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Adhesive Restorations, Centric


Relation, and the Dahl Principle:
Minimally Invasive Approaches
to Localized Anterior Tooth Erosion
Pascal Magne, DMD, MSc, PhD
Associate Professor, Primary Oral Health Care Division
Don and Sybil Harrington Foundation Chair of Esthetic Dentistry
University of Southern California School of Dentistry
School of Dentistry Oral Health Center
Los Angeles, California, USA

Michel Magne, CDT


Assistant Professor, Primary Oral Health Care Division
Director of Center for Dental Technology
University of Southern California School of Dentistry
Los Angeles, California, USA

Urs C. Belser, DMD, Prof Dr med dent


Professor and Chairman, Department of Prosthodontics
School of Dental Medicine, University of Geneva, Switzerland

Correspondence to: Dr Pascal Magne


3151 S. Hoover St, Suite E201, Los Angeles, CA 90089-7792; fax: 213 820 5324; e-mail: magne@usc.edu

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Abstract
The purpose of this article is to review bio- cal aspects. Cases of deep bite combined
mechanical and occlusal principles that with palatal erosion and wear can be par-
could help optimize the conservative treat- ticularly challenging. A simplified approach
ment of severely eroded and worn anteri- is proposed through the use of an occlusal
or dentition using adhesive restorations. It therapy combining centric relation and the
appears that enamel and dentin bonding, Dahl principle to create anterior interoc-
through the combined use of resin com- clusal space to reduce the need for more
posites (on the palatal surface) and indirect invasive palatal reduction. This approach
porcelain veneers (on the facial/incisal sur- allows the ultraconservative treatment of
faces) can lead to an optimal result from localized anterior tooth erosion and wear.
both esthetic and functional/biomechani- (Eur J Esthet Dent 2007;2:260273.)

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Tooth surface loss can present in various Facial enamel wear/
clinical forms with a wide range of etiolog-
erosion and additive
ic factors. Among these, dental erosion le-
sions constitute a growing problem in
porcelain veneers
younger individuals.1 Dietary acids are in- A natural tooths unique ability to withstand
creasingly popular (especially soft drinks). masticatory and thermal loads during a
Bulimia, consumption of acidic foods, acid lifetime is the result of the structural and
reflux, and chlorine exposure (from swim- physical interrelationship between an ex-
ming) are other typical etiologic factors in tremely hard tissue (enamel) and a more
young patients. While it is paramount to compliant tissue (dentin). Enamel can re-
identify the causes of the disease, includ- sist occlusal wear but is fragile and cracks
ing possible underlying medical condi- easily. Dentin, on the other hand, is flexible
tions, and institute a preventive regime, the and compliant but is not wear resistant and
restorative dentist will ultimately have to se- does not age favorably when directly ex-
lect the appropriate treatment strategy. In posed to the oral environment. Natural
this regard, severe cases of tooth erosion, teeth, through the optimal combination of
particularly in young people, present a enamel and dentin, demonstrate the per-
considerable challenge. Dentin sealing fect and unmatched compromise between
with a filled dentin bonding agent is certain- stiffness, strength, and resilience. The
ly the most conservative approach proven recognition of this relationship has allowed
to reduce the rate of wear and erosion.2 a better understanding of possible alter-
While it is an efficient and immediate pro- ations of the precious balance between
tective measure, the application of dentin enamel and dentin (Figs 1a to 1c). A sig-
bonding agents does not address the real nificant step was made when researchers
biomechanical issues and long-term prog- focused their attention on the biomechan-
nosis of the eroded tooth. The loss of form, ical side effects of enamel loss or enamel
function, and esthetics are additional rea- preparation. A number of studies710 analyz-
sons to consider a true restorative ap- ing biophysical stress and strain have
proach to the treatment of erosive lesions. shown that (1) enamel loss or preparation
If restoration is necessary, adhesive res- can make the tooth crown more de-
torative dentistry, due to its conservative formable and (2) the tooth can be strength-
nature, should be used whenever possi- ened by increasing its resistance to crown
ble.35 Based on the individual circum- deformation. Based on these principles,
stances and the perceived needs and con- tooth reinforcement was first achieved by
cerns of the patient, direct application of some form of full or partial coverage (extra-
resin composites3,6 and/or bonded porce- coronal strengthening) at the expense of
4,5
lain restorations can be proposed. The the intact tooth substance.1113 Today, adhe-
aim of this article is to present biomechan- sive technology has proved its efficiency in
ical and occlusal principles that will facili- simultaneously reestablishing crown stiff-
tate the selection or combination of adhe- ness and allowing maximum preservation
sive restorative materials and techniques of the remaining hard tissue in both anteri-
for the treatment of severe enamel loss in or1416 and posterior1719 teeth. While studies
the anterior dentition. demonstrated that bonded composite

