R E DS ET NO TRI AS T

R E S TO R AT I V E T IR VY E D E N T I S T R Y

Reviewing the Concept of Dahl

SHUVA SAHA AND ANTHONY J. SUMMERWILL

appearance of the enamel, and there may

Abstract: Toothwear may have a multifactorial aetiology but is often localized to the be an increased translucency, both
upper anterior teeth. This is normally accompanied by a loss of interocclusal space.
interproximally and at the incisal edges.
This paper aims to outline the management of localized anterior toothwear. It discusses
several options available to create space for anterior restoration, with particular Further loss of enamel may lead to
reference to the use of the ‘Dahl’ technique. Dahl described a non-invasive technique yellowing of the teeth as the underlying
to create increased interocclusal space. The increased space eliminates the need for dentine is exposed. Progressive
further occlusal reduction during crown preparation which is ideal in the worn toothwear can often result in thinning of
dentition. This paper illustrates and describes the clinical applications of Dahl’s the incisal enamel, chipping, fracture of
original technique. the enamel and reduced clinical crown
height. Ultimately, the form of the tooth
Dent Update 2004; 31: 442–447 may be lost.
Clinical Relevance: The general practitioner should be aware of the techniques Treatment may be indicated to protect
available for managing localized anterior toothwear. and conserve the remaining tooth
structure whilst also improving function.
Exposure of dentinal tubules and their
subsequent colonization by bacteria can

T oothwear is becoming an increasing

problem in both children and adults.
A recent survey has shown a prevalence
of 98% in adults.1 The severity varies
from mild to severe, although the
majority of cases will not require
operative treatment. Some degree of
toothwear can be regarded as
physiological wear and tear, and the
severity should be balanced with the
patient’s age and whether symptoms,
such as sensitivity and poor appearance,
are problems. Toothwear is usually a
combination of attrition, abrasion and
erosion, with differing proportional
effects. However, the contribution of
erosion to toothwear is increasing.2,3
Foods and beverages, especially citrus
fruits, fruit juices, and the acidic nature of
carbonated soft drinks have the erosive
potential to damage the tooth. These now
form a significant component of many
diets.4 Repeated self-induced vomiting
by anorexic or bulimic patients can also
lead to dental erosion.5 Erosion by
regurgitation of gastric acid contents
commonly occurs initially on the palatal
surfaces of the maxillary incisors, canines
and first premolars.6 Gastro-oesophageal
reflux is a common condition and
regurgitation of gastric acid into the
mouth can cause dental erosion.7 Other
causes of dental erosion include
environmental causes and medication.
Localized anterior toothwear (Figure 1)
is caused predominantly by erosion,
which either contributes to the wear itself
or accelerates the wear caused by attrition.
lead to pulpal inflammation and
sensitivity.8 A complaint of sensitivity
suggests that the wear is progressing
faster than the deposition of reparative
dentine and may indicate the rapid loss of
tooth substance.Tooth sensitivity, which
does not respond to local measures such
as fluoride application, may indicate the
need for restoration.
THE PROBLEM OF SPACE
The localized loss of anterior tooth tissue
is often accompanied by alveolar bone
growth, which maintains contact between
the opposing dentitions. This is called

Shuva Saha, BDS, MFDS RCS (Eng.), Specialist

Registrar, Department of Restorative Dentistry
and Anthony J. Summerwill, BDS, MPhil,
FDS (Rest. Dent.), MRD RCS (Edin.), FDS RCS
(Eng.), Consultant in Restorative Dentistry,
Birmingham Dental Hospital.
REASONS FOR
RESTORATION
Treatment of toothwear may be
requested for cosmetic improvement.
Early erosion produces a smooth shiny Figure 1. Localized anterior toothwear.

