Tooth wear treated with direct composite restorations at an increased vertical

dimension: Results at 30 months

Kenneth W. Hemmings, BDS, MSc,a Ulpee R. Darbar, BDS, MSc,b and Simon Vaughan, BScc
Eastman Dental Hospital and Institute for Oral Healthcare Sciences, London, United Kingdom
Statement of problem. Severe tooth wear localized to the anterior maxillary or mandibular teeth with
loss of interocclusal space is difficult to manage.
Purpose. This study evaluated the outcome of composite restorations placed at an increased vertical
dimension of occlusion in such patients.
Methods and material. Sixteen patients were restored with 104 restorations in 2 groups. In group A,
Durafill composite and Scotchbond Multipurpose dentine adhesive system were used to place direct anterior
restorations (N = 52). In group B, Herculite XRV composite and Optibond dentine bonding agent was
used (N = 52). The restorations were placed at an increased vertical dimension of occlusion creating a pos-
terior disclusion of 1 to 4 mm.
Results. Clinical follow-up showed that the posterior occlusion remained satisfactorily restored after a
mean duration of 4.6 months (range 1 to 11 months). Mean follow-up of 30 months has shown a com-
bined success rate of 89.4% for both groups with 93 of the restorations remaining in service. Maintenance
in group A was high with 33 failures, but low in group B with 6 failures. Patient satisfaction was reported as
good.
Conclusion. Direct composite restorations may be a treatment option for localized anterior tooth wear.
(J Prosthet Dent 2000;83:287-93.)

CLINICAL IMPLICATIONS
In this study, direct hybrid composite restorations with a dentine bonding agent placed
at an increased vertical dimension of occlusion effectively treated localized anterior
tooth wear. The occlusion was restored in 4 to 5 months, and maintenance was mini-
mal over 30 months.

I n 1975, Dahl et al1 reported the use of a removable

cobalt-chromium anterior occlusal device (bite splint)
in an 18-year-old person with advanced localized attri-
tion to generate interocclusal space for subsequent
restoration. Further studies using this technique
reported that tooth movement involving a combina-
tion of orthodontic anterior tooth intrusion and erup-
tion of the posterior teeth occurred consistently with
60% of the movement attributed to the latter and 40%
accounting for intrusion of the anterior teeth.2-4 This
technique is now increasing in popularity and clinicians
are using it in a variety of situations.5-7
Tooth wear has a multifactorial cause8 and may be
generalized throughout the dentition, but is often local-
ized to the incisor and canine teeth. In cases where the
rate of tooth wear has been rapid the interocclusal space
This study was presented as an abstract to the International Associa-
tion for Dental Research, Nice, France, June 1998.
aConsultant in Restorative Dentistry, Department of Conservative
Dentistry.
bConsultant in Restorative Dentistry, Department of Periodontology.
cClinical Audit Manager, Research and Development Department.
for restorations may be maintained. However, more
commonly the rate of tooth wear is slow and compen-
satory eruption of the opposing teeth eliminates space
for restoration.9,10 Niswonger, cited by Tallgren,11
found that 80% of severe tooth wear patients had a nor-
mal interocclusal rest space. Interocclusal rest space can
be generated by the following methods:
1. Occlusal adjustment if there is significant discrep-
ancy between the retruded contact position (RCP) and
the intercuspal position (ICP).
2. Reduction of the opposing teeth. Periodontal
crown lengthening surgery can increase the clinical
crown height, thereby allowing further tooth reduc-
tion.
3. Increasing the vertical dimension of occlusion
(VDO) by restoring the posterior teeth in 1 or both
jaws.
4. Elective endodontic treatment, followed by post-
retained restorations.
5. Orthodontic movement of teeth to create inter-
occlusal space.
It is important to establish the cause of wear before
intervention to help improve the effectiveness of any

