R E DS ET N

R E S T O R AT I V E O TR I AS TT IRVY E D E N T I S T R Y

Use of Tooth-coloured Restorations

in the Management of Toothwear
P.F. ALLEN

drinks, fruit juices and citric fruits. The

Abstract: The problem of toothwear appears to be increasing in both children and pattern of wear tends to be uneven and
adults. Recent developments in bonding and aesthetic restorations have added to the
the teeth may be quite jagged. They
dentist’s armamentarium for restoring worn teeth. Bonded ceramic and composite
restorations offer the possibility of conservative restoration of teeth already damaged
have a shiny appearance, and amalgam
by toothwear. Despite this, concern still remains regarding the durability and clinical restorations may stand proud from the
performance of these restorations. This paper reviews the currently available rest of the tooth tissue (Figure 2). Palatal
techniques for providing tooth-coloured restorations in toothwear cases. surfaces of the maxillary anterior teeth
tend to be affected most, as the tongue
Dent Update 2003; 30: 550–556 protects the mandibular anterior teeth
(Figure 3). Labial and occlusal surfaces
Clinical Relevance: Adhesive techniques and aesthetic restorations in the
management of toothwear. may also be affected by erosion.
Abrasion is defined as tooth surface
loss due to physical wear of the teeth by
an agent such as a toothbrush. It is seen
mostly on the buccal aspects of the
teeth (Figure 4).
T he prevalence of toothwear is on
the increase and a significant
proportion of a dentist’s time will need
pathological toothwear are:

to be devoted to the management of this
problem. For example, in the recent UK
adult dental health survey,
approximately 65% of adults had some
form of toothwear.1 The problem also
appears to be on the rise in children,
particularly young adolescents.2
Toothwear can be physiological or
pathological in origin. The distinction is
made depending on how advanced the
process is in relation to the patient’s
age. In an elderly patient, particularly a
partially dentate adult, toothwear could
be advanced, but not necessarily
pathological. If toothwear is considered
to be advanced for the age of the
patient, then it is considered
pathological. Possible causes of
P.F.Allen BDS, PhD, MSc, FDS(Rest. Dent.) RCPS,
Senior Lecturer/Consultant, Department of
Restorative Dentistry, University Dental School &
Hospital,Wilton, Cork, Ireland.
l Attrition
l Erosion
l Abrasion
l Abfraction.
Key clinical signs associated with
toothwear according to aetiology are
summarized in Table 1. Attrition can be
defined as tooth surface loss due to
physical wear caused by excessive
tooth-tooth contact and is commonly
seen in bruxists. An even wear pattern
shared between the dental arches is a
diagnostic sign (Figure 1).
Erosion is defined as tooth surface
loss caused by acid attack of the teeth
not due to caries. The source of the acid
can be intrinsic (e.g. from the
gastrointestinal tract) or extrinsic (e.g.
from the patient’s diet). Patients with
gastric disorders such as hiatus hernia
or excessive alcohol intake and women
with a history of multiple pregnancies
may present with toothwear. Dietary
sources of acid include carbonated
Abfraction is defined as non-carious
cervical toothwear. It is believed to be
due to the concentration of occlusal
forces on the cervical margins of teeth
and is frequently seen on teeth with high
cusp angles, such as maxillary premolar
teeth (Figure 5). The wedge-shaped
cavity is such that it is highly unlikely to
be caused by a toothbrush, although a
multifactorial aetiology including
abrasion or erosion cannot be excluded.3,4
Finally, it is commonplace to find that
the aetiology of toothwear is multi-
factorial and a number of reports have
indicated that it is unusual to have
toothwear with a single cause.5,6 In many
cases, toothwear will affect the
appearance of the teeth, and the purpose
of this paper is to review currently
available techniques for managing
toothwear with aesthetic restorations.
INITIAL MANAGEMENT
Once a process of toothwear has been
recognized, a diagnosis of the aetiology

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Aetiology Cause Key Presenting Signs

Erosion Acidic attack of tooth structure l Saucerized cupping of palatal surfaces of maxillary incisors, occlusal and/or palatal
which is not bacterial in origin. surfaces of posterior teeth, buccal surfaces of anterior or posterior teeth.
l Teeth appear shiny when erosion is active.
l Metal restorations stand proud of tooth tissue.

