1

Introduction

Tooth wear is loss of dental hard tissue due to non-carious processes, and can be identified as attrition, abrasion, or erosion . Tooth wear may impact on an individual’s perception of daily life and should be carefully considered . Moreover, an increased incidence of tooth wear is reported in young populations, which could represent an emerging dental problem for future generations . Irrespective of epidemiological concerns or even etiological factors, at an individual level, tooth wear may become severe and in many clinical situations, a restorative treatment has to be considered, because severe tooth wear may result in loss of vertical dimension of occlusion, tooth sensitivity, decreased oral health related quality of life and aesthetic complaints . In these cases, the choice of the restorative strategy should be based on evidence-based treatment protocols. However, the most common published studies are single case reports or case series showing direct and indirect restorative techniques.

The traditional restorative treatment for greater amounts of tooth loss is the fabrication of indirect restorations and onlays instead of the use of direct approaches . Recently, “minimally invasive treatment concepts” with partial covering all-ceramic restorations became also recommended . However, direct resin composites have the potential for direct rehabilitation of severely worn dentitions as well, with the advantages of having relatively low cost and preservation of sound tooth tissues, once this approach is less invasive than tooth preparation for indirect restorations . The current adhesive techniques allow minimal or even no preparation of teeth , include possibilities for repair or substitution of direct restorations in an easier way compared to indirect approaches . Yet, quality of direct restorations is more dependent on the operator, and long-term esthetical properties of direct dental materials may be limited when compared to indirect restorations .

A recent systematic review investigating the performance composites used to restore severely worn anterior teeth demonstrated a good performance of this material in short/medium time of follow-up . However, the focus of this review was in the use composites in the anterior teeth and there is still a lack of uniformity in guidelines and policies regarding the optimal technique and/or material to restore severely worn teeth.

As the rehabilitation of severely worn teeth usually include an extensive treatment at considerable cost, there is a need to identify the one combining the best relative cost-effective with the most acceptable longevity and with the greatest benefit to the patient, for the longest period of time, among the current available alternatives. Thus, the aim of this systematic review of clinical studies was to evaluate treatment performance of various dental materials and techniques to restore teeth with severe wear.

2

Materials and methods

This systematic review was based on the guidelines of Cochrane Handbook for Systematic Reviews of Interventions and the reporting based on PRISMA Statement . Medline was searched without restriction on language or publishing date ( Table 1 ) . The search was made to identify manuscripts meeting the following inclusion criteria: clinical studies that evaluated or compared techniques or materials to restore teeth with severe wear. Case reports or clinical studies that evaluated materials/techniques to restore non-carious cervical lesions were excluded.

Two researchers (MEM and RSO) carried out independently the literature search (June 2015) by first analyzing titles and abstracts for relevance and presence of the selection criteria listed above. The full text articles of included and uncertain records were obtained for further eligibility screening by the same two reviewers. In the event of an unsettled disagreement, the opinion of another co-author (TPC) was used. In case of identification of the same research in distinguished papers, the paper with the highest follow-up was included. References of all papers included were searched to identify any further relevant studies.

Two reviewers extracted all data simultaneously but independently using a standardized outline. The estimate probabilities were calculated considering the mean time of follow-up or the estimate reported in the paper. The annual failure rate (AFR) of the investigated restorations was calculated according to the formula: (1−y) ^z = (1−x), in which ‘y’ expresses the mean AFR and ‘x’ the total failure rate at ‘z’ years. Randomized clinical trials included in the review were assessed for bias using the Cochrane risk of bias tool by two researchers independently. The risk of bias of non-randomized studies was assessed with Downs and Black Scale.

2

Materials and methods

This systematic review was based on the guidelines of Cochrane Handbook for Systematic Reviews of Interventions and the reporting based on PRISMA Statement . Medline was searched without restriction on language or publishing date ( Table 1 ) . The search was made to identify manuscripts meeting the following inclusion criteria: clinical studies that evaluated or compared techniques or materials to restore teeth with severe wear. Case reports or clinical studies that evaluated materials/techniques to restore non-carious cervical lesions were excluded.

Two researchers (MEM and RSO) carried out independently the literature search (June 2015) by first analyzing titles and abstracts for relevance and presence of the selection criteria listed above. The full text articles of included and uncertain records were obtained for further eligibility screening by the same two reviewers. In the event of an unsettled disagreement, the opinion of another co-author (TPC) was used. In case of identification of the same research in distinguished papers, the paper with the highest follow-up was included. References of all papers included were searched to identify any further relevant studies.

Two reviewers extracted all data simultaneously but independently using a standardized outline. The estimate probabilities were calculated considering the mean time of follow-up or the estimate reported in the paper. The annual failure rate (AFR) of the investigated restorations was calculated according to the formula: (1−y) ^z = (1−x), in which ‘y’ expresses the mean AFR and ‘x’ the total failure rate at ‘z’ years. Randomized clinical trials included in the review were assessed for bias using the Cochrane risk of bias tool by two researchers independently. The risk of bias of non-randomized studies was assessed with Downs and Black Scale.

3

Results

A total of 511 articles were found and 23 articles were eligible for full-text analysis. Hand searches of references of these papers resulted in 7 more papers to be included for full text reading. From the resulting 30 studies, 12 papers were included in the review. Eighteen studies were excluded for the following reasons: 7 studies were case reports, 2 studies evaluated materials/restorations in non-carious cervical lesions, 2 studies evaluated wear between material/teeth, 2 studies evaluated restorations in teeth without wear, 2 studies were technique descriptions, 1 study evaluated restorations to correct tooth form and position, 1 paper is the first follow-up publication of the study of Al-Khayatt et al. and 1 paper the first follow-up publication of the study of Gulamali et al. ( Fig. 1 ).

