CLINICAL EBOOK SERIES

POWERED BY

DEVELOPMENTS IN
ESTHETIC DENTISTRY
FEBRUARY 2021

2 C E C R E D I T S

ESTHETIC REHABILITATION

Conservative, Functional, and

Esthetic Rehabilitation of Severe
Palatal Erosion (Class IV) Using
Modified Dahl Approach
Aliasger Tunkiwala, MDS; and Rajeev Chitguppi, MDS

C A S E S T U D Y

FUNCTIONAL ESTHETICS

Correction of Dysfunctional
Wear Results in Esthetic
Outcome for Reluctant Patient
Jacek Glebocki, DMD

SUPPORTED BY AN UNRESTRICTED GRANT FROM AACD • Published by AEGIS Publications, LLC © 2021
 Form with
Function
of Continuing Education in Dentistry

R
FEBRUARY 2021 | www.compendiumlive.com

PUBLISHER
Matthew T. Ingram
of Continuing Education in Dentistry
SPECIAL PROJECTS DIRECTOR
ehabilitation does not guarantee esthetic C. Justin Romano
results. Nonetheless, the challenges of ad- SPECIAL PROJECTS COORDINATOR
June Portnoy
dressing both within the same case often of Continuing Education in Dentistry
MANAGING EDITOR
inspire creative thinking by the restorative Bill Noone

team. This special Compendium eBook of- CREATIVE

Claire Novo
fers two articles that attest to that, first with a continuing
EBOOK DESIGN
education (CE) article on how combining two different treat- Jennifer Barlow

ment principles benefited the patient and second with a case

in which functionality and esthetics required each other.
The continuing education article details a challenging case
involving a patient’s deep bite coupled with palatal erosion
and wear. Separately, the principles of centric relation and
those by Dahl could not adequately address the situation at
hand. The restoration team, however, found that by combining
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these two approaches, they could create anterior interocclusal Printed in the U.S.A.

space to keep a less invasive approach. Additionally, adhesive

restorations helped address both the cosmetic and functional
challenges the patient wished to overcome.
In the case presented in the second article, the patient
wished to address the functional problems in his dentition—
namely, extensive wear on his upper anterior teeth—but little
interest in improving the look of his smile. However, in case
planning, it proved that the dental team could provide both
biomechanical and cosmetic benefits to the patient. Providing
Chairman & Founder
the patient with an esthetic mock-up and thorough education Daniel W. Perkins
in the recommended processes and procedures proved pivotal Vice Chairman & Co-Founder
Anthony A. Angelini
in his understanding and acceptance of the treatment.
Chief Executive Officer
Compendium takes pride in offering up-to-date and useful Karen A. Auiler

information on a wide variety of topics in dentistry. For more Corporate Associate

Jeffrey E. Gordon
information on esthetic dentistry and related areas, please Media Consultant, East
Scott MacDonald
visit us at compendiumlive.com.
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2 COMPENDIUM EBOOK SERIES February 2021 | Volume 42 Number 1 www.compendiumlive.com

 CONTINUING EDUCATION 1 REHABILITATING PALATAL EROSION

Conservative, Functional, and

Esthetic Rehabilitation of Severe
Palatal Erosion (Class IV) Using
Modified Dahl Approach
Aliasger Tunkiwala, MDS; and Rajeev Chitguppi, MDS

ABSTRACT: This article demonstrates the clinical application of biomechanical and

occlusal principles to conservatively provide optimal clinical outcomes in restoring an
eroded anterior dentition. The authors manage a challenging case involving limited palatal
clearance (ie, deep bite) coupled with palatal erosion and wear by combining the centric
relation (CR) and Dahl principles to create anterior interocclusal space to reduce the need
for more invasive palatal reduction. The combined use of adhesive restorations—resin
composites on the palatal surface and indirect porcelain veneers on the facial/incisal
surfaces—through enamel and dentin bonding helped optimize esthetic and functional/
biomechanical aspects. This ultraconservative approach enabled the desired esthetic and
biomechanical outcomes to be achieved through the treatment of localized anterior tooth
erosion and wear. In short, when treating eroded maxillary anterior teeth with deep bite,
adequate restorative space should first be created by conjoining CR and Dahl principles
before using adhesive dentistry to restore with bonded composites and porcelain veneers.

LEARNING OBJECTIVES

• Analyze the risk factors
involved in a case of severe
palatal erosion
• Discuss the role of the Dahl
technique and its modification
in managing maxillary anterior
teeth with severe palatal
erosion
• Assess the various options
available in adhesive dentistry
for managing cases of
severe palatal erosion with
and without posterior tooth

D
structure loss

Noncarious cervical lesions and developing a treatment plan.1,2 Erosion is

(NCCLs) have a multifactorial a physical mechanism causing wear by friction
etiology and result from complex from the movement of liquids. Tooth erosion,
interactions between corrosion described as tooth surface loss (TSL), is pro-
(chemical degradation), stress duced by chemical or electrolytic processes of
(abfraction), and friction (toothbrush/denti- nonbacterial origin; acids are usually involved.
frice abrasion), all of which a restorative dentist More recently, the term erosion has been re-
must consider for achieving a correct diagnosis placed by biocorrosion, which encompasses
DISCLOSURE: The authors had no disclosures to report.