442 Dental Update – October 2004

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Figure 2. Worn upper anterior teeth with
shortened clinical crowns. There is minimal
interocclusal clearance despite the extent of the
toothwear.
dento-alveolar compensation.9,10 As a
result of this compensatory tooth
eruption and alveolar bone growth, the
occlusal vertical dimension (OVD) is
maintained and the inter-occlusal space
remains constant. The resulting effect is
that there is a reduction in available
space to place restorations without
increasing the OVD (Figure 2). This may
lead to treatment difficulties unless space
is created. In patients already displaying
significant toothwear with shortened
clinical crowns, it is important that this
space is not created by carrying out
further tooth preparation for restorations.
Further tooth preparation may lead to risk
of pulpal exposure, short tooth height
and compromised retention for
restorations.
There are several treatment options
available to create interocclusal space:
l Increasing the occlusal vertical
dimension (OVD);
l Reduction of teeth in same/opposing
arch;
l Occlusal reorganization;
l Elective root treatment and
placement of post crowns;
l Surgical crown lengthening;
l Orthodontics;
l Dahl appliances.
Increasing the OVD
One method of treating short clinical
crowns in a patient who displays
generalized severe toothwear is to
provide extra-coronal restorations on
most of the teeth in one or both arches.
In patients where there has not been any
dento-alveolar compensation, the
Dental Update – October 2004
R E S TO R AT I V E
occlusal vertical dimension is decreased
as overclosure has occurred. Restoration
of the OVD by placement of multiple
restorations should therefore be well
tolerated. However, where dento-alveolar
compensation has occurred, an occlusal
splint can be used to assess whether the
patient can tolerate an increase in the
OVD prior to restoration. Usually, if
multiple restorations are required, a
reorganized occlusal approach is used.
This treatment approach may be
destructive, lengthy, and expensive and
can incur significant long-term
maintenance costs.
Reduction of Teeth in Same/
Opposing Arch
Occlusal reduction of the worn tooth
itself will result in loss of height of the
axial walls. This will compromise the
retention and resistance form of the final
restoration.
It is tempting to consider reduction of
the opposing teeth to create immediate
space for upper anterior restorations.
This is undesirable in a dentition where
there has already been loss of tooth
tissue. Furthermore, lower incisal edges
are important as they provide the support
for anterior guidance. It may be
appropriate to follow either of these
approaches for single unit restorations.
Occlusal Reorganization
Reorganization of the occlusion from
the intercuspal position (ICP) to a more
retruded position may create palatal
clearance for the upper incisors. It is
suitable in those patients who have a
large horizontal discrepancy between
ICP and the retruded axis position.
Occlusal adjustment may be carried out
to eliminate or reduce this anterior slide
to achieve a more posterior occlusion
and space behind the upper anterior
teeth. If occlusal adjustment does not
produce sufficient space,
reorganization will require extensive
restoration and thus destruction of
multiple posterior teeth.11 Thorough
occlusal analysis using mounted study
models should be carried out prior to
occlusal adjustment or restoration.
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D E N T I S T RY
Surgical Crown Lengthening
Surgical crown lengthening does not
create more space for tooth preparation
but will expose more tooth tissue for
improved retention of the final
restoration. The procedure involves
alveolar bone removal and repositioning
of the gingival margin in an apical
direction. Crown lengthening requires a
period of healing, of ideally 3 months, for
the gingivae to stabilize at its new
position. Patients should be advised that
they may experience sensitivity from the
exposed root surfaces following surgery.
The patient may be left with dark,
triangular spaces interdentally which are
poor aesthetically. This is a consequence
of the crowns being relatively wide
incisally and too narrow at the gingival
margin and may pose a problem in those
patients who have a high smile line.
Despite crown lengthening, inter-occlusal
space has not been created. Occlusal
reduction is still required and may lead to
pulpal exposure (Figure 1) and elective
endodontics may also be required.
Elective Root Treatment and
Placement of Post Crowns
A post-retained crown can be placed
where there is insufficient clinical crown
height to retain a conventional crown. In
these cases the teeth require elective root
treatment to gain retention for a post-
retained crown. This highly destructive
and expensive technique should be used
with caution as there is a high risk of
endodontic failure and of root fracture.12
Conventional Orthodontics
Conventional orthodontics can be used
to create interocclusal space. Increasing
the overjet and decreasing the overbite
both result in the increase of space
available for subsequent restoration. The
use of fixed orthodontic appliances is a
conservative method of providing
interocclusal space. It is particularly
suitable if there is an existing
malocclusion, or if there are a number of
posterior edentulous spaces. The
disadvantages of this method include an
extended treatment time and poor patient
compliance. In addition, the intrusion of
443
 R E S TO R AT I V E
Figure 3. Right buccal view showing the
disclusion of the posterior teeth after immediate
placement of ceramic crowns.
Figure 4. Removable Dahl Appliance.
teeth may be difficult and is associated
with an increased risk of root resorption.
Dahl Appliances
The Dahl appliance is a simple orthodontic
appliance acting as an anterior bite
platform. Dahl appliances create an
increased interocclusal space without
affecting the clinical crown height. The
principle behind the appliance is simple.
Coverage of the palatal surfaces of the
anterior teeth causes posterior disclusion.
A combination of posterior over-eruption
and intrusion of the anterior teeth leaves a
space between the anterior teeth. This
space eliminates the need for further
occlusal reduction during crown
preparation, which is ideal in the worn
dentition.
THE DAHL TECHNIQUE
In 1975, Dahl described a technique where
he created interocclusal space using a
removable anterior bite platform.13 The
appliance was first used on an 18-year-old
patient with localized anterior toothwear.
When inserted, the posterior teeth were
discluded (Figure 3) whilst the anterior
teeth contacted the anterior bite platform.
444
D E N T I S T RY
Dahl observed that, after a period of
several months, the posterior teeth
eventually achieved occlusal contact.
