Ricketts NJ, Smith BGN.

Clinical techniques for producing and monitoring

minor axial tooth movement

Ricketts NJ, Smith BGN., (1993) "Clinical techniques for producing and monitoring minor axial tooth movement" from European journal
of prosthodontics and restorative dentistry 2 pp.5-9, Lowestoft: FDI World Dental Press Ltd ©

Staff and students of King's College are reminded that copyright subsists in this extract and the work from which it
was taken. This Digital Copy has been made under the terms of a CLA licence which allows you to:
* access and download a copy;
* print out a copy;

Please note that this material is for use ONLY by students registered on the course of study as stated in the
section below. All other staff and students are only entitled to browse the material and should not download
and/or print out a copy.

This Digital Copy and any digital or printed copy supplied to or made by you under the terms of this Licence are for
use in connection with this Course of Study. You may retain such copies after the end of the course, but strictly for
your own personal use.
All copies (including electronic copies) shall include this Copyright Notice and shall be destroyed and/or deleted if and
when required by King's College.
Except as provided for by copyright law, no further copying, storage or distribution (including by e-mail) is permitted
without the consent of the copyright holder.
The author (which term includes artists and other visual creators) has moral rights in the work and neither staff nor
students may cause, or permit, the distortion, mutilation or other modification of the work, or any other derogatory
treatment of it, which would be prejudicial to the honour or reputation of the author.
This is a digital version of copyright material made under licence from the rightsholder, and its accuracy cannot be
guaranteed. Please refer to the original published edition.
Licensed for use for the course: "DENCMID - Conservative and MI Dentistry".
Digitisation authorised by Helen Cargill
ISSN: 0965-7452
Eur. J. Prosthodont. Rest. Dent., Vol. 2, No. I, pp 5- 9 {) 1993 Mosby-Year Book Euro pe Ltd.
Printed in Great Britain

Clinical Techniques for Producing and Monitoring

Minor Axial Tooth Movement

David N.J. Ricketts* and Bernard G.N. Smitht

Abstract - In this second article a range of clinical techniques for producing minor axial tooth movement is
described, including the simple, cemented metal anterior bite-plane which has proved to be one of the most use/ul of
the techniques. Methods of monitoring and measuring the relative tooth mov ements are also described.

KEY WORDS: Fixed prostheses; crowns; tooth wear; tooth eruption.

INTRODUCTION difficult to tolerate. However, this teenage patient with

extensive erosion at the palatal surfaces of the upper
The first in this series of two papers (see Vol l, pp incisor teeth coped with it very well and the lower
145-49) reviewed the work of Dahl et al. ( 1975-1985) 1- 3 incisor teeth were depressed in less than 3 months
and discussed the indications for producing minor axial (Figure J(b)), which allowed crowns to be made for the
tooth movement. This paper describes alternatives to upper anterior teeth with no reduction of the eroded
the original technique described by Dahl et al in 1975 1, surfaces (Figure l (c)).
together with quick, effective methods of monitoring
relative tooth movement. Removable Cobalt-Chromium (Dahl) appliance
This type of appliance was illustrated in Figure 1 of the
first paper in this series (sec Vol 1, pp 145-49). It is more
TREATMENT TECHNIQUES expensive to produce than a simple acrylic bite-plane,
but is better tolerated, particularly by adult patients. It
The choice of techniques is between: can be made so that very little of the appliance shows,
but it still requires a high level of patient compliance.
• A removable conventional orthodontic appliance
incorporating an anterior bite-plane. Cemented Anterior Cast Metal Bite-plane
• A removable cobalt-chromium (Dahl) bite-plane. (a Fixed Dahl Appliance)
• A cemented cast metal bite-plane (a fixed Dahl appli- These arc simpler to make than the removable cast metal
ance). appliance and, provided the patient is prepared to accept
• Provisional restorations, deliberately encroaching the treatment, patient compliance is not a problem.
upon the interocclusal space. A fixed Dahl appliance can be used both to create
• Definitive restorations, deliberately encroaching space for anterior crowns in cases of tooth-wear and to
upon the interocclusal space. create space for resin-bonded bridges.
A typical example is shown in Figure 2. The patient
Conventional Orthodontic Appliances was a 35-year-old man who presented with extensive
These are indicated when tooth movements in addition erosion of the palatal surfaces in the upper anterior
to minor axial movements are required. For example, teeth to a degree that he was concerned about the short
when upper lateral incisor teeth are missing congeni- appearance of the teeth. There was also some sensi-
tally, conventional orthodontic treatment may be used tivity and the 2..J had lost its vitality. Although all teeth
to recreate the spaces for the lateral incisors, close a had a degree of tooth wear, only the upper anterior
midline diastema and create interocclusal space for a teeth were worn sufficiently to justify metal-ceramic
resin-bonded bridge all at the same time. crowns.
When the only movement req ui red is ax ial tooth A nickel-chromium fixed Dahl appliance covering
movement, an advantage of a conventional anterior bite- the palatal surfaces of all the upper anterior teeth was
plane is that it can be made very thick, as it is the made on a working model articulated with a lower
authors' impression that tooth movement is then more model in the terminal hinge axis position. The interoc-
rapid. Figure l (a) shows an example of such an appli- clusal distance was increased by raising the incisal pin
ance. Many adult patients would find such an appliance point on the articulator and the appliance waxed up to
produce an ocdusal platform at right angles to the long
axis of the lower incisor teeth. When cast the appliance
"BDS. MSc. Part-Time Lecturer in Conservative Dental Surgery. was sandblasted and cemented under rubber dam with
tBDS, MSc. PhD, FDSRCS. Professor of Conservative Dental Surgery. Panavia-Ex to the etched peripheral enamel and

