full mouth rehabilitation / Labial orthodontics


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full mouth rehabilitation / Labial orthodontics

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. Contents Introduction Occlusal disease Determinants of occlusion Temporomandibular joint Masticatory musculature Centric relation Determining centric relation Recording centric relation Classification of occlusionswww.indiandentalacademy.com
  3. 3. Introduction The defining philosophy that underlies an honest concern for patients can be summarized in one word: complete. Embracing the concept of complete dentistry always puts the patient first. It says that every patient is entitled to a complete examination and a clear understanding of every problem that should be treated. www.indiandentalacademy.com
  4. 4. It is axiomatic that patients cannot perceive a need for treatment if they do not clearly understand what problems are present. That is the primary purpose of the complete examination. Patients cannot make a truly informed decision about treatment unless they also understand the implications of not treating each problem within a reasonable time frame. www.indiandentalacademy.com
  5. 5. Practitioners cannot reliably predict implications if they don't have a working knowledge of the total masticatory system, which includes the interrelationships of the teeth, the temporomandibular joints (TMJs), the muscles, and the supporting tissues, in addition to a clear picture of the causes and effects of occlusal disease. www.indiandentalacademy.com
  6. 6. Types of implications A. Immediate implications. B. Deferrable implications. C. Implications for optional treatment www.indiandentalacademy.com
  7. 7. Goals for complete dentistry I. Freedom from disease in all masticatory system structures II. Maintainably healthy periodontium III. Stable TMJs IV. Stable occlusion V. Maintainably healthy teeth VI. Comfortable function VII. Optimum esthetics www.indiandentalacademy.com
  8. 8. Occlusal disease Most common destructive dental disorder. Contributing factor to eventual loss of teeth. Reason for needing extensive restorative dentistry. Factor associated with discomfort within masticatory system structures. This includes pain/discomfort in the musculature, the teeth, and the region of the temporomandibular joints (TMJs). www.indiandentalacademy.com
  9. 9. Factor in instability of orthodontic treatment. Reason for tooth soreness and hypersensitivity. Most commonly missed diagnosis leading to unnecessary endodontics. Most undiagnosed dental disorder until severe damage becomes too obvious to ignore. www.indiandentalacademy.com
  10. 10. Attrition Attrition is wear due to tooth- to-tooth friction. E.g. bruxism and empty mouth parafunction. In dentin, wear increases seven times faster Wear on the lower anterior teeth is one of the most common untreated problems. www.indiandentalacademy.com
  11. 11. Abrasion Abrasion is wear due to friction between a tooth and an exogenous agent. Chewing on a food bolus or from tobacco chewing. From overzealous toothbrushing or improper use of dental floss, toothpicks, pencils, or any foreign object. www.indiandentalacademy.com
  12. 12. Erosion Erosion is tooth surface loss due to chemical or electrochemical action. It can be endogenous or exogenous. It does not include association with bacterial activity. Endogenous erosion: Bulimia, Gastroesophageal reflux disease (GERD) and Gingival crevicular fluid. www.indiandentalacademy.com
  13. 13. Exogenous erosion: Any food or liquid with a pH of less than 5.5 can demineralize teeth. "Coke swishers" and "fruit mullers“ Evidence of erosion is obvious because cupped-out dentin areas cannot be contacted by opposing teeth.www.indiandentalacademy.com
  14. 14. Splayed teeth Mandibular deflection force the upper anterior teeth forward. Other signs are fremitus and soreness of the anterior teeth. Improperly contoured restorations that are too thick on the lingual of the upper anterior teeth or overcontoured lower restorations. www.indiandentalacademy.com
  15. 15. Destroyed Dentition Result of not intercepting occlusal disease early. Severe wear, fractured teeth, and elongated alveolar processes are typical when treatment of delta-stage bruxism is delayed. www.indiandentalacademy.com
  16. 16. Advanced occlusal disease This disease results from a combination of attritional wear and moved teeth. www.indiandentalacademy.com