3 COMPENDIUM EBOOK SERIES February 2021 | Volume 42 Number 1 www.compendiumlive.com

 CONTINUING EDUCATION 1
the chemical, biochemical, or electrochemical
action that causes the molecular degradation
of the essential properties in a living tissue.1,2
Adhesive technology has progressed consid-
erably in recent decades and has shown that,
along with excellent esthetics, it can also be
used to reestablish crown stiffness while al-
lowing maximum preservation of the residual
hard-tissue structure in both anterior and pos-
terior teeth. Adhesive technology offers two
primary benefits3-5: (1) adhesive ceramic res-
torations can be used via an additive approach,
ie, they do not require a significant amount
of tooth reduction because the existing space
provided by the missing tissues is utilized;
and (2) conventional “resistance and reten-
tion form” principles can be omitted; instead
the bonds between the porcelain and luting
resin composite and between the luting resin
composite and tooth are exploited.
Localized Palatal Wear/Erosion
and Restorative Challenges
The palatal surfaces of anterior teeth present
clinicians a threefold challenge in achieving
optimal surface preparation and restoration6:
(1) they offer limited stability and retention due
to their concave geometry; (2) tensile stresses
tend to concentrate on the concave surface;
and (3) limited space is available with regard
to their antagonistic dentition.
The authors suggest two treatment possi-
bilities for managing cases on anterior palatal
erosion.
Restorative Options
Three restorative options can be considered7-10:
1. Full-coverage crown preparations: The task
of optimal preparation and restoration be-
comes even more daunting in cases of deep
overbite and combined facial/palatal erosion,
and, in such instances, clinicians may be in-
clined to attempt traditional full-coverage
crown preparations. However, this approach
4 COMPENDIUM EBOOK SERIES February 2021 | Volume 42 Number 1 www.compendiumlive.com
REHABILITATING PALATAL EROSION
has several disadvantages. First, such prepa-
rations sacrifice a significant amount of in-
tact tooth structure in teeth that are already
eroded and have lost the critical tooth sub-
stance needed for sufficient retention and
resistance and have become short, thin, and
flat. The clinician may be required to use even
more invasive procedures such as intraradic-
ular posts, thereby compromising pulp vital-
ity and rendering the teeth nonvital. Second,
this approach can lead to a higher rate of sec-
ondary caries, due to the restorative margins
being on dentin that is exposed due to enamel
erosion. Third, these preparations are poten-
tially clinically less satisfactory than veneers
because of the stiff metal-ceramic coping,
which renders the underlying flexible tooth
structure prone to fracture. Finally, there is
the issue of gingival inflammation around
full-coverage restorations with intracrevic-
ular margins. Adhesive restoration margins
and finish lines that can generally be left
equigingival or supragingival are less likely
to generate gingival inflammation compared
to traditional full-crown coverage.
Hence, clinicians should mimimize the
use of approaches that involve more invasive
palatal reduction and consider other treat-
ment modalities.
2. Orthodontic repositioning: Though a conser-
vative option that can sometimes be ideal,
time constraints and economic consider-
ations may negate the use of orthodontic
repositioning in many cases.
3. Enameloplasty: With the patient’s consent,
performing enameloplasty on opposing teeth
can provide additional space, but it may lead
to hypersensitivity.
Occlusal Principles
In an effort to develop a simple, highly conser-
vative approach to localized anterior erosion
and wear, various authors have described two
 CONTINUING EDUCATION 1 REHABILITATING PALATAL EROSION

occlusal principles: centric relation (CR) and
the Dahl principle. A combined approach ac-
counts for a third principle.
1. Centric relation: Lucia11 first proposed the
use of an acrylic jig for CR recording. The
same technique was later refined to retain
the space needed to allow for the placement
of restorations. Cardoso et al12 proposed
the use of a modified Lucia jig—an anterior
deprogrammer to reposition the mandible in
CR to first create some space, and then use
that space to enable direct composite res-
torations. Because of the resilience of resin
material and their ease of manipulation even
in limited thicknesses, direct composites can
be employed as anterior deprogrammers
themselves, and, for the same reasons, can
be regarded as an ideal material for palatal
surface restorations.
2. Dahl principle13-16: Dahl proposed the use
of an anterior bite plane in the treatment
of localized anterior tooth wear. With this
approach, a cast-metal appliance is used for
approximately 4 to 6 months to create space
by separating the posterior teeth. Posterior
teeth are allowed to undergo passive eruption,
and the anterior teeth experience intrusion.
This combination approach reestablishes
the posterior occlusion while maintaining
anterior space. Now, with the availability of
adhesive dentistry, direct resin composites
can be used as provisional restorations and
achieve the same objectives.
3. Combined clinical approach10: In severe
generalized TSL, due to erosion involving
anterior and posterior teeth, it may be pru-
dent to restore the lost vertical dimension by
opening the bite through the restoration of
posterior teeth (ie, additive approach). This,
combined with harmonizing the maximum
intercuspation (MIP) with CR, provides the
crucial few millimeters needed to restore lost
form without aggressive tooth preparation.
A greater challenge, however, presents in
cases of localized TSL on the palatal surfaces
of the upper anterior teeth with little or no
TSL on the posterior teeth. The use of palatal
veneers utilizing a modified Dahl principle is
a conservative option and is advocated in such
cases whenever possible. Documented cases
of successful management of these situations17
have employed a simple, additive approach

TABLE 1

Anterior Clinical Erosive (ACE) Classification and Management Guidelines for Damaged
Maxillary Anterior Teeth18

ACE Class Clinical Characteristics Treatment Options

Class I Flattened cingula without dentin exposure No restorative treatment
Class II Dentin exposure on palatal aspect (contact areas), no damage to Palatal onlays (direct/indirect)
the incisal edges
Class III Distinct dentin exposure on palatal aspect, damage to the incisal Palatal veneers
edge length (≤2 mm)
Class IV Extended dentin exposure on palatal aspect, loss of the incisal Sandwich approach
length of the tooth (>2 mm), preserved facial enamel
Class V Extended dentin exposure on palatal aspect, loss of the incisal Sandwich approach (experimental)
length of the tooth (>2 mm), distinct reduction/loss of facial enamel
Class VI Advanced loss of tooth structure leading to pulp necrosis Sandwich approach
(highly experimental)
Adapted from Vailati F, Belser UC. Int J Periodontics Restorative Dent. 2010;30(6):559-571.18

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 CONTINUING EDUCATION 1 REHABILITATING PALATAL EROSION

Fig 1. Fig 2.

