wear mx of teeth

7/30/2019 wear mx of teeth

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Current concepts on themanagement of tooth wear:part 3. Active restorative care 2:

the management of generalisedtooth wearS. B. Mehta,1 S. Banerji,2 B. J. Millar3 and J.-M. Suarez-Feito4

VERIFIABLE CPD PAPER

the establishment o an accurate diagnosis

and the identication o possible aetiologi-

cal actors, an appropriate preventative

regime should be implemented, usually

ollowed by a period o passive monitor-

ing. The purpose o the latter is primar-

ily to ascertain the patients compliance

with the preventative programme, thus a

reduction (or ideally) an elimination o

the aetiological actors, to ensure that the

process o active tooth wear has stopped

(or considerably reduced) and nally to

allow the dental operator to develop a rap-

port with the patient, and the patient to

orm a clear understanding o the com-

plexities associated with the provision o

active restorative care. While or some

cases the elimination o possible causa-

tive actors may suce, or a proportion ocases active restorative intervention will be

required. The indications or active restor-

ative intervention or a patient presenting

with pathological tooth wear have been

discussed in detail in paper 2.2

For descriptive purposes, the restora-

tive management o patients presenting

with generalised tooth wear (TW) will be

considered according to the three catego-

ries described by Turner and Missirilian,3

hence:

Category1 excessive wear with losso vertical dimension o occlusion

Category2 excessive wear without

loss o vertical dimension, but with

space available

INTRODUCTION

Generalised tooth wear

The principles or the management o cases

presenting with generalised tooth wear

(ull arch or both arches respectively) ol-

low the same basic tenets as outlined or

localised wear cases in papers 1 and 2 o

this series respectively.1,2 Hence, ollowing

Paper 3 o this series on the current concepts o tooth wear management will ocus on the provision o active restora-

tive intervention or cases presenting with generalised tooth wear. The use o both contemporary adhesive and traditional

conventional techniques applied to treat cases o generalised tooth wear will be discussed, including a consideration o themerits and drawbacks o each approach respectively.

Category3 excessive wear without

loss o vertical dimension, but with

limited space.

Regardless o the category, or any case

o generalised TW where active interven-

tion is being sought, a set o diagnostic

casts mounted in centric relation (CR) is

strongly advised.

While a semi-adjustable articulator with

an arbitrary acebow may be considered

to be acceptable, a kinematic transverse

horizontal axis acebow transer is preer-

able in helping to plan a tentative increase

in the occlusal vertical dimension (OVD)

without introducing errors in the horizon-

tal jaw relationship. The true transverse

horizontal axis may be signicantly di-

erent anatomically rom that determinedwith the use o an arbitrary acebow.4 In

such cases, an alteration in the OVD will

result in a loss o accuracy in the horizon-

tal jaw relationship, culminating in errone-

ous restorations.

The desired increase in OVD will primar-

ily be determined by what is necessary to

produce unctionally stable, aesthetic dental

restorations and an adequate reeway space.

Clinically this can be estimated by meas-

urement o the existing OVD o the worn

dentition and the ace height with the man-dible at rest with an adequate lip seal; the

dierence between the two measurements

needs to accommodate the desired increase

in the OVD and the reeway space. Once this

1,2General Dental Practitioner and Senior C linical Teach-er, Department o Primary Dental Care, Kings College

London Dental Institute, Bessemer Road, London, SE59RW; 3*Proessor, Consultant in Restorative Dentistry,

Department o Primary Dental Care, Kings CollegeLondon Dental Institute, Bessemer Road, London, SE59RW; 4Section o Periodontology, Faculty o Dentistry

and Medicine, University o Oviedo, Oviedo, Spain

*Correspondence to: Proessor Brian J. MillarEmail: [email protected]

Refereed PaperAccepted 14 November 2011DOI: 10.1038/sj.bdj.2012.97British Dental Journal 2012; 212: 121-127

Emphasises the need for an accuratediagnosis and the strategic managementof occlusal changes to treat complexcases effectively and predictably.

Stresses the role of fully reversible andadjustable techniques (where possible)to evaluate planned functional andaesthetic changes.

Provides an overview of the merits anddrawbacks of contemporary adhesiverestorations used to treat tooth wear.