5
 D.N.J. RICKETrS AND B.G.N. SMITH

(a) (b)

Figure I. (a) Thick anterior acrylic bite-plane. (b) Study models

before and 3 months o~er provision of the appliance. (c) The upper
anterior teeth hove been prepared with no reduction of the palatal
surfaces.
(c)

dentine. The patient experienced no change in the sen- was removed by sectioning it and using an ultrasonic
sitivity or vitality of the teeth during or after treatment scaler5• Removal was time consuming and would have
as a result of applying Panavia-Ex to the untreated den- proved easier if a glass ionomer luting cement or poly-
tine; this is consistent with previous findings•. The carboxylate cement had originally been used instead of
appliance was adjusted to establish even contact of all Panavia-Ex. The teeth were prepared without any
teeth in occlusion with the splint and it was confirmed palatal/ occlusal reduction and heat-cured provisional
that none of the posterior teeth made contact in ary crowns cemented. The crowns were left for a period of
excursion of the mandible. There was no problem with 6 months as orthodontic retainers to ensure that the
retention of the appliance throughout the acti\'e phase occlusion was stable and that the anterior guidance
of treatment, even though the amount of enamel which had been established was satisfactory. During this
around the exposed dentine on the palatal surfaces of time occlusal analysis and adjustment, if necessary,
the teeth was minimal. would have been carried out in the event that any unde-
After 4 months, sufficient space was created palatally sired tooth movement had taken place. In this case no
for metal coverage for the anterior teeth. The appliance adjustment was necessary. The patient and operator
were also able to assess the appearance.
After 6 months the provisional restorations were
replaced with metal-ceramic crowns. Even contact in
intercuspal position was checked with Shimstock Foil
between the crowns and opposing teeth and between
the posterior teeth.
Figure 3 shows a similar case in which space was cre-
ated by attaching the appliance to the upper teeth, but
the lower teeth were then restored using pin-retained
metal-ceramic crowns with no further reduction of the
lower incisor teeth.

Provisional Restorations
The advantage of the fixed Dahl appliance is that no
tooth preparation is necessary; therefore if the treatment
Figure 2. A cemented, adhesive bite-plane (a fixed Dahl appliance). does not work for some reason, the appliance can be

6
 PRODUCING AND MONITORING MINOR AXIAL TOOTH MOVEMENT

(a) (b)

Figure 3. A fixed Dahl appliance cemented to the upper indsor

teeth, viewed palatally (a) and in ocdusion (b). Sufficient space was
created for pin retained metakeramic crowns on the worn lower
incisor teeth (c) without further incisal reduaion.
(c)

abandoned. Nevertheless, an additional stage is when the aetiology is primarily erosion, as it is in most
required, and so an alternative is to eliminate this stage cases in which the teeth in one jaw are being worn more
and simply prepare the teeth to be crowned, without rapidly than the teeth in the other.
reducing the worn surface, and then make provisional
restorations deliberately encroaching into the interoc- Permanent Restorations
clusal space and relying on these to produce the axial When one or more upper anterior teeth are missing, and
tooth movement. Figure 4 shows an example in which there is not sufficient clearance for the wings of a resin-
this was done. It is important that the provisional retained bridge, it may be acceptable to make a bridge in
restorations are sufficiently durable, and heat-cured such a way that it encroaches on the interocclusal space;
acrylic or cast metal are the materials of choice. If the however, a palatal platform should be incorporated into
cause of the wear is attrition, heat-cured acrylic will the metal work so that the occlusal force is directed
wear too rapidly. This technique works best, therefore, down the long axis of the lower incisor teeth. The

(a) (b)

Figure 4. Heat<ured acrylic provisional restorations. The restorations on the upper incisor teeth are linked (a) and provide adequate separation
of the posterior teeth to produce axial tooth movement (b).

