I learned a lesson again this week that I have learned over and over in twenty plus years of practicing, limited occlusal equilibrations are a journey into uncharted waters.
There are many pieces of altering a patient’s bite that can be challenging if they are unknown. The first question that comes up for me, is why is the patient experiencing a change in their occlusion. The answer could be related to a change at the level of the joints, muscles or teeth, but having an understanding of the cause allows the patient and I to understand the risks and benefits. If the underlying condition is an instability in the joints due to inflammation or a loss of the disc then until the joints are stabilized the bite will continue to change, and we could be chasing a moving target. A similar scenario is present when the existing occlusion is a learned muscle position, or has changed due to a change in the musculature.
Creating a reproducible starting point from which to alter the occlusion is critical in being able to understand the outcome. Otherwise as the bite is changed, the muscles adjust and the occlusion wanders, and we are left trying to chase it with a high-speed handpiece. The last piece of uncertainty can be summed up in one question, ” When I adjust this tooth, which one will hit next?” An occlusal equilibration is done in order to improve or optimize the occlusal contacts. If we are unclear where the contacts will move to and what the extent of the treatment will be in order to reach this outcome, the treatment is inherently unpredictable.
So the lesson of adjusting a contact the patient requests, to have them than notice it is heavy someplace else, and randomly chase the contacts around the arch at the patients direction hoping that they will say it feels good quickly, I learned again this week. One more time I am clear that equilibration is a process that requires understanding and planning.
Dr. Ray Becker says
Hi Lee Ann, Well said! I totally agree with how frustrating it can be to deal with occlusion in a real world setting. Through my personal experience and exposure as the interpretation instructor for the Total BioPAK system (including Tscan/EMG link, JVA, 3DJT) I have taught students from literally all different ‘camps’ of occlusion. I have found the frustration they ALL universally share is that they believe they understand the theory of treatment, but often struggle with how to implement (planning), or to determine IF they even got to their intended treatment goals. This understandably is then posed to the patient with ‘how does it feel’? which as you accurately note is often a ‘moving target’ which further frustrates the practitioner to wonder if perhaps they did something wrong.
I think the concern we note (and you mirror with this thread) is simply the difference between objectivity and subjectivity. Everything we ask of the patient (like how does it feel) is subjective. Treatment(s) based on theory, while well intended, and certainly well beyond just routine centric occlusion dentistry is still subjective since no reproduceable, standardized quantifiable measurements are typically taken before, during and after any treatments. Routinely quantifying the status of the joint (through JVA) puts well researched numerics…or biometrics… beneath determination of the accurate status of the joint before, during and after any treatment(s) rendered, and it takes seconds to obtain. As you accurately note, without a stable joint its questionable at best to control the many variables of occlusion.
Diagnosis, treatment, and re-evaluation of the entire stomatognathic system using Total BioPAK gives hard -data-, and numbers to understand these complex interactions between the teeth, muscles and joint to base any treatment on those definable numbers that can be understood, evaluated, and most importantly replicated to make treating occlusion a predictable objective science.
I have found it’s far easier to treat occlusion objectively than it is subjectively, biometrics provides that critical component, regardless of philosophy …numbers just make it easier. Just like its far easier (and therefore more practical to expect its routine use) to quickly glance at a gas gauge to determine objectively how much fuel you have vs. trying to calculate how many gallons you added and how many miles you drove to determine the same thing (beyond recognizing who is going to routinely do that?…realizing that ‘real life’ traffic, hills, detours often confound even the best of those theoretical ‘calculations’… and perhaps tangentially they mirror frustrations we ‘see’ with the same phenomenon in treating occlusion??). By way of example, its far easier to quickly and accurately determine the exact place to quickly and conservatively adjust teeth using the objective data from Tscan/EMG link to obtain efficient canine rise without excessive MOM firing (and objectively determine you actually got it), than it is to use articulating paper and then ask a patient ‘how it feels’ even knowing that in theory quick disclusion turns MOM off.
Seeing is believing and numbers build confidence that any dentist can easily use to determine in fact you are adjusting the ‘right place’. I personally have also ‘chased’ that elusive contact many many times over the years before using biometrics. Now I can show with numerical clarity and graphics that oftentimes perhaps that area that ‘feels’ like it is hitting more is perhaps because it is now contacting for the first time (its an instant connect for a patient to see and believe it on a computer screen vs. us trying to tell them perhaps the exact same thing)…subjective vs objective.
Great post Lee Ann!!