Definitive treatment
In many cases, if the tooth surface loss is diagnosed early, preventive counselling may
be sufficient. It is a good idea to make study casts of all patients with signs of tooth
surface loss and to give these to the patient to keep. The rate of progression of the
wear can then be monitored. However, in more advanced cases, where there are
sensitivity or cosmetic problems, active intervention is required. 575HTable 10.8 shows the
relative merits of the options available.
Key Points
Main treatment objectives for tooth-surface loss:
- resolve sensitivity;
- restore missing tooth surface;
- prevent further tooth tissue loss;
- maintain a balanced occlusion.
In some cases there will be only localized tooth wear and an incomplete overbite,
leaving enough space to place the restorations. 576HFigure 10.20 (a) and (b) show the same
patient as shown earlier in 577HFig. 10.16 (a) and (b) who consumed considerable
quantities of carbonated drinks in association with sporting activities. This habit
caused considerable palatal wear of his upper incisors with characteristic chipping of
the incisal edges. Cast adhesive veneers were placed on the palatal aspect of the upper
incisors to protect from further wear, and direct resin-based composite labial veneers
were used to restore the aesthetics. Note in this case the slight grey 'shine through'
effect on the incisal tips due to the cast restorations.
In many other cases compensatory growth, which will help to maintain the occlusal
vertical dimension, or the presence of a significant malocclusion, may result in
inadequate space for the necessary restorations. 578HFigure 10.21 (a) shows a case of a 12-
year-old boy who has a class II, division II malocclusion and who consumed three
cans of carbonated drinks everyday. The combination of the erosive drink and the
attrition brought about by the close tooth-to-tooth contact has resulted in a loss of
palatal tooth tissue from the upper central incisors. There is insufficient space
palatally to place any form of restoration, but a simple removable orthodontic
appliance with a flat anterior bite plane can be used to reduce the overbite (579HFig. 10.21
(b)). In children this occurs relatively quickly (within 6 weeks) principally by
compensatory overeruption of the posterior segments. Once sufficient space has been
created cast metal palatal veneers can be placed.
Alternatively, if there has been marked wear of the posterior teeth, as shown in 580HFig.
10.22 (a), it will be necessary to restore the occlusal surfaces and protect them from
further wear prior to placing anterior restorations. Cast adhesive occlusal onlays are
recommended in these cases (581HFig. 10.22 (b)). Young patients will accommodate the
increase in vertical dimension easily, providing a balanced occlusal contact is
achieved. The use of a facebow record facilitates this. The main advantage of using
cast metal onlays is the minimal thickness of material needed and its resistance to
abrasive wear. Indirect composite veneers are a recent addition to our armamentarium
and they offer considerable advantages, particularly in cases where the aetiology is
unclear or the patient cannot stop the habit/problem. These restorations facilitate