I N BR I E F

PRACTIC

E

1. Assessment, treatment planning andstrategies for the prevention and thepassive management of tooth wear

2. Active restorative care 1:the management of localised tooth wear

3. Active restorative care 2: themanagement o generalised tooth wear

4. An overview of the restorative techniquesand dental materials commonly applied forthe management of tooth wear

CURRENT CONCEPTS ONTHE MANAGEMENT OFTOOTH WEAR

BRITISH DENTAL JOURNAL VOLUME 212 NO. 3 FEB 11 2012 121


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PRACTICE

has been determined, the planned increase

may be programmed into the articulator (by

raising the pin on the articulator), and a

diagnostic wax up abricated accordingly

(preerably on duplicate casts).

The transer o the prescribed increase inOVD to the patients dentition should be

initially done by the use o ully revers-

ible and adjustable materials (such as resin

composite), so as to determine the patients

tolerance and aesthetic acceptance o 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 appropri-

ate period o time to evaluate tolerance

o the proposed changes, but will also

avoid the propagation o potential errors

which may arise where denitive 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 o basic aesthetic principles, as

discussed in Paper 1 (such as tooth shape,

length, inclination and relationship o the

incisal edge to the lip line).1 It should also

aim to provide occlusal stability, based

on the principles o a mutually protective

occlusal scheme.5

In essence, the nal occlusal scheme

should provide:

Simultaneous stable bilateral tooth

contacts

Centric relation (CR) coincident

with centric occlusion (CO)Disclusion o the posterior teeth,

upon lateral and protrusive

mandibular movements

Anterior teeth disclusion,

when posterior teeth contact in

maximum intercuspation

Shared/even anterior guidance

Canine guided occlusion, with planned

group unction upon loss o canine

guidance (or where the canine toothmay be unsuitable as a guiding unit),

with the absence o working or non-

working side occlusal intererences.

The diagnostic wax up should be pre-

sented to the dental patient, to permit

an evaluation o the anatomy, size, con-

tours and shape o denitive restorations.

It will also help to explain the proposed

occlusal changes.

It is oten useul to have a vacuum

ormed matrix (thermoplastic template)

produced rom a duplicate cast o the diag-

nostic 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 o the restorative end point,

particularly where there may be planned

signicant changes to the anterior denti-

tion. Alternatively, resin composite mock-

ups may be placed directly to evaluate

proposed changes. Depicted by Figure 1 is

an example o such a composite resin mock

up applied to a worn dentition to display

proposed aesthetic and unctional changes.

Unrealistic expectations may be appar-

ent at this stage, which may require ur-

ther patient education or revision o the

treatment plan.

RESTORATIVE TECHNIQUES- ADHESIVE VERSUSCONVENTIONAL

Beore discussing the approach taken orthe management o a patient present-

ing with generalised tooth wear, regard-

less o the category o wear as described

above, it is worthwhile overviewing the

possible restorative protocols which are

usually applied, hence the adhesive addi-

tive approach versus the conventional

approach.

Conventional restorative techniques

(those which depend on mechanical toothpreparation eatures to provide retention

and resistance orm) have traditionally

been the mainstay or the management o

tooth surace loss. In recent times, with

improvements in adhesive technology and

the availability o superior resin compos-

ites, adhesive retained restorations have

become ever increasingly popular.

The choice o a particular technique will

depend on a variety o actors as listed

below. However, it is important to state

that any single case may well involve a

combination o techniques as depicted by

the case examples described above.

Conventional restorations will require

the copious removal o sound dental

hard tissue (rom tooth structure

which will have already been

compromised by the process o TW).

Adhesive preparations in contrast are

minimally invasive

Conventional, ull coverage

restorations have been associated with

high risks o loss o pulp tissue vitality.

Saunders and Saunders reported

in 1998 that 19% o crowned teeth

among a Scottish subpopulation had

radiographic signs o peri-radicular

disease.6 The latter may be heightened

among teeth aected by tooth surace

loss, as their pulpal tissues may have

already been stressed by the process

o tooth wear. Furthermore, iatrogenic

pulp exposure is more likely among

teeth which have been aected by theprocess o wear, by virtue o the pulp

chamber being closer to the occlusal

surace o the aected tooth

Conventional tooth preparations are

Figs 1a-c Composite resin mock-up to demonstrate proposed aesthetic and unctional changes to a worn dentition. Warmed resin composite(Gradia Direct, GC), has been applied to a worn dentition with the aid o a thermoplastic template, without any hard tissue conditioning