Flowchart.

As the selected studies showed heterogeneity in experimental designs and different clinical criteria for analysis, a meta -analysis was not possible. As a meta -analysis can only be planned if a common statistical measure is shared among studies, the analysis was not undertaken.

However, a direct comparison could be performed considering the annual failure rate failure data. The agreement level between the two researchers that performed data extraction was 91%. Table 2 represents the summary, characteristics and main findings of each included study. From the 12 studies ( Table 2 ), 7 were defined as prospective , 3 of these were randomized trials and the remaining 5 studies were defined as retrospective. Time of follow-up had variations among these studies but could be grouped ranging from 6 months up to 12 years of follow-up.

Table 2

Characteristics of the included studies.

^b Indication of occlusal splint therapy, in bruxists or for protection.

Study	Study design	Number of patients/ restorations	Location	Aetiological factors	Restorative materials	Evaluation criteria	Main findings	Conclusion
Walls b	Prospective Non-randomized	12/54	Anterior and premolars	Not mentioned	Porcelain veneers for all rehabilitated teeth	Bulk failure and Marginal staining/discoloration	2 complete and 4 partial failures (n = 43)	Porcelain performed well in service.
Nohl et al.	Retrospective case-series	48 individuals	Anterior	Primarily erosion	Cast metal palatal veneers with incisal resin composite when necessary	Debonding	Debonding did not occur in the youngest patients where parafunction was infrequent	Palatal tooth wear can be restored with this method
Hemmings et al. a	Prospective randomized	16/52 restorations for each group	Anterior (Dahl’s concept)	Not mentioned	Resin composite: Microfilled vs. Hybrid	Loss/Fracture/Marginal discoloration/Marginal integrity wear/Noticeable wear/Pain/Sensitivity/ Endodontic and esthetical failure	Microfilled: 33 failures Hybrid: 6 failures	Direct resin restorations are feasible in short-term evaluation. Hybrid composite perform better than microfilled.
Gow and Hemmings a	Prospective case series	12/75	Anterior (Dahl’s concept)	Not mentioned	Indirect palatal veneer restorations with ceromer	Restoration fracture/Marginal failure/Discoloration/Discomfort/overall satisfaction (USPHS)	10 failures up to 2 years	Effective treatment option for anterior tooth wear
Bartlett et al. a	Prospective randomized	32/64	Posterior	Combination of bruxism and erosion	Indirect micro-filled composite and Direct microfilled composite	Success rates – modified USPHS criteria	Overall failure rate in the tooth wear group of 28% (n = 16) for the indirect restorations and 21% (n = 16) for the direct restorations	High fracture rate both materials used to restore worn teeth
Smales et al. a	Retrospective cohort	25/345	Anterior and posterior	Combination of tooth grinding, gastric, erosion and abrasive antagonists	Direct resin-based composites and Indirect crowns (gold crowns and ceramo-metal)	Tooth and restoration failure.	46 failures in direct resin (n = 202) and 30 failures in indirect crows (n = 143)	There were differences between the two restoration groups
Schmidlin et al. a , b	Prospective Case series	07/85	Posterior	Mixed erosion/abrasion processes	Fine particle hybrid resin composite	Modified USPHS criteria	Most of the restorations (>90%) showed almost complete “Alpha” and “Bravo” scores with the criteria assessment	Direct resin composite materials can restore severely worn teeth medium term
Hamburger et al., a	Retrospective case-series	18/332	Anterior and posterior	Bruxism (n = 12), erosion (n = 3) and combination of bruxism and erosion (n = 3	Hybrid resin composite	Modified FDI	Failure in 23 restorations	Good clinical performance of direct composite restorations
Gulamali et al. a	Prospective non-randomized	26/283	Anterior (Dahl’s concept)	Mainly erosive wear with only two patients diagnosed as abrasion as primary aetiological factor	Direct resin composite, Indirect resin composite and combined direct/indirect	Failure of restorations/Biological complications/Patient satisfaction/Modified USPHS criteria	More than 50% of the restorations failed − exact number not reported	Resin composite restorations are viable options for treating tooth wear in short- to medium-term
Attin et al. a , b	Retrospective case series	6/75	Posterior	Mainly erosive wear	Fine hybrid composite	Modified USPHS criteria	Most restorations received Alpha score	Technique provides a possible treatment option
Al-Khayatt et al. a	Prospective randomized	18/107	Anterior lower (Dahl’s concept) for most patients	Erosive and attritional tooth wear	Hybrid resin composite	Anatomical form/Restoration staining/Marginal discoloration/Color match/Surface roughness/Marginal adaptation	51% considered successful	Direct composite restorations are predictable process with long-standing satisfactory and good long-term survival.
Vailati et al. a , b	Retrospective case series	12/204	Anterior with palatal direct composite and buccal porcelain veneer and Posterior with direct or indirect restorations to increase the vertical dimension	Severe dental erosion for all and association with bruxism or clenching in four patients	Direct palatal composite/feldspathic ceramic veneer (anterior region) and Direct Composite (posterior)	USPHS criteria	Most restorations received Alpha or Bravo scores	This approach of treatment represents an excellent and tooth structure-preserving alternative in comparison to full crowns

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