Restorative Dentistry/Prosthodontics

Enhanced CPD DO C

David Goh

Matthew McLaughlin and Iven Klineberg

A 5-year Observation of the Dahl

Principle to Manage Localized
Anterior Tooth Wear
Abstract: This clinical report reviews and assesses a 5-year observation of a minimal intervention approach (using the Dahl concept) for the
management of severe anterior tooth wear in a 44-year-old male.
CPD/Clinical Relevance: The Dahl concept is a versatile, inexpensive and conservative technique for the management of localized severe
anterior tooth wear.
Dent Update 2022; 49: 732–736

Tooth wear is a physiological process Tooth wear often leads to a reduced Other alternatives include:
that occurs throughout life and its occlusal vertical dimension (OVD)  Tooth preparation;
prevalence in the community increases and the potential loss of ‘interocclusal  Re-organize to RCP;
with age.1 However, when the rate of restorative space’ (IRS). The IRS is the
wear exceeds the sustainability of the space required to restore proper occlusal
teeth, it may be considered pathological, form and anatomy to a worn dentition.4 a
which causes concern for the patient.2 The To re-establish the IRS, the OVD is
aetiology of tooth wear is multifactorial often raised. This is a critical factor to
and the clinical presentations are consider in the management of tooth
varied.3 Management of tooth wear wear. Often, a considerable removal of
may vary from the conservative ‘watch sound tooth structure would be required
and review’, to extensive prosthodontic for restorative purposes with multiple
oral rehabilitations. The decision to crowns or occlusal veneers, increasing
intervene, and the extent, is determined the biological costs to the patient. One
by the impact the problem has on the alternative is to remove minimal sound
individual’s aesthetic concerns, functional tooth structure and follow a conservative
capacity, as well as the cost, both approach, as introduced by Dahl b
biological and financial. and colleagues.5

David Goh, BMedSci, BDent (Hons), DClinDent (Prosthodontics), MRACDS, Specialist

Prosthodontist, Private practice, Sydney; Faculty of Medicine and Health, University of
Sydney, Sydney, Australia. Matthew McLaughlin BDS (Lond), FDS RCS (Eng), MClinDent
(Prosthodontics) (Lond), MRD RCS (Eng), Specialist Prosthodontist, Westmead Centre
for Oral Health, Sydney, Australia. Iven Klineberg, AM, RFD, MDS, BSc, PhD, FDSRCS,
FRACDS, FICD, Emeritus Professor of Prosthodontics, Faculty of Medicine and Health,
University of Sydney, Sydney, Australia . Figure 1. (a,b) Examples of fixed appliances that
email: [email protected] use the Dahl concept.

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a a

b
c

The amount of published data for this

method of treatment has grown since the
review by Poyser and colleagues.2 Current
publications report the Dahl technique
using composite resin on anterior teeth
at the desired OVD.6-12 However, the use
of a bonded cast gold plate (or variations)
is not frequently reported in the current
literature.13 This case report describes the
treatment of a patient with severe localized d
anterior tooth wear using the Dahl concept
and a bonded cast gold bite plate, with a
follow-up observation period of 5 years.

