functional and esthetic restoration of the worn dentition
TRANSCRIPT
Functional and Esthetic Restoration of the Worn Dentition
Leonard A. Hess, DDSSenior Faculty, The Dawson Academy Private Practice, Monroe, NC
Ontario Dental Associtation ASM 2015
Thank You!!!!!
What do we think about when someone says “The Worn Dentition”???
Please don’t break anything if I restore a tooth.
Treatment Planning is very Important!!!!!
What happens when this guy walks in the door???
This is someone near the end point of a process. Really????
Do you have people who wonder why these things happen?
Have you seen excessive wear in young patients?
This is where it starts. And where we can make a difference!!!!
Can we prevent people from getting worse?
Would you want to know?
What are the ramifications of not telling people?
Have you ever had a restoration break? I have, more than once!
ARE THESE INCISAL EDGES
WORKING???????
??
We must be good at asking one question......
We must become an expert at answering this question!!
However..........Why????
Complete Treatment Planning is the goal...
‣“90% of cases that fail, fail not during the restorative phase but in the treatment planning phase.
1. Proper esthetics (or form) is derived from proper function. Not the opposite.
2. Not properly following (or incompletely following) function can lead to failed function and failed form.
Consider This....
Consider This....
3. If you are restoring teeth due to wear and breakage......... the system they are in is not working!
4. As teeth wear and break down, they are changing position. Often compounding the issue.
Occlusal Disease‣most common dental disorder ‣contributing factor to eventual tooth loose ‣ reason for needing extensive restorative dentistry ‣ factor associated with discomfort within masticatory system
structures ‣ factor in instability of orthodontic treatment ‣ reason for tooth sorness/hypersensivity ‣most common missed diagnosis leading to endo ‣most undiagnosed dental disorder
1#From “Functional Occlusion From TMJ to Smile Design”, Pete E. Dawson, DDS
Signs of instability
‣ Teeth with wear, mobility or migration
‣ Sore muscles of mastication
‣TM Joint instability
So Why Does This Happen?
Abrahamson IDJ 2005
Grippo, Simring, Coleman JADA Vol 135 2004 J Esth Rest Dent Vol 24 2012
Tripathi J Dent Med Sci 2014
Fernandes J Pros Dent 1991
Attrition-Tooth to tooth friction
(Parafunction? Centric Relation/Maximum Intercuspation interference?)
Abrasion- Friction between tooth and exogenous agent. (Toothpaste, Pencil, Tobacco)
Corrosion-Chemical or electrical Cupping, thinning. (Soda, aspirin powders, fruit mulling, gastric acids, etc.) Anterior vs. Posterior?
Abfraction- Concentrated stress transmitted thru occlusal loading forces
Dr. John Grippo coined the term in the 1990’s
Loaded teeth show a loss of enamel 10x greater than unloaded teeth.
Fernandes study shows enamel rods run parallel to the long axis, not perpendicular as thought in the past.
Tripathi in 2014 J of Dent. Med. Sci.
Abfraction= FORCE + ABRASION/CORROSION
Ken
9 years later!!!
Pathologic Wear
Wear is a Multi-Factor Issue
AttritionAbrasionCorrosion
Occlusal Stress Parafunction
Normal wear is 10.7 microns per year (.000039 inch)
Larson TD Northwest Dent. 2007
Most will be a combination of two or more issues
Whatto
consider?
Teeth and Periodontal Structures
Position
Esthetics
Functional Arrangement
Current Condition
They all must be respected. What if you ignore one or more of the above?
Restoration Selection
It is or responsibility to determine where the teeth go in space
What material will be used
Into what functional relationship they are placed
What specialists should be involved
It can be an overwhelming burden!!!
“Determination of precisely correct incisal edges is the
second most important decision a dentist must
make regarding occlusion. Centric relation is first.”
Need------------------
Want
We must be cautious of these two important aspects working against each other.
How do we make this Easy and Predictable?????
Checklists!!! And using them consistently.