Attrition Excessive contact between l Affects mandibular and maxillary teeth simultaneously.
occlusal surfaces of teeth. l Even contact between worn mandibular and maxillary teeth inexcursive movements.

Abrasion Excessive contact between l Wear on buccal aspect of teeth which corresponds with agent, e.g. toothbrush.
tooth and a physical agent.

Abfraction Non-carious cervical toothwear l Wedge-shaped lesion which is not obviously related to an agent such as a toothbrush.
possibly associated with
concentration of occlusal stresses.
Table 1. Key presenting signs associated with toothwear depending on main aetiological factor.

should be made, based on the clinical
signs and a carefully elicited history.
The emphasis should be on prevention
of further toothwear, and appropriate
advice should be given including:
l Reducing the frequency of intake of
acidic food and beverages;
l Liaising with the patient’s medical
practitioner to treat any
gastrointestinal disorders;
l Avoidance of abrasive tooth-
cleaning agents; and
l Prescription of occlusal splints to
protect the teeth during
parafunctional movements. Once
preventive advice has been given,
then the condition should be
monitored.
RESTORATIVE
MANAGEMENT
Restorative intervention may be
indicated if:
l The patient is unhappy with the
appearance of the teeth;
l The teeth are sensitive;
l The occlusion is unstable;
l Oral function is compromised;
l There is a danger that the pulp will
be exposed.
techniques, materials were not
chemically bonded to teeth and cements
were used to fill the space between
veneer crowns and teeth. Bonding
provides the possibility of adhesion
between restorative materials and teeth.
Over the years, bonding strength of
materials to dentine has increased as
bonding systems have grown more
sophisticated. There are a variety of
approaches to the bonding of materials
to dentine, but almost all involve

The timing of intervention is critical,

Figure. 1. Pattern of toothwear associated with
attrition. Note that wear pattern affects
mandibular and maxillary dentition (Courtesy of
Dr F.M. Burke).
Figure 2. Appearance of posterior teeth affected
by erosion. The amalgam restoration in the /6
stands proud of the tooth. This patient had gastric
oral reflux disorder.
as if it is delayed for too long then pulp Figure 3. Tooth surface loss associated with
vitality will be compromised. Prior to the erosion of dietary origin. The incisal edges of the
advent of dentine-bonding agents, full maxillary anterior teeth have become jagged
veneer crowns constructed with cast and translucent. The mandibular teeth are
gold or porcelain fused to metal were the mostly unaffected possibly due to protection by
the tongue.
mainstay of treatment. These involved
extensive tooth preparations and this in
turn could be the final insult to the pulp,
leading to loss of pulp vitality. With the
advent of dentine-bonding agents and
improvement in ceramic technology, it is
now possible to provide aesthetic
adhesive restorations in the
management of toothwear cases.
BONDING Figure 4. Abrasion of buccal aspects of posterior
teeth associated with long term use of baking
Prior to the advent of bonding soda and a hard bristle toothbrush.

