VERIFIABLE CPD PAPER

CLINICAL Tooth wear

Treatment planning for patients with tooth wear

Robert Stone1

Key points
Outlines a comprehensive assessment for Describes the treatment planning process as Details how diagnoses can be multiple and may
patients with tooth wear. being both holistic and thorough to enable a clear require irreversible investigative processes.
pathway and vision.

Abstract
Providing restorative dental care for patients with tooth wear can, at times, seem complex and demanding. The key
to this process lies in a systematic approach that breaks down the component parts. In this chapter, the importance of
a comprehensive assessment at the outset will be highlighted. This should include identification of the patient’s chief
complaint, taking a thorough history, completing the clinical examination, undertaking any special tests and arriving
at clinical diagnoses. Together, this information will influence the treatment planning process, identify appropriate
treatment concepts and options available and the individual stages that may be involved. The process should be
both holistic and thorough to enable the patient and clinician to build a clear pathway and vision. In parallel, and
with patient input throughout, it is essential to manage patient expectations as best as possible whilst remaining
pragmatic and honest about treatment outcomes, longevity of restorations and the risks of failure.

Introduction Patient history: a guide to diagnosis In parallel, a comprehensive medical history,

Treatment planning is the synthesis of the
information gathering process, clinical
diagnosis, and reflection on a patient’s needs,
wishes and expectations. Unfortunately, this
process is not always linear with respect to
restorative dentistry. Diagnoses can be multiple
and may require irreversible investigative
processes to achieve diagnostic confirmation
and reassessment of treatment planning.
To achieve comprehensive treatment
planning a clinician should provide:
1. A modern comprehensive diagnostic
evaluation
2. Prevention and stabilisation of primary
disease processes
3. Protection and restoration of tooth
structure and function
4. Maintenance and review.
Book chapter originally published in Andrew Eder and
Maurice Faigenblum (eds), Tooth Wear, BDJ Clinician’s
Guides, https://doi.org/10.1007/978-3-030-86110-0_10.
1
UCL Eastman Dental Institute and Private Practice,
London, UK.
Correspondence to: Robert Stone
Email address: robert.stone@ucl.ac.uk
https://doi.org/10.1038/s41415-023-6116-y
and a tool for assessing risk
Identifying the patient’s chief complaint,
perceived desires and preferred outcomes at
the outset is essential although aspects may
change as the information gathering and
diagnostic processes progress. For example,
patients may be unaware of the full extent of
their tooth wear at initial presentation.
The European Consensus Statement on
Managing Severe Tooth Wear 1 recommends
‘the OHIP-49 questionnaire to test the Oral
Health Related Quality of Life of patients
with severe tooth wear’. The paper goes on
to suggest that even with the most thorough
investigatory and examination processes,
the multifactorial nature of tooth wear often
prevents a clear diagnosis of the aetiological
factors. However, an experienced clinician
should be able to consider the relative
weighting of each individual process.
Furthermore, the ability to negate long
established contributory factors may be
limited; examples include night and day
bruxism, bulimia and chronic gastro-
oesophageal reflux disease. That said, steps
can be taken to minimise their effects from
both a preventive and a therapeutic stance.
dental history and social history should be
investigated and recorded as follows:
• A medical history should be taken to
prevent complications and guide a holistic
approach, before, during and after dental
treatment
• The dental history should include the
restorative, endodontic, orthodontic,
periodontal, soft tissue, craniofacial and
trauma histories
• The social history should include
occupation, lifestyle, diet and oral hygiene
regimes past and present.
When all is considered together, this
information will not only assist the clinician in
determining the primary source of tooth wear
but may also have implications on the future
management, treatment decision making and
ultimately the predictability and longevity of
any treatment outcomes.
Examination and records
Extra-oral examination
The extra-oral examination should include
analysis of the temporomandibular joints
(TMJs) and associated musculature. Pain,