‣Reshape ‣Reposition Dentition ‣Restore ‣Reposition Bone
Treatment options:
Treatment options: Reshape • Reposition • Restore • Reposition boney segment
Treatment options: Reshape • Reposition • Restore • Reposition boney segment
Treatment options: Reshape • Reposition • Restore • Reposition boney segment
Treatment options: Reshape • Reposition • Restore • Reposition boney segment
10 Step 3D Treatment Planning Checklist
Step 1: Choose Condylar Position
(Based on Restorative TMJ-Occlusal Examination)a.) Maximum intercuspationb.) Centric Relationc.) Treatment Position
Step 2: Go Tooth by Tooth
With casts, restorative chart, periodontal probings & photos, and mark hopeless teeth, questionable teeth, and teeth that need to be restored (crowned or onlayed) due to weakness or breakdown.
Step 3: Evaluate Maxillary, Mandibular Occlusal Plane
Use photographs (full face, profile, and smile shots) & mounted casts.
Step 4: Choose Vertical & Horizontal Position of Mandibular Incisal Edge
Step 5: Choose Vertical & Horizontal Position of Maxillary Incisal Edge
Step 6: Choose Vertical Dimension of Occlusion
Step 7: Provide Equal Intensity Stops
Step 8: Eliminate Balancing & Working Interferences
Step 9: Harmonize Anterior Guidance
Step 10: Final Functional-Esthetic Check
©2011 The Dawson Academy • www.TheDawsonAcademy.com
What we do in the lab
LABLab communication checklist
We must communicate: Condylar position Vertical dimension Vertical and horizontal position of the mandibular incisal Vertical and horizontal position of maxillary incisal edge Lingual contour of maxillary incisors (EOF) Precise Margin Placement Preparation Shade Desired shade and contour
Required Records for Effective Lab Communication: Facebow/ or facebow preservation model Final impression Opposing impression or model Bite registration to mount provisional model/models Bite registration to mount die model/models Dr & patient approved provisional impression/model Full series of preop photos/provisional photos/dentin shade/desired shade tab Detailed laboratory prescription Request for custom guide table & incisal matrix Complete treatment plan (if cases to be completed in phases)
Following the checklists allows a systematic approach to treatment planning. Which leads to predictable success.
Comprehensive Examination and Records
1.
2Comprehensive
Treatment Planning to determine appropriate
treatment options
Provisional Prototypes3
Definitive Restorations4
Esthetically, Functionally or Both
General
patientsSpecialty patients
Two Patient Populations
Size, shape, contour, position work Not working
How do we identify the “Specialty” from the “General” patient’s?
‣ They will be the ones who:
‣ 1.) Desire an esthetic change.
‣ 2.) Present with occlusal disease (signs of instability).
‣ 3.) Need extensive dentistry
‣ 4.) Or have a combination of the above.
In Dental school we were trained to treatment plan only the former.
Moving tooth by tooth, making the final decision with regards to the definitive restoration.
The problem:
Definitive Restorations
(In Our Mind) 2D tx
planning
When changing tooth position, size or contour requires a more thorough process.
Definitive Restorations
(In Our Mind) 2D tx
planning
(In Wax) 3D tx planning
Prototype Provisionals
Understanding the System in Which Teeth Function
Condition
What treatment position?
Effect of treatment?
Most problems occur when we try to segment our plans. We loose sight of the big picture.
To identify ‘General’ from ‘Specialty’ patients it is incumbent on the Restorative Dentist to do a thorough examination.‣Oral cancer examination ‣Periodontal examination (full probing) ‣Restorative charting ‣TMJ Occlusal Examination ‣Full mouth series of x-rays ‣Potential for additional records (mounted diagnostic casts or imaging?)
We must make a proper diagnosis to identify the weak link in the system.
The Teeth
The Joint
The muscles
The Periodontium
Our fight is against either bacteria, force or both.
The components of the TMJ-Occlusal Examination‣The History (7 questions)
‣Range of Motion Test
‣The Centric Relation Load Test
‣TMJ Doppler Ausculation/JVA
‣Muscle Palpation
‣Evaluation of the Dentition for wear, mobility and migration
‣ Imaging
Goals of TMJ-Occlusal Examination‣Assess “restorability” of joint.
‣Make Diagnosis regarding level of parafunctional activity.
‣Determine if Occlusal Therapy is required for this patient.