Fig 3. Fig 4.

Fig 5. Fig 6.

Fig 1. Preoperative frontal smile view. Fig 2. Preoperative frontal retracted 1:2 view. Fig 3. Preoperative view
showing erosion of palatal surfaces of upper anteriors. Fig 4. Centric wax record with Lucia jig. Fig 5. Wax-
up for restoration of palatal erosion. Fig 6. Palatal surfaces etched and ready to receive composite resin.

using direct resin for management of local-
ized palatal wear along with a modified Dahl
principle, which allows patients to retain their
residual anterior tooth structure.
A classification for damaged maxillary an-
terior teeth and guidelines for their clinical
management has been published18 (Table 1).
The following case report discusses a compre-
hensive and holistic approach to restoration of
maxillary anterior teeth with palatal erosion.
Case Analysis and Treatment
Sequence
A combined approach of the clinical application of
CR and the Dahl principle is described as follows:
A 40-year-old female patient complained of
short teeth and asked for various options to
improve her smile. On clinical examination,
the palatal surfaces of the maxillary anterior
teeth were found to be eroded, with the residual
tooth structure having a smooth and shiny ap-
pearance (Figure 1 through Figure 3). In MIP,
no restorative space was available, as the lower
anterior teeth fit tightly into the upper palatal
surfaces, making this a clinically challenging
situation to treat conservatively. In most cas-
es of conventional treatment protocols, such
upper teeth are devitalized and restored with
crowns that structurally leave the teeth in a
compromised condition.10

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 CONTINUING EDUCATION 1 REHABILITATING PALATAL EROSION

A difference between MIP and CR was iden-
tified through a gentle maneuver using a Lucia
jig that guided the mandible into CR (Figure
4). The upper cast was then mounted on a
semi-adjustable articulator with a facebow
record and the lower cast with a centric record.
Articulator mounting showed that when the
condyles were in CR, the teeth did not occlude
in MIP. On opening the centric lock on the
articulator and allowing the teeth to touch in
MIP, the authors found a lack of space avail-
able to restore the palatal surfaces of the max-
illary anteriors. Thus, a decision was made to
keep the condylar rods in CR on the articu-
lator, which would create some space in the
anterior zone to restore the palatal surfaces
of the maxillary anteriors.
This space, acquired by recording the CR
correctly, was utilized to prepare the pala-
tal surface wax-up (Figure 5). This, in turn,
opened up the posterior contacts by 1 mm.
This new maxilla-mandibular relation was
created intraorally and stabilized by restoring
the palatal surfaces of the maxillary anteriors
with palatal composite resin veneers (Figure 6
and Figure 7). The principles used here dem-
onstrate the Dahl technique that was modified
from its original version to suit the esthetic
requirements of the patient and to make use
of adhesive techniques with contemporary
restorative resins.
The open contacts and interocclusal space
created between the posterior teeth (Figure
8) resulted in supraeruption of the posteriors
in approximately 4 months’ time. After supra-
eruption was complete, occlusal equilibration
was performed to harmonize the occlusion
and attain bilaterally uniform and simulta-
neous contacts between all posterior teeth. A
labial esthetic wax-up was then fabricated for
the upper anterior teeth to produce an esthetic
enhancement in the smile.
A provisional was fabricated intraorally us-
ing a matrix fabricated on the wax-up (Figure
9). Once the patient approved the proposed
changes in the anterior tooth form, minimalis-
tic tooth preparations for monolithic lithium-
disilicate veneers were performed (Figure 10),

Fig 7. Fig 8. Fig 9.

Fig 10. Fig 11. Fig 12.

Fig 7. Resin build-up accomplished for palatal surfaces to restore lost form. Fig 8. Posterior teeth out of oc-
clusion due to palatal build-up. Fig 9. Smile view with provisional facial veneers. Fig 10. Final minimal facial
preparations with tissue management. Fig 11. Postoperative frontal smile view. Fig 12. Postoperative view
showing posterior teeth in MIP.

