The longevity of tooth-coloUred materials used for restoration of tooth wear: an evidence-based approach.

Patients with tooth wear are commonly encountered in general dental practice. When indicated, restorative rehabilitation is often accompanied by a request from the patient for an aesthetic, tooth-coloured outcome. This article seeks to provide an evidence-based approach, focussing on the longevity of the materials which can be used for the restorative treatment of tooth wear, as well as their modes of failure and observed performance.

The clinical performance of bulk-fill versus the incremental layered application of direct resin composite restorations: a systematic review.

OBJECTIVES: To systematically review the scientific evidence comparing the clinical effectiveness of bulk-fill versus incrementally layered conventional resin composites and to evaluate if one method offers clear merits with specific clinical outcomes. MATERIALS AND METHODS: Using relevant mesh terms and pre-established eligibility criteria in PubMed, Embase, Scopus and Web of Science, a thorough scientific search was conducted with an end-date of 30.04.2023. Randomized controlled clinical trials that involved the direct comparison of Class I and Class II resin composite restorations applied using incremental layering techniques versus bulk-filled in permanent teeth with an observation period of at least six months were considered. To evaluate the bias risk of the finalized records, a revised version of the Cochrane risk-of-bias tool for randomized trials was implemented. RESULTS: Out of the 1445 records determined, 18 eligible reports were chosen for qualitative analysis. Data obtained was categorized as per, the cavity design, the intervention, the comparator(s), the methods of success/failure assessment, the outcomes, and follow-up. Two studies demonstrated an overall low-risk of bias, fourteen studies raised some concerns, and two studies exhibited high-risk. CONCLUSION: Bulk filled resin composite restorations demonstrated clinical outcomes similar to those of incrementally layered resin composite restorations within a review interval of 6 months to 10 years.

Perception of oral health related quality of life and orofacial aesthetics following restorative treatment of tooth wear: A five-year follow-up.

OBJECTIVES: Non-carious tooth wear often has a multifactorial etiology and may lead to functional or aesthetically related problems. The most common complaints associated with tooth wear are dissatisfaction with dental appearance and a negative impact on the experienced Oral Health Related Quality of Life (OHRQoL). The aim of this study was to investigate the change in OHRQoL and the perception of aesthetics, following restorative treatment of moderate to severe tooth wear patients, with a five-year follow-up. METHODS: An explorative study, based on prospective data, was performed. OHRQoL and the perception of aesthetics were measured with the OHIP-NL and OES-NL. These questionnaires were completed before treatment, one month after treatment, and at 1-, 3- and 5-years post-treatment. Treatment involved full mouth reconstruction with composite resin restorations. The data was analysed as repeated measures by using a linear mixed-effects model. RESULTS: One hundred and twenty-three tooth wear patients that received restorative rehabilitation were included (97 males, 26 females, 37.5 ± 8.8 years-old). Data showed a statistically significant increase in both experienced OHRQoL and orofacial appearance after restorative treatment. The OHIP-scores remained stable over time, while the OES-scores slightly decreased during the years after treatment. Regarding the seven domains of the OHIP, the largest difference in OHIP-score was found in the domain of 'Psychological Discomfort'. The mean overall OHIP-score was 1.8 at baseline and 1.3 at the 5-years recall. The mean OES score increased from 41.8 at baseline to 66.1 at the 5-years follow-up. CONCLUSIONS: Tooth wear patients reported significant improvements in their OHRQoL and their perception of orofacial aesthetics after restorative treatment. This increase remained at least five years post-treatment. CLINICAL SIGNIFICANCE: The clinical impact of restorative treatment for tooth wear patients is considerable. This paper emphasizes the need to include a discussion of the patient related outcome measures when planning care.

Developing diagnostic criteria for tooth wear, a preliminary beta version based on expert opinion, and a narrative literature review.