a b c

122 BRITISH DENTAL JOURNAL VOLUME 212 NO. 3 FEB 11 2012


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PRACTICE

irreversible. There are risks that some

patients may not be able to tolerate

planned changes to their occlusal

scheme. Adhesive restorations oer

a large element o fexibility, as

minimal tooth reduction is required to

accommodate the latter orms o dental

restoration

Conventional restorations require

careul tooth preparation to provide

adequate resistance and retention

orm. The process o preparation may

be hampered by a lack o dental hard

tissue in the case o a worn dentition

The success o adhesive restorations

is dependent to a large extent on the

presence o a copious quantity o high

quality tooth enamel. However, in thecase o conventional restorations, the

process o tooth preparation may lead to

the loss o any residual enamel, which

will reduce the intrinsic strength o the

tooth and compromise the longevity o

the restoration. According to a study

by Edelho and Sorenssen,7 between

63% and 72% o coronal tooth tissue

may removed during the preparation

o a tooth to receive an all-ceramic or

porcelain used to metal crown

Adhesive techniques are highly

operative sensitive and require

meticulous moisture control

Conventional techniques are dependent

on the need or provisional restorations.

They are seldom required where

adhesive methods are being planned

Conventional restorations are

associated with higher initial

nancial costs - perhaps three old

that o adhesive restorations (in the

experience o the authors)

Conventional restorations may oer

superior levels o longevity when

compared to adhesive restorations (as

discussed below); however ailures in

the longer term tend to be catastrophic

and oten un-amenable to repair.8

In contrast, ailures associated with

adhesive restorations used to treat

wear are oten readily addressed,

without urther biological detriment

to the dental hard tissue(s), as will be

discussed urther in the ourth paper inthis series.

In general, it would be prudent (where

possible) to primarily consider an adhesive,

additive approach, when attempting to

actively manage a worn dentition. As

discussed in the preceding article in this

series,2 adhesive restorations may very

eectively serve as medium term resto-

rations, where eventually they may be

replaced with conventional techniques,

having established the patients tolerance

and adaptability to their new occlusal

scheme (should a non-conormist approach

be adopted). In addition, the undertaking

o tooth preparations o teeth which havebeen additively restored by the addition o

adhesive materials, may at times largely

involve removal o the restorative material

(as opposed to dental hard tissues).

CATEGORY 1 PATIENTS: EXCESSIVETOOTH WEAR, TOGETHER WITHA LOSS IN THE OVD

Such cases may be considered the most

straightorward o all three categories to

manage, as the resultant inter-occlusal

clearance created through the process o

tooth wear will provide most, i not all the

required space or the restorative material,

without the need or aggressive occlusal

reduction (by a planned increase in the

OVD), while maintaining a physiologicalFreeway Space (FWS).9

A ull coverage, hard acrylic stabilisa-

tion splint, such as a Michigan splint, can

be used to evaluate the patients tolerance/

Fig. 2 Clinical case 1. a-b) Pre-operative views o case. c) Close up view o overlay restoration(Ceramage, Shou). d-e) Cemented overlays and provisional crowns at LL5, 6 and 7. Note thepresence o even occlusal contacts in centric occlusion. Provisional restorations were retainedor eight weeks to enable assessment o tolerance/adaptability to the new occlusal prescription.-h) Provisional restorations have been replaced with defnitive restorations. Edentulous spacehas been restored with a tooth and mucosally supported lower partial denture. Note thepresence o canine guidance on lateral excursive and protrusive mandibular movements

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PRACTICE

adaptability to the planned occlusal

changes (as described in urther detail

in paper 11). This should be abricated to

not only provide the planned increase in

OVD, but also the occlusal prescription as

described above, hence a mutually pro-

tective occlusal scheme. For category 1

patients however, the use o such a splint

is usually not considered to be manda-

tory.9 Where an adhesive re-constructive

approach is planned, all the involved teeth

can be potentially prepared in one visit. It

would be hoped that tooth preparation will

be conned to the application o nishing

lines to the aected teeth to assist with

the abrication and placement o any indi-

rect restorations, and also possibly help

to augment resistance orm. Pre-existingamalgam and composite resin restorations

should be replaced with new resin based

materials, to improve bonding. Preparation

designs or the latter orms o restoration

have been detailed urther in the preced-

ing article o this series, however, the

importance o a copious quantity o high

quality tooth enamel and the attainment

o meticulous moisture control cannot be

overemphasised (in order to attain a suc-

cessul restorative outcome).