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 CONTINUING EDUCATION 1
Fig 13.
Fig
Fig13.
13. Postoperative frontal retracted 1:2 view. Fig 14. Postoperative
Fig 14.
tal surfaces of upper anteriors.
bearing in mind the need to keep within the
facial enamel.
Monolithic lithium-disilicate pressed ve-
neers were fabricated for the maxillary six
most anterior teeth. Staining was done to
achieve polychromy and subtle incisal trans-
lucency. While layering the incisal character-
istics will produce a superior esthetic result, in
this case it would have required reducing the
incisal edges to create room for the ceramic.
To prevent loss of precious tooth structure in
a patient with minimal esthetic needs, the au-
thors opted for an acceptable esthetic result of
a stained veneer and, thereby, made a biologi-
cally sound restoration completely in enamel.
A few weeks later, the facial veneers were
bonded directly to the underlying enamel. A
postoperative photograph (Figure 11) revealed
the restored harmony of the patient’s smile
and the occlusal contacts in MIP (Figure 12).
The palatal surfaces restored with nanofilled
composite resin developed good anterior
guidance that was harmonized to the patient’s
chewing cycle (Figure 13 and Figure 14).19
Discussion
Prior to the emergence of adhesive technol-
ogy, the clinical management of tooth erosion
or biocorrosion1,2 focused primarily on bio-
mechanical aspects alone, whereby the top
priority was to achieve tooth reinforcement
by extracoronal strengthening through some
8 COMPENDIUM EBOOK SERIES February 2021 | Volume 42 Number 1 www.compendiumlive.com
REHABILITATING PALATAL EROSION
Fig 14.
view showing additively restored pala-
form of coverage (full or partial).1-9 With the
development of adhesive technology, an ad-
ditive approach was introduced that utilizes
the existing space provided by missing tissues,
preserves the residual tooth structure, and ex-
ploits the bond strength of luting resin com-
posite that bonds the porcelain to the existing
tooth structure.3-5
The unique challenges that palatal surfaces
of anterior teeth typically present—ie, con-
cave geometry, limited stability and retention,
tensile stress concentration, limited space for
the opposing dentition—become even more
daunting in cases of deep overbite and com-
bined facial/palatal erosion.6 Conventional
full-coverage crown preparations in such
cases result in further sacrifice of significant
amounts of tooth structure in already dam-
aged teeth and present other risks such as ren-
dering the teeth nonvital and a higher rate for
secondary caries.7-10
As described earlier, two occlusal prin-
ciples—centric relation (CR) and the Dahl
principle—were developed as simple, highly
conservative approaches to localized ante-
rior erosion and wear. With CR, an anterior
deprogrammer is used11,12 to reposition the
mandible in CR to create space that en-
ables the room for direct composite resto-
rations. Resilient and easy to manipulate,
direct composites can be used as anterior
deprogrammers themselves and for palatal
 CONTINUING EDUCATION 1
An anterior deprogrammer is used to reposition the
mandible in CR to create space for direct composite
restorations…. The Dahl employs the use of an anterior bite
plane in the treatment of localized anterior tooth wear.
surface restorations. The Dahl principle13-16
employs the use of an anterior bite plane
in the treatment of localized anterior tooth
wear, whereby a cast-metal appliance is used
to create space by separating the posterior
teeth, which are then able to undergo passive
eruption while the anterior teeth experience
intrusion. This reestablishes posterior occlu-
sion while maintaining anterior space.
Adhesive dentistry can be used to achieve the
same objectives, employing direct resin com-
posites as provisional restorations through an
additive approach. In cases of severe gener-
alized TSL caused by erosion involving both
anterior and posterior teeth, restoring the
lost vertical dimension by opening the bite
through the restoration of posterior teeth (ie,
additive approach) may be optimal. Combined
with harmonizing the MIP with CR, this strat-
egy allows lost form to be restored without
aggressive tooth preparation.10
However, the greatest challenge presents
in cases of localized TSL on the palatal sur-
faces of only the upper anteriors, with little,
if any, TSL on posteriors. The option of pala-
tal veneers using a modified Dahl principle is
conservative and encouraged in such cases
whenever possible.10,17
This article presented a comparable case in
which the Dahl technique was modified to suit
the esthetic requirements of the patient. First,
a new maxilla-mandibular relation was cre-
ated intraorally, which was stabilized in the
second step by restoring the palatal surfaces
9 COMPENDIUM EBOOK SERIES February 2021 | Volume 42 Number 1 www.compendiumlive.com
REHABILITATING PALATAL EROSION
of maxillary anteriors with palatal composite
resin veneers. The interocclusal space gener-
ated between the posteriors resulted in pos-
terior supraeruption, which generated a new
occlusion that was harmonized by occlusal
equilibration. Monolithic lithium-disilicate
veneers were placed on the maxillary anteri-
ors to enhance the final smile.
Composite restoration wear was once a
significant worry; that concern, though, has
substantially subsided in recent years due
to improved technology, which has led to
enhanced formulations and significantly
better products.10 For patients with no para-
functional habits, posterior composite resin
wear is now considered a resolvable problem.
Individuals with parafunctional habits, how-
ever, warrant careful monitoring and supple-
mental protection with nightguards to reduce
wear-related failures.10 In addition, palatal
surface composites may wear off in the me-
dium to long term.10However, even cases of
significant palatal restoration wear can be
easily managed using a conservative repair
of the resin composite.
Conclusion
When warranted, use of noninvasive addi-
tive approaches should be considered before
opting for traditional full-crown coverage. In
eroded maxillary anterior teeth with limited
palatal clearance (ie, deep bite), clinicians
should first create adequate restorative space
through a combined use of CR and the Dahl
 CONTINUING EDUCATION 1
principle before utilizing adhesive dentistry
to restore with bonded composites and por-
celain veneers.
ACKNOWLEDGMENT
The authors wish to acknowledge the artis-
tic contribution of ceramic work by Danesh
Vazifdar at Adaro Dental Laboratory in
Mumbai, India.
ABOUT THE AUTHORS
Aliasger Tunkiwala, MDS
Prosthetic Dentistry, University of Mumbai, Mumbai, India
Clinical Practice, Mumbai, India
Director, Impart Education, Mumbai, India
Rajeev Chitguppi, MDS
Periodontics, University of Mumbai, Mumbai, India
Consulting Periodontist, Mumbai, India
Director, Perioindia, Mumbai, India
Queries to the author regarding this course may be submitted
to authorqueries@aegiscomm.com.
REFERENCES
1. Grippo JO, Simring M, Schreiner S. Attrition, abra-
sion, corrosion and abfraction revisited: a new per-
spective on tooth surface lesions. J Am Dent Assoc.
2004;135(8):1109-1118.
2. Grippo JO, Simring M, Coleman TA. Abfraction,
abrasion, biocorrosion, and the enigma of noncari-
ous cervical lesions: a 20-year perspective. J Esthet
Restor Dent. 2012;24(1):10-23.
3. Magne P, Douglas WH. Additive contour of porce-
lain veneers: a key element in enamel preservation,
adhesion, and esthetics for aging dentition. J Adhes
Dent. 1999;1(1):81-91.
4. Magne P, Belser UC. Novel porcelain laminate
preparation approach driven by a diagnostic mock-
up. J Esthet Restor Dent. 2004;16(1):7-16.
5. Magne P, Magne M. Use of additive waxup and
direct intraoral mock-up for enamel preservation
with porcelain laminate veneers.  Eur J Esthet Dent.
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REHABILITATING PALATAL EROSION
2006;1(1):10-19.
6. Magne P, Versluis A, Douglas WH. Rationalization
of incisor shape: experimental-numerical analysis.  J
Prosthet Dent. 1999;81(3):345-355.
7. Edelhoff D, Sorensen JA. Tooth structure removal
associated with various preparation designs for ante-
rior teeth. J Prosthet Dent. 2002;87(5):503-509.
8. Edelhoff D, Sorensen JA. Tooth structure re-
moval associated with various preparation designs
for posterior teeth.  Int J Periodontics Restorative
Dent. 2002;22(3):241-249.
9. Pippin DJ, Mixson JM, Soldan-Els AP. Clinical evalu-
ation of restored maxillary incisors: veneers vs PFM
crowns. J Am Dent Assoc. 1995;126(11):1523-1529.
10. Magne P, Magne M, Belser UC. Adhesive restora-
tions, centric relation, and the Dahl principle: mini-
mally invasive approaches to localized anterior tooth
erosion. Eur J Esthet Dent. 2007;2(3):260-273.
11. Lucia VO. A technique for recording centric rela-
tion. J Prosthet Dent. 1964;14(3):492-505
12. Cardoso AC, Canabarro S, Myers SL. Dental ero-
sion: diagnostic-based noninvasive treatment. Pract
Periodontics Aesthet Dent. 2000;12(2):223-228.
13. Dahl BL, Krogstad O, Karlsen K. An alternative
treatment in cases with advance localized attrition. J
Oral Rehab. 1975;2(3):209-214.
14. Dahl BL, Krogstad O. The effect of a partial bite
raising splint on the occlusal face height. An x-ray
cephalometric study in human adults. Acta Odontol
Scand. 1982;40(1):17-24.
15. Mizrahi B. The Dahl principle: creating space and
improving the biomechanical prognosis of anterior
crowns. Quintessence Int. 2006;37(4):245-251.
16. Mizrahi B. A technique for simple treatment of
anterior toothwear. Dent Update. 2004;31(2):109-114.
17. Tunkiwala A. Minimalistic approach to GERD-relat-
ed tooth surface loss.  Inside Dentistry. 2013;9(1):56-
68.
18. Vailati F, Belser UC. Classification and treatment
of the anterior maxillary dentition affected by dental
erosion: the ACE classification. Int J Periodontics Re-
storative Dent. 2010;30(6):559-571.
19. Bakeman EM, Kois JC. The myth of anterior guid-
ance: 10 steps in designing proper clearance for
functional pathways.  Journal of Cosmetic Dentistry.
2012;28(3):56-62.
 CONTINUING EDUCATION 1 QUIZ 2 Hours CE Credit