Dental Update – December 2003 551

 R E S T O R AT I V E D E N T I S T RY
Figure 5. Cervical toothwear associated with
occlusal stresses (‘abfraction’). Note the wedge-
shaped appearance of the lesions at the
cemento-enamel junction.
Figure 6. Diagnostic etching undertaken to
assess the amount of enamel available for
bonding restorations to teeth affected by erosion.
A rim of etched enamel was noted around the
periphery of the maxillary anterior teeth following
this procedure.
modification or removal of the dentine
smear layer using an acidic agent
(‘conditioner’). The enamel and dentine
are then etched and subsequently dried
or left moist (so called ‘wet bonding’),
depending on the material used. The
dentine is then coated with a primer
which facilitates the bonding of the
hydrophobic bonding resin to the
dentine. Despite the dramatic
improvements in bond strengths to
dentine, bonding to etched enamel is
still the strongest and most reliable
bond. In toothwear cases, much of the
enamel may be lost and consequently
bonding may be compromised. A useful
diagnostic aid is to etch the periphery of
the tooth to assess how much enamel
remains. In Figure 6, the patient has
palatal toothwear with an erosive
aetiology. The patient is 16 years old,
with large pulps and a conservative
approach to restoration of the tooth was
552
preferable. Using 37% phosphoric acid
gel, the periphery of the tooth was
etched. This revealed that sufficient
enamel remained to have confidence in a
bonded restoration rather than full
coverage crowns and direct composites
were subsequently placed over the worn
tooth surfaces (Figure 7). Where
bonding is compromised by the lack of a
suitable bonding substrate, then a
cemented restoration may be preferable.
COMPOSITE RESIN
RESTORATIONS
Composite resin restorations offer a
number of advantages in the
management of toothwear:
l Good aesthetics;
l Bonded restorations thus reducing
the need for tooth preparation to
provided mechanical retention;
l Ease of repair.
They have most commonly been used in
abrasion and abfraction lesions,
particularly the micro-filled variety
(‘flowable composites’). These
composites have less filler content, and
thus are less opaque and easier to polish.
They are also more flexible and thus likely
to be displaced from cervical cavities
than more heavily filled composite resin
materials.7 Recently, a group of materials
which have modified conventional resin
composites by adding carboxylic acid
have been developed. These materials,
called ‘compomers’ (e.g. Dyract
[Dentsply, Weybridge, UK]), are
becoming popular for Class V
restorations and non-carious cervical
wear. Despite the belief that they combine
composite resin and glass ionomer
technology, they behave more like
composite resins. They are easy to
manipulate and have a simple self-etching
primer method for bonding to tooth
tissue.
Increasingly, composite resins are
being used in attrition and erosion
cases. In the former, a resin with high
filler content is preferable as it increases
abrasion resistance. A hybrid composite
offers a reasonable compromise between
durability and aesthetics. The key
Figure 7. Direct composite restorations bonded
to the palatal surfaces of anterior maxillary teeth
of the patient shown in Figure 6.
points in the technique for placing direct
composite resin restorations in
toothwear cases are:
l Remove sharp enamel edges;
l Isolate teeth using a rubber dam;
l Pulp protection using calcium
hydroxide should be provided
where pulp tissue is visible; this is
not necessary if the ‘Total Etch’
technique is used;
l Acid-etch teeth and apply enamel
and dentine-bonding agents (follow
the manufacturer’s instructions
carefully – pay particular attention
to the instructions for wetting the
tooth as some bonds rely on the
dentine being moist);
l Incremental build-up of composite
resin;
l Check the occlusion for even
contacts, finish and polish
restorations.
In cases where the toothwear process
has been relatively slow, insufficient
space may be present for restorations
owing to compensatory eruption of
opposing teeth. Hemmings et al.8 have
reported on the use of composite resins
to increase the occluding vertical
dimension on anterior teeth in toothwear
cases. The results they report are very
encouraging, and suggest that
composite resin restorations offer a
predictable result in difficult wear cases.
They suggest that hybrid composites
are better than micro-filled composites
when management requires an increase
in occluding vertical dimension on the
restorations to create space. Direct
build-up of composites on teeth with
lesions of erosive aetiology can be used
in young patients where extensive tooth
Dental Update – December 2003
R E S T O R AT I V E D E N T I S T RY
preparation is likely to damage the pulp.
These can be used to restore contour to
the palatal surfaces of the teeth at the
intercuspal position or at a small
increase in occluding vertical dimension.
In the latter situation, the restorations
will be slightly ‘high’ and will separate
the posterior teeth. However, as