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restorations permit the recovery of tooth
stiffness, which was not possible with alloy
fillings, it should be remembered that the
physical properties of composite veneers
are somewhat limited.12 One limitation is the

Surface palatal tangential stress (MPa)


elastic modulus, which for an average mi-
crofilled hybrid can be one eighth to one
fourth (approximately 10 to 20 GPa) of the
elastic modulus of enamel (approximately
80 GPa). Because of its enamel-like elastic
modulus, porcelain used as an enamel re-
placement proved to be instrumental in the
way stresses are distributed within the
crown.16 The well-acclaimed clinical suc-
cess of porcelain veneers confirms this
fact. Porcelain veneers proved able to as-
sume the role of facial enamel, which is es-
sential to the balance of functional stress-
b
es in the anterior dentition.16,20
Fig 1b Tooth preparation (bottom) by total facial
enamel removal was simulated in finite element analy-
sis. The plot of tangential stresses proceeds for each
tooth along the palatal surface from cervical (top) to in-
cisal (bottom). A dramatic increase in tensile stresses
is found in the remaining enamel of the palatal fossa
(blue line, teeth loaded palatally with 50 N onto incisal
edge, deformation factor X10 on stress mapping). Mod-
ified from Magne and Douglas.16
Relative crown flexibility

a c Hard tissue removal from incisors

Fig 1a Clinical situation featuring severe loss of fa- Fig 1c Relative compliance (changes of compliance
cial enamel of maxillary anterior teeth (note dentin ex- relative to the baseline) for natural incisors after removal
posures) and infiltrated Class 3 restorations. of coronal tissues. Total removal of proximal enamel
(second column) does not affect crown rigidity, while to-
tal removal of facial enamel (last column) is most ad-
verse.

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a b

Figs 2a and 2b Preoperative situation. Severe case of localized erosion and wear with marked and multiple
dentin exposures. A conservative approach with bonded porcelain restorations (facial veneers type IIIB accord-
ing to Magne and Belser4) is indicated, provided the dentin exposures are sealed immediately after tooth prepa-
ration, before final impressions.

Therefore, it is logical to submit that in cas- lain restorations to evolve from type I (sim-
es of severe loss of enamel by erosion and ple laminates) to types II and III indications
wear, restoring enamel thickness is a com- (Fig 2).4,26,27 Immediate dentin sealing (IDS)
bined esthetic and biomechanical endeav- should significantly enhance the prognosis
or. Adhesive ceramic restorative proce- of indirect bonded porcelain in cases of se-
dures have the potential to reverse the vere erosion.24 IDS is a revised application
esthetic manifestations of aging or erosion procedure for dentin bonding when plac-
in teeth (Fig 2)21 and do not require a sig- ing indirect bonded restorations such as
nificant amount of tooth reduction because composite/ceramic inlays, onlays, and ve-
of the existing space provided by the miss- neers. Immediate application and polymer-
ing tissues (additive approach).2123 Be- ization of the dentin bonding agent to the
cause the principles of resistance and re- freshly cut dentin, prior to impression tak-
tention form are omitted, the success of ing, is recommended. IDS appears to
the biomimetic approach relies on the achieve improved bond strengths,25,28,29
bond between the porcelain and the luting fewer gap formations,16,30 decreased bacte-
resin composite on one hand and the rial leakage, and reduced dentin sensitivi-
bond between the luting resin composite ty.31,32 The use of a filled dentin bonding
and the tooth on the other hand. While agent facilitates the clinical and technical
resin-to-enamel bonding was proved to aspects of IDS.
give predictable results more than 50 years
ago, significant resin-dentin bonds have
only been measured during the last
decade. Essential developments, such as
dentin hybridization and immediate dentin
sealing24,25 allowed indirect bonded porce-

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c d

Figs 2c and 2d Clinical view just before tooth preparation while placing a first deflection cord (c) and just pri-
or to final impression after placement of a second deflection cord (d). Note the ultraconservative preparation and
immediately sealed facial dentin surfaces (smooth texture of sealed dentin on all four incisors), which is a key el-
ement in the long-term success of indirect bonded restorations. Palatal surfaces were left intact and unprepared.

Fig 2e Final restorations in feldspathic porcelain.