What you need...‣A New Patient/Records System in your practice
‣A process to evaluate the TM Joint/occlusion & dental structures
‣A semi-adjustable articulator, that accepts a facebow
‣A quality digital camera
‣A well trained team member dedicated to the ‘records gathering process’
1.) History: Seven Questions‣Have you ever had or been diagnosed with a problem with
either jaw joint?
‣Does your jaw joint click, pop or make noise when you open and close?
‣Do you have pain or tenderness in your jaw joint when you open, close or chew?
‣Has your jaw ever locked open or closed?
‣Do you have frequent headaches? If so, how often?
‣Do you Clench or Grind your teeth, or ever been told that you do?
‣Have you ever had trauma to your chin or jaw?
2. Range of Motion Test
‣Opening: 40-55 mm
‣Protrusion: 8-12mm
‣Lateral: 8-12mm
3. Centric Load Test ‣Key Question:
‣“Is there any sign of tension or tenderness in either joint?”
1. Recline the patient so that your arms are parallel to the floor.
Correct Position Incorrect Position
When a patient is not reclined enough, the operators arms will be too high resulting in a bowed wrist position. This makes it nearly impossible to “turn the doorknob”, and often promotes distalization of the mandible as the operator then pulls back on the mandible.
2. Point the chin of the patient up.
Correct Position Incorrect Position
A chin up position allows easier placement of the hands on the mandible, and easier visualization for the operator. This will also prevent the patient from protruding their mandible.
The Dawson Academy Bimanual Manipulation Checklist
If the disk is displaced, compression of the retrodiskal tissue will lead to pain or discomfort
Tension and tenderness will result from muscle tension keeping the condyle from completely seating
Don’t start out with the firm pressure first. You will shock the muscles and they will not cooperate.
If you have a reason to wonder, figure it out.
1. Unreleased pterygoid 2. Medial pole displacement 3. Retrodiskitis
4.) Joint Sounds
‣TMJ Doppler Auscultation
‣Joint Vibration Analysis
Doppler Auscultation
A healthy joint will be quite on rotation and translation
It is simple, efficient and easy to use
Noise on translation is not a deal killer. Noise during rotation should bring caution and perhaps trigger imaging
if restorations are necessary.
You get to demonstrate and document for the patient
‣Masseter
‣Temporalis
‣Medial Pterygoid
‣Lateral Pterygoid (resistance check)
‣Digastrics/suprahyoids
5.) Muscle Palpation
6.) Evaluation of dentition for:
‣Tooth Wear
‣Tooth Mobility
‣Tooth Migration
Recognize Instability
Wear beyond normal Tooth movement that is not wanted
Excessive mobility
When a lack of functional harmony exists between the muscles and the teeth........the teeth will lose this battle. Often times the joint will also
show ill effects from this relationship.
Sore Muscles
Unhealthy Joints
Examination of the Occlusion and Teeth
Is there a CR/MI discrepancy?
Where? How much? Which direction?
Is there tooth wear, mobility, migration?
Look for Functional Patterns
Cows Rats
Is it Parafunction?
This does not mean that every patient becomes a full mouth rehab candidate.
We learn to recognize
Instability Stability
Dangerous
Crazy People
TMD
Bruxers
Concept of Collateral Damage
“The point that should not be missed is that masticatory system disorders are rarely ever confined to a single structure. There will almost always be collateral effects from disorder in the joints, the teeth, or the muscles. These will be evident as signs or symptoms. Careful observation will usually show that there is a chain of cause-and-effect reactions as one disorder leads to another.”
-Dr. Peter Dawson Text: Functional Occlusion
From TMJ to Smile Design
Treatment options: Reshape • Reposition • Restore • Reposition boney segment
The joint can be in 3 possible conditions
1. Structurally intact
2. Altered at the lateral pole
3. Altered at both poles
“If the TMJ’s are not stable, the occlusion will not be stable, so it is a risky proposition to undertake occlusal changes without knowing the condition of the TMJ’s.” -
Dr. Dawson
Treatment options: Reshape • Reposition • Restore • Reposition boney segment
Let’s talk about function!
Goal #1: TMJ’s Healthy and the Condyles In Centric Relation
Let’s talk about Centric Relation
What it isn’t
Forced
Unnatural
Dependent on teeth
Mythical
What it is.
