14 Occlusal therapy for management of TMDs.pptx

Occlusal Therapy For Management
of Temporomandibular Disorders
Presented by:
Dr.Ch.Praveena,
Third year PG Student,
Department of Prosthodontics,
Sibar Institute of Dental Sciences,
GUNTUR.

Previously Asked Questions
Prosthodontic maagement of disturbed masticatory
system. (100 Marks,1999; NTRUHS)
Methods of occlusal correction in TMJ pain syndrom
(7 marks, 2003 & 2012; NTRUHS)
Pathologic occlusion (7 marks; NTRUHS)

C
O
N
T
E
N
T
S
 Introduction
 What is occlusal therapy??
 Reversible
 Irreversible
 General Considerations for occlusal
therapy
 Centric Relation & Adaptive centric posture
 Methods of recording
 Indications for occlusal therapy
 Treatment goal for MS position
 Treatment planning
 Rule of thirds
 Factors influencing the treament planning
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Occlusal Therapy for Managenment of TMDs - 85

C
O
N
T
E
N
T
S
 Use of articulators in Occlusal therapy
 Occlusal Equilibration/Selective grinding
 Developing acceptable CR contact position
 Developing acceptable lateral & protrusive
guidance
 Restorative considerations in occlusal
therapy
 Operative considerations
 Fixed Prosthodontics considerations
 Criteria for success of occlusal treatment
 Post-operative care of occlusal therapy
patients
 Review of literature
 Conclusion
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5 Occlusal Therapy for Managenment of TMDs - 85

What is Occlusal Therapy
Occlusal therapy is “any treatment that alters a
patient's occlusal condition ”.
 It can be used to improve function of the
masticator
system through the influence of the occlusal
contact
patterns and by altering the functional jaw
position.
 Occlusal therapy can be reversible or
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• Temporarily alters occlusal
condition, joint position, or both.
• Eg: Occlusal appliances.
Reversible
Occlusal
Therapy
• Permanently alters occlusal
condition.
• Eg: Selective grinding, Fixed
prosthetic procedures &
orthodontic therapy.
Irreversible
Occlusal
Therapy
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Centric Relation & Adaptive Centric Posture
Centric Relation Adaptive Centric Posture
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Five Criteria for Mandible in CR /
Adaptive Centric Posture
1. The condyles are comfortable when fully seated
at
the highest point against the eminentiae.
2. The medial poles are braced against bone.
3. The inferior lateral pterygoid muscle has
released its
contraction and is passive.
4. The condyle-fossae relationships are at a
manageable level of stability.
5. Just as in centric relation, the joints must be
totally
free of any tension or tenderness when load
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Determining Centric Relation by
Bimanual Method and why ???
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12

Other Methods For Determining Centric
Relation Or Adapted Centric Posture
The Lucia Jig
Ant deprogramming device The Pankey jig The Best-bite appliance
NTI Device Leaf Guage
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13

Treatment Goals For The
Musculoskeletally Stable Position (CR)
1.The condyles are resting in their most
superoanterior position against the posterior
slopes of the articular eminences.
2. The articular discs are properly interposed
between
the condyles and the fossae. In those cases
when a disc derangement disorder has been
treated, the condyle may now be articulating on
adaptive fibrotic tissue with the disc still
displaced or even dislocated. 10/21/2022
14

3. When the mandible is brought into closure in the
MS
position, the posterior teeth contact evenly and
simultaneously. All contacts occur between
centric
cusp tips and flat surfaces, directing occlusal
forces
through the long axes of the teeth.
4. When the mandible moves eccentrically, the
anterior
teeth contact and disocclude the posterior teeth.
5. In the upright head position (alert feeding
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Treatment Planning for Occlusal Therapy
Two general considerations exist:
(1) The simplest treatment that will accomplish
the
treatment goals is generally the best, and
(2) Treatment should never begin until the
clinician
can visualize the end results.
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The “Rule of Thirds”
 Divide Inner Incline
of Centric Cusp into
1/3
 Where opposing
cusp hits is a guide
to treatment:
1. Closest to
Fossa: Selective
Grinding
2. Middle 1/3:
Restorative/Fixe
d
Buccal
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Occlusal Therapy for
Managenment of TMDs - 85