Conservative, Functional, and Esthetic Rehabilitation of

Severe Palatal Erosion (Class IV) Using Modified Dahl Approach
Aliasger Tunkiwala, MDS; and Rajeev Chitguppi, MDS

TAKE THIS FREE CE QUIZ BY CLICKING HERE: COMPENDIUMLIVE.COM/GO/DAHLAPPROACH

ENTER PROMO CODE: ESTHETICREHAB

1. More recently, the term erosion has been 6. Who proposed the use of an anterior bite
replaced by: plane in the treatment of localized anterior
A. abfraction. tooth wear?
B. corrosion. A. Cardoso
C. biocorrosion. B. Lucia
D. surface erosion. C. Dahl
D. Myers
2. The palatal surfaces of anterior teeth present
limited stability and retention due to their: 7. With the Dahl technique, a cast-metal
A. convex geometry. appliance is used for approximately how long
B. concave geometry. to create space by separating the posterior
C. flat geometry. teeth?
D. variable geometry. A. 1 to 2 months
B. 3 to 4 months
3. Though a conservative restorative option that C. 4 to 6 months
can sometimes be ideal, time constraints and D. 6 to 9 months
economic considerations may negate the use
8. The combination approach by Dahl principle
of:
re-establishes the posterior occlusion while:
A. enameloplasty.
A. maintaining anterior space.
B. conventional restorations.
B. reducing anterior space.
C. adhesive technology.
C. increasing anterior space.
D. orthodontic repositioning.
D. None of the above
4. Performing which of the following 9. In the case presented, monolithic lithium
restorative options on opposing teeth can disilicate pressed veneers were fabricated for
provide additional space but may lead to the:
hypersensitivity? A. maxillary central incisors.
A. enameloplasty B. maxillary central and lateral incisors.
B. conventional restorations C. maxillary 6 anterior teeth.
C. adhesive technology D. full maxillary arch.
D. orthodontic repositioning
10. With CR, an anterior deprogrammer is used
5. Who first proposed the use of an acrylic jig to reposition the mandible in centric relation
for centric relation (CR) recording? to create space that enables the room for:
A. Cardoso A. a cast-metal appliance.
B. Lucia B. an anterior bite plane.
C. Dahl C. orthodontic braces.
D. Myers D. direct composite restorations.