Functional Occlusion From TMJ to Smile DesignDr. Peter Dawson
“Centric Relation is the relationship of the mandible to the maxilla when the properly aligned condyle-disk assemblies are in the most superior position against the eminentiae irrespective of vertical dimension or tooth position.
At the most superior position, the condyle disk assemblies are braced medially, thus centric relation is also the most midmost position.
A properly aligned condyle disk assembly in centric relation can resist maximum loading by the elevator muscles with no sign of discomfort.
TMJ Examination
Bi-concave self positioning disk
We must understand the anatomy first
We don’t have disk problems, we have disk position problems
The Temporomandibular Joint
Posterior Attachment
Retrodiscal tissue
Superior Belly of the lateral pterygoid
Inferior Belly of the lateral pterygoid
Centric Relation
It is the stable axial position of the mandible
The only position that will allow an interference free occlusion
It is not about teeth. But don’t lose sight of their influence
It is about allowing muscle comfort and coordination
Allows an anatomic, and physiologic position to begin restoration of teeth
In CR the load is on the Medial Pole
In rotation, the force stays centered on the medial pole and in centric relation. When movement transitions into translation, the force transfers to the lateral pole.
What happens when the joint can’t seat?
For many people it is simple incline interferences that keeps them from being comfortable, and that can cause
us so many problems
CR gives us a tripod of stability
2 seated Condyles + Anterior contact = Stable Tripod
I Consider it the 8th wonder of the world
It is a source of stability and the solution to so many problems that wet fingered
dentists face every day
Goal #2: Equal Intensity Stops on all Teeth (or a Substitute)
(Remember Goal 1 has Been Satisfied)
This is a Key Point in Creating Stability in a Patient
Even, stable holding contacts on all teeth with the condyles in Centric Relation
Exception to the rule
Neutral Zone
“More than any other factor, the neutral zone programs the envelope of
function. The neutral zone is a major determinant of how teeth erupt. And it is
the position of the anterior teeth that
influences the neuromuscular
programming of functional jaw movements.”
Goal #3: No Posterior Tooth Contact in Excursive Movements
Get The Canines Doing Their Job
“The success or failure of many
occlusal treatments
hinges on the correctness of
the anterior guidance.”
Stability
Anterior Guidance that immediately separates the posterior teeth in a lateral or protrusive movement. And which allows these excursive movements within the envelope
of function. The lingual anatomy must be concave enough for the EOF as well.
Neff
Canine Guidance shuts down the elevating muscles, protecting the posterior teeth.
Influence of altered occlusal guidance on masticatory muscle during clenching. Okano, Baba, Igarashi J Oral Rehabil. 2007;34(9): 679-684
Anterior Guidance: its effect on electromyographic activity of the temporal and masseter muscles. Williamson, Lundquist. J Prosthet. Dent. 1983; 49(6): 816-823
Influence of group function and canine guidance on eletromyographic activity of elevator muscles. Manns, Chan, Miralles. J Prosthet Dent. 1987; 57(4): 494-501
Effects of occlusal contact on the level of mandibular elevator muscle activity during maximal clenching in lateral positions. Shinogaya, Kimura, Matsumoto J Med Dent Sci. 1997; 44(4): 105-112
Mansour RM, Reynik RJ, J Dent. Res (1975) 54:114-120
Bite force differs by a factor of 9!!!!
Create posterior teeth the patient cannot rub.
Three reasons posterior teeth interfere or rub.
1.) Poor/bulky posterior morphology.2.) Lack of anterior guidance.3.) Condyles that are not seated.
In an ideal world, the patients occlusal contacts would be in harmony with a seated joint
position.
The reality is, mostof our patients do
not have this.
Interferences to centric relation,
can cause posterior teeth to
rub.
Interferences to centric relation,
can cause posterior teeth to
rub.
Anybody see teeth that look like this?
Goal# 4: Anterior Guidance in Harmony with the Envelope of Function
Ever have a patient who can’t get comfortable?
“When restoring maxillary anterior teeth, the lingual
contours should be in harmony with the EOF from the CR contact point to the incisal
edges.”
long term stabilitypredictable comfort
PRINCIPLE
best phoneticsbest esthetics
protection of back teeth
to insure...