BACKGROUND: Tooth wear is a multifactorial condition, leading to the irreversible loss of dental hard tissues. The availability of an unambiguous, universally applicable assessment protocol remains lacking. OBJECTIVES: The goal of the authors is to develop a set of diagnostic criteria for the assessment of tooth wear (DC-TW). A two-step approach will be used to achieve this objective: (1) to develop a preliminary beta version of the DC-TW, based on the authors' clinical experience and their shared expertise and supported by a narrative review of the existing literature, and (2) to develop the final DC-TW, with input from a larger group of experts using an international Delphi process. This paper relates to the first step. METHODS: The authors outlined the components that should be incorporated into the DC-TW. The literature search was performed to investigate if their concept was in line with the available literature. The search was conducted to identify eligible publications from inception to July 11, 2022. Two authors independently screened all publications, and differences in judgements were resolved through a consensus procedure. RESULTS: The search yielded 5362 publications, resulting in the final inclusion of 383. These publications were divided into four main topics: (1) nomenclature/taxonomies; (2) self-report tools; (3) clinical assessment tools; and (4) clinical decision-making. CONCLUSIONS: The information from the publications was used and fused with the clinical experience and shared expertise of the authors to contribute to the development of a preliminary beta version of the DC-TW.

Managing tooth wear with respect to quality of life: an evidence-based decision on when to intervene.

Patients with more severe forms of tooth wear may require restorative rehabilitation. The decision to commence treatment must be taken carefully and there are a multitude of factors to consider. Alongside the clinical signs and symptoms typically associated with tooth wear, there is also the need to assess the impact of the condition on the patient's oral health-related quality of life. As part of the discussions relating to the attainment of informed consent for the restoration of the worn dentition, not only is it relevant to appropriately appraise the risks, benefits, costs, reasonable alternatives and likely prognosis of the proposed treatments, but to also elaborate on the expected impact of the intervention on the patient's oral health-related quality of life. The aim of this article is to review the evidence relating to the impact of the quality of life with the management of tooth wear, with the introduction of the concept of an evidence-based approach to decision-making when planning care.

Monitoring of erosive tooth wear: what to use and when to use it.

Although we are increasingly recognising the need to assess patients for accelerated rates of tooth wear progression, it is often difficult to do so within a feasible diagnostic window. This paper aims to provide evidence-based timelines which a diagnosing clinician can expect to assess tooth wear progression in study models, clinical indices, clinical photographs and visually with intraoral scans. It also discusses new technologies emerging for the quantitative assessment of tooth wear, timelines for diagnosis, and caveats in the 3D scan registration and analysis process.

Posterior Dahl: A Minimally Invasive Method for the Treatment of Localized Posterior Tooth Wear.

PURPOSE: This retrospective case series of 9 patients aimed to describe clinical outcomes and patient satisfaction following the implementation of the posterior Dahl concept to manage localized posterior tooth wear. MATERIALS AND METHODS: Localized occlusal space was created in the posterior dentition. Supra-occluding direct restorations were placed bilaterally for the restoration of molars. Intraoral scans were taken at the pre-treatment stage, immediately post-restoration, and during follow-up appointments. Scans were used to undertake analysis of any occlusal changes and re-establishment of the occlusion. A questionnaire was used to assess patient satisfaction, alleviation of any pre-treatment concerns, and evaluation of post-treatment complaints. RESULTS: Immediately post-treatment, all patients showed an increase in the vertical dimension. Opening of the bite in the untreated areas following restoration of worn posterior molars resulted either in a tendency towards or the actual reestablishment of the occlusion. One patient completely lacked compensatory vertical tooth movement in the untreated areas, culminating in the persistence of a vertical open bite. One restoration displayed cohesive fracture after 4 months. Pre-treatment problems (eg, sensitivity) were fully resolved amongst all patients after 6 months. Post-treatment complaints were minor and demonstrated resolution within a relatively short period of time. Eight patients reported being "very satisfied" with their treatment outcomes. CONCLUSION: Application of the posterior Dahl concept appears to offer a promising, relatively simple, minimally invasive and effective approach for the management of localized posterior tooth wear, which is well accepted by patients.

Evaluation of dental practitioner habits with occlusal assessment and the clinical application of practical techniques in occlusion, amongst a cohort of participants based in the UK, South Africa, Malta and Malaysia.