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Volume 42
42 Number
Number 1 1 www.compendiumlive.com
 CASE REPORT CORRECTING DYSFUNCTIONAL WEAR

Correction of Dysfunctional
Wear Results in Esthetic
Outcome for Reluctant Patient
Jacek Glebocki, DMD

ABSTRACT: Patients sometimes present with functional problems but may not be mo-
tivated to improve esthetics. By gaining an understanding of the patient’s individual risk
factors, clinicians can design treatment so that risk to the entire dentition is decreased
while esthetics are improved. This case involved a patient concerned about wear on his
upper front teeth and who was interested in the most predictable and efficient treatment
possible. After a thorough diagnosis, risk assessment, and prognosis were carried out, an
esthetic mock-up was used to play a key role in engaging the patient in both the cosmetic
and functional benefits of the proposed treatment. The treatment required alleviation of
a constricted chewing pattern and utilized an occlusal splint to protect against potential
parafunctional clenching. Vertical dimension of occlusion was increased using minimally
invasive methods. Incisal length was addressed additively, and esthetic crown lengthening
was used to mitigate excessive tissue display.
In the present case, a male patient was concerned about extensive wear on his upper ante-
rior teeth, but had no interest in addressing issues dealing with esthetics. It was important
for the clinician to engage the patient in the treatment, because to be effective the treatment
would change the appearance of his smile. There was a need to improve function and achieve
precise, simultaneous, bilateral contacts on the patient’s posterior teeth and minimize chew-
ing friction on the anterior teeth. The use of an esthetic mock-up and a Kois deprogrammer
would prove pivotal to increasing the patient’s understanding of the situation.

Clinical Case Overview diagnosis did he become interested in not only

A 25-year-old male patient presented with a
chief concern of wear on his upper front teeth.
The patient was particularly aware of the short-
ening of the upper teeth, thinning of lingual
surfaces, and the changing appearance of his
smile (Figure 1 through Figure 3). Initially,
the patient was not interested in undergoing
any esthetic changes to his teeth. Only after
hearing and gaining some understanding of his
DISCLOSURE: The author had no disclosures to report.
decreasing his risk but also restoring his smile.
Medical and Dental History
The patient had an unremarkable medical his-
tory and took no medications or supplements.
There were no contributory medical conditions
and no contraindications for treatment.
The patient claimed no history of periodon-
tal disease or treatment and had very few

12 COMPENDIUM EBOOK SERIES February 2021 | Volume 42 Number 1 www.compendiumlive.com

 CASE REPORT
Fig 1.
Fig 1. Patient’s Duchenne smile, initial situation.
Fig 2. Lips in repose, initial situation. Fig 3. Maximum
intercuspation, initial situation.
previous dental interventions. There was one
interproximal carious lesion restored within
the previous 3 years, and the patient also re-
ported the shortening of his upper teeth and
that the lingual sides of the same teeth were
“feeling thin.”
Notably, he described the inability to get his
posterior teeth to touch except by clenching
his teeth and moving his jaw back excessive-
ly. After discussing this issue with the clini-
cian, the patient revealed that he would often
squeeze and clench his teeth while working
out regularly at the gym.
Diagnosis, Risk Assessment, and
Prognosis
Periodontal: Probing depths were less than 3
mm, and no areas of bleeding on probing were
found. Bone support was within 1 mm to 2 mm
of the cementoenamel junctions, and there
were no infrabony defects. No recession was
found.
Risk: Low
Prognosis: Good
Biomechanical: As noted above, the pa-
tient had one interproximal carious lesion
within the previous 3 years. A questionable
13 COMPENDIUM EBOOK SERIES February 2021 | Volume 42 Number 1 www.compendiumlive.com
CORRECTING DYSFUNCTIONAL WEAR
Fig 2.
Fig 3.
restoration was found on tooth No. 30 (Figure
4). Also detected were minimal signs of abra-
sion combined with erosion facially on teeth
Nos. 19 through 22 and 27 through 30 and
minimal to moderate erosion combined with
abrasion on occlusal surfaces of teeth Nos. 5,
14, 18 through 20, and 29 through 31. Attrition
on anterior teeth Nos. 8 and 9, however, was
found to be severe.
Risk: Moderate overall; high on severely
worn teeth Nos. 8 and 9
Prognosis: Fair to poor
Functional: The patient’s maximum opening
was within normal range (44 mm) with no de-
viation upon opening. No joint sounds were
detected and joint loading testing was negative.
Mandibular immobilization testing caused dis-
comfort for the patient. Severe attrition was
noted on lingual and incisal surfaces of teeth
Nos. 8 and 9, and low to moderate attrition
was seen on teeth Nos. 6, 7, 10, and 11 (Figure
5). The lower incisors had moderate attrition.
Primary occlusal traumatism with fremitus
was found on teeth Nos. 8 through 10.
By combining the functional diagnostic
findings with the patient’s dental history,
which had established that the patient has to
 CASE REPORT
Fig 4.
Fig 6.
Fig 4. Lower arch, initial situation. Note questionable restoration on tooth No. 30. Fig 5. Upper arch, initial
situation. Fig 6. Therapeutic jaw joint position. Fig 7. Diagnostic wax-up.
squeeze his posterior teeth to gain contact and
has to pull his jaw back as well, a diagnosis
of a constricted chewing pattern was made.
Parafunction also was considered a contribu-
tory factor given the patient’s admission of
clenching during workouts. The risk for a
constricted chewing pattern typically would
be considered moderate; however, with the
patient’s daytime parafunction and the severe,
active attrition on teeth Nos. 8 and 9, the risk
was considered higher.
Risk: Moderate to high
Prognosis: Poor
Dentofacial: During the Duchenne smile, the
patient revealed high lip dynamics and full dis-
play of maxillary tooth height, and gingiva and
asymmetrical gingival contours showed as far
back as the patient’s molars (Figure 1). During
lip repose the maxillary teeth were completely
hidden from view and the canine was above the
lip approximately 2 mm (Figure 2). All maxil-
lary teeth were angled toward the palate and
some small spaces existed between anterior
teeth in both arches. Because all aspects of any
14 COMPENDIUM EBOOK SERIES February 2021 | Volume 42 Number 1 www.compendiumlive.com
CORRECTING DYSFUNCTIONAL WEAR
Fig 5.
Fig 7.
restorative treatment would be fully displayed,
the risk for esthetic treatment was greatly
increased.
Risk: High
Prognosis: Fair to poor, especially consider-
ing the patient’s initial reluctance to allow any
visible changes to be made to his smile
Treatment Goals
The first treatment goal was to engage the
patient in the need to improve function and
achieve precise, simultaneous, bilateral con-
tacts on his posterior teeth and minimize
chewing friction on the anterior teeth. The
patient would need to be fully engaged in the
outcome because any effective treatment
would change the appearance of his smile. The
use of an esthetic mock-up and a Kois depro-
grammer would prove pivotal to the patient’s
understanding.
The next goal was to maintain the patient’s
ongoing overall health with sound preventive
measures. Functional risk would be managed
by relieving the constricted chewing pattern
 CASE REPORT CORRECTING DYSFUNCTIONAL WEAR