Localized palatal wear/ surface.20 Therefore, it is concluded that con-


vex surfaces with thick enamel experience
erosion and occlusal
fewer stress concentrations than do con-
therapy cave areas, which tend to accumulate
One limitation in the use of porcelain res- them.20 The palatal surface of anterior teeth
torations is geometry and thickness. It is im- is always a difficult area to prepare not only
portant to remember that low stress levels because of its geometry, which provides lit-
are found in surfaces of maximum convex tle retention and stabilization and concen-
curvature, ie, the cingulum and the facial trates tensile stresses (concave), but also

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f g

Figs 2f to 2h Clinical situation after placement of the four


bonded porcelain restorations, rehabilitating not only esthetics,
but also function and mechanical integrity of the anterior teeth.
The final outcome was tested beforehand using a provisional
acrylic template (not shown).

due to the limited space with the antagonis- in significant elimination of intact tooth sub-
tic dentition. Lack of palatal space for the stance, up to two times the elimination of
restorative material is particularly challeng- tooth substance compared to a traditional
ing in cases of deep overbite and combined veneer or adhesive preparation.33,34 In addi-
facial/palatal erosion (Fig 3). While it may be tion, eroded teeth are often short, thin, and
tempting to proceed to full-coverage crown flat and may present insufficient retention
preparations, such a procedure would result and resistance (Fig 3e), calling for even

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more invasive procedures compromising
pulp vitality (eg, intraradicular posts). Finally,
full-crown coverage restorations (porcelain-
fused-to-metal and all-ceramic) present
more secondary caries and are clinically
less satisfactory than veneers,35 perhaps be-
cause of the stiff metal/ceramic coping,
which makes the underlying tooth structure
hypofunctional. Because margins of adhe-
sive restorations are esthetically seamless,
preparation finish lines can generally be left a b

equigingival or supragingival and are there- Figs 3a and 3b Localized anterior tooth erosion
fore less likely to generate gingival inflam- may result in a deeper bite (b) compared to normal an-
terior relationships (a). This is often the result of an an-
mation compared to traditional full-crown
terior-superior slide of the mandible (arrows).
35
coverages.
Because of these reasons, and in order
to reduce the need for more invasive
palatal reduction, it is justified to look for the
most conservative treatment of the eroded
and worn palatal surface through an addi-
tive approach.3 There are several ways of
creating palatal interocclusal space to ad-
ditively restore this volume. In cases of gen-
eralized erosion and wear, the bite can be
opened through the restoration of posteri-
or teeth. In cases of localized anterior ero-
sion with an intact posterior dentition, it is c
possible to create interocclusal palatal
space using orthodontics. Unfortunately,
some patients may not be able to afford
these expensive multidisciplinary treat-
ments. In an effort to develop the simplest
and most conservative approach to local-
ized anterior erosion and wear, two oc-
clusal principles have been described:
centric relation and the Dahl principle.

Centric relation d

Figs 3c and 3d Clinical case with obvious facial


Cardoso et al3 proposed the use of an an-
erosion (c) but also marked palatal notches located on
terior deprogrammer (modified Lucia jig) to the MIP stops (d). Worn and infiltrated existing Class 3
help reposition the mandible in centric re- restorations are also visible.

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posites, because of their resilience and
ease of manipulation even in small thick-
nesses, represent an ideal material to re-
store the palatal surface.

Dahl principle
Dahl38 proposed creating space in the
treatment of localized anterior tooth wear
e f by separating the posterior teeth through
an anterior bite plane for about 4 to 6
months. A combination of passive eruption
(posterior teeth) and intrusion (anterior
teeth) allowed the reestablishment of pos-
terior occlusion while maintaining the an-
terior space.39 Dahl originally used a cast
metal appliance to separate posterior teeth.
The same goal can be achieved today us-
ing provisional restorations or adhesive
dentistry (direct resin composites).40,41

g
Combined approach
Figs 3e to 3g Aggressive reduction of the remain-
ing tissues occurs when preparing eroded teeth for full-
crown coverage (totally contraindicated) (e). Palatal
This article presents a combined approach
clearance (restorative space) can be regained by or- using CR and the Dahl principle, which is
thodontic intrusion or more simply by using occlusal summarized in Fig 3. The practical ap-
therapy (f). The first step in occlusal therapy is the iden-
proach first involves identifying that a differ-
tification of an anterior slide of the mandible, which can
be assessed by gently guiding the patient towards CR ence between the maximal intercuspal po-
(g). Most patients with localized anterior erosion will sition (MIP) and CR is present by gently
present with such a slide. A bite splint or an anterior de- guiding the mandible. An anterior depro-
programmer may be used to facilitate this operation.
grammer such as a Lucia jig or an NTI (no-
ciceptiv trigeminal inhibition) appliance can
be used if necessary to facilitate that step.
lation (CR) and retain the space for the As mentioned earlier, resin composite
placement of direct composites. The use of restorations reproducing the original anato-
an acrylic jig for recording CR was original- my of the palatal surface can also be used
ly presented by Lucia in 196436 and then re- as a deprogrammer. While the case pre-
fined to retain the space required for the sented in Fig 3 focuses on simplicity and
placement of restorations.3,37 Direct com- demonstrates the use of freehand compos-
posites themselves can be used as an an- ite restorations, a more sophisticated
terior deprogrammer (Fig 3i). Resin com- method would be to use articulated casts