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© Springer Nature Switzerland AG 2022. Republished 2023.
 Tooth wear CLINICAL

clicking, crepitus, deviation and range of

movement should be assessed. The TMJs
should be palpated, laterally and posteriorly,
for pain and tenderness. Palpation should
also be used to assess the muscles of
mastication (masseter, temporalis, occipitalis,
medial pterygoid, sternocleidomastoid and
suprahyoid). This is also a convenient time to
palpate the submandibular and cervical lymph
nodes along with the parotid for enlargement
and tenderness. Parotid tenderness is often
seen in patient’s suffering from bulimia.2
Additional analysis of the craniofacial, Fig. 1 Centric jaw relationship record (bimandibular manipulation)
facial, dento-labial soft tissues and phonetics
are important parameters when considering
tooth wear. Good photography and even video
skills are essential to augment and record many
of these aspects.
Tooth wear often has a significant aesthetic
component. The lips, gingival and ‘incisal show’
should be noted and recorded both at rest and
when smiling broadly. The vertical dimension
can be recorded at rest and in maximum
intercuspation. This will enable an assessment
of the degree of dento-alveolar compensation
and have significant implications on space
requirements.

Intra-oral examination
The intra-oral examination should assess soft
tissue health and the presence of any pathology
and also record indicators of tooth wear
associated parafunction. Examples include linea
alba and tongue scalloping. The endodontic
status, remaining tooth structure, periodontal
status and orthodontic requirements should all
be analysed, with the assistance of appropriate
radiographs where necessary. Lastly, a detailed
occlusal evaluation is performed, recorded and
reproduced in the form of accurate mounted
study casts that capture the mandible closing on
the hinge axis. Once again, high quality intra-
oral photography is vital.
At the end of this comprehensive
information gathering process, the clinician
should have the best possible representation
of the patient without the patient actually
being present in the surgery. The process of
care planning can then begin with time and
space to think clearly; starting on a tooth-by-
tooth basis and then expanding to consider
groups of teeth, their strategic importance, the
availability of anterior guidance and posterior
stability before moving to consider both arches
as one stomatognathic system.
An invaluable tool in this analysis is the
production of accurate study casts (Figures 1
Fig. 2 Facebow record, Lucia jig, centric relation record and maxillary and mandibular alginate
impressions in metal Rimlock trays
and 2) mounted on a semi-adjustable
articulator. Impressions taken using rigid,
preferably metal, trays with alginate or an
elastomeric material if they cannot be poured
in good time. The casts should be mounted on
the hinge axis with the aid of a face-bow record
and using a tooth apart inter-occlusal record
using a Lucia jig, bimandibular manipulation
and a rigid wax carrier. The mounted study
casts should be verified and checked against
the clinical findings but caution should be
exercised as the mouth is far better at hiding
fine occlusal contacts than an articulator.
An endodontic evaluation should record
the vitality of the teeth using a cold test in
conjunction with an electronic pulp tester. If
negative, this can then be followed up with a
long cone periapical radiograph that can be
used to evaluate the periradicular structures
and the presence of pathology. Loss of vitality
due to tooth wear is relatively uncommon
(0.96%).3 Tooth wear is, usually, a slow process
that allows the pulpal tissues to adapt and
lay down tertiary dentine. Baseline bitewing
radiographs give an indication of bone levels,
caries, pulpal changes, restorative margins and
the availability of proximal enamel.
Tooth structure evaluation can be difficult at
times, especially when extra coronal restorations
have been placed; old working dies or digital
impressions are helpful but seldom present.
Ultimately, the only solution is to investigate
the tooth by removing the existing extra-
coronal or large intra-coronal restorations and
assessing the remaining tooth structure. This
can be problematic and is often one of the most
difficult treatment planning concerns for a
dental practitioner. The investigation commits
the clinician to irreversible intervention and
the findings could drastically alter the working

