Purpose: The aim of this retrospective clinical study was to evaluate the performance of direct composite restorations that were placed in patients with severe tooth wear requiring an increase of the occlusal vertical dimension. Methods and Materials: Eighteen patients with severe tooth wear, who had been treated in a private practice between April 1996 and July 2007, were selected. All subjects had been treated with direct composite resin restorations in increased vertical dimension using a three-step etch-and-rinse adhesive system and a hybrid composite resin. From the dental records, information about re-intervention and replacement of restorations was obtained. Patients were then clinically examined to evaluate the status of the restorations and interviewed about their satisfaction with the restorative treatment using a Visual Analogue Scale (VAS). Results: Eighteen patients (16 male, 2 female with an average age of 44.8 years) with severe tooth wear were included in the study. Time since treatment ranged from 6 months to 12 years and the mean observation time was 3.98 years. Of the 332 restored teeth, 23 restorations showed failures (6.9%). Eight restorations (2.4%) showed major fractures, 11 restorations (3.3%) showed minor fractures, and four restorations (1.2%) failed due to secondary caries. VAS data on a scale of 0 to 10 revealed high patient satisfaction with this type of restoration (mean 9.0). Conclusion: Treatments with direct hybrid composite restorations placed in an increased occlusal vertical dimension showed good clinical performance in patients with severe tooth wear. Keywords: tooth wear, composite, treatment, occlusal vertical dimension