In two previous posts I discussed a patient I suspected of having a restricted envelope of function due to his symptoms and repeatedly breaking his provisonals. At the last appointment when we remade the anterior provisonals we also captured full arch impressions a facebow and a protrusive record so I could mount the case and work out a new occlusal scheme. My goal on the mounted models is to increase his freedom in the anterior. There are two ways to approach this, decrease overbite and increase overjet. Decreasing overbite is also an esthetic decision. In this case we already had minimal tooth display at rest so shortening the upper anterior teeth to decrease the overbite was out of the question. That leaves me with the options of shortening lower anteriors. We definitely had room to level the lower anteriors and shorten them a small amount.
This winter I hosted an online seminar entitled “Occlusal Diagnosis:Identifying Risk”. The course, divided into three online sessions covered the diagnosis of the joints, muscles and dentition to identify patients with functional risk. The following is a short audio clip from the first session where I discuss the questions I ask during a patient interview around their Temporomandibular joints.
It is not uncommon to place a restoration on an upper second molar and have the contact open over time. The new crown is checked diligently at the seat appointment, and the contact flossed to ensure that it has the proper tension. The patient presents on an emergency because they are packing food, or at a routine hygiene exam and the open contact is detected. This can be frustrating and disconcerting for both the patient and the dentist. So why does this happen? As with many things in dentistry it is most likely multi-factorial, but one of the first things I check is the occlusion.
I utilize a leaf gauge as a routine part of my practice to load test, identify first point of contact, take centric relation bite records and perform occlusal equilibration. With this much utility it is a tool I want to make sure we are taking care of. It may seem silly to worry over the maintenance of something that costs less then fifteen dollars. However, they are not disposable so I want the assistant to pass me a leaf gauge that is visually clean and in good shape, as well as sterile.
Lee Ann Brady, DMD
As a woman and a mother I am very well acquainted with preventive medicine. Prevention requires three vital components. They are patient education, comprehensive examination, and active monitoring. The medical profession has done a phenomenal job incorporating this concept into our lives. We are all part of this process as it relates to breast cancer, pre- term birth and low birth-weight babies, and well child care. I have watched over the last 2 decades as dentistry has incorporated these same concepts into our profession. Our patients are well educated around the topics of decay and periodontal disease. It is standard of care to complete a thorough examination on our patients to look for signs of caries and periodontal disease and the techniques for early detection are constantly being improved. Patients who become an active part of our practice are continually monitored for any changes in their condition so we can intervene at the first sign of caries or periodontal breakdown. It would be remiss of us to wait until our patients had symptoms of either of these diseases before we treated. Why then do we treat TMD and occlusion so differently?
For me Temporomandibular disorders and occlusion are important for several reasons. The first is that I became aware of my own TMD when I developed frank symptoms. As I began a journey to understand my own condition I realized that there had been many signs along the way that if I had been aware of and proactively treated, the current breakdown of my joints, muscles and teeth might have been prevented. I also discovered that having a thorough understanding of my patient’s current condition was the key to eliminating some of the frustration and failures around the dentistry I was providing. Armed with this new understanding I expanded my comprehensive examination to include all of these areas and it transformed my practice, changed my relationship with my patients and is a key component to my personal satisfaction in the office.
It is up to us as a profession to educate patients and raise their awareness of temporomandibular disorders and occlusal disease. We don’t have large corporations helping us with national advertising campaigns as is the case with caries and perio, because they aren’t selling any products to treat or prevent these problems. First we have to educate ourselves and raise our own awareness because I truly believe the following. You only treat what you diagnose, you only diagnose what you see and you only see what you know. I find it amazing and somewhat bothersome when I think back on the patients in my practice that had mild wear, crazing, sensitivity, muscle fatigue, and even fractured teeth and I never “saw” it because I didn’t have the knowledge to put the pieces together until the symptoms set in. Now I can look at the twenty year old patient with mild wear and in my mind’s eye see the forty year old who will come in concerned that her front teeth are so short and offer the option of not having to have crown lengthening, endodontics and major restorative twenty years later.
So where do I start? I need to have the answer to several questions about the patient. Are the joints healthy and are the joints stable? I use a thorough patient history, palpation and auscultation of the joints and careful observation of mandibular movement to help me begin to understand the current condition. If I find signs I am concerned about I can include further diagnostics to help finalize my diagnosis. Next I look at the cervical and masticatory musculature. Patient history, palpation, range of motion measurements and careful observation are the ingredients of a comprehensive muscle examination.
Finally I look at the occlusion. I want to understand the current functional occlusion and how it relates to a seated condylar position. I also document any signs consistent with parafunctional activity or maladaption to the current occlusal scheme. Some of the signs I look for are inappropriate wear, crazing, cracks and exostoses. For me the examination isn’t complete without mounted study models and a series of digital photographs that includes functional and parafunctional movements. It’s common for me to make new discoveries about the patient when studying the models and photographs as I work through all the diagnostic data I collected.
The time I invest in the comprehensive examination is well worth it because I gain confidence about my treatment recommendations and confidence about treatment success. More importantly I have partnered with my patient to prevent or slow the future deterioration of their dental health from another possible threat.
I am not the same dentist I was before my journey to understand. I “see” way more than I used too when I observe the patient’s present condition. When I share what I have observed with the patient and help them understand how it will affect the treatment we may be undertaking together, or there dental condition in the future I am giving them the very best I have to offer as a dentist.