving the palatal and incisal edges, with reduced clinical crown height

3. Tooth wear limited to labial surfaces only.

Tooth coloured aesthetic materials and metallic restorations, such as metal palatal veneers can
be given. In some cases, particularly where the rate of tooth wear may be very rapid, or
compensatory mechanisms evolve at a relatively slower rate, or in the case of a patient with
an anterior open bite, deep overbite or increased overjet adequate space may be available
between the upper and lower dentition in centric occlusion (CO) in order to accommodate
restorations without the need to reduce healthy tooth tissue aggressively or follow a
reorganised approach. Adhesive restorations may simply be bonded into the available space
in order to restore form, aesthetics and function, while conventional restorations may require
minimal reduction of the affected surfaces.
The Dahl concept
This concept is frequently referred to in dental literature as a means of gaining space in cases
of localised tooth wear, where there is insufficient space available in either CO or CR. In
1975, Dahl et al. described the use of a removable anterior bite platform, fabricated from
cobalt chromium, retained by clasps in the canine and premolar regions to create interocclusal space in a patient with tooth wear localised to the anterior maxillary segment. The
appliance was designed to cover the cingulum areas of the affected teeth and increase the
occlusal vertical dimension in the region of 2-3 mm.
The placement of this appliance culminated in posterior teeth disclusion; occlusal contacts
were only present between the mandibular anterior teeth and the bite platform. The appliance
was prescribed for continual wear for several months until the posterior teeth re-established
inter-occlusal contact. Removal of the appliance resulted in an inter-occlusal space between
the anterior maxillary and mandibular dentitions respectively, which was subsequently
utilised to restore the worn surfaces without the need for further tooth reduction. Other
phrases used to describe this concept include minor axial tooth movement, fixed
orthodontic intrusion,localised inter-occlusal space creationor relative axial tooth
movement.
Space requirements will range from 0.5 mm for minimally invasive metal palatal veneers, up
to 2.0 mm for ceramic based materials. The provision of this space may necessitate
aggressive tooth reduction of an already compromised tooth by way of the quantity of dental
hard tissue, but may also compromise the health of the dental pulp
LOCALISED ANTERIOR MANDIBULAR TOOTH WEAR
According to Milosevic, where only lower anterior teeth are affected by the process of
pathological tooth wear, then the processes of prevention and monitoring will suffice. If,
however, both upper and lower teeth are affected, then space should be gained through the
process of the Dahl concept and the lower dentition restored before the upper. Where
adequate space may be present in CO, restorations can be placed with a conformative
approach. In some cases space may be made available in centric relation (CR) to

accommodate restorative materials, which would avoid increasing the vertical component of
the patients occlusion. Alternatively, space can be created through the use of the Dahl
concept. A fixed or removable Dahl prosthesis may be applied to the maxillary dentition to
create space, or restoration fabricated resin composite can be applied directly to the affected
lower anterior teeth The application of less invasive, dentine bonded crowns may have a
promising role in the management of worn lower anterior teeth. Dentine bonded crowns may
be defined as an all ceramic crown bonded to dentine (and any available enamel) using a
resin based luting material conventional crowns can be used to restore the above teeth in
conjunction with procedures such as surgical crown lengthening.
LOCALISED POSTERIOR WEAR

Restorative care being to provide posterior disclusion and canine guidance. For canine guided
occlusions, resin composite can be added superiorly to the centric stop either directly
(perhaps with the aid of a diagnostic waxin), so as to insure posterior tooth separation on
lateral excursive and protrusive mandibular movements, to prevent the affected tooth from
further wear. Alternatively an indirect restoration may be applied. The placement of
restorations in supraocclusion should be avoided among periodontally involved or
endodontically treated teeth, as well as among cases which display signs of limited eruptive
potential or TMJ dysfunction.

Management of Generalised tooth wear.

Following the establishment of an accurate diagnosis and the identification of possible
aetiological factors, an appropriate preventative regime should be implemented, usually
followed by a period of passive monitoring.
The restorative management of patients presenting with generalised tooth wear (TW) will be
considered according to the three categories described by Turner and Missirilian
Category 1 excessive wear with loss of vertical dimension of occlusion
Category 2 excessive wear without loss of vertical dimension, but with space available
Category 3 excessive wear without loss of vertical dimension, but with limited space.
A set of diagnostic casts mounted in centric relation (CR) is strongly advised. A semiadjustable articulator with an arbitrary facebow may be considered to be acceptable, a
kinematic transverse horizontal axis facebow transfer is preferable in helping to plan a
tentative increase in the occlusal vertical dimension (OVD) without introducing errors in the
horizontal jaw relationship.
The desired increase in OVD will primarily be determined by what is necessary to produce
functionally stable, aesthetic dental restorations and an adequate freeway space. Clinically
this can be estimated by measurement of the existing OVD of the worn dentition and the face
height with the mandible at rest with an adequate lip seal; the difference between the two