A new acebow record and intra-occlusal

record may be required. Where it may be

decided to sequence the placement o res-

torations, such that either the anterior or

posterior segments are restored in sepa-

rate visits, the use o a stabilisation splint

(which may be sectioned to accommodate

the new restorations) can prove vital to

ensure short term longevity o the new

restorations, by providing some level o

protection rom excessive occlusal loads.

Ideally, hal the increase in OVD should

be incorporated into each arch, but this

depends on the pattern o wear, and the

desired aesthetic outcome. Where the

increase in OVD is shared equally between

the dental arches, it will not only allow

or a better distribution o the increase

in crown to root ratio, but also make

the increase in OVD less abrupt, thereby

improving the chances o successul

adaptation.7

Clinical case 1, Figure 2, is an exam-

ple o a category 1 patient treated via anadhesive, additive approach. It is a case

o a 67-year-old male, presenting with an

edentulous space in his lower right quad-

rant, and wearing lower anterior dentition,

with an FWS o 6 mm. The likely cause

o tooth wear in this case is a combina-

tion o a bruxist tendency, which has been

accentuated in the lower anterior region

by the presence o an abrasive antagonis-

tic porcelain used to metal crowns (with

ceramic on the occluding surace[s]) The

upper arch had been previously restored

entirely by the means o porcelain-used

to metal crowns and bridges. Metallo-

ceramic crowns were present at LL5, 6

and 7. It was decided to restore the worn

lower anterior teeth (LL321, LR123) with

indirect resin ceromer overlays (Ceramage,

Shou), and to concomitantly increase the

OVD by 3 mm. The rst stage involved

the elective removal o the crowns at

LL5, 6 and 7. This was ollowed by the

placement o the composite onlays (luted

with Variolink II, Ivoclar, Vivadent) and

the tting o provisional crowns at LL5, 6

and 7 to the new occlusal vertical height.

Ater a period o adaptation, the provi-

sional crowns were replaced with deni-

tive metallo-ceramic crowns. The crowns

were designed so as to include rest seats,

guide planes and undercuts in accordance

to the partial denture design. The restora-tions were designed to provide a canine

guided occlusion, with even centric stops

in CO and posterior disclusion on protru-

sion and lateral excursions.

Where conventional restorations are

being planned, preliminary tooth prepa-

rations (o at least one arch) can be carried

out in one single visit. This will allow or

the abrication o the provisional restora-

tions or all the teeth at the planned OVD.

The choice o which arch to prepare rst

will depend on the occlusal plane dis-

crepancy (usually the arch with the great-

est discrepancy will be prepared rst).

Acrylic or silicone indices ormed rom the

diagnostic wax up can be used to assist

the operator with the level o occlusal

reduction required.

The patient should be maintained in indi-

rectly ormed provisional restorations or aperiod o 6-8 weeks.9 This time period will

allow or an evaluation o the aesthetics

and unction. The provisional restorations

may, however, require adjustments. Once

deemed acceptable, the provisional resto-

rations may be used as an occlusal and

aesthetic guide or the abrication o the

denitive restorations. The construction

o a customised anterior guidance table

can prove to be very benecial (to copy

the anterior occlusal scheme) as achieved

with the use o the provisional restora-tions), where the anterior guidance has been

shown to be mechanically acceptable.

Where metallo-ceramic crowns are

being prescribed, it may be worthwhile

Fig. 3 Clinical case 2. Generalised tooth wear case treated by the means o conventional

porcelain used to metal crowns. a) Pre-operative view o category 1 generalised wear casewith loss o OVD. b) Diagnostic wax up. c) Laboratory abricated provisional restorations.d) Porcelain used to metal restorations abricated to copy the occlusal and aestheticprescription derived rom the placement o provisional restorations

This case was completed several years ago. The authors would not advocate this method otreatment provision in current times (in the frst instance) given the pre-existing dentalcondition, as it would be considered to be a highly invasive, aggressive approach

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PRACTICE

undertaking either metal and/or biscuit

try-in stages, so as to minimise the risk o

errors propagating during the undertak-

ing o restorative care. The nal occlusal

scheme should aim to leave the patient

with a mutually protected occlusion as

discussed above.

Clinical case 2, Figure 3, is an exam-

ple o a category 1 patient treated by the

means o conventional restorations. Please

note, this approach given the state o the

pre-existing dental health is not advocated

by the authors (as a rst line means or

tooth wear management), as it is consid-

ered to be biologically highly invasive.