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© Springer Nature Switzerland AG 2022. Republished 2023.
 CLINICAL
treatment plan. If this is the case, the patient
needs to be fully informed of the possible
outcomes and consent to the investigation.
Having investigated the tooth, how much tooth
structure is actually required? This is a complex
question and rather depends on the desired
treatment modality. If the clinical approach is
developing along conventional lines; clinical
crown height and remaining dentine are critical.
For example, if 2–4 mm of crown height remains
there may be options to augment the core with a
composite or amalgam albeit dependent on the
availability and positioning of tooth structure
to providing resistance form. Tooth structure
is required to provide protection for a post and
core restoration. A 2 mm collar, known as a
ferrule, confluent with the margin is an essential
prerequisite for success.4 However, if the crown
height is less than 3 mm one must attempt to
increase the height by crown lengthening or
orthodontic extrusion (Chaps. 13 and 14).
Over the last 20 years, there has been a
paradigm shift in the management of tooth
wear. Adhesive management has been embraced
(Chap. 15). Adhesive restorative treatment
allows for an additive rather than a subtractive
approach. This makes perfect sense as the
concept of removing more tooth structure to
restore already heavily damaged teeth is surely
flawed. When employing an adhesive approach,
the presence of circumferential enamel,
sometimes referred to as the ‘tennis racket effect’
is preferred to crown height, resistance form and
ferrule. Isolation, cleaning and specific bonding
protocols are essential for success. There is even
possibility of raising a sub-gingival margin in a
small section to provide supragingival isolation
and an accessible margin for further bonding;
this has been described as deep margin
elevation.5
An orthodontic evaluation is an invaluable
adjunct to conservative treatment of tooth
wear (Chap. 14). The ability to create inter-
occlusal space, align teeth and their gingival
margins are vital considerations in planning
for functional and aesthetic integration. A
multidisciplinary approach is often essential,
with input from all clinical disciplines at
the earliest possible opportunity, to plan for
the best possible outcomes with particular
attention being given to determining the
critical occlusal requirements (Fig. 3).
A full periodontal examination should be
carried out. Six-point pocket charting, plaque
and bleeding indices will give the clinician the
most thorough clinical picture. Attachment
levels, furcation involvement and mobility
192
© Springer Nature Switzerland AG 2022. Republished 2023.
Tooth wear
a b
c d
Fig. 3 a) Incisal tooth wear and uneven gingival margins. b) Orthodontic treatment to align
teeth and gingival margins. c) Post-orthodontic treatment with balanced gingival margins. d)
Tooth wear restored with direct composite resin
Table 1 Turner classification: categories of generalised tooth wear patients
Turner classification
Category 1 Excessive tooth wear with loss of occlusal vertical dimension
Category 2 Excessive wear without loss of occlusal vertical dimension but with space available
Category 3 Excessive wear without loss of occlusal vertical dimension but with limited space
should also be recorded although it must be Mounted study casts in conjunction with
noted that chronic periodontal disease and the relevant photographic images are essential
generalised tooth wear are rarely seen together. for planning the space requirements which
Where short clinical crown height is a particular are normally critical to the management of
issue, crown lengthening might be a viable most tooth wear cases. Turner and Missirlian6
adjunct to facilitate care (Chap. 13). considered three categories of generalised
The occlusal evaluation should be the tooth wear patients (Table 1).
synthesis of the information gained from Patients who fall into category 1, can be
the clinical examination and analysis of treated by re-establishing the original occlusal
the mounted casts (Chap. 11). With time vertical dimension. The loss of occlusal vertical
and experience, analysis of the mounted dimension is most usually because of rapid
casts will be an essential addition to the loss of tooth structure. Those in category 2
clinical examination as the soft tissues and and 3, however, are less clear cut as a slower
neuromuscular condition often hinder the progressive loss of tooth structure results in
ability to visualise and record occlusal contacts dento-alveolar compensation and maintenance
clinically. of the occlusal vertical dimension. For these
The analysis should include static inter- patients, space is only available by increasing
cuspal holding contacts, the presence of the occlusal vertical dimension. Space is
posterior stability, the nature and availability rarely available and a working knowledge
of anterior guidance, dynamic contacts in of the methods available, and how they may
protrusion and lateral excursions including be combined, to create space is critical and
both working and non-working contacts. The outlined below:
first point of contact in the retruded position, 1. Altering the position of mandibular closure
the presence and the nature and size of any (Chap. 11): if a slide is present a clinician
slide observed. Finally, the curves of Spee and can alter the mandibular position by
Monson should be assessed along with any performing an occlusal equilibration to
disturbances in the occlusal plane. You will make the retruded position coincident
also be able to evaluate more accurately the with the inter-cuspal position. This will
nature of parafunctional activity and pattern maintain the existing occlusal vertical
of attrition. dimension and will usually create a small
BRITISH DENTAL JOURNAL | VOLUME 235 NO. 3 | August 11 2023

