https://doi.org/10.53453/ms.2025.6.10
Treatment of tooth wear by restoring the occlusion with direct and
indirect restorations
Kamilė Poškaitė
1
, Gaivilė Pileičikienė
2
1
Faculty of Dentistry, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania.
2
Clinic of Dental and Maxillofacial Orthopedics, Faculty of Dentistry, Medical Academy, Lithuanian University of
Health Sciences, Kaunas, Lithuania.
Abstract
Introduction. Tooth wear is a natural, gradual, and irreversible process involving the loss of hard dental tissues,
including enamel and dentin. Although commonly associated with ageing, excessive wear can lead to significant
clinical problems such as compromised aesthetics, changes in occlusion, and pain in the temporomandibular joint
and masticatory muscles.
Aim. The aim of this study was to systematically review the scientific literature and compare the effectiveness of
two methods of occlusal restoration for worn dentition direct and indirect approaches focusing on anatomical form
retention and fracture resistance.
Materials and Methods. This systematic review was conducted according to PRISMA guidelines. A
comprehensive literature search was carried out using PubMed, ScienceDirect, and Wiley Online Library, including
studies published in English up to 6 February 2025. Seven in vivo studies were selected that evaluated the clinical
outcomes of direct and indirect restorative techniques. Each study was also assessed for quality.
Results. The studies were grouped based on their focus. The first group evaluated changes in anatomical form, with
results indicating that indirect ceramic restorations maintained their shape most effectively. The second group
analysed fracture risk, which was also lowest in the indirect ceramic restoration group.
Discussion. The findings demonstrate that the method of bite restoration significantly affects the clinical durability
of restorations. Indirect ceramic restorations showed superior outcomes in both anatomical stability and resistance
to fracture, making them the preferred option in the treatment of worn dentition.
Keywords: worn dentition, tooth wear, indirect restorations, direct restorations, occlusal rehabilitation.
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Medical Sciences 2025 Vol. 13 (4), p. 113-122, https://doi.org/10.53453/ms.2025.6.10
113
Dantų nudilimo gydymas atstatant sąkandį tiesioginėmis bei
netiesioginėmis restauracijomis
Kamilė Poškaitė
1
, Gaivilė Pileičikienė
2
1
Odontologijos fakultetas, Medicinos akademija, Lietuvos sveikatos mokslų universitetas, Kaunas, Lietuva.
2
Dantų ir žandikaulių ortopedijos klinika, Odontologijos fakultetas, Medicinos akademija, Lietuvos sveikatos
mokslų universitetas, Kaunas, Lietuva.
Santrauka
Įvadas. Dantų dilimas – tai natūralus, laipsniškas ir nuolatinis kietųjų danties audinių nykimo procesas. Jo
progresavimas gali lemti estetinės išvaizdos pokyčius, sąkandžio funkcijos sutrikimus bei skausmus smilkininio
apatinio žandikaulio sąnario ir kramtymo raumenų srityje.
Tikslas. Atlikti mokslinės literatūros apžvalgą ir palyginti dviejų skirtingų sąkandžio atstatymo metodų efektyvumą,
vertinant restauracijų anatominės formos pokyčius ir lūžių riziką, esant nudilusiems dantims.
Metodika. Sisteminė literatūros apžvalga atlikta remiantis PRISMA gairėmis. Literatūra ieškota iki 2025 m. vasario
6 d., naudojantis elektroninėmis duomenų bazėmis: PubMed, ScienceDirect, Wiley Online Library. Analizei
atrinktos 7 anglų kalba publikuotos in vivo studijos, vertinančios tiesioginius ir netiesioginius dantų nudilimo
atstatymo būdus. Taip pat įvertinta tyrimų kokybė.
Rezultatai. Atrinkti 7 in vivo tyrimai buvo suskirstyti į dvi grupes pagal tiriamą aspektą. Pirmoje grupėje vertinti
restauracijų anatominės formos pokyčiai – nustatyta, kad netiesioginės keramikinės restauracijos išlaikė formą
geriausiai ir pasirodė efektyviausios gydant dantų nusidėvėjimą. Antroje grupėje analizuota lūžių rizika – rezultatai
parodė, kad ši rizika buvo mažiausia taip pat naudojant netiesiogines keramikines restauracijas.
Išvados. Straipsnių analizė atskleidė, kad pasirinktas sąkandžio atkūrimo metodas turi įtakos restauracijų
ilgaamžiškumui ir atsparumui. Vertinant anatominės formos stabilumą bei lūžių riziką, geriausi klinikiniai rezultatai
pasiekiami taikant netiesiogines keramikines restauracijas.