CATEGORY 2: EXCESSIVE WEARWITHOUT LOSS OF OVD, BUT WITHLIMITED SPACE AVAILABLE

In such cases, a discrepancy will usu-

ally exist between centric occlusion (CO)

and centric relation (CR). CR may provide

space to accommodate restorative materi-

als; however, it might not always be ully

adequate and there may be a need to plan

an increase in the OVD. For such cases,

the patient should be provided with a ull

coverage, hard acrylic occlusal splint,

which will provide an increase in the OVD

to the required range, while the mandi-

ble is manipulated into its retrusive arc

o closure.9

The occlusal prescription o the splint

should aim to provide a removable mutu-

ally protective scheme. The patient should

be instructed to wear the splint continually

or a period o one month (at all times

other than when eating) to evaluate the

tolerance o the increase in OVD.

Once the operator is satised that the

patient can tolerate the planned change,

the process o preliminary tooth prepara-

tion may begin, as described or category

1 patients.

Unpredictable compliance with splint

therapy has prompted an alternative

approach, as described by Vialati and

Belser in 2008.10 The latter have sug-

gested that a more realistic approach

would involve the placement o indirect

provisional resin composite onlay and/

or palatal resin veneers respectively at

the same occlusal prescription as wouldbe provided by a ull coverage, hard

occlusal splint. The true reversibility o

this approach may, however, be a con-

cern (as some level o tooth reduction may

be required to accommodate the desired

thickness o composite resin) as may be

the additional nancial costs incurred.

While resin based restorations may be

applied directly to reduce costs, this

approach is very time and skill demanding

and indeed, it may be impossible to attain

the desired dynamic occlusal scheme par-

ticularly or complex posterior restora-

tions, which will need to be placed in a

supra-occlual position (at the desired new

vertical dimension).

Clinical case 3, Figure 4, involvesthat o a 31-year-old male patient who

presented with generalised TW due to a

combination o bruxism and extrinsic

erosion. While a discrepancy was elicited

between CO and CR, there was inadequate

inter-occlusal clearance to accommo-

date restorations without maintaining a

physiological FWS. A Michigan splint was

provided to increase the OVD by 3.5 mm.

Following a period o successul adapta-

tion (or one month), the patients denti-

tion was restored by adhesive means, with

minimal tooth preparation. The posterior

teeth were managed by the application o

Type III cast gold adhesive onlays, where

the t surace had been heat treated at

400C. The onlays were cemented usingPanavia 2.0F (Kuraray, Japan). The max-

illary anterior dentition was restored

by the means o indirect resin ceromer

(Ceramage, Shou) palatal veneers with

Fig. 4 Clinical case 3. a-c) Pre-operative views o case. d-h) Post-operative views. Wornocclusal suraces have been restored with cast gold adhesive onlays posteriorly, while themaxillary anterior teeth have been restored with indirect resin composite restorations. Theplacement o these restorations culminated in a very small separation o the second molarteeth. These teeth were allowed to Dahl into occlusion

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PRACTICE

incisal edge coverage (cemented using

Variolink II). It is worth noting is that

there was little need to restore the sec-

ond molar teeth or lower incisor teeth.

The ormer were allowed to re-establish

occlusal contacts through the combined

processes o mandibular repositioning

and the controlled intrusive and extrusive

movements o involved dento-alveolar

processes respectively.

CATEGORY 3: NO LOSS OF OVD,WITH INSUFFICIENT SPACE FORRESTORATIVE MATERIALS

A typical example o a category 3 case is

shown by Figure 5.

These are usually the most diicult

cases to restore because space is not read-ily available due to tooth repositioning

brought about by alveolar compensatory

growth. According to Rivera-Morales and

Mohl,9 or such cases, every eort should

be made to obtain space by means other

than an increase in the OVD. Only i such

methods ail to provide enough space,

would an increase in the OVD be advo-

cated. The latter would be accomplished by

the programmed modication o the OVD

through the careul use o occlusal splints.

Other methods which may be used to

create space include:

1. Surgicalcrownlengthening,with

osseousre-contouring. Surgical

crown lengthening with osseous

re-contouring can be used to increase

the quantity o coronal tooth tissue,

particularly in the case o teeth with

short clinical crown heights, where

urther occlusal reduction may

severely compromise retention and

resistance orm where conventional

restorations are being planned.