MARCH 2000 THE JOURNAL OF PROSTHETIC DENTISTRY 287

THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 1. Anterior view of teeth showing labial abrasions and
mild tooth wear.
Fig. 2. Palatal view of maxillary anterior teeth shows dentine
exposure.
preventive and restorative care.12 Management of these
patients using fixed or removable prostheses is complex
and are among the most difficult to restore.13,14 Care-
ful and comprehensive treatment planning is required
for each individual case and an assessment of the verti-
cal dimension at rest and in occlusion is essential. Artic-
ulated study casts, together with a diagnostic wax-up,
provide the necessary information required to evaluate
the treatment options and tolerance of changes to the
vertical dimension of occlusion is usually confirmed
with a diagnostic splint or prosthesis.13 Treatment
using conventional crowns results in further loss of
tooth substance in an already compromised dentition.
Cast adhesive restorations, although effective and more
conservative in replacing missing tooth tissue can com-
promise appearance,15-17 particularly if there is reduced
clinical crown height. Use of porcelain onlays to treat
288
HEMMINGS, DARBAR, AND VAUGHAN
Fig. 3. Immediate postoperative palatal view of 6 composite
restorations.
Fig. 4. Immediate postoperative view of right buccal seg-
ment shows posterior disclusion.
patients with tooth wear has been described,18,19 but
long-term follow-up has not been reported.
Direct composite restorations are relatively simple to
place, esthetic, and predictable provided moisture con-
trol is maintained. Their use in treating patients with
tooth wear has been described20,21; however, clinical
studies have not been reported. The purpose of this
study is to report a 30-month prospective clinical trial
using direct composite restorations for the treatment of
localized anterior tooth wear.
MATERIAL AND METHOD
Patients were selected from new patient consultation
clinics in the Department of Conservative Dentistry at
the Eastman Dental Hospital. Cause of tooth wear was
identified as far as possible by taking a careful history
and examination and a diagnosis and treatment plan
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HEMMINGS, DARBAR, AND VAUGHAN
Fig. 5. Right buccal segment view showing posterior occlu-
sion reestablished at 5 months.
established. Depending on the cause, preventive care
including dietary advice was instituted and patients
entered into the study. The following inclusion criteria
were used:
1. Tooth wear was localized to the maxillary or
mandibular anterior teeth (incisors and canines) with
loss of interocclusal space;
2. At least 4 teeth were in need of restoration;
3. Tooth wear was clinically significant with dentine
exposure usually with a reduction in clinical crown
height. Patients with wear of the labial surfaces were
not excluded from the study;
4. Patients had intact dentitions with no fixed partial
or removable dentures;
5. There was a stable periodontal condition, good
oral hygiene, and no probing depths over 3 mm.
Before participating in the study patients were given
a full explanation concerning proposed treatment
before informed consent was gained. As the technique
using fixed conventional metal alloy “Dahl” appliances
has been used in the department for over 18 years, for-
mal ethics committee approval was not sought. Patients
were informed that their new occlusion provided ante-
rior contact only and that the posterior occlusion
should be restored in 6 to 9 months time. They were
also informed to expect some difficulty in eating and
occasionally speaking for 2 to 3 weeks.
The baseline data were collected from: (1) clinical
examination and photographs. This included examina-
tion of the temporomandibular joints and the VDR and
VDO; (2) articulated study casts; and (3) radiographs.
This comprised a dental panoramic radiograph and
periapical radiographs of the teeth to be restored.
Patients were then randomly allocated into 2 patient
groups. Patients in group A were restored with Durafill
composite (Kulzer, Wehrheim, Germany) and Scotch-
MARCH 2000
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 6. Palatal view of composite restorations at 1 year.