7
 D.""-J. RICKETI~ A"ID B.G.N. SMITH

(a) (b)

Figure S. (a) The occlus1on of the patient shown in Figure 2 at the appliance cementation appointment Acrylic occlusal indices have been made
either side of the arch with the patient biting on the appliance. (b) The patient occluding on the indices 3 months a~er cementing the appliance,
showing the amount of anterior space created.

permanently cemented bridge will then act as an ante-

rior bite-plane and produce axial movement of the
lower incisor teeth. If the bridge is made without an
exaggerated palatal contour, there is a danger that the
upper anterior teeth will be proclined by the occlusal
force, opening spaces either side of the abutment teeth
of the bridge. Once the occlusion has stabilised, it is
possible to grind off the palatal shelf, but this may not
be necessary.
This technique carries a number of risks and the
patient should be fully informed before giving consent
to the treatment. The risks arc that tooth movement
does not occur in the anticipated manner, that the exces-
sive occlusal force on the bridge will produce partial or
complete debonding, and that some axial movement of
the upper incisor teeth may occur leaving a slightly
uneven incisal plane. Therefore, although the technique Figure 6. Measuring the amount of axial tooth movement A third
works, it is better to rely on more conventional mdex has been made by the patient biting the anterior teeth into sili-
cone putty with the posterior acrylic indices in situ. The thickness of
orthodontic treatment or a fixed Dahl appliance when-
this third index 1s bemg measured with callipers.
ever possible.

anterior teeth, either in acrylic or silicone putty, with

TECHNIQUES FOR MONITORING the posterior indices in place. The thickness of the ante-
AXIAL TOOTH MOVEMENT rior index can then be measured with crown thickness
measuring callipers (Figure 6). When the required
Dahl and Krogstad 2 monitored tooth movement by amount of space has been produced, the appliance can
means of metal reference points implanted in the bone be removed without further delay.
of upper and lower jaws and repeated radiography. An alternative is to make the appliance the same
These techniques would not, today, be acceptable even thickness as the required restoration and wait until the
as research techn iques, and certainly not for routine posterior teeth re-establish occlusal contact. However,
patient treatment. T herefore it is necessary to develop in this case, the appliance will be thin and tooth move-
methods of measuring whether tooth movement is ment wi ll be slower. It is also less convenient to make
occurring. A satisfactory way of doing this is to make a flat occlusal platforms producing occlusal forces
simple acrylic occlusal index on either side of the mouth directed along the long axis of opposing teeth.
at the appointment when the appliance is fitted. These
techniques arc illustrated in Figure 5 for the patient
shown in Figure 2. The indices are carefully preserved CONCLUSIONS
and replaced in the mouth at subsequent appointments.
As tooth movement occurs a space begins to appear In the authors' experience, cemented cast metal ante-
between the appliance and the opposing teeth (Figure rior-bite planes (fixed Dahl appliances) and provisional
5(b)). The amount of space created in the anterior region restorations, deliberately encroaching upon the interoc-
can be measured by making a further index between the clusal space, have proved to be the most successful of

8
 PRODUCING AND MONITORING MINOR AXIAL TOOTH MOVEMENT

the techniques described. The other techniques still have REFERENCES

a role to play in some cases, particularly conventional
1
orthodontic treatment when tooth movement in addi- Dahl, B.L., Krogstad, 0. and Karlsen, K. An alternative
tion to axial tooth movement is required. treatment in cases with advanced localised attrition. j. Oral
Rehabil., 1975; 2: 209-214.
1
Dahl, B.L., and Krogstad, 0. The effect of a partial bite
raising splint on the occlusal face height. An X-ray cephalo-
ADDRESS FOR CORRESPONDENCE metric study in human adults. Acta Odontol. Scand., 1982;
40: 17-24.
Mr David N.J. Ricketts, Department of Conservative 1 Dahl, B.L., and Krogstad, 0. Long term observations of an
Surgery, UMDS, Guy's Hospital, London SEl 9RT, increased occlusal face height obtained by a combined
UK. orthodontic prosthetic approach. j. Oral Rehabil., 1985; 12:
173- 176.
4 Inokoshi, S., Fujitani, M. and Hosoda, H. Pulpal Response to
MANUFACTURER DETAILS Panavia-Ex. Adhesive Prosthodontics. Chicago: Academy of
Dental Materials, pp 47-54.
1 Walmsley, A.D., Lumley, P.J. and Laird, W.R.E. Ultrasonic
• Panavia-Ex, Cavex Holland BV, Holland. instruments in dentistry: the removal of restorations. Dent.
• Shimstock Foil, Hanel-GHm-Dental GmBH, Germany. Update, 1988: 15: 401-404.