and providing an occlusal splint to protect possibility of orthodontic repositioning of teeth,

against potential parafunctional clenching
during gym workouts. Vertical dimension of
occlusion (VDO) would be increased using
minimally invasive methods, as most of the
patient’s posterior teeth had no restorations.
Finally, incisal length would be added to the
anterior teeth restoratively, and excessive tis-
sue display would be decreased through es-
thetic crown lengthening.
Treatment Plan
The treatment plan and options, including the
were discussed with the patient. While in some
cases orthodontic treatment can be helpful in
aligning and intruding anterior arch segments or
repositioning rotated or malposed teeth, in this
case the interarch relationship, individual tooth
positions, and the arch forms all were acceptable
(Figure 3 through Figure 5). Even with the use
of orthodontics, restorative treatment would be
needed to replace the considerable amount of
missing tooth structure. Instead of orthodontics,
the choice was made to restore both arches ad-
ditively with porcelain to increase the VDO and

Fig 8. Fig 9.

Fig 10. Fig 11.

Fig 12. Fig 13.

Fig 8. Mock-up for functional and esthetic evaluation. Fig 9. Gingivotomy, first cut with guides in place.
Fig 10. Osteo-gingivoplasty done after flap was raised. Fig 11. Patient’s smile, 3 months after osteo-gingivo-
plasty procedure. Fig 12. Platform between teeth Nos. 8 and 9, in maximum intercuspation on all back teeth.
Fig 13. Bite registration.