bond Multipurpose dentine adhesive system (3M, St
Paul, Minn.). In group B, patients were restored with
Herculite XRV composite (Kerr Mfg USA, Orange,
Calif.) and Optibond dentine bonding agent (Kerr Mfg
USA). Direct composite restorations were placed on
the worn teeth and shaped to restore the original con-
tour as described in a previous study.20 All teeth were
restored at the same visit and the following clinical
technique was used.
Minimal tooth preparation was carried out to reduce
sharp enamel edges. Moisture control was obtained by
using a rubber dam, enamel and dentine bonding was
carried out according to the manufacturers’ instruc-
tions. An incremental buildup of the composite restora-
tion was performed. A clear matrix strip was used to
separate contact points. Alternate teeth were built up to
facilitate the procedure. Teeth were restored to normal
contour and no attempt was made to create an anteri-
or occlusal plane for long axis loading of opponent
teeth. Finishing of composite restorations was carried
out conventionally with Soflex disks (3M Healthcare,
Loughborough, U.K.) and/or polishing points,
(Enhance, Dentsply, Weybridge, U.K.). Occlusion was
arranged to provide even contacts in the RCP on the
restored teeth. This was commonly on the 6 maxillary
anterior teeth. Canine guidance was established in lat-
eral excursions where possible. Posterior disclusion was
measured from a wax record taken postoperatively
between the first molar teeth.
Postoperative follow-up was at 1 week, 1 month, and
then every 3 months until the posterior occlusion had
reestablished. Thereafter, they were reviewed on an
annual basis. Posterior tooth contacts were assessed by
use of Shim Stock occlusal foil (Hanel, Langenau, Ger-
many). Figures 1 through 7 show a patient treatment
with mild tooth wear and dentine exposure restored with
289
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 7. Labial view of restorations at 1 year.
Fig. 8. Anterior view of teeth exhibit severe wear that affects
maxillary and mandibular anterior teeth.
Durafill and Figures 8 through 12 illustrate a case of
severe tooth wear affecting the maxillary and mandibular
anterior teeth restored with Herculite XRV material.
Criteria for success or failure of the restorations were
defined as any adverse event affecting a restoration was
considered a failure. This included loss, fracture, mar-
ginal discoloration, loss of marginal integrity, notice-
able wear, pain or sensitivity, endodontic failure, and
esthetic failure. The total number of failures was also
recorded as some restorations were able to continue in
service after repair or replacement.
Survival analysis was carried out with the Kaplan-
Meier method. This allows analysis of each restoration
until its first failure only.
RESULTS
Sixteen patients (average age 33.8 years, range 19-54
290
HEMMINGS, DARBAR, AND VAUGHAN
Fig. 9. Palatal view of maxillary anterior teeth with dentine
exposure on maxillary canine and central incisor teeth.
Fig. 10. Teeth in occlusion showing complete overbite and
insufficient space for restoration.
years) were entered into the trial. Both groups of 8
patients required 52 restorations to be placed making a
total of 104 restorations. The patient’s age, occlusion,
increase in VDO after treatment, time taken before the
posterior occlusion was reestablished and the duration of
follow-up for groups A and B is presented in Tables I
and II, respectively. In 15 of the 16 patients, posterior
occlusion was restored between 1 and 11 months (mean
4.6 months). One patient in group B did not achieve the
desired tooth movement.
Type and total number of failures in both groups is
shown in Table III. In group A there was a total of 33
failures, of which 6 were replaced and subsequently
failed allowing a total of 27 to be used in survival analy-
sis. In group B, a total of 6 failures occurred during the
study period, 2 of these failures were minor and were
not repaired or replaced. Mean follow-up of 30 months
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Fig. 11. Labial view of maxillary and mandibular anterior Fig. 12. Teeth in occlusion at 1 year. Posterior occlusion has
teeth restored with composite at 1 year with increased clin- been reestablished.
ical crown height.