Raktažodžiai: dantų nusidėvėjimas, dantų nusidėvėjimo gydymas, netiesioginės restauracijos, tiesioginės
restauracijos, tiesioginis gydymas, netiesioginis gydymas.
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1. Introduction
One of the main oral health problems of our time is
excessive tooth wear. Tooth wear is a physiological
phenomenon characterised by the progressive and
irreversible loss of tooth hard tissues [1]. The process
is divided into severe, in which the dentin layer is
exposed and a large part (≥1/3) of the clinical crown
is lost, and pathological, which is not specific to the
age of the patient. This can lead to impaired dental
aesthetics and quality of life, impaired occlusal
function, or even pain in the temporomandibular joint
and masticatory muscles [1-7, 20, 22]. For this
reason, the treatment of dental abrasions should focus
on prevention, counselling and monitoring [18-20].
When dental wear causes functional or aesthetic
problems, a treatment plan should be selected,
discussed with the patient and based on a minimally
invasive intervention approach. Direct and indirect
treatment approaches using appropriate materials are
recommended to restore the occlusion based on this
principle [5-11, 21]. Of all the restorative materials
available, resin composites and ceramics closely
mimic the aesthetics of natural tooth tissue and have
a similar solid content. This results in a similar tooth
wear process as in natural teeth. Unfortunately, these
restorative materials are also not permanent due to
their inherent fatigue and wear processes, which can
lead to changes in the anatomical shape of the
restoration and to cracks or fractures in the restoration
[1, 10, 23]. The main method used in the articles to
track changes in different restorations was the
USPHS criteria scale, which was used to determine
the quality and success of treatment. Other auxiliary
tracking methods used in the studies, such as the tooth
wear index and the Kaplan Meier curve, showed
some different and some similar age-related changes
in the structures. Therefore, the objective of this
systematic review was to compare the effectiveness
of two different bite restoration techniques in
assessing the risk of anatomical changes and fractures
in worn teeth.
2. Materials and methods
2.1. Protocol
This systematic review was conducted and reported
following the guidelines of Preferred Reporting Items
for Systematic Reviews and Meta-Analysis
(PRISMA).
2.2. Focus question
According to the Participants Intervention
Comparison Outcome Study design scheme
(PICOS), the study included randomized,
prospective, and retrospective controlled non-
randomized trials (S) on human patients of any age,
ethnicity or sex that focus on patients undergoing
dental abrasion treatment (P). The intervention (I)
was defined as a restorative treatment data and the
comparison (C) was made between results of
different restorative methods. The outcome (O)
evaluated was changes in anatomical shape and
fracture risk between different types of restorations.
The developed focus question was: does the method
of bite restoration used in dental abrasion treatment
affect the subsequent wear (anatomical changes) and
fracture of restorations.
The literature search was conducted using three
electronic databases: PubMed, Cochrane Library, and
Sciences Direct. Medical Subject Headings (MeSH)
terms used were “tooth wear treatment’’ combined
with “direct and indirect restorations” and “USPHS
scale’’.
Inclusion criteria:
1. Randomized, prospective, and retrospective
studies published in English.
2. Access to the full text of the article;
3. Clinical studies in humans (in vivo);
4. Studies involving adult patients.
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5. Studies in patients with a diagnosis of
dental wear;
6. Studies analysing different treatments for
tooth wear;
7. Studies have been carried out to assess the
resistance of anatomical anomalies to
changes in shape and to fracture of restorations.
2.3. Selection of studies
After removing duplicates, the abstracts were
evaluated based on inclusion and exclusion criteria.
An independent reviewer conducted the selection,
with a senior reviewer making the final decision.
Full-text articles were screened, and eligible studies
were included. A search in PubMed, Wiley Online
Library, and ScienceDirect identified 8,482 articles
using specified keywords and filters. Literature
reviews, meta-analyses, topic articles, and those not
relevant to the aim were excluded, leaving 646
articles, which were further rejected due to
inappropriate abstracts or incomplete texts.
Ultimately, 7 studies were selected for final analysis.
The study selection process is shown in Figure 1.
Figure 1. The study selection process
2.4. Data extraction
The study characteristics, such as design, sample size,
observation period and measurements, were extracted
independently by the author.
2.5. Assessment of methodological quality
The quality of the included study protocols was
assessed following study selection by reviewing the
full-text articles. The Cochrane Collaboration
recommends using the Newcastle-Ottawa Scale
(NOS) as a tool for assessing the quality of
observational studies. This scale assigns a maximum
of nine points (stars) across three domains to indicate
the lowest risk of bias: (1) selection of study groups
(four points), (2) comparability of groups (two
points), and (3) outcome ascertainment (three points).