15 COMPENDIUM EBOOK SERIES February 2021 | Volume 42 Number 1 www.compendiumlive.com

 CASE REPORT
Fig 14.
Fig 16.
Fig 18.
restore length to the worn anterior teeth. The
patient was interested in the most predictable
and efficient treatment possible.
Phase 1: Education and Initiation of
Kois Deprogrammer
The patient was educated about the causes of
tooth decay, abrasion, and the importance of
rebalancing the pH of the mouth. To help ad-
dress this issue, products were recommended
for the patient to use (CTx4 Gel and Cari Free
CTx3 Rinse, CariFree, carifree.com). Dietary
changes were recommended as well, including
avoidance of acidic beverages, and fluoride
16 COMPENDIUM EBOOK SERIES February 2021 | Volume 42 Number 1 www.compendiumlive.com
CORRECTING DYSFUNCTIONAL WEAR
Fig 15.
Fig 17.
Fig 19.
Fig 14. Lower arch, final outcome. Fig 15. Upper
arch, final outcome. Fig 16. Maximum intercuspation,
final outcome. Fig 17. Lips in repose, final outcome.
Fig 18. Patient’s Duchenne smile, final outcome.
Fig 19. Panoramic radiograph, final outcome.
varnish was suggested at recare appointments.
To execute this plan predictably a repeat-
able jaw joint reference position had to be es-
tablished and recorded. Use of a Kois depro-
grammer was initiated for this purpose.1
Phase 2: Diagnostic Wax-up
The patient wore the Kois deprogrammer for 2
weeks and noticed that every time he removed
the device, his anterior teeth were in contact.
At that time, an interocclusal record was taken
using bite registration materials (LuxaBite and
O-Bite, DMG America, dmg-america.com) with
the deprogrammer in the mouth to record the
 CASE REPORT
The patient would need to be fully engaged in the outcome
because any effective treatment would change the
appearance of his smile. An esthetic mock-up and a Kois
deprogrammer proved pivotal to the patient’s understanding.
repeatable jaw joint reference position. A Kois
dentofacial analyzer was used to record the
maxillary position, and photographs and vinyl-
polysiloxane (VPS) impressions on the upper
and lower teeth were taken. The casts were then
mounted to the articulator in the previously cap-
tured reference position (Figure 6).
Based on the photography and observed
facial position of the upper anterior teeth,
in particular the upper canines, which were
hidden approximately 2 mm under the lip in
repose,2 it was determined that the incisal edg-
es required addition of approximately 2 mm.
Also, the gingival contours from teeth Nos. 3
through 8 would need to be raised 1 mm to 2
mm in order to frame the teeth esthetically in
the patient’s face and create teeth of average
dimensions.3 A diagnostic wax-up was fabri-
cated in that manner (Figure 7) and a silicon
mock-up template was made.
Phase 3: Intraoral Mock-up
At the next appointment, the mock-up was
fabricated intraorally to engage the patient in
the esthetic and functional benefits of the pro-
posed treatment (Figure 8). This allowed the
patient to visualize the extent of the positive
change that would occur by going through with
the treatment.
Phase 4: Gingivoplasty and
Osteoplasty
Using the wax-up, gingivoplasty guides were
made, placed on the patient’s teeth, and used
to incise the planned gingival heights for teeth
17 COMPENDIUM EBOOK SERIES February 2021 | Volume 42 Number 1 www.compendiumlive.com
CORRECTING DYSFUNCTIONAL WEAR
Nos. 3 through 14 (Figure 9). A flap was then
raised and the necessary osteoplasty was
performed to create an ideal, normal crest
height and dentogingival complex after heal-
ing (Figure 10).4 Tissues healed unremarkably
(Figure 11).
Phase 5: Temporary Restorations
During healing from the crown lengthening
procedure, the patient wore the Kois depro-
grammer for 3 weeks to maintain orthopedic
joint function and stability. At the next appoint-
ment, the composite esthetic mock-up was
placed over the teeth to be used as a prepara-
tion guide. A small platform was added to the
lingual surface between teeth Nos. 8 and 9 to
confirm deprogramming and verify the amount
of VDO needed to fulfill the treatment goals
(Figure 12). With the mock-up and platform in
place the posterior teeth were minimally pre-
pared occlusally and facially on both arches,
and bite registration was accomplished with
the lower incisors touching the platform re-
peatably in the same exact spot on the platform
(Figure 13).
A new dentofacial analyzer recording was
taken against the prepared maxillary posterior
teeth for mounting the case at the laboratory.
The anterior teeth were prepared for veneers
on the mandibular. Maxillary anterior teeth re-
quired full coverage to replace the lingual hard
tissue lost to attrition. Tissues were retracted
using a two-cord technique, and VPS impres-
sions were taken of both arches. Temporary
restorations were created from the mock-up
 CASE REPORT
using bisphenol A glycidyl methacrylate (BIS-
GMA) resin (ProTemp™, 3M ESPE, 3m.com)
and cemented with temporary dental cement
(Temp-Bond™, Kerr, kerrdental.com).
E.max® (Ivoclar Vivadent, ivoclarvivadent.com)
ceramic restorations were used for occlusal-facial
overlays on 12 posterior teeth veneers, lower an-
terior teeth, and full-coverage crowns on upper
anterior teeth. The four second molars were to
be restored with direct composite.
Phase 6: Final Restorations
Provisional crowns were removed and the
final restorations were successfully tried in.
Adhesive protocols were used for all veneers
and overlays using luting composite (Variolink®,
Ivoclar Vivadent), and the crowns were cement-
ed using a cohesive protocol (RelyX™ Unicem,
3M ESPE). The second molars received direct
composite to create acceptable occlusal con-
tacts. Occlusion was checked and after minor
adjustments an impression was taken for a
maxillary occlusal splint.
The final result far exceeded the patient’s
expectations (Figure 14 through Figure 19).
Conclusion
Gaining an understanding of the patient’s
individual risk factors allows treatment to be
designed such that risk to the entire denti-
tion may be decreased. In this case, almost
all of the necessary tooth preparations were
kept in enamel, which further minimized
additional biomechanical risk. The occlu-
sal management and increased VDO elimi-
nated the concerns associated with friction
18 COMPENDIUM EBOOK SERIES February 2021 | Volume 42 Number 1 www.compendiumlive.com
CORRECTING DYSFUNCTIONAL WEAR
due to the constricted chewing pattern that
was contributing to ongoing tooth structure
loss. The protective splint, however, was still
recommended to safeguard the restorations
following any episodes of parafunction dur-
ing gym exercises. The patient remains on
4-month recare interval for maintenance.
The only anticipated liability is the resto-
rations, ie, chipped porcelain, and not the
remaining teeth. The patient’s periodontal
prognosis remains excellent. Biomechanical,
functional, and dentofacial prognoses were
elevated to good.
ACKNOWLEDGMENT
Laboratory support and ceramics were pro-
vided by Katarzyna and Miroslaw Kapusta,
Kapdent, Krakow, Poland.
ABOUT THE AUTHOR
Jacek Glebocki, DMD
Mentor, Kois Center, Seattle, Washington; Private Practice,
Novadent, Lomza, Poland
Queries to the author regarding this course may be submit-
ted to authorqueries@aegiscomm.com.
REFERENCES
1. Jayne DJ. A deprogrammer for occlusal analysis
and simplified accurate case mounting. J Cosmetic
Dentistry. 2006;21(4):96-102.
2. Misch CE. Guidelines for maxillary incisal edge po-
sition - a pilot study: the key is the canine. J Prostho-
dont. 2008;17(2):130-134.
3. Arnett GW, Gunson MJ. Facial analysis: the key to
successful dental treatment planning. J Cosmetic
Dentistry. 2005;21(3):20-34.
4. Kois JC. The restorative-periodontal interface: bio-
logical parameters. Periodontol 2000. 1996;11:29-38.
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