Case report
A male of European origin, aged 44 years
old, presented for prosthodontic treatment,
concerned ‘his teeth would continue to
deteriorate’. He requested a solution that
e
Figure 2. (a,b) Pre-treatment OPG (with would restore function, aesthetics and
prognostic markers) and PA UR2. quality of life, with minimal intervention,
and would minimize future maintenance
requirements. Treatment was undertaken
as part of the University of Sydney specialty
 Increase OVD; program in Prosthodontics, at the Westmead
 Elective endodontics and post/core; Centre for Oral Health, Sydney, Australia.
 Crown lengthening and preparation; Medical history included medication-
 Tooth movement: relative axial tooth controlled depression and anxiety, with Figure 3. (a-e) Pre-treatment intra-oral images.
movement (Dahl), orthodontics; selective serotonin reuptake inhibitors
 Segmental osteotomy. (SSRI). Social and diet history identified
The Dahl Concept uses simple repeated occupational exposure to dust and
orthodontic principles for ‘relative’ axial tooth silicates, a high acid food intake (fruit, fruit tooth (UL2), a peri-apical abscess (UR2) and
movements to gain IRS.2 The palatal surfaces juice), and minimal water consumption. mild maxillary posterior tooth wear. The
of the maxillary anterior teeth are placed in The patient also reported sleep and awake mandibular teeth displayed severe localized
supra-occlusion creating disclusion of the bruxism, which was partner confirmed. tooth wear in the anterior region (LL3–LR3),
posterior teeth. This can be undertaken using Radiographic and clinical examination with signs of generalized mild tooth wear
a removable or a fixed appliance (Figure was undertaken to determine the on the mandibular posterior teeth, and
1). The posterior teeth progressively erupt prognosis, diagnosis and treatment plan tooth LL6 showed an unsatisfactory root
into occlusion with possible intrusion of (Figures 2 and 3). canal therapy and post crown. Oral hygiene
the anterior teeth, consequently providing Extra-oral examination noted a reduced was fair, and mild generalized gingivitis
the desired restorative space between the OVD and subsequent loss of aesthetics. was evident, with moderate soft and hard
anterior teeth. Intra-oral examination indicated a missing deposits present.

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a f a

b
g

h
c
Figure 5. (a, b) Axial tooth movement after 8
months in situ.

surfaces of teeth (UR3–UL3) (Figure 4).

The bonding procedure was undertaken
Figure 4. (a) Wax pattern of the gold palatal bite using rubber dam isolation, ensuring that
plate. NB: wax space carved out at the incisal the desired posterior tooth separation
edges of the maxillary anterior teeth. (b) Gold of 1 mm (Figure 4) was established and
d
palatal bite plate. (c) The gold palatal bite plate. creating a 2–3 mm separation of the
(d) Addition of composite resin (Filtek Supreme anterior teeth. The addition of composite
XTE, 3M) to the incisal edges of the maxillary resin (Filtek Supreme XTE 3M, MN, USA)
anterior teeth. (e) Occlusal view of the issued was also bonded to the incisal edges of the
Dahl appliance. (f) Frontal view of the Dahl
mandibular teeth LL3, LL2, LL1, LR1, LR2,
appliance. (g, h) Lateral views of the left and right
e LR3 to provide a stable occlusal platform for
sides showing separation of the posterior teeth.
the Dahl appliance.
The patient was monitored monthly,
until stable posterior tooth contacts were
The appropriate OVD was determined by achieved bilaterally.
assessing the physiological postural (rest)
position as well as extra-oral assessment of
the facial thirds.17
Treatment progress
A diagnostic wax-up was made after Initial posterior tooth contact was observed
accurate transfer records allowed the after 8 months in situ (Figure 5). Minor
casts to be mounted on a semi-adjustable adverse effects occurred, and included
articulator (Figure 4). For this case, a fixed chipping of the composite resin on lower
Dahl appliance was preferred due to patient anterior teeth, difficulty with speech and
A diagnosis of localized anterior compliance and comfort. The patient mastication, aesthetic and social concerns.
tooth surface loss, due to both internal presented with a notable bruxing habit The minor restorative failures were
and external factors, resulting in and, therefore, the choice of a bonded managed conservatively and concerns
loss of aesthetics and quality of life cast gold compared to provisional crowns with speech and mastication, as well as the
was determined.14-16 was decided because of the strength and social concerns, resolved at the 1-month
Stabilization of the soft and hard tissues favourable properties of gold as a material.18 follow-up and improved signficantly over
was established by referral to a periodontist The incisal spaces that were created in the observation period. The patient did
for non-surgical periodontal therapy, the cast gold appliance were filled with not advise of any temporomandibular joint
extraction of the UR2, and oral hygiene composite resin, to improve the aesthetics dysfunction, pulpal or periodontal concerns.
education was undertaken. The patient was of the appliance (Figure 4). The cast gold After a period of 11 months, adequate
also counselled and educated about the appliance contained a 6% copper content posterior tooth contacts were established
importance of a healthy and balanced diet and was sandblasted and heat treated at bilaterally and the increased OVD was
with referral to a dietitian. 400oC, which assisted with the bonding stable. The Dahl appliance was removed
The prosthodontic phase followed of the appliance with Panavia-F (Kuraray and teeth UR3, UR1, UL1 and UL3 were
compliance with a preventive regimen. Dental, New York, NY, USA) to the palatal prepared as abutments for tooth-supported