BACKGROUND: Currently, there is a lack of data relating to dental practitioners' habits with clinical occlusal assessment and the application of practical techniques in occlusion. OBJECTIVES: The aim of this study was to investigate habits with clinical occlusal assessment and the practical application of established concepts in occlusion amongst a cohort of international dentists. METHODS: A piloted questionnaire with 20 statements was distributed by 5 recruiters. The recruiters were based in Malta (1), South Africa (1), Malaysia (1) and the UK (2). Outcomes were analysed using descriptives, chi-squared and Fisher's exact test. All the analyses were carried out in Stata, Version 12. Significance was inferred at p < .05. RESULTS: Four hundred thirty-five completed responses were included in the sample (response rate, 70.7%). Overall, high levels of agreement were reported with the provision of single-unit crown and onlay restorations (78.8%) and bridge prostheses (up to 3 units, 77.9%), respectively. One-third (33.6%) agreed to observing dynamic occlusal relationships during an adult patient dental examination, 40.7% reported using articulators for crown and bridge cases, and 25.1% agreed to taking facebow records. Under half (47.3%) of the dentists expressed dissatisfaction with their undergraduate training in occlusion, with no significant association with the variables of the number of years of experience, the country of practice or being in general practice (p ≥ .226). CONCLUSION: The results indicate a disparity between traditionally taught and applied concepts in clinical occlusion and the undertaking of occlusal assessments and the management of occlusion in clinical practice.

Esthetic, mechanical, and biological outcomes of various implant abutments for single-tooth replacement in the anterior region: a systematic review of the literature.

BACKGROUND: The choice of the appropriate implant abutment is a critical step for a successful outcome. Titanium abutments have demonstrated high survival rates, due to their excellent biocompatibility and high mechanical strength, although they often result in a grayish discoloration of the peri-implant mucosa. This esthetic concern culminated in the introduction of ceramic abutments. The aim of this review was to assess the esthetic, mechanical, and biological outcomes as well as the survival of the different types of abutments used for single-implant restorations in the anterior area. MATERIAL AND METHODS: An electronic search was conducted in Medline, Embase, and Cochrane Central databases using the appropriate Mesh terms and predetermined eligibility criteria. The quality of the studies was assessed using the ROB 2 tool. The last search was conducted on 18th of March 2020. RESULTS: From the 2074 records initially identified, 23 randomized controlled trials (32 publications) were included for qualitative analysis. Data were classified based on study information, specific characteristics of the intervention and comparator, and information related to the outcome measures. Seven studies exhibited an overall low risk of bias, while twelve studies raised some concerns. CONCLUSIONS: The rate of abutment failure was low and was associated with the ceramic abutments, especially those with internal connection. Limited correlation was noted between soft tissue thickness and color difference. Titanium abutments caused significantly more discoloration to the soft tissues than ceramic abutments, while hueing (gold or pink) slightly improved their color performance. Zirconia allowed a better color match than titanium or gold abutments, still discolored slightly the soft tissues. The submucosally modified zirconia abutments exhibited encouraging results. No significant difference was reported between materials or different types of retention on recession, papillary fill, and biological outcomes.

Clinical performance of direct composite resin restorations in a full mouth rehabilitation for patients with severe tooth wear: 5.5-year results.

OBJECTIVES: To evaluate the 5.5-year performance of direct resin composite restorations, prescribed for patients with severe tooth wear, requiring full-mouth rehabilitation. METHODS: A convenience sample of 34 patients were recruited to a prospective trial between December 2010 and June 2013. The participants were provided 1269 full-mouth direct resin composite restorations (Clearfil AP-X) by 5 experienced operators, using the DSO-technique. Treatment resulted in an increase in the vertical dimension of occlusion (VDO). Failure was assessed at three levels. Frequencies of failure were analysed using Kaplan Meier survival curves and the effects of the relevant variables calculated with a multifactorial Cox regression (p < 0.05). RESULTS: Annual failure rates (for all levels of failure, 'Level 3- ') of ≤ 2.2% and ≤ 2.9% were respectively reported for the anterior and posterior restorations with a mean observation time of 62.4 months. The completion of an anterior restoration with the need for further appointments resulted in significantly more Level 2- & 3- failures. An evaluation of the performance of the premolar and posterior maxillary restorations showed significantly lowered risks of certain types of failures, compared to the molar and posterior mandibular restorations. CONCLUSIONS: At 5.5 years, 2.3% of the overall restorations displayed catastrophic, (Level 1) failures. Molar restorations, posterior mandibular restorations and the anterior restorations requiring two further sessions for completion, were associated with significantly higher risks for failure. CLINICAL SIGNIFICANCE: Direct resin composite can offer an acceptable medium-term option for the treatment of severe, generalized tooth wear; molar restorations may require higher maintenance.

The effect of pre-treatment levels of tooth wear and the applied increase in the vertical dimension of occlusion (VDO) on the survival of direct resin composite restorations.