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3. Results
3.1. Study characteristics
A total of 202 patients with a diagnosis of tooth wear
were enrolled in the in vivo studies reviewed. A total
of 2538 restorations of two different types were
applied to the patients: 1363 direct restorations and
1175 indirect restorations. The restorations were
evaluated using a Canon EOS 300D Digital SLR
camera, t-tests, various analysis systems and a 3D
computer model. The USPHS scale was used to
assess the quality of the restorations in almost all
studies (Figure 2). The following criteria were used
for the study participants: subjects had to be over 18
years of age with full dental arches, have a diagnosis
of moderate or severe generalised tooth wear
requiring treatment, and an assessed need for an
increase in the vertical dimension of the occlusion
(<3mm in the molar area). People with diagnosed
bruxism and gastro-oesophageal reflux disease were
also included in the tooth wear restoration studies.
Patients with the following clinical features were
excluded: limited mouth opening,
temporomandibular dysfunction, advanced
periodontitis, deep caries lesions or multiple large
restorations, including teeth with endodontic
problems, and patients with local or systemic
diseases. The subjects also had no harmful habits and
did not smoke.
Figure 2. Restorations quality criteria according to the USPHS scale.
3.2. Restorations anatomical changes
Several studies examined changes in anatomical
parameters using direct restorations [11,13,15,16].
The USPHS criteria scale was used for treatment
quality and analysis, describing changes in
anatomical shape. In a study by Wedad Hammoudi
and co-authors [16], comparing two different and the
most durable materials for anatomical shape changes
in indirect restorations, better clinical results were
observed in the group of clear zirconia restorations.
After 6 years of follow-up, not only was the treatment
itself more successful (99.1% of cases compared with
98.6% for lithium disilicate restorations), but all
zirconia restorations were also rated with alpha value.
The other material used in the study, lithium disilicate
ceramics, also showed excellent clinical results, with
83.6% of the restorations retaining an ideal or almost
unchanged anatomical shape. According to the
authors, the colour, margin and anatomical shape of
the ceramic restorations remained stable over a 10-
year period. Effective treatment of tooth wear was
found in up to 90.1% of cases, which was influenced
by the increased vertical dimension of the occlusion,
in addition to the type of restorative material. The
study by Al-Khayatt and co-authors [13] also showed
excellent clinical results with the use of a
USPHS criteria
Alpha (A)
Bravo (B)
Charlie (C)
Changes in the anatomical
shape of the restoration
Restoration, ideal or
almost unchanged.
Restoration worn within
the composite material.
Restoration and tooth hard
tissue wear.
Restoration fractures
The restoration is intact,
with no cracks or breaks
and in excellent condition.
Minimal complications to
the restoration - polishing
or replacement required.
Restoration lost or
severely fractured,
replacement required.
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microhybrid composite for the direct treatment of
tooth wear. The vertical dimension of the occlusion
was increased from 0.5 to 5 mm. The majority of
these, 63 (88%) patient restorations, had lost less than
50% of the restorative material and only 3 (4%) had
deteriorated and lost more than 50% of the
microhybrid composite. These findings are
complemented by K. Ning and co-authors in their
study [11], where direct restorations reduced the bite
height after one year to 0.5 mm in all tooth groups,
but the highest wear was recorded in the molar
region, irrespective of the composite chosen.
3.3. Restorations fracture risk
The lowest risk of fracture was observed with indirect
ceramic restorations in the remaining articles
[12,16,17]. This is supported by a study by Wedad
Hammoudi and co-authors, which reported only one
restoration (0.9% of the total sample) that cracked at
the cemento-enamel junction [16]. In this analysis,
the authors investigated an important criteria for the
prevention of fracture in ceramic restorations: the
thickness of the restoration, which should be at least
1 mm. In this way, the indirect restoration consisted
of a thicker layer of solid material, which resulted in
a higher resistance to cracking and fracture. Indirect
composite restorations had a higher risk of fracture.
This is supported by the article by L.A.M.J. Crins and
co-authors, who concluded that more fractures
occurred in anterior teeth with indirect composite
restorations (5.6%) than with direct restorations
(3.96%) [17]. Significant differences were found in
the first molars, where indirect composite
restorations caused as many as 27.36% of fractures,
whereas direct restorations caused only 7.04%.
Similarly, the results of the study by B.A.C. Loomans
and co-authors showed a low risk of cracks and
fractures (3.42%) with direct composite restorations
in both anterior and posterior teeth [12]. This direct
restoration method with composite materials was
favourable in 94.8% of cases.