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Figure 8. UKOHQoL results over the 5-year period.

d (FDP) from right and left canines to the that it is a safe and predictable treatment
central incisor teeth with lateral tooth option with appropriate case selection as
pontics (UR3–UR1 and UL1–UL3; Figure 6). this case demonstrated.8 Adequate anterior
At 5 years, stable tooth contacts were restorative space was obtained within
evident and maintained (Figure 7). 11 months, with stable posterior occlusal
The UK oral health-related quality of contact at the desired OVD. At 12 months,
Figure 6. (a) Desired restorative space was life questionnaire (UKOHQoL) assessed full arch occlusal contacts were achieved
achieved after 11 months’ observation. (b)
patient outcomes at specific stages at intercuspal position and this has been
Polyvinyl siloxane impression. (c) Full coverage
throughout treatment and at 5 years.19 maintained over the 5-year observation
preparations of UR3 and UL3 as abutments for
FDPs UR3–UR1 and UL1–UL3 (d) Provisional
Figure 8 demonstrates a significant period. The patient was advised of possible
tooth-supported fixed dental prostheses (UR3– improvement in all measures after the adverse effects prior to commencing
UR1 and UL1–UL3) Dahl appliance was issued. At the 5-year treatment; however, the adverse effects that
observation, a decline in the effect rating were encountered were transient. Minor
a was noted for confidence, and carefree restorative failures did occur with chipping
manner, when compared with the pre- of the composite resin, which was expected
treatment rating. The patient advised this and discussed with the patient initially, and
to be due to personal aspects of daily life. were dealt with as required and at minor
Functional and aesthetic assessments inconvenience to the patient.
confirmed improvements. The effects of tooth wear can have an
adverse impact on the quality of life and
Discussion aesthetic satisfaction in many patients.21
b The attitudes and behaviours of the dental Assessing this impact can be undertaken
profession towards the management of using the suitable questionnaires, such as
tooth wear are changing. Greater emphasis the UKOHQoL, which was used in this case.
is now placed on the implementation of The questionnaire scored 16 items before
preventive measures including dietary and after the Dahl appliance had been
counselling and fluoride management, removed, and at 5 years.
and on primary clinical goals of managing The implementation of the Dahl
tooth wear conservatively to restore technique demonstrated a significant
Figure 7 (a, b) Occlusal stability at the 5-year
function and aesthetics, whilst preventing improvement in the quality of life for the
follow-up.
further loss of tooth structure. This holistic patient across all 16 items. With only two
and conservative approach is integral to scores at 5 years below the pre-treatment
treatment success.20 The Dahl appliance score. This was attributed to the patient’s
fixed dental prostheses (FDP). The meets the clinical goals of conservatively personal experiences at the time. Overall,
Panavia-F that was used to bond the Dahl managing localized anterior tooth wear.5 the scores Indicate the adaptability of the
appliance was removed on preparation of This approach has been shown to be patient and the powerful improvement this
the abutment teeth. The established IRS an effective and conservative management simple appliance can have on improving
allowed initial placement of provisional option for patients with localized anterior quality of life, while maintaining a
tooth-supported fixed dental prostheses tooth wear 2. The available literature suggests conservative approach.

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Aesthetics, comfort and eating are maintenance of this case, in the in the management of severe tooth
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Conflict of Interest: The authors declare
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for assistance with ongoing clinical of direct composite restorations

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