volume of anterior space by eliminating
the slide between the retruded and inter-
cuspal positions. The process should be
investigated and rehearsed on articulated
casts to assess the biological cost and
practicality of transferring this to the
dentition
2. Surgical crown lengthening (Chap. 13):
can be very effective in facilitating more
traditional tooth preparation techniques
that rely on retention and resistance form.
The ability to simultaneously balance the
gingival architecture is also very appealing
3. Orthodontics (Chap. 14): changing tooth
position can create space but it may be
difficult to provide ideal tooth-to-tooth
contacts. A combination of restorative and
orthodontic treatment is likely to achieve
the best results in such tooth wear cases
4. Increasing the occlusal vertical dimension
(Chaps. 15 and 16): whilst this can be a helpful
solution, it does mean that all teeth in at least
one, or possibly both, arches will need to be
restored. The amount of increase required is
governed by the space requirements of the
intended restorative material, to correct the
aesthetic tooth display, to establish effective
anterior guidance, to establish posterior
stability and to avoid the need for tooth
preparation, surgical crown lengthening
and endodontic treatment. By analysis of
the retruded position and the nature of
the slide into the inter-cuspal position, it
is possible to create space by restoring the
worn teeth at the first point of contact.
Often this first point of contact provides
the perfect starting point to restore the lost
tooth structure. Occasionally, it provides
too little space and more vertical opening
is required. However, clinicians must
remember that in most Class 2 skeletal base
situations, the relative anterior-posterior
(horizontal) position of the incisors becomes
less favourable as the vertical dimension
increases. Additionally, the opening is
obviously limited by the degree of vertical
overlap of the anterior teeth. Both can lead
to challenges in re-establishing satisfactory
anterior guidance. However, there are
occasions when one finds there would be too
much space if the retruded position were to
be adopted. In these cases, a pre-restorative
occlusal adjustment is sometimes required
to reduce the space available and facilitate a
workable incisal relationship. Studies show
that opening the vertical dimension by up
to 5 mms is safe and predictable7 with no
BRITISH DENTAL JOURNAL | VOLUME 235 NO. 3 | August 11 2023
© Springer Nature Switzerland AG 2022. Republished 2023.
Tooth wear
a b
Dahl B, Krogstad O, Karlsen., J. Oral Rehabil, Dahl B, Krogstad O, Karlsen., J. Oral Rehabil,
1975: 2: 209-214 1975: 2: 209-214
Fig. 4 a, b, c) The ‘Dahl Concept’ illustrated
Table 2 Stages of treatment in the management of patients with tooth wear
Stages of treatment
Stage one Prevention and stabilisation of primary dental disease and further diagnosis
Stage two Protection and/or restoration of tooth structure, appearance and function
Stage three Maintenance and review with an emphasis on prevention
incidences of long lasting TMJ symptoms.8
Whilst a satisfactory solution if all teeth in
one or both arches needs restoring, relative
axial movement as outlined below may be
more appropriate if a rather more localised
approach is required for just a few teeth
5. Tooth preparation (Chap. 16): preferable to
avoid wherever possible in a patient with tooth
wear but occasionally needed to facilitate
occlusal adjustment, level the occlusal plane
or when adhesive strategies are not an option
6. Relative axial tooth movement (Chaps. 14,
15 and 16): this method was first described
by Dahl in 19759 (Fig. 4).
Dahl and co-workers used removable metal
bite planes to help reduce deep traumatic
overbites and restore worn anterior teeth
without resorting to restoring the posterior
teeth at the same time. Since the 1970’s, and
in conjunction with the progress made in
adhesive dentistry, the ‘Dahl Concept’ has
become instrumental in the paradigm shift
in how we, as clinicians, approach tooth
wear cases. With careful planning to ‘axialise’
the occlusal forces generated down the long
axis of the teeth in contact, we can create the
space required. The space can be immediately
restored with a restorative material or used
in a staged approach. Planning is key and
while some authors have suggested this can
be planned from the inter-cuspal position, or
even worse by ‘eye-balling’, others believe it is
essential to work from the retruded position to
provide the desired accuracy and to facilitate
far superior control of the resulting occlusal
forces. This requires a retruded relation
CLINICAL
c
Dahl B, Krogstad O, Karlsen., J. Oral Rehabil,
1975: 2: 209-214
mounting, diagnostic waxing and replication
in the mouth. When planned carefully, the
posterior occlusion re-establishes full arch
contacts over time and dispenses with the
requirement of full mouth or whole arch
restorations. Modern adhesive techniques
and composite material make immediate and
purely additive treatment of anterior tooth
wear a reality. Patient satisfaction (aesthetic and
functional) is very high and although repairs
will be required, they are easy to do and seldom
require more complex intervention. Studies
show that the thicker the composite material
is used, the better the longevity.10 All must
be considered with regard to the underlying
aetiology of the tooth wear, opposing tooth
substance and the materials used.
Thinking time and space: the
planning process
Having recorded and considered all the
diagnostic elements, it is important to allow
time and space away from the patient to
consider and reflect upon the patient, your
findings and their expectations. Within this
planning process, it will be essential to decide
whether any further information is required,
if diagnoses can be made and whether
expectations are realistically deliverable. All can
then be shared with the patient, normally in the
form of a comprehensive report or treatment
planning letter which should include the
history, your findings, the diagnoses, treatment
options and recommendations. Additionally,
you can take this opportunity to set out the
stages of treatment (Table 2), an appointment
193
 CLINICAL Tooth wear