MUSTget this right
The anterior guidance is in harmony with the envelope of function. (CR contact to incisal edges)
Make Restoration that work for the patients EOF
Envelope of Function
Excessive Contour
Lines in the frontDots in the back
Envelope of function is influenced by: Centric relation
Need for long centric Correct Incisal Edge Smooth Protrusive Lateral Disclusion
EOF
EOF can only be refined in the mouth!!!!!!
Dawson
Don’t forget about the lower teeth. (The hammer)
How do we work with this and meet our goals?
Lower Incisal Edge Position
Lower Incisal Edge Position
Occlusal Plane
Curve of Spee
Occlusal Plane
Curve of Wilson
Function of the anterior teeth
Determination of Lower Incisal Edge Position And Contour Is The FIRST Decision That Must
Be Made Regarding The Whole Occlusal Scheme After Centric
Relation Has Been Verified.
“The mandible does have favored pathways of
function. And if teeth interfere with these favored pathways, there will be a price
to pay in deformation or dysfunction. The weakest
link will be the prime focus of the damage.”
What does it look like when EOF isn’t working?
Where do we go now?
How much damage has been done?
“I want my veneers replaced!”
Where We Place Incisal Edges Influences Excursive Movements and Envelope of Function!!!!
So how do we decide where to place them????
“Determination of precisely correct
incisal edges is the second most
important decision a dentist must make
regarding occlusion. Centric
relation is first.”
The dentist will pay great attention to the vertical length of anterior teeth. The horizontal position of the incisal edge is commonly overlooked and left to chance. Yet the horizontal position can alter the perceived length greatly.
We must appreciate the 3-dimensional system in which teeth function. Failure to do so will lead to many esthetic, patient comfort, and functional failures.
Creating Esthetic and Functional Incisal Edges
1Determination2Communication Quality control
Verification3
Restoration of the Incisal Edge
Length (Vertical Incisal Edge)
Central Incisors: Average 11 mm in length
Try to make them fit the smile line, fill the display zone, do not violate functional parameters or phonetics
Length
The smile line follows or compliments the lip line
Rest Position
Vig and Brundo determined women show an average of 3.4mm at rest and men 1.91mm at rest
“E” position
Incisal edge approx. 50 to 60%
Length Review
1. You need to fill your canvas. Most people will have central length of 10 to 11mm
2. Do not alter phonetics (Cross into the dry portion of the lip)
3. Do not alter function4. Width of the tooth will often help to dictate the ideal
length .7 to .8 of length5. 2 to 3 mm of tooth show at rest 6. About 60% in “E” position
Incisal Edge Position (Horizontal)
--Keep the teeth in the neutral zone
--Edge should line up with inner vermillion boarder of lower lip
--it must fit within the patients envelope of function
--the position is estimated during our diagnostics, but patient tested with our temporaries
--this is why the lab needs impressions of your temps
The tip down shot
The 90 degree smile shot
How do I know if I messed up?
--teeth feel too dry, or lip hangs-up upon closure
--the patient has a new speech impediment involving “f” words
--you can keep the temps on
--pt complains their mouth muscles feel tired, “my teeth feel long
--porcelain chipping and debonding problems
--problems saying “s” sounds
--restorations feel like they are hitting first in the arc of closure
--fashizzzzell
Neutral zoneEnvelope of function
Esthetic Factors That Relateto the Incisal Edge
Length to width
80%
Width to length ratio
Create ideal length based on the width of existing tooth
Anterior Dominance
The golden proportion
.6 1.0
1.6
The midline
philtrum
Incisal plane
Beyer and Lindauer--- 2mm is the threshold for noticing a midline deviation. Nose and maxillary midline were the two most recognized deficiencies
Incisal Embrasures
Embrasures get wider and taller as you move distally
Central embrasure will be the smallest
Incisal Embrasures
Contact points
Gingival Form Get the tissue healthy
Tissue tells the story. Be smooth.
Gingival FormIdeal
Gingival FormLeast Favorable
Cervical Embrasures
The older the patient the harder it is to have ideal cervical embrasures
How do I avoid black triangles?
Tarnow says that the distance from the bone to the contact point cannot be greater than 5.0mm. If it is less, it will fill in.