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h i

j k

Figs 3h to 3k The anterior interocclusal space is immediately retained by the placement of direct composite
restorations (h and i) (red articulating paper was rubbed to outline the new palatal anatomy; blue marks show
the new MIP stops), including the replacement of existing Class 3 restorations. Minor occlusal adjustments can
be carried out until simultaneous bilateral contacts are obtained on premolars (j). The remaining contacts on the
molars will be obtained in a few months through the Dahl principle without additional adjustments (k).

and a waxup along with transparent matri- ments of premature contacts can be made
ces or silicon indexes to guide the palatal to increase the number of contacting teeth
restorative process. These palatal compos- in the posterior dentition. The residual inte-
ite veneers could also be fabricated with an rocclusal space (in the most posterior
indirect technique. The newly established teeth) should be progressively eliminated
position (slightly posterior to MIP), will usu- through the Dahl principle by the passive
ally feature anterior contact on the definitive eruption of posterior teeth and slight intru-
palatal restorations as well as premature sion of anterior teeth. Careful monitoring of
contacts in posterior teeth. Minor adjust- the patient is recommended to assure the

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l m

o p

Figs 3l to 3p To achieve proper contour, function, and mechanics, anterior teeth can be supplemented with
porcelain veneers (l). Following tooth preparation driven by the mock-up (m), the final restorations are provided
(n). The situation is totally stable after 4 years of clinical service without any further treatment (o and p).

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proper development of the new occlusal sit- the existing composite by airborne particle
uation, particularly the establishment of a abrasion (microsandblasting) with alu-
stable posterior occlusion. Insufficient pos- minum oxide or by tribochemical silica
terior occlusal support may lead to incisal coating (with silane) followed by the use of
occlusal pathology and breakdown of the a bonding resin provide strong repair
anterior palatal composites. bonds.4850
After a couple of months of stabilization,
anterior teeth can receive adjunct treat-
ment, such as porcelain veneers, if indicat- Conclusions
ed by the alteration of the facial/incisal sur-
face. The final adjustment of the occlusal While the severe loss of enamel constitutes
scheme can be carried out at this stage to an alteration to the function, mechanics,
take into account the newly established an- and esthetics of anterior teeth, it is also an
terior guidance, which can be tested in the opportunity for the additive (as opposed to
form of a provisional mock-up prior to tooth subtractive) restoration of the missing hard
preparation and fabrication of the final tissues. Traditional full-crown coverage
22,23
veneers. could be avoided in all cases in favor of
The example shown in Fig 3 should be noninvasive approaches combining addi-
viewed with a guarded prognosis since no tive bonded composites and porcelain ve-
long-term data are available for this type of neers. The combined use of CR and the
approach. In the medium- to long-term, Dahl principle will assist in creating ade-
palatal wear of the composites may occur. quate restorative space in cases with limit-
While once considered a major concern ed palatal clearance (deep bite).
for posterior restorations, wear of dental
composites has been substantially re-
duced by changes in formulation and is of- Acknowledgments
ten considered a solved problem in pa-
The authors wish to express their gratitude to Antonio
tients without bruxing and clenching habits. C. Cardoso (Professor, Department of Stomatology,
Patients with parafunctional behavior University of Santa Catarina, Florianopolis, Brazil) for
sharing his expertise, and Dr Richard Kahn (Phillip
should be monitored carefully because of
Maurer Tennis Professor of Clinical Dentistry, Division of
the increased risk of wear-related fail- Primary Oral Health Care, USC School of Dentistry) for
ures,42,43 and supplemental protection with his helpful discussions and review of the English draft.
a night guard is recommended. However, In his heart, a man plans his course, but the Lord de-
termines his steps (The Bible, Proverbs 16:9).
the worst-case scenario, in which the pa-
tient would wear off significant amounts of
the palatal restoration, should not constitute
a major concern. Due to the conservative
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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 2 NUMBER 3 AUTUMN 2007