Table I. Results for group A (Durafill) showing age of patient, presenting occlusion, number of restorations, increase in vertical
dimension of occlusion after restoration, time taken for the occlusion to reestablish, duration of follow-up, and number of fail-
ures for each patient
Age Occlusion Restorations VDO inc (mm) Post occ (mo) Duration (mo) Failures

19 I 6 1.5 3 38 3
54 II.2 10 2.0 11 38 2
25 II.2 6 1.0 1 38 6
28 I 6 2.0 3 36 2
26 I 6 1.0 6 35 5
26 II.2 6 1.0 9 34 2
24 I 6 2.0 5 34 2
24 III 6 2.0 3 14 11
VDO inc = Vertical dimension of occlusion increase; Post occ = time taken for posterior occlusion to reestablish.

Table II. Results for group B (Herculite)

Age Occlusion Restorations VDO inc (mm) Post occ (mo) Duration (mo) Failures

27 III 6 1.0 2 30 1
29 II.2 4 1.5 7 27 1
35 I 6 2.0 4 29 —
55 II.2 4 1.5 4 30 —
34 I 6 1.0 4 27 1
50 II.2 6 1.0 3 27 2
49 III* 12 4.0 — 22 —
27 III 8 1.5 5 24 1
VDO inc = Vertical dimension of occlusion increase; Post occ = time taken for posterior occlusion to reestablish.
*Desired tooth movement not obtained.

revealed a success rate of 89.4% with 93 of the restora-
tions remaining in service.
Kaplan-Meier survival analysis and comparison
between groups is depicted in Figure 13. Median sur-
vival time for restorations in group A was 35 months.
The log-rank test demonstrated a significant difference
between the 2 groups with P<.0015 (log-rank statistic
10.04 ).
There was continued tooth wear in 3 patients in
group A and 2 patients in group B. Two of these
patients were continuing to have treatment for eating
disorders and 1 patient had not been able to reduce her