originally described by Dahl using a
nickel chrome prosthesis9 and reaffirmed
by Hemmings et al.,8 experience has
shown that these teeth will over-erupt to
restore occlusal contact in a matter of
months. One drawback of this technique
is that it is a time-consuming procedure,
and it takes approximately 30 minutes
per tooth to complete the restoration. In
addition to direct free-hand placement of
the restorations, a pull down matrix
constructed on a duplicate stone model
of a diagnostic wax-up of the desired
restorations can also be used. This acts
like a crown former, but it may be
difficult to adapt the composite resin to
the teeth. They can also be constructed
from an impression of the teeth using
laboratory cured composite resin
materials, but this adds significantly to
the cost. A further disadvantage when
compared to metallic restorations is that
composite resin materials will wear down
with time and require replacement.
Posterior composite resin restorations
can be bonded onto the occlusal surface
of previously unrestored teeth, or used
as inlay/onlay restorations in restored
teeth using direct or indirect placement
techniques. Directly placed composite
resin restorations are time consuming to
place, very technique sensitive and
integrity of the bond to tooth tissue may
be compromised owing to
polymerization shrinkage. There is also
concern that composite resin
restorations are not durable enough to
withstand occlusal forces on posterior
teeth. In posterior teeth, indirect
laboratory manufactured composite
inlay restorations may also be used. As
they are fully cured prior to placement
in the tooth, the problem of
polymerization shrinkage is removed.
The technique involves recording an
impression of the tooth preparation as
for a cast restoration and a model from
this impression is cast in dental stone.
554
Key points in the preparation of teeth
for composite resin inlay/onlay
restorations are:
l Divergent internal walls;
l Rounded internal line angles;
l Proximal boxes can be used but
retention grooves should be avoided;
l 2 mm occlusal reduction when
conforming with ICP (2 mm thickness
of material will be required if
restorations are placed at increased
OVD);
l Avoid bevels to reduce the risk of
chipping.
The restoration is constructed on this
model and cured using a specialized
light curing unit. It is then tried in the
tooth and, following isolation of the
tooth with rubber dam, bonded to the
tooth using a dentine-bonding agent
and composite luting resin (Figure 8).
Ironically, this method of curing the
resin restoration uses up all the free
radicals on the surface of the material
and this may compromise bonding of the
material to the tooth. This can be
improved by air-abrasion of the fitting
surface of the resin onlay using
aluminium oxide (50 microns in
diameter). There is concern that the
integrity of the bond of these
restorations to the tooth is not ideal,
and clinical trials of these materials
reported varied results. Furthermore,
clinical trials seem to indicate that they
perform no better than directly placed
composites.10 In view of the possibility
of occlusal wear of these restorations,
they are more suited to wear of erosive
aetiology than attrition.
A recent development has been the
combination of polymer and ceramic
technology to produce ‘ceromers’ (e.g.
Artglass [Heraeus Kulzer, Hanau,
Germany], Targis [Ivoclar-Vivadent,
Schaan, Liechtenstein]). Ceromer
restorations may be bonded to tooth
tissue in the same way as composite
resin inlay/onlay restorations and it has
been claimed that they have better
durability and wear resistance compared
with traditional resin composites.11 At
present there are no reports of their use
in toothwear cases.
Figure 8. Indirect, laboratory fabricated
composite resin inlay placed in the first
molar tooth.
GLASS IONOMER
RESTORATIONS
Glass ionomers have a good bond
strength to dentine, and have the ability
to leach fluoride into surrounding tooth
tissue. This can be particularly
advantageous in patients where
toothwear affects exposed root surface.
However, the use of glass ionomers in
toothwear management has been limited
by their poor abrasion resistance. They
are also opaque and their aesthetics are
not as good as composite resin.
Resin-modified glass ionomer
materials (e.g. Vitremer, 3M ESPE,
Minnesota, USA) have been developed
in an attempt to combine the desirable
properties of both composite resins and
glass ionomers. To date, no long term
data have been reported on their use in
toothwear management, but they have
poorer wear resistance than
conventional composites and should
not be used in load-bearing areas.12
CERAMIC RESTORATIONS
Even though they offer excellent
aesthetic possibilities, traditional
feldspathic porcelains are not strong
enough for use in attrition cases. In the
mid 1960s, the use of aluminous cores
improved the strength of porcelain
crowns, but they were still not as strong
as porcelain fused to metal crowns.
Recent developments in ceramic
technology have led to materials with
improved physical properties. Reported
Dental Update – December 2003