  17. 17. Anterior guidance attrition Occurs when anterior teeth that either interfere with centric relation closure or interfere with functional jaw movement patterns (envelope of function). www.indiandentalacademy.com
  18. 18. Sensitive teeth One of common cause of hypersensitivity is occlusal overload Pulp may be vital. Result from pulpal hyperemia or from the effects of non- carious cervical cracks. www.indiandentalacademy.com
  19. 19. Sore teeth Compression of periodontal ligaments and pulpal hyperemia If empty mouth clenching causes any discomfort in a tooth, it is an indication that the sore tooth is in occlusal interference. www.indiandentalacademy.com
  20. 20. Hypermobility An early sign of occlusal disease. Result in widened periodontal space and greater susceptibility to periodontal disease. Deflective contact or occlusal overload is a factor. www.indiandentalacademy.com
  21. 21. Split teeth and fractured cusps Fracture lines routinely develop when a cusp incline interferes with strong occlusal forces. Sign of occlusal disease that precedes cusp fracture or split tooth. www.indiandentalacademy.com
  22. 22. Painful musculature Deflective occlusal interferences that require the jaw joints to displace to achieve maximum intercuspation are a potent cause for painful masticatory musculature. Excessive wear, hypermobility, fractured cusps, and hypersensitivity. www.indiandentalacademy.com
  23. 23. Determinants of occlusion Determination of the correct physiologic jaw relationship must always be determined before we can determine the correct alignment and occlusal relationship of the teeth. The teeth must fit into the harmony of the jaw relationship and not vice versa www.indiandentalacademy.com
  24. 24. Primary requirements for successful occlusal therapy I. Comfortable and stable TMJs: Must be able to function and accept loading forces with no discomfort. Starting point for any dental treatment that involves the occlusal surfaces of the teeth. II. Anterior teeth in harmony with the envelope of function and in proper relationship with the lips, the tongue and the occlusal plane.www.indiandentalacademy.com
  25. 25. III. Non-interfering posterior teeth: posterior occlusal contacts should not interfere with either the comfortable TMJs in the back or the anterior guidance in the front. www.indiandentalacademy.com
  26. 26. Temporomandibular Joint The first requirement for successful occlusal treatment is stable, comfortable TMJs. The jaw joints must be able to accept maximum loading by the elevator muscles with no sign of discomfort. The articulating surfaces: In opening-closing movements the two condyles form a common axis and act as one hinge joint. www.indiandentalacademy.com
  27. 27. The fact that the condyles are rarely symmetric, the axial rotation occurs around a true hinge that is on a fixed axis when the condyles are fully seated. www.indiandentalacademy.com
  28. 28. Each condyle is normally at about a 90-degree angulation with the plane of the mandibular ramus, which places their alignment at an obtuse angle to each other. The medial pole serve as a point of rotation. Its triangular shape serves this mechanical function very well. www.indiandentalacademy.com
  29. 29. The medial part of the fossa is reinforced with thick bone so it can also serve as a stop for the upward force of the elevator muscles and the inward force of the medial pterygoid muscles. www.indiandentalacademy.com
  30. 30. The TMJ is designed as a load-bearing joint and must be capable of resisting forces that measure into hundreds of pounds. The articular eminence forms the anterior part of the articular fossa. Because of the slightly forward pull of the elevator muscles, the condyles are always held firmly against the eminence. The importance of the biconcave articular disk that fits between the two convex surfaces. www.indiandentalacademy.com
  31. 31. The disk divides the joint into an upper and a lower compartment. The lower compartment serves as the socket in which the condyle rotates, whereas the upper compartment allows the socket to slide up and down the eminence. Thus the mandible can hinge freely as either one or both condyles translate forward. The disk itself is a classic example of design for function. www.indiandentalacademy.com
  32. 32. It is composed of layers of collagen fibers oriented in different directions to resist the shearing effect that might occur in a sliding joint. The bearing area is avascular, and so it is nourished by synovial fluids that also lubricate the joint for smooth gliding function. The disk is firmly attached to the medial and lateral poles of the condyle. www.indiandentalacademy.com