Factors that Influence the Treatment Planning
(1) Symptoms
(2) Condition of the dentition
(3) Systemic health
(4) Esthetics, and
(5) Finances.
Prioritizing the factors
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Use of Articulators in Occlusal Therapy
 In Diagnosis
 Improve visualization
 Ease of mandibular movement
 In treatment planning
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Understanding the limitations of Articulators
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20

Occlusal Equilibration/ Selective Grinding
“The modification of the occlusal
form of the teeth with the intent
of equalizing occlusal stress,
producing simultaneous occlusal
contacts or harmonizing cuspal
relations.”
1.Don’t equilibrate if the outcome is in doubt.
2. A successful outcome can be determined in
advance
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Important Considerations in
Selective Grinding
 Patient awareness and acceptance. The
treament outcome should be explained.
 A well-performed selective grinding will enhance
function of the masticatory system. On the other
hand, a poorly performed selective grinding may
a create positive occlusal awareness.
 Selective grinding is performed in a quiet and
peaceful setting. The patient is reclined in the
dental chair and approached in a soft, gentle,
and
understanding manner.
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Indications of Occlusal Equilibration
 Assist in managing certain
temporomandibular disorders (TMDs) and
 Complement treatment
associated with major
occlusal changes.
“Selective grinding: one of the most difficult
and demanding procedures in dentistry.”
- JP Okeson.
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Acceptable CR
Contact Position
Acceptable
Lateral &
Protrusive
Guidance
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Interference to
Line of Closure/
Buccolingual
discrepancy
Interference to
Arc of Closure/
Anteroposterior
discrepancy
Developing an Acceptable
CR Contact Position
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Interferences to Line of Closure
 Line of closure interferences refers to deviation
of mandible to left or right from the first point of
contact in centric relation to the most closed
position.
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 The “rule of thirds” is helpful in predicting the
success of a selective grinding procedure. It deals with
the buccolingual arch discrepancy when the
condyles are in the musculoskeletally stable position.
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27

10/21/2022
28

Anteroposterior Discrepancy/
Interferences to Arc of Closure
 Once the buccolingual discrepancy of the posterior
teeth is examined (rule of thirds), the patient applies
force to the teeth.
 An anterosuperior shift of the mandible from CR to
ICP will be noted.
 The shorter the slide, the more likely it is that selective
grinding can be accomplished within the confines of
the enamel.
 Normally an anterior slide of less than 2 mm can be
successfully eliminated by a selective grinding
procedure.
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“Slide” In Centric
RC POSITION
MI POSITION
Pin Height
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MI POSITION
RC POSITION
Pin Height
VERTICAL SLIDE
HORIZONTAL SLIDE
HABITUAL
ARCH OF
CLOSURE
CR=HINGE AXIS
Measuring Amount of Slide
10/21/2022

RC POSITION
Pin Height
Correcting the slide RC MI
CUT #1: HOLLOW
GRIND FOSSA
MESIAL-FACING
SLOPE OF
UPPER TEETH
(MU)
CUT #2: HOLLOW
GRIND FOSSA
DISTAL-FACING
SLOPE OF
LOWER TEETH
(DL)
GRINDING
RULE
MUDL
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CR OCCLUSION
Pin Height
“OLD” MI POSITION
“LONG” CENTRIC
The Result…
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Grinding Rules
 Rule 1: Narrow stamp cusps before reshaping
fossae
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34

 Rule 2: Don’t shorten a stamp cusp
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 Tilted Teeth
A, Moving cusp tip by selective grinding.
B, Grinding upper fossa does not improve cusp tip position
and mutilates the upper tooth.
C, Grinding buccal of lower positions tip in the center.
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 Rule 3: Adjust centric interferences first.
 Improving cusp-tip position.
Occlusal grinding is more evenly distributed
to both arches.
Eccentric interferences can be eliminated
with speed and simplicity.
 Rule 4: Eliminate all posterior incline contacts.
Preserve cusp tips only.
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Developing An Acceptable
Lateral and Protrusive Guidance
1. Acceptable laterotrusive contacts occur
between the buccal cusps and not the lingual
cusps. Lingual laterotrusive contacts, as well
as mediotrusive contacts, are always
elimininated.
2. Protrusive movements are best guided by the
anterior teeth and not the posterior teeth.
During a
 straight protrusive movement - mandibular
incisors
 lateroprotrusive movement- the laterals
 more lateral movement- the canines begin to
contribute to the guidance.
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Lateral Excursion Interferences
Border
movement of
Condyle
The Anterior
Guidance
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 Lateral Interferences can be working side and
balancing side interferences.
 No balancing side contacts
to be present.
 Grinding rule: BULL.
 Working side Rule: LUBL.
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Lateral Slide in Centric – Cut #1
45
CUT #1 – WIDEN
FOSSA & REMOVE
PORTION OF
LINGUAL CUSP IF
ABSOLUTELY
NECESSARY
10/21/2022