MARCH 2000 291

THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 13. Kaplan-Meier survival function of composite restora-
tions shows survival function of group A (Durafill) lower
tracing and group B (Herculite) upper tracing.
high daily intake of a cola soft drink. In the remaining
patients, there was no apparent further tooth wear with
reference to study casts.
DISCUSSION
This technique overcomes poor appearance associat-
ed with Dahl appliances. It has produced the desired
tooth movements in all but 1 patient who had unusual
occlusal features, namely, a gross Class III malocclusion
and a mandibular facial asymmetry. Composite restora-
tions restored the appearance but did not provide this
patient with stable occlusal contacts in RCP or ICP.
The restorations performed well but the patient was
later treated with a mandibular posterior overlay den-
ture. Although the original idea was to provide space
for subsequent conventional restoration of the affected
teeth, it was clear after the tooth movement had
occurred that these restorations may indeed prove to
be more durable.
The restorations did not incorporate a deliberate
occlusal plane to provide axial loading of the antagonist
teeth. Therefore, occlusal forces on the restored teeth
and the antagonist teeth were on an inclined plane.
Despite this, no adverse tooth movements were
observed. This may be because teeth prefer to move
through the cancellous trough of bone in a similar way
to orthodontic tooth movement rather than simply
move in response to an occlusal force.22
Tooth movement in some situations was rapid, occur-
ring within 1 to 2 months of placement of restorations.
It may be that mandibular repositioning occurs to some
extent in these situations as the tooth movement appears
to be faster than possible with orthodontic tooth move-
ment. Adverse tooth movements such as splaying of the
292
HEMMINGS, DARBAR, AND VAUGHAN
Table III. Table showing mode of failure and action taken
after failure. In group B, 2 failures were not repaired as they
were clinically insignificant
Total
Group Fracture Stain Lost (Repair) (Replace) failures
A 18 10 5 (24) (9) 33
B 2 2 2 (2) (2) 6
anterior teeth was not seen and is probably due to the
patients in this study having no periodontal disease.
Splaying of the teeth could be a potential problem in
periodontally unstable patients and the technique should
not be used unless the periodontal health has been sta-
bilized. In all situations, posterior tooth contacts
occurred on the last molars first and finally the occlusion
was restored when contact on the premolars occurred.
The Department’s experience using conventional Dahl
appliances has shown that, in 4% of cases, there is no
apparent tooth movement.23 A similar clinical perfor-
mance with the restorations described in this study
would also be expected.
The main failures experienced with these restorations
was either bulk fracture or staining after a period of use.
These failures are amenable to simple maintenance in the
form of repair or replacement of the restoration. A fur-
ther advantage is that this technique is conservative of
tooth tissue and thus particularly suitable in the young
patient. In the authors’ opinion, the technique can also
be applied to patients with mild, moderate, or severe
tooth wear due to its relative simplicity and cost-effec-
tiveness. In contrast, conventional techniques would
usually require a combination of crown lengthening
periodontal surgery, an increase in the occlusal vertical
dimension and possibly the use of post-retained restora-
tions, resulting in protracted treatment time. Although
these restorations may not last more than 3 to 5 years,
the maintenance is relatively simple in comparison to
conventional fixed alternatives that have proven success
rates but are often associated with complicated problems
when failures are encountered.24
Wear of the restorations and the remaining dentition
has been judged clinically. There is still considerable dif-
ficulty in relating tooth wear to a fixed reference point
within the mouth or on study casts. It was not consid-
ered ethical to place a permanent reference marker either
on the teeth or in the jaw bones to measure wear from
this respect. The differential wear of teeth against dental
materials is well noted.25 Significant wear of the restora-
tions would not be expected over this relatively short
period of the study, though this can occur in the estab-
lished bruxist patient. Failures judged clinically by our-
selves and by the patients were macroscopic in nature.
Composite was selected to restore against worn teeth. It
was considered preferable to have restorations “wear
VOLUME 83 NUMBER 3
HEMMINGS, DARBAR, AND VAUGHAN
out” rather than the opposing teeth to show continued
wear. It was of some concern that continued tooth wear
was noticed in a number of the dentitions, despite pre-
ventive care being instituted. Occlusal splint therapy was
not prescribed for these patients, but may have reduced
the number of failures.
Despite a random allocation of patients into the 2
patient groups, the restorations in group A were in ser-
vice approximately 6 months longer than those in
group B. It is unlikely that this observation and better
performance by group B is the result of a learning
curve experience. Both operators were experienced
clinicians in this technique but had predominately used
Durafill composite in this way before the study. We
would expect the Herculite XRV hybrid composite to
perform better than the Durafill microfill composite.
The Durafill composite was used as a test group as this
provided good esthetics and had excellent handling
characteristics.
It is the authors’ opinion from this study that there
is a higher failure rate experienced when restorations
are placed in thin section or in patients in whom there
is a Class III edge-to-edge incisal relationship. Eleven
of the failures were concentrated in such a patient in
group A. All of these restorations were replaced and
subsequently failed and ultimately the patient was pre-
scribed 6 anterior porcelain-fused metal crowns. Nev-
ertheless, these restorations were able to generate suffi-
cient interocclusal space facilitating the provision of
conventional crowns.
The main disadvantage of the technique is the clini-
cal time involved in providing the restorations.
Depending on the size of the buildup this may total
approximately 30 minutes per tooth, including finish-
ing procedures. Some of this time may be overcome by
using indirect restorations. An impression of the teeth
would be required and a laboratory charge would be
incurred. We are still unclear as to the best solution for
worn teeth when there has been significant reduction
in clinical crown height. A good appearance can be
obtained with direct composite palatal and labial
veneers in such a situation. When indirect palatal
veneers are used, an unesthetic cement line is usually
apparent on the labial surfaces. This can only usually be
improved if a labial composite or porcelain veneer is
subsequently placed. Clinical trials of these techniques
are continuing within our department.
CONCLUSIONS
Within the limitations of this study, it is concluded
that direct composite restorations placed at an
increased occlusal vertical dimension can provide a sim-
ple, short-term restorative solution to patients with
localized anterior tooth wear and loss of interocclusal
space. Hybrid composites were shown to perform bet-
ter than the microfill composites in such cases.
MARCH 2000
THE JOURNAL OF PROSTHETIC DENTISTRY
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Reprint requests to:
DR K. W. HEMMINGS
DEPARTMENT OF CONSERVATIVE DENTISTRY
EASTMAN DENTAL HOSPITAL AND INSTITUTE FOR ORAL HEALTHCARE SCIENCES
256 GRAY’S INN ROAD
LONDON
WC1X 8LD
UNITED KINGDOM
FAX:(44)171-915-1028
E-MAIL: K.Hemmings@eastman.ucl.ac.uk
Copyright © 2000 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2000/$12.00 + 0. 10/1/104626
doi:10.1067/mpr.2000.104626
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