measurements needs to accommodate the desired increase in the OVD and the freeway space.
Once this has been determined, the planned increase may be programmed into the articulator
(by raising the pin on the articulator), and a diagnostic wax up fabricated accordingly
(preferably on duplicate casts).The transfer of the prescribed increase in OVD to the patients
dentition should be initially done by the use of fully reversible and adjustable materials (such
as resin composite), so as to determine the patients tolerance and aesthetic acceptance of the
proposed changes (although this may not always be required or indeed be possible). Once the
latter have been ascertained and the prescription accepted, then the interim material can be
substituted accordingly.
This will not only permit an appropriate period of time to evaluate tolerance of the proposed
changes, but will also avoid the propagation of potential errors which may arise where
definitive longer term restorations designed extra-orally (at a new occlusal vertical dimension
on an articulator) are placed clinically (without applying interim, short to medium term
restorations), as centric relation cannot always be recorded with absolute accuracy.
The diagnostic wax up should take account of basic aesthetic principles. It should also aim to
provide occlusal stability, based on the principles of a mutually protective occlusal scheme. It
is often useful to have a vacuum formed matrix (thermoplastic template) produced from a
duplicate cast of the diagnostic wax-up, which may be applied to the unrestored dentition,
with an intervening provisional crown and bridge material in the matrix, to provide the
patient with a rough visual of the restorative end point,
CATEGORY 1 PATIENTS: EXCESSIVE TOOTH WEAR, TOGETHER WITH A
LOSS IN THE OVD
The inter-occlusal clearance created through the process of tooth wear will provide most, if
not all the required space for the restorative material, without the need for aggressive occlusal
reduction (by a planned increase in the OVD), while maintaining a physiological Freeway
Space (FWS). A full coverage, hard acrylic stabilisation splint, such as a Michigan splint, can
be used to evaluate the patients tolerance/adaptability to the planned occlusal changes. For
category 1 patients however, the use of such a splint is usually not considered to be
mandatory.
Where an adhesive re-constructive approach is planned, all the involved teeth can be
potentially prepared in one visit. Pre-existing amalgam and composite resin restorations
should be replaced with new resin based materials, to improve bonding. Ideally, half the
increase in OVD should be incorporated into each arch, but this depends on the pattern of
wear, and the desired aesthetic outcome.
Where conventional restorations are being planned, preliminary tooth preparations (of at least
one arch) can be carried out in one single visit. This will allow for the fabrication of the
provisional restorations for all the teeth at the planned OVD. The choice of which arch to
prepare first will depend on the occlusal plane discrepancy (usually the arch with the greatest
discrepancy will be prepared first). Acrylic or silicone indices formed from the diagnostic

wax up can be used to assist the operator with the level of occlusal reduction required. The
patient should be maintained in indirectly formed provisional restorations for a period of 6-8
weeks
CATEGORY 2: EXCESSIVE WEAR WITHOUT LOSS OF OVD, BUT WITH
LIMITED SPACE AVAILABLE
A discrepancy will usually exist between centric occlusion (CO) and centric relation (CR).
CR may provide space to accommodate restorative materials; however, it might not always
be fully adequate and there may be a need to plan an increase in the OVD. For such cases, the
patient should be provided with a full coverage, hard acrylic occlusal splint, which will
provide an increase in the OVD to the required range, while the mandible is manipulated into
its retrusive arc of closure. The occlusal prescription of the splint should aim to provide a
removable mutually protective scheme. The patient should be instructed to wear the splint
continually for a period of one month (at all times other than when eating) to evaluate the
tolerance of the increase in OVD. Once the operator is satisfied that the patient can tolerate
the planned change, the process of preliminary tooth preparation may begin.
Unpredictable compliance with splint therapy has prompted an alternative approach, as
described by Vialati and Belser in 2008. The latter have suggested that a more realistic
approach would involve the placement of indirect provisional resin composite onlay and/ or
palatal resin veneers respectively at the same occlusal prescription as would be provided by a
full coverage, hard occlusal splint.
CATEGORY 3: NO LOSS OF OVD, WITH INSUFFICIENT SPACE FOR
RESTORATIVE MATERIALS
These are usually the most difficult cases to restore because space is not readily available due
to tooth repositioning brought about by alveolar compensatory growth. According to RiveraMorales and Mohl, for such cases, every effort should be made to obtain space by means
other than an increase in the OVD. Only if such methods fail to provide enough space, would
an increase in the OVD be advocated.
Methods which may be used to create space include:
1. Surgical crown lengthening, with osseous re-contouring.
Surgical crown lengthening with osseous re-contouring can be used to increase the quantity
of coronal tooth tissue, particularly in the case of teeth with short clinical crown heights.
Surgical crown lengthening may result in unsightly black triangles between the teeth and
also lead to unfavourable crown to root ratios. Gingival recession often accompanies the
healing process, which may result in the exposure of subgingival margins.
2. Elective endodontics.
Elective endodontics may be considered to permit the application of a post and core system to
further augment the available core material, or in the case of a grossly over-erupted tooth,

where there is a need to correct the occlusal plane discrepancy.

3. Orthodontic tooth movement.
Orthodontic tooth movement can also be used to permit the intrusion of grossly over-erupted
teeth or the extrusion of teeth with short clinical crowns.

CONCLUSION
The provision of active restorative care for a patient presenting with generalised tooth wear
can be considerably demanding even for more experienced dental operators. There is an
obviously profound prerequisite for the latter to have a very clear perspective of the planned
outcome, which in turns requires a very good working knowledge of the principles of
occlusion and an appreciation of the shortcomings of available materials and techniques
available to the contemporary practitioner. Where possible, reversible, additive techniques
should be applied to restore worn dentitions (at least in the short to medium term).
Conventionally retained indirect restorations may be applied where adhesive resin bonded
restorations may be inappropriate or display recurrent failures

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