  33. 33. The diskal ligaments allow it to rotate from the front of the condyle to the top and vice versa. In normal function, the disk is always positioned so that pressure from the condyle is directed through its central bearing area. Positioning of the disk is controlled by the combination of elastic fibers attached to the back of the disk and the superior lateral pterygoid muscle that is attached to the front of the disk. www.indiandentalacademy.com
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  35. 35. Condyle disk alignment Medial and lateral diskal ligaments The disk is designed to rotate on the condyle like a bucket handle that attaches to the medial and lateral poles of the condyle (collateral ligaments). www.indiandentalacademy.com
  36. 36. This allows the disk to rotate from the top of the condyle to the front and back so it can stay aligned with the direction of force as the condyle moves up and down the curved eminentia. www.indiandentalacademy.com
  37. 37. Posterior ligament The disk is tethered to the back of the condyle by an inelastic band of collagen fibers. Prevents the disk from rotating too far forward and being displaced anteriorly. To permit any forward displacement it must be stretched or torn. www.indiandentalacademy.com
  38. 38. Superior elastic stratum Elastic fibers bind the disk to the temporal bone behind it and maintain constant tension on the disk toward the distal. www.indiandentalacademy.com
  39. 39. Superior lateral pterygoid muscle The only forward pulling force that could anteriorly displace the disk In combination with the elastic fibers behind the disk controls the position of the disk on the condyle so it is always aligned with the direction of force as the condyle moves down the slope of the eminentia. www.indiandentalacademy.com
  40. 40. How muscle controls disk alignment Opening Condyle disk assembly is fully seated in centric relation with disk positioned at the most forward position that the posterior ligament allows. Forces from condylar loading are directed up through the medial third of the disk and forward through the anterior surface of the condyle against the steepest part of eminentia.www.indiandentalacademy.com
  41. 41. As the inferior lateral pterygoid muscle (+) starts to pull the condyle forward the superior lateral pterygoid muscle (-) releases contraction to allow the elastic to start pulling the disk more to the top of the condyle www.indiandentalacademy.com
  42. 42. Maximum opening When the condyle reaches the crest of the eminence, the disk should be directly on top of the condyle as forces are directed upwardly against the flattest part of the articular eminence. Elastic fibers have rotated the disk back because the superior lateral pterygoid muscle is in controlled release. www.indiandentalacademy.com
  43. 43. Closing As the jaw closes, the condyle starts to move back and up steeper slope of the articular eminence, so the disk must be pulled back to the front of the condyle. Superior lateral pterygoid muscle ( +) starts its contraction as the inferior lateral pterygoid muscle ( -) releases condyle to the elevator muscles. www.indiandentalacademy.com
  44. 44. Closed When the condyle reaches centric relation, the disk has been pulled as far forward as the posterior ligament will allow. If the ligament is intact the disk is stopped in perfect alignment with the direction of loading through the condyle. In the absence of occlusal interferences to centric relation, the inferior lateral pterygoid muscle will stay passive, even if the patient clenches. The superior belly holds its contraction to maintain the disk in its correct alignment. www.indiandentalacademy.com
  45. 45. www.indiandentalacademy.com
  46. 46. Disk rotates to the top of the condyle as it approaches the crest of the eminentia, the inelastic posterior ligament folds. The functional aligning of the disk is an example of the importance of the coordinated contraction and release of the neuromusculature system in harmony with mandibular function. www.indiandentalacademy.com
  47. 47. The temporomandibular ligament Does not come into function until the jaw opens to 20 mm or more and reaches its limit of length and stops the mandible from opening further in centric relation. The attachment of the ligament to the posterior side of the neck becomes a fulcrum that forces the condyle to translate forward as the jaw opens further. Not a factor in centric relation as it is not at its full length when the condyle disk assemblies are fully seated. www.indiandentalacademy.com