OBJECTIVES: To investigate the effects of the level of pre-treatment tooth wear and increasing the VDO on the performance of direct resin composite restorations for the rehabilitation of pathological tooth wear. METHODS: Full-mouth (pre-treatment) grading was performed on digital greyscale scan records for 34 participants (35.3 ± 8.4 years) with signs of moderate-to-severe generalised tooth wear, using the Tooth Wear Evaluation System and the Basic Erosive Wear Examination. Each participant received full-mouth direct resin composite restorations, with increased VDO. The post-treatment increase in the VDO was determined. Recalls were planned after 1 month, and after 1, 3, and 5 years. Three 'levels' of restoration failure were described. The effects of the variables on the frequencies of restoration failure were calculated with a multivariable Cox regression, (p < 0.05). RESULTS: 1269 restorations were placed with a mean observation period of 62.4 months. Increasing the VDO by 1 mm significantly reduced the risks of all levels of anterior restoration failure (HR ≤ 0.62, p ≤ 0.025). A higher anterior BEWE surface score was associated with increased risks of Level 2- & 3- failures, (HR ≥ 1.29, p ≤ 0.019). Premolar restorations showed lower risks of Level 2- & 3- failure, compared to the molar restorations, (HR ≤ 0.5, p ≤ 0.005). CONCLUSION: Levels of pre-treatment wear and the applied change in the VDO significantly affected failure risk. CLINICAL RELEVANCE: Direct resin composite restorations for the rehabilitation of wear should be made as voluminous as possible, respecting the presenting biological, functional, and esthetic constraints.

A comparative evaluation between the reliability of gypsum casts and digital greyscale intra-oral scans for the scoring of tooth wear using the Tooth Wear Evaluation System (TWES).

BACKGROUND: The Tooth Wear Evaluation System (TWES) is a type of tooth wear index. To date, there is the lack of data comparing the reliability of the application of this index on gypsum cast records and digital greyscale intra-oral scan records. OBJECTIVES: A comparative evaluation between the use of gypsum cast records and digital greyscale intra-oral scan records with the reliability of tooth wear scoring using the TWES amongst a group of patients with tooth wear. METHODS: Records for 10 patients with moderate to severe tooth wear (TWES ≥ 2) were randomly selected from a larger clinical trial. TWES grading of the occlusal/incisal, buccal and palatal/lingual surfaces was performed to determine the levels of intra- and interobserver agreement. Intra-observer reproducibility was based on the findings of one examiner only. For the interobserver reproducibility, the findings of two examiners were considered. One set of models/ records were used per patient. Cohen's weighted kappa (κW ) was used to ascertain agreement between and within the observers. Comparison of agreement was performed using t tests (P < .05). RESULTS: For the scoring of the of the total occlusal/incisal surfaces, the overall levels of intra- and interobserver agreement were significantly higher using the gypsum cast records than with the digital greyscale intra-oral scan records, (P < .001) and (P < .001), respectively. For the overall buccal surfaces, only a significant difference was found in the intra-observer agreement using gypsum casts, (P = .013). For the palatal/lingual surfaces, a significant difference was only reported in the interobserver agreement using gypsum casts, (P = .043). At the occlusal/incisal surfaces, grading performed using gypsum casts, culminated in significantly higher TWES scores than with the use of the digital greyscale intra-oral scans (P < .001). At the buccal and palatal/lingual surfaces, significantly higher wear scores were obtained using digital greyscale intra-oral scan records (P < .009). CONCLUSIONS: The TWES can offer a reliable means for the scoring of wearing occlusal/incisal surfaces using gypsum casts. The reliability offered by digital greyscale intra-oral scans for consecutive scoring was in general, inferior.

The impact of e-training on tooth wear assessments using the BEWE.

OBJECTIVE: To investigate the impact of an e-training resource with the consistency of tooth wear scoring using the Basic Erosive Wear Examination (BEWE). METHODS: Gold standard (GS) BEWE scores were attained from a trained examiner using the photographic and dental cast records for three conveniently selected cases representing low, medium and severe tooth wear. Four successive cohorts of first year post-graduate students, (n = 76, mean age, 35.4 years) undertook a training exercise. Each was given written guidance on using the BEWE. Following e-training, scoring was repeated, and the results expressed as mean, confidence Intervals, (95% ci) and p-values (values <0.05 were considered statistically significant). RESULTS: The e-training resulted in a mean improvement in the agreement with the GS score by 15.6% and 15.3%, using the records of the medium and severe tooth wear cases, (cumulative BEWE scores of 13 and 15 respectively). Post-training reductions were reported, with the mean number of disagreements with the GS and the mean change in the size of disagreement with the GS scores with records for the medium and severe cases (p = 0.001 and p < 0.001). No significant difference was revealed for the low wear case. CONCLUSION: e-training resulted in significant improvements in scoring BEWE, compared to the gold standard. CLINICAL RELEVANCE: Online training resources can help provide training with the BEWE.