3.4. Quality assessment
The articles reviewed in our study were evaluated
using the Newcastle-Ottawa Scale and were
classified as "Good" quality. The ratings for the
chosen studies ranged from 7 to 8 out of a possible 9
points on the scale.
4. Discussion
When comparing the changes in the anatomical shape
of the different types of restorations, it was found that
the least altered shape and the most effective result in
the treatment of tooth wear was achieved with
indirect ceramic restorations. Another important
feature of the success of the treatment of tooth wear
is the presence of cracks and fractures in direct and
indirect restorations [12, 14, 16, 17]. The best results
also showed direct zirconia restorations. As the
lowest wear of this restorative material was observed
compared with direct restorations [11, 13, 15, 16].
Less wear and anatomical shape changes are
observed in the nanocomposite group compared to
the microhybrid composite. The reduction in
restoration height in mandibular teeth varied from
0.25 to 0.5 mm. The results of this treatment modality
were favourable in 95% of cases. Direct restorations
showed a 94.8% treatment success rate and a 99.3%
restoration durability at 3.5 years after application.
Only 3.42% of fractures were observed with direct
restorations [11,12]. Direct restoration with
composite materials had favourable results in 94.8%
of cases while the success rate for Lithium disilicate
ceramics was 98.6% and for Translucent zirconia
restorations 99.1%. The risk of fracture in indirect
restorations was estimated at only 0.9%. All zirconia
restorations were assessed with alpha value. Lithium
disilicate ceramics also showed excellent clinical
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results, with 83.6% of restorations having an ideal or
almost unchanged anatomical shape [16,17].
5. Conclusion
The method of bite restoration used in the treatment
of tooth wear has been shown to influence the
subsequent anatomical shape changes and fractures
of restorations. Indirect ceramic restorations were the
most effective in assessing changes in anatomical
shape and fracture risk. Of the composite materials,
nanocomposite was the most resistant to fracture and
anatomical shape changes, and clear zirconia ceramic
was the most resistant to fracture and anatomical
shape changes.
References
1. Kanaan M, Brabant A, Eckert GJ, et al.
Tooth wear and oral-health-related quality of life in
dentate adults. J Dent 2022; 125: 104269;
2. Kitagawa, H., Yoshimi, Y., Sugimoto, K.,
Nakai, K., & Minagi, S. (2022). Effect of masseter
muscle activity during wakefulness and sleep on
tooth wear. Journal of Prosthodontic Research, 66(4),
551–556.
https://doi.org/10.2186/jpr.JPR_D_21_00171;
3. Schmidt CW. Dental macrowear and
microwear. The International Encyclopedia of
Biological Anthropology 2018;
4. Ohlmann, B., Borrie, F., & Kopp, S. (2020).
Correlations between sleep bruxism and
temporomandibular disorders. Journal of Oral
Rehabilitation, 47(3), 312-320.
https://doi.org/10.1111/joor.12979;
5. Ways To Improve The Efficacy Of
Orthopedic Treatment Of Patients With Severe
Excessive Tooth Wear – PubMed 2021;
6. Mehta SB, Loomans BAC, Banerji S, et al.
An investigation into the impact of tooth wear on the
oral health related quality of life amongst adult dental
patients in the United Kingdom, Malta and Australia.
J Dent 2020; 99: 103409.
7. Delgado-Delgado R, Iriarte-Álvarez N,
Valera-Calero JA, Centenera-Centenera MB,
Garnacho-Garnacho VE, Gallego-Sendarrubias GM.
Association between temporomandibular disorders
with clinical and sociodemographic features: An
observational study. Int J Clin Pract. 2021
May;75(5):e13961. doi: 10.1111/ijcp.13961. Epub
2021 Jan 8. PMID: 33387380;
8. Lopez-Cazaux S, Aiem E, Velly AM, et al.
Preformed pediatric zirconia crown versus preformed
pediatric metal crown: study protocol for a
randomized clinical trial. Trials; 20. Epub ahead of
print 24 August 2019. doi: 10.1186/S13063-019-
3559-1. PMID: 31445509.
9. Mehta SB, Lima VP, Bronkhorst EM, et al.
Clinical performance of direct composite resin
restorations in a full mouth rehabilitation for patients
with severe tooth wear: 5.5-year results. J Dent; 112.
Epub ahead of print 1 September 2021.
doi:10.1016/J.JDENT.2021.103743. PMID:
34229000;
10. Hamam FM, Bader BAM, Slewa MY.
Evaluation of Mechanical Properties for Selected
Dental Composite Resin Polymerized by Light
Curing Technology at Different Thickness. MSF
2020;1002:331–9.
https://doi.org/10.4028/www.scientific.net/msf.1002
.331.