  48. 48. Misconception about joint physiology and anatomy Centric relation is not a physiologic position because "it is a border position in which joints do not normally function." All joints, including the TMJs, function in a fully seated position in their sockets. Fully loaded at an end point of compression, the condyles are similarly loaded in centric relation by the elevator muscles. Centric relation is not a ligament braced position, but rather it is the physiologic end point that is achieved by coordinated muscle function during jaw closure. www.indiandentalacademy.com
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  50. 50. The arteriovenous shunt As each condyle disk assembly moves down the eminence it evacuates the space up in the fossa. So the retrodiskal tissue must expand to fill the space evacuated by the condyle and disk. It does this by a rush of blood into a network of vessels that are spread through the spongy retrodiskal tissues. When the condyle and disk return to centric relation, the blood flows out and the vessels contract in size. www.indiandentalacademy.com
  51. 51. www.indiandentalacademy.com
  52. 52. It makes the retrodiskal tissue highly vascular and richly innervated. If the disk is displaced anteriorly, the condyle loads onto this tissue and causes pain. Inflammation and edema in these tissues are always considerations when the joint is traumatically loaded www.indiandentalacademy.com
  53. 53. Masticatory musculature When bone and muscle war; muscle never loses. (Harry Sicher) When teeth and muscle war; muscle never loses. (Peter E. Dawson) Muscle is the primary focus in vertical dimension, the neutral zone, arch form, occlusal disease, orofacial pain, and even smile design. Incoordinated, hyperactive musculature can over time, displace the disk from a condyle and cause a variety of structural deformations to the TMJs.www.indiandentalacademy.com
  54. 54. Coordinated muscle function during jaw opening Timely release of muscle or group of muscles as contraction of antagonistic muscles takes place. As the jaw opens, the depressor muscles contract while the elevator muscles release their contraction. www.indiandentalacademy.com
  55. 55. Coordinated muscle function during jaw closure As the jaw closes, the elevator muscles contract while the depressor muscles release contraction. In the absence of deflective occlusal interferences, inferior lateral pterygoid muscle stays passive even during firm clenching.www.indiandentalacademy.com
  56. 56. Coordinated muscle function at maximum intercuspation Release of the inferior lateral pterygoid muscle during elevator muscle contraction is the goal of occlusal harmony. Condyle-disk assemblies can completely seat up into their respective fossae during closure into maximum intercuspation. www.indiandentalacademy.com
  57. 57. Disharmony between the occlusion and the TMJs If the condyles must be displaced from centric relation to achieve maximum intercuspation, the inferior lateral pterygoid muscle must contract Condyles must be pulled down as they are pulled forward. www.indiandentalacademy.com
  58. 58. Muscle response to occlusal interference Occlusal interference evokes a response of hyperactivity and incoordinated contraction Interfering tooth becomes sensitive and sore. Prolonged hyperactivity of the temporal muscles, tension headaches in that region occur www.indiandentalacademy.com
  59. 59. Placement of a simple flat interocclusal device on the anterior teeth separates the posterior teeth. Lateral pterygoid muscles releases contraction and return to coordinated muscle function. The relief of all symptoms is almost immediate unless there is an intracapsular structural disorder. www.indiandentalacademy.com
  60. 60. Muscle response to posterior disclusion When the posterior teeth are separated in all eccentric jaw movements by the combination of anterior guidance and condylar guidance more than two-thirds of the elevator muscle force is shut off. i. It greatly reduces the horizontal forces against the anterior teeth, which are the only teeth in contact during excursions. ii. It reduces the compressive loading forces on the TMJs. iii. It makes it impossible to overload or wear the posterior teeth, even if the patient bruxes.www.indiandentalacademy.com