When the appliance was removed, a space
could clearly be seen between the upper
and lower anterior teeth. This technique
eliminates the need for extensive anterior
palatal tooth preparation.
Further studies by Dahl14 have
demonstrated that the possible
mechanism for the creation of
interocclusal space involves both the
anterior intrusion of teeth in contact with
the appliance and eruption of the
posterior teeth free of contact. They also
showed that the effect of posterior
eruption was predominant over anterior
intrusion by the fact that patients
demonstrate an overall increase in
occlusal vertical dimension.
The principles behind this technique
have since been used to create
interocclusal space in patients with
localized anterior toothwear.
TYPES OF DAHL APPLIANCE
Original Dahl Appliance
(Removable Dahl Appliance)
The original appliance, as described by
Dahl, consists of a removable cobalt
chrome splint approximately 2 mm thick
covering the palatal surfaces of the upper
anterior teeth. The appliance is retained
using buccal clasps on the canines and
premolars (Figure 4). Patients are required
to wear the appliance constantly. Clinical
observations demonstrate that re-
establishment of the posterior teeth
occurs within 6 months.15 Owing to the
poor aesthetics and ability to remove this
appliance, patient compliance may be low.
An appliance made from acrylic or
polycarbonate, providing occlusal
coverage, can also be worn. These types
of appliances are easier both to fabricate
and wear.
Cemented Cast Dahl
Appliances (Fixed Dahl
Appliance)
This fixed metal appliance consists of a
non-precious alloy which is cemented
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onto the palatal surfaces of the upper
anterior teeth (Figure 5). It is cemented in
place until such time as the posterior
teeth make contact. It is suggested that a
weak mix of glass ionomer or
polycarboxylate is used for cementation.
The appliances can be very difficult to
remove, especially if acid-etched
composite is used. Furthermore, the
composite will impregnate the tooth
tissue which may compromise bonding
of the permanent restoration if adhesive
technology is required for retention. The
benefits of the fixed appliance compared
with the removable are that aesthetics
are better and, because it is fixed,
compliance is less of a problem. The
main difficulties arise with removal of
this fixed appliance.
Individual Definitive Adhesive
Restorations
In many patients, toothwear may be
localized to the palatal surfaces of upper
anterior teeth, with the labial surfaces
being minimally affected. In these
situations, it is preferable to place
palatal restorations rather than full
coverage restorations, thus avoiding
extensive and unnecessary tooth
preparation. The palatal restorations will
help protect against further erosion and
are useful in patients complaining of
sensitivity. Traditionally, these palatal
veneers have been made as individual
metal castings (Figure 6). However, they
often produce undesirable aesthetics.
Tooth-coloured options include
composite or ceramic.
Composite is especially useful in
cases where the aetiology of the
toothwear is unclear or uncontrolled,
since it can be repaired and maintained
Figure 5. The fixed Dahl Appliance.
Dental Update – October 2004
 R E S TO R AT I V E D E N T I S T RY
Figure 6. Maxillary arch following placement of
six gold palatal veneers.
easily. Ceramic palatal veneers may be
abrasive to the opposing dentition and
are more difficult to repair than composite
veneers.
Placing palatal restorations directly
onto the worn surface will leave the
posterior teeth discluded. By the same
Dahl effect, anterior intrusion and
posterior eruption will lead to re-
establishment of the occlusion. If there
is excessive wear of the composite
restorations or poor aesthetics, the
affected teeth may then be prepared for
definitive full coverage restorations.
Intermediate Temporary Full
Coverage Restorations
Ricketts and Smith16 described the use of
full coverage temporary restorations to
create interocclusal space. The teeth are
prepared for full coverage restorations and
temporary restorations are placed. The
posterior teeth will be initially discluded,
however, when they have achieved
contact impressions, they can be taken for
the definitive crowns. The problem with
this technique is that it is irreversible and,
if the desired tooth movement has not
occurred, treatment has failed.
Definitive Conventional Full
Coverage Restorations
The most recent technique which
applies the Dahl principle is the direct
placement of the definitive full coverage
restorations. The benefit of this single
stage technique is the rapidity of the
treatment and reduced number of patient
visits. Worn teeth can be restored with
446
full coverage composite restorations
(dentine-bonded crowns or directly
built-up restorations) at an increased
vertical dimension. Directly building up
composite restorations at chair-side is a
relatively cost-effective technique and is
completely reversible. Dentine-bonded
crowns are lab-made, all ceramic full
coverage crowns which use a dentine
bonding agent to link the restoration to
the tooth (Figures 7, 8, 9).17 The
advantages of using these adhesive
techniques over conventional crowns is
that retention is not dependent upon
tooth preparation. However, long-term
outcomes of this technique have not
been tested.
MATERIALS FOR
RESTORATION (TABLE 1)
The ideal material for restoration of
toothwear should have the following
qualities:11,18
l A high fracture strength, i.e. be
physically strong in thin sections.
(This will allow minimal loss of tooth
tissue);
l Be reparable in the mouth, especially
where further toothwear is expected;
l Possess wear resistance similar to the
opposing tooth;
l Have a high bond strength;
l Be aesthetic;
7 8
9
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l Be resistant to erosion;
l Be economical.
TREATMENT
Case Selection
The primary treatment objective is to
identify, control and advise the patient
regarding causative factors and to relieve
any sensitivity or pain. Long-term
rehabilitation can be carried out after
thorough clinical examination,
radiographic assessment and occlusal
analysis with the aid of articulated study
casts.
Suitable Cases for Treatment
using the Dahl Approach
Conditions making patients suitable
cases for treatment using the Dahl
approach include:
l Localized anterior toothwear;
l Good oral hygiene;
l Good periodontal health and bone
support;
l Stable posterior support.
However, patients with a history of
temporomandibular dysfunction should
be treated cautiously.
Using the Dahl approach, a significant
Figures 7, 8, 9. Labial and palatal views
showing the improvement in appearance
following the placement of ceramic anterior
restorations.
Dental Update – October 2004
 R E S TO R AT I V E D E N T I S T RY