A study to investigate habits with tooth wear assessments among UK and non-UK dental practitioners.

Aim To assess the habits of tooth wear risk assessment and charting using a tooth wear index, by UK and non-UK dental practitioners.Design A questionnaire-based evaluation.Methods Three hundred and two completed questionnaires were returned and the outcomes analysed using descriptives, Chi-squared test and Fisher's exact test in SPSS. Significance was inferred at p <0.05.Results Based on a sample of 297 responses, 81% agreed to the need to undertake risk assessment for all dental patients attending for a first-time consultation. Fifty-nine percent undertook risk assessments for 'new patients' previously identified with signs of severe tooth wear. The routine use of a clinical index to perform tooth wear charting was described by 13.5%, with 5% documenting the frequent use of the BEWE tool. While specialist dental practitioners or those with further post-graduate training were more likely to use a tooth wear index (p <0.05), there were no other significant relationships between any of the variables in the sample and the practising habits assessed.Conclusion This investigation alludes to good levels of professional awareness of tooth wear. However, the need for improvement with the actual undertaking of risk assessments for tooth wear and consistency with tooth wear assessment and charting was determined. The need for appropriate professional guidance for the undertaking of tooth wear assessments is supported by the outcomes of this investigation.

A Guided, Conservative Approach for the Management of Localized Mandibular Anterior Tooth Wear.

The successful management of the worn mandibular anterior dentition may present an awkward challenge to the dental operator. The purpose of this article is to describe a case report illustrating the use of a guided, three-dimensional protocol for the ultra-conservative and predictable restoration of the worn lower anterior dentition using direct resin composite. This technique utilizes information based on established biomechanical and occlusal principles to fabricate a diagnostic wax-up, which is duplicated in dental stone. This is used to prepare a vacuum-formed modified stent, assisting the clinician to place directly bonded resin composite restorations to restore the worn lower anterior dentition. The technique, described in 2012 and referred to as 'injection moulding' has the potential to offer optimal form, function and an aesthetic outcome in an efficient manner. CPD/Clinical Relevance: This article aims to describe an alternative technique to simplify the processes involved with restoration of worn lower anterior teeth.

Class II Resin Composites: Restorative Options.

Tooth-coloured, resin composite restorations are amongst the most frequently prescribed forms of dental restoration to manage defects in posterior teeth. The attainment of a desirable outcome when placing posterior resin composite restorations requires the clinician to have a good understanding of the benefits (as well as the limitations) posed by this material, together with a sound knowledge of placement technique. Numerous protocols and materials have evolved to assist the dental operator with this type of demanding posterior restoration. With the use of case examples, four techniques available are reported here. CPD/Clinical Relevance: This article explores varying techniques for the restoration of Class II cavities using resin composite.

Patient assessment: preparing for a predictable aesthetic outcome.

The flux of patients seeking to make changes to the appearance of their smile zone appears to be on a pathway of continual increase. This is possibly due to an increase in awareness towards oral health, and perhaps social, peer and media pressures, respectively. Cohorts of dental practitioners have thus responded to the latter demands by attending a plethora of educational courses, often focusing on either restorative techniques or other disciplines, notably orthodontics and clear aligners in particular. Consequently, treatment planning and thus treatment provision may carry the risk of being biased or indeed 'outcome driven' whereby the skills and knowledge of any clinician towards a particular faculty may significantly influence the ultimate treatment plan, with the unfortunate tendency sometimes to overlook the role of the interdisciplinary approach of concomitant restorative and contemporary techniques. The role of orthodontics to facilitate the provision of such treatment, along with predictable enamel bonding, has the distinct advantage of providing an acceptable aesthetic result with minimal biological intervention. However, to achieve an optimal result in such cases requires meticulous treatment planning and patient selection to avoid pitfalls with regards to long-term stability and function. This article suggests a standardized approach to patient assessment, with an interdisciplinary perspective in mind. Clinical Relevance: With the growth of patient demand for improving the appearance of the smile, a meticulous assessment protocol is required along with effective interdisciplinary communication. This enables a comprehensive treatment plan to be developed with the correct priorities.