Preserve your papilla people
Support the tissue
anatomic contouring
Don’t risk losing the one you have
Goals of the TMJ Exam: ‣Assess the health of the TMJ
Signs of Instability: • Medial Pole issues • DJD
TMJ-Occlusal ExaminationNegative Occlusal Exam Positive Occlusal Examination
Work in Patient’s Habitual Occlusion (Maximum Intercuspation)
Signs of Instability: • Tooth wear/erosion • Tooth mobility • Muscle pain • Occluso-muscle pain • Lateral Pole issues
Equilibrate/Reposition/ Restore/or Orthognathic to Centric Relation with ideal occlusal scheme
Verifiable CR Treat TM Joint. Must be stable before restorative phase “Treatment Position Approach”
Non-verifiable CR
No signs of Instability: • Healthy TM Joint
1 2 3
Signs of Instability: • Medial Pole issues • DJD
TMJ-Occlusal ExaminationNegative Occlusal Exam Positive Occlusal Examination
Work in Patient’s Habitual Occlusion (Maximum Intercuspation)
Signs of Instability: • Tooth wear/erosion • Tooth mobility • Muscle pain • Occluso-muscle pain • Lateral Pole issues
Equilibrate/Reposition/ Restore/or Orthognathic to Centric Relation with ideal occlusal scheme
Verifiable CR Treat TM Joint. Must be stable before restorative phase “Treatment Position Approach”
Non-verifiable CR
No signs of Instability: • Healthy TM Joint
1 2 3
Specialty patients
Photographic Full Series
©2013 The Dawson AcademyUpper Occlusal Lower Occlusal
Right Lateral Retracted(Teeth Apart)
Front Retracted(Teeth Apart)
Left Lateral Retracted(Teeth Apart)
Right Lateral Retracted(Teeth Together)
Front Retracted(Teeth Together)
Left Lateral Retracted(Teeth Together)
Right Lateral Retracted(Close Up)
Front Retracted(Close Up)
Left Lateral Retracted(Close Up)
Rest Position ‘E’ Position Tipped Down Smile Profile Smile
Right Lateral Smile Left Lateral SmileFull Smile
Full face Profile Face Face, Lips Retracted
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4.
11.
14.
17.
7.
2.
5.
12.
15.
18.
20.
8.
3.
6.
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9. 10.
‣ Face bow mounted, CR articulated models
‣ Photographic Full Series
Additional Records
Signs of Instability: • Medial Pole issues • DJD
TMJ-Occlusal ExaminationNegative Occlusal Exam Positive Occlusal Examination
Work in Patient’s Habitual Occlusion (Maximum Intercuspation)
Signs of Instability: • Tooth wear/erosion • Tooth mobility • Muscle pain • Occluso-muscle pain • Lateral Pole issues
Equilibrate/Reposition/ Restore/or Orthognathic to Centric Relation with ideal occlusal scheme
Verifiable CR Treat TM Joint. Must be stable before restorative phase “Treatment Position Approach”
Non-verifiable CR
No signs of Instability: • Healthy TM Joint
1 2 3
Signs of Instability: • Medial Pole issues • DJD
TMJ-Occlusal ExaminationNegative Occlusal Exam Positive Occlusal Examination
Work in Patient’s Habitual Occlusion (Maximum Intercuspation)
Signs of Instability: • Tooth wear/erosion • Tooth mobility • Muscle pain • Occluso-muscle pain • Lateral Pole issues
Equilibrate/Reposition/ Restore/or Orthognathic to Centric Relation with ideal occlusal scheme
Verifiable CR Treat TM Joint. Must be stable before restorative phase “Treatment Position Approach”
Non-verifiable CR
No signs of Instability: • Healthy TM Joint
1 2 3
Specialty patients
Why do we need a facebow? What does it do?
It provides the correct arc of closure associated with the condylar axis of
rotation.
Because a CR record is an open bite record! It still needs to be closed into MI.
Recording the correct axis allows us to open or close the vertical dimension
without a change from CR
That is why unmounted casts or casts on a flap articulator are useless
Ever wonder why some crowns need so much adjustment than others!
Should we use the eyes to level?
This is not a facebow.......mmmmkay.