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  63. 63. Causative factor in disk derangements In a healthy, intact TMJ, the disk is self-centering. Incoordinated muscle activity pulls the disk forward while the elevator muscles pull the condyle up and back, applying tensile force to the posterior ligament of the disk. The ligament must be stretched www.indiandentalacademy.com
  64. 64. The ligament must be torn The attachment of the ligament must migrate. www.indiandentalacademy.com
  65. 65. Centric relation 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 emineniae irrespective of vertical dimension or tooth position. www.indiandentalacademy.com
  66. 66. At the most superior position, the condyle-disk assemblies are braced medially, thus centric relation is also the midmost position. www.indiandentalacademy.com
  67. 67. A properly aligned condyle- disk assembly in centric relation can resist maximum loading by the elevator muscles with no sign of discomfort. www.indiandentalacademy.com
  68. 68. The mandible is in centric relation if five criteria are fulfilled:  The disk is properly aligned on both condyles.  The condyle-disk assemblies are at the highest point possible against the posterior slopes of the eminentiae.  The medial pole of each condyle-disk assembly is braced by bone. www.indiandentalacademy.com
  69. 69.  The inferior lateral pterygoid muscles have released contraction and are passive.  The TMJs can accept firm compressive loading with no sign of tenderness or tension www.indiandentalacademy.com
  70. 70. Using bilateral manipulation to find and verify centric relation or adapted centric posture PROCEDURE: Step one: Recline the patient all the way back Step two: Stabilize the head. www.indiandentalacademy.com
  71. 71.  Step three: After the head is stabilized, lift the patient's chin again to slightly stretch the neck  Step four: Gently position the four fingers of each hand on the border of the mandible. www.indiandentalacademy.com
  72. 72. Step five: Bring the thumbs together to form a C with each hand Ensure that the fingers are properly positioned www.indiandentalacademy.com
  73. 73. Step six: With a very gentle touch, manipulate the jaw so it slowly hinges open and closed Step seven: After the mandible feels like it is hingeing freely and the condyles seem to be fully seated up in their fossae, the mandible is in centric relation. www.indiandentalacademy.com
  74. 74. The position and alignment of each condyle must be tested by applying firm pressure Load testing must be applied in increments starting with gentle upward pressure through the condyles while the thumbs keep the teeth apart www.indiandentalacademy.com
  75. 75. If there is no response of discomfort, proceed to moderate pressure and then firm pressure. With correct manipulation, there is a torque effect from the thumbs and fingers that loads the joints in an upward and forward direction. www.indiandentalacademy.com
  76. 76. With proper hand position, very firm upward pressure be maintained through the condyles, while still allowing them to rotate freely www.indiandentalacademy.com
  77. 77. Bilateral manipulation provides a quick verification of: a. The correctness of the position. b. The alignment of the condyle-disk assembly. c. The integrity of the articular surfaces. www.indiandentalacademy.com
  78. 78. OTHER METHODS Directly fabricated anterior deprogramming device Mandible is manipulated to centric relation, or as close to it as can be achieved. The jaw is then closed so the lower incisors indent the soft acrylic, but closure is stopped short of posterior contact. www.indiandentalacademy.com
  79. 79. The tooth contact surface is ground to a smooth flat surface that permits full horizontal movement of the mandible. If the TMJs are intact and the lateral pterygoid muscles are completely released and passive, the patient can squeeze firmly to hold the condyles in centric relation as a fast setting bite material is injected between the posterior teeth. www.indiandentalacademy.com
  80. 80. The Pankey Jig. The Best-bite Appliance: A kit is available with an injection material for stabilizing the appliance. www.indiandentalacademy.com
  81. 81. The Lucia jig NTI (Nociceptive trigeminal Inhibition) www.indiandentalacademy.com
  82. 82. Leaf Gauge: consists of layers of flexible mylar that can be adjusted to varying thicknesses. The material is smooth and slick, so it allows the mandible to move horizontally as the condyles seat up. www.indiandentalacademy.com