While restoration margins may

be placed subgingivally, ideally the

restoration margin should be placed

no more than 0.5 mm subgingivally

to prevent encroachment o the

biological width. Where the lat-

ter is invaded, chronic periodontal

infammation with concomitant

periodontal breakdown will ollow,

permitting the re-establishment o

the biological width at a more api-cal position. To avoid this, surgi-

cal crown lengthening is indicated

(Briggs and Bishop, 199311). However,

surgical crown lengthening may

result in unsightly black triangles

between the teeth and also lead to

unavourable crown to root ratios.11

Gingival recession oten accompa-

nies the healing process, which may

result in the exposure o subgingivalmargins. Where possible, methods

o tissue retraction and impression

making should avoid damage to the

supra-crestal attachment (Talbot et

al.12). It is also important to allow an

adequate period o healing beore the

placement o denitive restorations

(particularly in the anterior region),

or the avoidance o poor post-restor-

ative aesthetics and to allow the level

o the gingival crest to stabilise.12 A

period o up to six months between

that o the undertaking o periodon-

tal surgery to that o the placement

o the denitive restorations has been

advocated by Wise.13

Other drawbacks associated with

crown lengthening include signicant

post-operative sensitivity, especially

as the restorative margins will need

to be placed up on newly exposed

root dentine.11 Where the treated

tooth has a marked coronal-cervical

taper, this may also culminate in the

need or a highly destructive prepa-

ration orm. The presence o high

urcal areas must also be considered

pre-operatively.

Figure 6 shows an example o

a lower anterior dentition display-

ing signs o reduced clinical crown

height due to pathological tooth wear.

Clinical crown lengthening has been

achieved by the means o a conven-

tional periodontal surgical approach.2. Electiveendodontics. Elective

endodontics may be considered to

permit the application o a post and

core system to urther augment the

available core material, or in the

case o a grossly over-erupted tooth,

where there is a need to correct the

occlusal plane discrepancy (where

occlusal reduction would otherwise

result in iatrogenic pulpal exposure).

However, as discussed in paper 2 o

this series,2 post and core restorations

particularly when placed in dentitions

where there may be signs o wear

as a result o paraunctional tooth

clenching or grinding habits may be

associated with a very bleak outlook.14

Furthermore, the undertaking o

elective endodontic therapy might

also compromise the long term

prognosis o the aected tooth,

should root canal therapy prove to

be unsuccessul

3.Orthodontictoothmovement.

Orthodontic tooth movement can

also be used to permit the intrusiono grossly over-erupted teeth or the

extrusion o teeth with short clinical

crowns (where there is a copious

quantity o alveolar bone support).15

Figs 5a-b Example o a category 3 case

a b

Fig. 6 a-b) Limited crown height o loweranterior teeth. c) Increased crown heightater healing has taken place

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PRACTICE

SUMMARY

The provision o active restorative care or

a patient presenting with generalised tooth

wear can be considerably demanding even

or more experienced dental operators. There

is an obviously proound prerequisite or the

latter to have a very clear perspective o the

planned outcome, which in turns requires a

very good working knowledge o the prin-

ciples o occlusion and an appreciation o

the shortcomings o available materials and

techniques available to the contemporary

practitioner. The nal article o this our part

series o papers on the subject o tooth wear

will provide an account o the commonly

used materials and techniques which may be

applied to treat cases o tooth wear.

1. Mehta S B, Banerji S, Millar B J, Suarez-Feito J-M.Current concepts on the management o tooth

wear: part 1. Assessment, treatment planning

and strategies or the prevention and the passive

management o tooth wear. Br Dent J2012;

212: 1727.2. Mehta S B, Banerji S, Millar B J, Suarez-Feito J-M.

Current concepts on the management o tooth

wear: part 2. Active restorative care 1: themanagement o localised tooth wear. Br Dent J2012; 212: 7382.

3. Turner K, Missirilian D. Restoration o the extremely

worn dentition. J Prosthet Dent1984; 52: 467474.4. Rosenstiel S, Land M, Fujimoto J. Contemporary

fxed prosthodontics. 3rd ed. Mosby, 2011.

5. Staurt C, Stallard H. Concepts o occlusion.

Dent Clin North Am 1963; 7: 591.6. Saunders W, Saunders E. Prevalence o peri-radic-

ular periodontitis associated with crowned teethin an adult Scottish subpopulation. Br Dent J1998;

185: 137140.7. Edelho D, Sorenssen J. Tooth structure removal

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