the maxillary central incisors. Functional

elements include ensuring there is sufficient
vertical and horizontal overlap to provide
smooth shallow to steep anterior guidance,
ideally, with canine lift. Speech should be
checked for comfort and particularly fricative
(F and V) and ‘S’ sounds. Adjustments and
refinements can be made either in the
actual mock-up or in the wax-up. Multiple
mock-ups may have to be used to correct
different elements or try different ideas.
Such examples might include whether if it is
Fig. 5 Diagnostic wax-up determining aesthetics and function appropriate to carry out periodontal plastic
surgery to reduce gingival show or obtain
appropriate height-width ratios without
a b having to lengthen the maxillary incisors
beyond the lower lip resting position.

Restorative treatment concepts

Beyond purely preventive strategies, we have

c d
Fig. 6 a) Severe maxillary anterior palatal tooth wear, caries and missing teeth. b) Diagnostic
wax-up. c) Bis-acryl mock-up. d) Anterior maxillary restoration with indirect composite palatal
veneers on the incisors and resin bonded bridges protecting the canines and replacing the first
premolars
schedule, finances and ongoing maintenance
requirements. More often than not, multiple
treatment options will be available and further
explanations may be required for the patient to
be able to make an informed decision and give
consent for treatment to progress (Chap. 8).
The prevention and stabilisation phase
targets the aetiological factors, relieves
pain and discomfort, ensures periodontal
health, provides endodontic treatment,
addresses caries and defective restorations,
removes teeth that have a hopeless prognosis
and makes any pre-restorative occlusal
adjustments, possibly with the provision of
a diagnostic occlusal splint (Chap. 11).
Once the stabilisation phase has been
completed, the clinician can enter the
critical diagnostic phase and produce a
diagnostic wax-up (Fig. 5). This wax-up
should utilise the space available or the space
created, by any one or more of the methods
described above, to provide a restorative
plan that fulfils the aesthetic and functional
requirements of the patient. At this point,
it becomes essential that this master plan
(the ‘mock-up’) is tried in the mouth. This
stage is essential when contemplating an
adhesive approach and important but not
critical if pursuing a conventional extra-
coronal restorative strategy as provisional
restorations can be used to elicit and refine
critical information.
The mock-up should be evaluated for
appearance, function and phonetics (Fig. 6).
Aesthetic considerations include establishing
the correct vertical centre line, incisal lip
position, height-width ratios, adequate
lip support and satisfactory dominance of
seen a dramatic change in the approach
to restorative care. Previously there were
good reasons to watch, monitor and wait to
commence restorative care as the available
treatment options were usually destructive
of remaining tooth tissue and more likely to
fail in an irreparable manner. There is now
a strong case for much earlier intervention
using additive rather subtractive techniques.
Adhesion and space creation through the
‘Dahl concept’ allow for early protection of
worn teeth and far easier repairs in the event
of material failure—an approach described
by some as being of minimal and sustainable
intervention. Ultimately, this concept
will hopefully free the patient from the
destructive restorative cycle. First described