Figure 9. High strength porcelain cores on the
master cast prior to application of veneer
porcelain (Courtesy of Dr H. Ziada).
Figure 10. Appearance of high strength, all
ceramic crowns ( Procera, Nobel Biocare)
following application of veneer porcelain
(Courtesy of Dr H. Ziada).
flexural strength of current generation
ceramic restorations ranges from 160
Mpa for IPS Empress (Ivoclar-Vivadent)
to 450 MPa for In-Ceram (Vita
Zahnfabrik, Bad Sackingen, Germany)
and 600 MPa for Procera (Nobel
Biocare, Gothenburg, Sweden). Current
techniques involve the use of a high
strength core material with a veneer of
feldspathic porcelain and/or glazing
porcelain and tints for aesthetics (Figure
9). The core material can be aluminous
porcelain, heat-pressed leucite,
reinforced porcelain, castable glass,
lithium disilicate or infiltrated alumina.
The difference between the systems is
largely how the core material is
manufactured. Some systems (e.g.
Empress 2 [Ivoclar-Vivadent]) will
require specialist laboratory equipment,
whilst others (e.g. Procera [Nobel
Biocare]) involve CAD-CAM
technology. In the case of CAD-CAM
restorations, the technique involves
scanning the prepared tooth surface
(e.g. Cerec 2 [Sirona Dental Systems,
Bensheim, Germany], a wax pattern of
the tooth preparation [CELAY system]
or a model of the preparation [Procera]
using an optical reader. This information
Dental Update – December 2003
R E S T O R AT I V E D E N T I S T RY
is relayed to a computer which then
creates a computer image of the
prepared tooth. Finally, a milling
machine linked to the computer in the
surgery (in the case of Procera, the
information is sent via the internet to a
laboratory in Sweden) then produces a
restoration from a porcelain block
(Figures 9, 10). Treatment time using this Figure 11. Patient with all-ceramic crowns in the
anterior mandible. Note the gingival inflammation
approach is shorter and, in the case of
associated with bulky crowns. The likely cause of
the CEREC system, no laboratory stages this problem was failure to reduce tooth tissue
are required. There is, however, concern adequately during crown preparation.
regarding the marginal integrity of these
restorations, and further long-term
research is required.
Possible advantages of ceramics in
toothwear include excellent aesthetics
and durability. However, in comparison
with composite resins, they increase
expense and complexity of treatment. In
the event of fracture of the material, they
are also more difficult to repair. Porcelain
can be used in laminate veneers, inlay/
onlay restorations and full or partial
coverage all ceramic crowns. Figure 12. Appearance of the fitting surface of
In the case of anterior teeth, a porcelain laminate veneer when etched with
drawback with this technique for full hydrofluoric acid. This provides micromechanical
retention for the luting cement and should be
veneer crowns is the requirement for undertaken after the veneer has been tried in the
extensive tooth preparation (2 mm mouth.
reduction) to allow room for the
thickness of core and veneer material.
Where preparation has been hydrofluoric acid gel (Figure 12) to
insufficient, the crowns tend to be enhance micromechanical retention. A
bulky, leading to difficulties with plaque silane coupling agent is then applied to
control (Figure 11). Very dense materials increase bonding of the resin luting
such as In-Ceram cannot be bonded to cement to the porcelain. Full veneer all
the tooth and must be cemented using ceramic crowns can be used in
conventional cements. Other new toothwear cases (Figure 13a, b), but the
generation materials can be bonded to appearance of the crowns is dependent
the tooth. This involves etching the on the skill of the technician and the
fitting surface of the porcelain using adequacy of tooth reduction. Current
b
a
Figure 13. (a) Pre-treatment view of a patient with moderate toothwear who was dissatisfied
with the appearance of her teeth, including the median diastema; (b) Post treatment view
following the placement of all-ceramic bonded crowns ( IPS-Empress, Ivoclar-Vivadent).
555
R E S T O R AT I V E D E N T I S T RY
systems have adequate strength to resist
normal functional load. However, in
parafunction situations, fracture of
porcelain restorations is a significant
risk. General recommendations are that
all ceramic restorations can be used in
mild to moderate parafunction situations
and should be avoided in patients with
severe parafunction (e.g. bruxists),
although this is not underpinned by
extensive clinical research. If the
bonding area is compromised, then the