Material Composite Dentine-Bonded Cast Metal / Gold Porcelain-Bonded Crowns

(Indirect/Direct) Crowns

Advantages - excellent aesthetics - excellent aesthetics
- repair by simple addition - high bond strengths
- low cost - high fracture strength
- minimal tooth preparation
- retention not dependent
upon parallel preparation
- high fracture strength
- high wear resistance
- margins can be placed
subgingivally
- high fracture strength
- high wear resistance
- margins can be placed
subgingivally
- acceptable aesthetics

Disadvantages - low wear resistance - subgingival placement - poor aesthetics - significant tooth reduction
- subgingival placement contra-indicated - repair is not possible required
contra-indicated - difficult to repair - only partially repairable
- direct build-up can be time- - few long-term clinical
consuming and difficult results
Table 1. Comparing the different materials available for restoration.

amount of space can be created in a
reasonable period of time without
destroying tooth tissue. The procedure is
generally well tolerated and patients seem
to adapt to the altered mandibular position.
Additional Use of the Dahl
Effect – Adhesive Bridges
For adhesive bridges in the upper
anterior region, space can be created
using the Dahl approach.19,20 If there is
insufficient interocclusal space for the
wings of the bridge retainers, the
retainers can be cemented in ‘high’. This
avoids the need for tooth preparation.
Intrusion of these teeth is expected to
occur, along with posterior eruption, and
the occlusion should re-establish. The
adhesive bridge must be designed so that
occlusal forces are directed through the
long axes of the teeth; this is to avoid
unwanted proclination of the upper
anterior teeth. There is a possibility that
debonding of the bridge could occur.
Complications
The following complications may occur:
l Patients need to be informed that
posterior teeth will not occlude
during initial stages of the treatment
and that there could be difficulties in
eating some types of food.
l Re-establishment of the posterior
occlusion is expected within 6
months. In a few cases, active tooth
movement may not occur –
unfortunately it is not possible to
predict which patients this will
affect.15
l It is possible that patients may
develop temporomandibular joint
dysfunction or periodontal
symptoms of tenderness.
l When the posterior teeth are
discluded, there is a period of
uncontrolled tooth movement. If
there are posterior edentulous
spaces, there is a potential for
unfavourable tooth tilting and
drifting movements.
l There is a potential for further
erosive wear around the margins of
the restorations and it is also
important to monitor the opposing
dentition for signs of attrition.21
SUMMARY
There are a variety of methods that can be
employed to manage the worn dentition.
This article has reviewed the concepts,
rationales and techniques for treating
localized anterior toothwear. The lasting
success of any treatment is heavily
dependent upon re-inforcing preventive
measures and monitoring of the integrity
of the restorations and occlusion. It is
therefore recommended that all patients
are placed on a suitable long-term
maintenance programme.
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