by Elderton, 11 well-illustrated by Vailati
and Belser in their paper introducing the
ACE Classification 12 and comprehensively
updated in this book by Loomans and Mehta
(Chap. 9).
Restorative treatment options
Direct and indirect adhesive options are
available and decision-making is based on
the accessibility of enamel margins, aesthetic
requirements, clinical skill, technical support
and patient finances.
Composite, ceramic, gold and a plethora
of hybrid materials are available. Aesthetics,
wear, the nature of the opposing dentition
and presenting aetiology must all be
considered. Gold palatal veneers have
provided beneficial protection for composite

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© Springer Nature Switzerland AG 2022. Republished 2023.
 Tooth wear CLINICAL

Fig. 7 a) Gold palatal veneers restoring the maxillary anterior teeth. b) Gold palatal veneers with buccal composite restorations. c) Hybrid
approach with composite palatal veneers on the maxillary incisors and gold palatal veneers on the maxillary canines

a b additions to lengthen anterior teeth in

bruxists (Fig. 7).
Bruxists rarely stop bruxing and composite
only restorations will require regular repair
of fractures and chipping. Patients need to be
aware of the limitations from the outset. Hard
wearing materials are less critical in cases
where erosion is the principal driving force for
c the tooth wear. In these cases, early coverage
d
with composite materials should provide a
satisfactory solution (Fig. 8) with step-by-step
treatment outlined (Fig. 9).
Lastly, there are occasions where a wide
range of adhesive, conventional and removable
options are required to re-establish appearance
and function and fully care for patients with
rather more significant tooth wear and missing
teeth (Fig. 10).
Fig. 8 a) Buccal view showing moderate anterior tooth wear. b) Palatal view of the worn
maxillary anterior teeth. c) Maxillary anterior teeth restored with indirect composite backings.
d) Buccal view of restored maxillary anterior teeth Conclusion: maintenance and
review
a b c Patients with a history of tooth wear, whether
monitored or restored, require careful and
frequent review. Restored patients ultimately
require multiple restorations and it is essential to
remember that all restorations will only have a
finite lifespan. Additionally, it is naïve to assume
d e f that all the presenting aetiological factors will
have stopped and caries, periodontal disease
and all or some of the primary aetiologies that
drive tooth wear may still be present.
However, as for all patients and their
restored teeth, there is a fine balance between
g h managing the biological and the biomechanical
challenges. If we focus here on biomechanical
failures, these normally occur because of
excess occlusal loading. It necessarily follows
that the control of the occlusion and excess
loading is key to enduring restorative success.
Fig. 9 Patient attending for anterior tooth wear management showing a) pre-treatment; Good restoration design to axialise forces,
b) diagnostic wax-up; c) clear silicone matrix over diagnostic-wax-up; d) clear silicone matrix spread load and minimise contact areas will
with stabilisers; e) isolation; f) clear silicone matrix in situ; g) direct composite restorations;
promote longevity. To prevent early failure,
and h) post-treatment
additional protection with an occlusal splint

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 CLINICAL Tooth wear

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