11. Ning K, Bronkhorst E, Bremers A, et al.
Wear behavior of a microhybrid composite vs. a
nanocomposite in the treatment of severe tooth wear
patients: A 5-year clinical study. Dental Materials
2021; 37: 1819– 1827.
Journal of Medical Sciences. 4 Jun, 2025 - Volume 13 | Issue 4. Electronic - ISSN: 2345-0592
119
12. Loomans BAC, Kreulen CM, Huijs-Visser
HECE, et al. Clinical performance of full
rehabilitations with direct composite in severe tooth
wear patients: 3.5 Years results. J Dent 2018; 70: 97–
103. doi: 10.1016/j.jdent.2018.01.001. PMID:
29339203.
13. Al-Khayatt AS, Ray-Chaudhuri A, Poyser
NJ, et al. Direct composite restorations for the worn
mandibular anterior dentition: a 7-year follow-up of
a prospective randomised controlled split-mouth
clinical trial. J Oral Rehabil 2013; 40: 389–401.
14. Edelhoff D, Erdelt KJ, Stawarczyk B, et al.
Pressable lithium disilicate ceramic versus
CAD/CAM resin composite restorations in patients
with moderate to severe tooth wear: Clinical
observations up to 13 years. Journal of Esthetic and
Restorative Dentistry 2023; 35: 116–128.
15. Taubck TT, Schmidlin PR, Attin T.
Vertical Bite Rehabilitation of Severely Worn
Dentitions with Direct Composite Restorations:
Clinical Performance up to 11 Years. J Clin Med; 10.
Epub ahead of print 2 April 2021. doi:
10.3390/JCM10081732. PMID: 33923679.
16. Hammoudi W, Trulsson M, Svensson P, et
al. Long-term results of a randomized clinical trial of
2 types of ceramic crowns in participants with
extensive tooth wear. Journal of Prosthetic Dentistry
2022; 127: 248–257. doi:
10.1016/j.prosdent.2020.08.041. PMID: 33303191.
17. Crins LAMJ, Opdam NJM, Kreulen CM, et
al. Randomized controlled trial on the performance of
direct and indirect composite restorations in patients
with severe tooth wear. Dental Materials 2021; 37:
1645– 1654. doi: 10.1016/j.dental.2021.08.018.
PMID: 34497023.
18. Hamburger JT, Opdam NJM, Bronkhorst
EM, et al. Indirect restorations for severe tooth wear:
Fracture risk and layer thickness. J Dent 2014; 42:
413–418. doi: 10.1016/j.jdent.2013.10.003. PMID:
24120523.
19. Kruzic JJ, Arsecularatne JA, Tanaka CB, et
al. Recent advances in understanding the fatigue and
wear behavior of dental composites and ceramics. J
Mech Behav Biomed Mater 2018; 88: 504–533. doi:
10.1016/j.jmbbm.2018.08.008. PMID: 30223214.
20. Sierpinska T, Kuc J, Golebiewska M.
Assessment of masticatory muscle activity and
occlusion time in patients with advanced tooth wear.
Arch Oral Biol 2015; 60: 1346–1355. URL:
https://doi.org/10.1016/j.archoralbio.2015.06.006.
21. Srisilapanan P, Jindarat M, Roseman J. The
Prevalence and Severity of Tooth Wear in Type 2
Diabetic Patients. Int J Dent; 2018. Epub ahead of
print 2018. doi: 10.1155/2018/3608158.
22. Hammoudi W, Trulsson M, Smedberg JI, et
al. Clinical presentation of two phenotypes of tooth
wear patients. J Dent 2019; 86: 60–68.
23. Kanaan M, Brabant A, Eckert GJ, Hara AT,
Carvalho JC. Tooth wear and oral-health-related
quality of life in dentate adults. J Dent. 2022
Oct;125:104269. doi: 10.1016/j.jdent.2022.104269.
Epub 2022 Aug 23. PMID: 35998742.
24. Edelhoff D, Gth JF, Erdelt K, et al. Clinical
performance of occlusal onlays made of lithium
disilicate ceramic in patients with severe tooth wear
up to 11 years. Dental Materials 2019; 35: 1319–
1330.
25. Klink A, Groten M, Huettig F. Complete
rehabilitation of compromised full dentitions with
adhesively bonded all-ceramic single-tooth
restorations: Long-term outcome in patients with and
without amelogenesis imperfecta. J Dent 2018; 70:
51–58.
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Table 1. Results of individual studies.
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