restorations should be cemented in
place using conventional cements. A
further relative contraindication to
bonded ceramic restorations is for
abfraction cases. In this situation,
flexure of the tooth may cause porcelain
fracture or microleakage. Porcelain
laminate veneers offer excellent
aesthetics when the appearance of the
labial surfaces of anterior teeth is
unacceptable. However, in toothwear
cases, the amount of dentine exposed is
critical to long-term outcome. Troedson
and Derand13 have reported that bond
strength of the veneers to teeth
decreases as the amount of dentine
exposed during tooth preparation
increases. Furthermore, sclerotic dentine
which may be evident in an ‘old’ tooth
offers a poor quality bonding surface.
As with composites, diagnostic etching
can give an indication of the amount of
enamel available for bonding. If this is
considered insufficient, then full veneer
crowns would be preferable to porcelain
laminate veneers.
When planning inlay/onlay
restorations for posterior teeth, the
preparation features are the same as
previously described for composite
resin restorations. They have
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556
advantages over composite resin inlay/
onlay restorations, namely:
l The bond to tooth tissue is
stronger;
l There is less wear and thus occlusal
stability is increased.
In view of the brittle nature of
porcelain restorations, they should be
avoided in cases of parafunction and
contacts in excursive movements should
be minimized. As with composite resin
inlays, the restorations should be
bonded to the tooth under rubber dam.
A final consideration with porcelain
restorations is the potential for wear of
the opposing tooth. Traditional
feldspathic porcelain causes significant
wear of enamel, but this is less of a
problem with newer materials,
particularly Empress 2 (Ivoclar-
Vivadent). In any event, the final
restoration should be highly glazed
when finished. In an acidic environment,
ceramic surfaces are susceptible to
degradation and wear of the opposing
enamel may result. Consequently, it is
recommended that an occlusal splint for
night wear is provided to protect these
restorations from parafunction and acid
degradation.14
CONCLUSIONS
The recent developments in bonding
agents and aesthetic restorations have
increased the predictability of adhesive
tooth-coloured restorations. Case
selection is critical to achieving a
successful outcome when using these
restorations. They should be considered
to be relatively contraindicated when
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parafunction is evident and when only
sclerotic dentine is available for bonding.
REFERENCES
1. Kelly M, Steele JG, Nuttall N et al. Adult Dental
Health Survey. Oral Health in the United Kingdom,
1998. London: ONS.
2. O’ Brien M. Children’s Dental Health in the
United Kingdom, 1993. London: OPCS HMSO.
3. Piotrowski BT, Gillette WB, Hancock EB.
Examining the prevalence and characteristics of
abfractionlike lesions in a population of US
veterans. J Am Dent Assoc 2001; 132: 1694–1701.
4. Bader JD, McClure F, Scurria MS, Shugars DA,
Heymann HO. Case-control study of non-carious
cervical lesions. Comm Dent Oral Epidemiol 1996;
24: 286–291.
5. Smith BGN, Knight JK. A comparison of patterns
of toothwear with aetiological factors. Br Dent J
1984; 157: 16–19.
6. Watson ML, Burke FJT. Investigation and
treatment of patients with teeth affected by tooth
substance loss: a review. Dent Update 2000; 27:
175–183.
7. Bayne SC, Thompson JY, Swift EJ, Stamatiades P,
Wilkerson M. A characterization of first-
generation flowable composites. J Am Dent Assoc
1998; 129: 567–577.
8. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent 2000; 83: 287–293.
9. Dahl BL, Krogstad O, Karlsen K. An alternative
treatment in cases with advanced attrition. J Oral
Rehabil 1975; 2: 209–214.
10. Wendt SL, Leinfelder KF. Clinical evaluation of
heat treated composite inlay: 3 year results. Am J
Dent 1992; 5: 258–262.
11. Reich S, Sindel J, Morneburg TH. Wear of
prosthetic composites dependent on mechanical
matrix properties [abstract 2260]. J Dent Res 1998;
77: 914.
12. Abdalla AI, Alhadainy HA, Garcia-Godoy F. Clinical
evaluation of glass ionomers and compomers in
Class 5 carious lesions. Am J Dent 1997; 10: 18–20.
13. Troedson M, Derand T. Shear stresses in the
adhesive layer under porcelain veneers – a finite
analysis study. Acta Odontol Scand 1998; 56: 257–262.
14. Oh W, DeLong R, Anusavice KJ. Factors affecting
enamel and ceramic wear:A literature review.
J Prosthet Dent 2002; 87: 451–459.
Dental Update – December 2003