  83. 83. Disadvantages of anterior bite stops During equilibration procedures, marking occlusal interferences with an anterior bite stop in place. Even with an anterior bite stop in place, load testing to verify centric relation is the only sure way to ensure accuracy. Combining bilateral manipulation with an anterior deprogrammer appliance if helpful to the operator, should be used. www.indiandentalacademy.com
  84. 84. Recording of centric relation Reasons for error: Improper manipulation (chin point guidance or forcing) No guidance or verification of centric relation Flimsy bite-recording materials. Rubbery materials are consistently inaccurate because there is no stable position for seating the casts in the record. www.indiandentalacademy.com
  85. 85. Too-deep indentations into the bite material causing the compression of soft tissue in the mouth. Use of soft waxes that are easily distorted when casts are seated into the record. Too shallow or nonexistent indentations into part of a bite record so there is no verifiable position for the casts to seat into the record Unstable bite-recording materials that warp or distort after the recording is made www.indiandentalacademy.com
  86. 86. Criteria for accuracy The bite record must not cause any movement of teeth or displacement of soft tissue. It must be possible to verify the accuracy of the interocclusal record in the mouth The bite record must fit the casts as accurately as it fits in the mouth Must be possible to verify the accuracy of the bite record on the casts. The bite record must not distort during storage or transportation to the laboratory. www.indiandentalacademy.com
  87. 87. Wax bite record Delar wax: brittle-hard wax supplied in sheets that are thicker at the front for more even penetration teeth from back to front. www.indiandentalacademy.com
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  90. 90. Anterior stop techniques www.indiandentalacademy.com
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  93. 93. Dawson's classification Type I: Maximal intercuspation is in harmony with centric relation. Implications for type I  Centric relation is verifiable with the teeth separated.  No discomfort in the TMJ region even when loaded. www.indiandentalacademy.com
  94. 94. Jaw can close to maximal intercuspation without pre mature tooth contacts or deflections . Occlusal equilibration is not needed except for possible excursive interferences. Patient can clench with no sign of discomfort. An occlusal splint is not indicated. Type I occlusion can occur with any Angle's classification. www.indiandentalacademy.com
  95. 95. Type I A: Maximal intercuspation occurs in hamony with adapted centric posture. Implications for Type I A  Inter capsular structures have deformation but have adapted  TMJs can accept loading with no discomfort.  Treatment for TMD is not needed.  Occlusal correction is not needed because there is no occlusion disharmony. www.indiandentalacademy.com
  96. 96. Type II: Condyles must displace from a verifiable centric relation for maximum intercuspation to occur. Type IIA: Condyles must displace from an adapted centric posture for maximum intercuspation to occur. www.indiandentalacademy.com
  97. 97. Implications for Type II or IIA Centric relation or adapted centric posture has been verified so discomfort from an intracapsular disorder has been ruled out. Prognosis is excellent if all occlusal interferences are eliminated. TMJ surgery, arthroscopy, joint injections, or lavage are contraindicated. The occlusal therapy goal is to achieve type I or IA. www.indiandentalacademy.com
  98. 98. Type III: Centric relation cannot be verified. Implications for Type III Need for Piper classification of TMJs. Focus on correcting the TMD before occlusal treatment Treatment vary from a simple permissive occlusal device to relieve muscle spasm, to surgical correction of intracapsular disorders. The treatment goal is Type I or IA. www.indiandentalacademy.com
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  100. 100. Type IV: The occlusal relationship is in an active stage of progressive disorder because of pathologically unstable TMJs. Implications for Type IV An actively progressive disorder of the TMJs Impossible to establish a stable TMJ/occlusion relationship Typical signs of type IV are:  Progressive anterior open bite  Progressive asymmetry  Progressive mandibular retrusion www.indiandentalacademy.com
  101. 101. Stop the progression of the TMJ deformation until manageable stability of the TMJs can be confirmed. Occlusal treatment is contraindicated at this stage www.indiandentalacademy.com
  102. 102. For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com