Lateral Slide in Centric – Cut #2,3
45
CUT #2 & 3-WIDEN
FOSSA (FACES
DIRECTION OF
SLIDE) & REMOVE
PORTION OF
NON-WORKING
CUSP IF
NECESSARY 10/21/2022
42

Lateral Slide in Centric-Cut #4
45
CUT # 4-WIDEN FOSSA OF
35 (FACES AWAY FROM
DIRECTION OF SLIDE) &
REMOVE PORTION OF
NON-WORKING CUSP IF
NECESSARY
10/21/2022

Lateral Slide in Centric-Final Result
35
10/21/2022

Technique
 After the CR contacts are established, they
should never be altered. All adjustments for
the eccentric contacts occur around the CR
contacts .
 The patient closes in CR, and the relationship
of the anterior teeth is visualized.
Canine
Guided
Group
Function
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A) Canine Guidance
B) Cross- over
A
A
B
B
A) In ICP, Canine providing
Anterior Guidance
B) In working movement
1st PM providing guidance.
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 After determining desirable
guidance eccentric contacts
are eliminated.
 All eccentric contacts are
marked in blue, & CR contacts
are marked in red.
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 Procedure for canine guidance:
All blue marks on the posterior teeth are
eliminated without alteration of the
established CR contacts (red).
 Procedure for group function guidance:
All the blue contacts on the posterior teeth
are not eliminated. Selected posterior teeth
are necessary to assist in the guidance.
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Protrusive Excursion
Interferences
 Only the front teeth should touch in protrusive
excursions.
 Grinding Rule: DUML
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Desired result of Selective
Grinding
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Evaluation in Alert Feeding Position
 In the upright position with the head tilted
forward approximately 30 degrees (to FH
plane), the patient closes on the posterior
teeth.
 If the posterior teeth are contacting
predominantly, minimal postural change has
occurred and the selective grinding procedure
is complete.
 If, however, the anterior teeth are contacting
heavily or both anterior and posterior teeth are
contacting evenly, a final adjustment in the
alert feeding position is necessary.
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Locating Contacts
 DRY TEETH FIRST!
 Use both shim stock
and articulating
paper
 Shim stock tells you
if a contact is there,
and how heavy it is.
 Paper tells you
where the contact is.
Arnamentarium for
Equilibration
Ribbons
Miller’s ribbon holder
Marking paper
Waxes
Pates, Sprays/ Paint on
material
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T- Scan and Mat Scan
10/21/2022 53

Operative Considerations in Occlusal Therapy
 Treatment Goals
1) For Tooth Contacts
a) Posterior contacts: Even simultaneous contacts
with existing posterior tooth contacts.
b) Anterior contacts : Should not exert heavy
forces.
2) For mandibular position : Restorations are
developed in ICP.
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Establishing Posterior Contacts
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56

Establishing Anteriors contacts
Heavy anterior tooth contacts can be detected by placing the
finger on the labial surface of the anterior teeth while the
patient repeatedly closes and taps the posterior teeth
together.
10/21/2022
57

Fixed Prosthodontic Considerations
in Occlusal Therapy
Surface
to
surface
contact
Tripod
contact
Cusp tip
to fossa
contact
Types of Centric holding
contact
10/21/2022
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Treatment goals
1) For Tooth Contacts
a) Posterior contacts:
b) Anterior contacts : Should not exert heavy
forces.
2) For mandibular position :
a) Functional disturbance
b) Extent of treatment
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Steps in fabricating custom guide
table
 Raise the incisal pin
atleast 1mm above
the incisal table
 Lubricate the
spherical end of Pin
with petroleum jelly
 Pantacrylic is mixed
to an almost putty
consistency
Establishing Anteriors contacts
Adequate guidance
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Straight protrusion
10/21/2022

Establishing Anteriors
contacts
Inadequate guidance
 Provisionalization
 Diagnostic Pre-wax
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Establishing Posterior Contacts
 When adequate guidance is present, the
posterior teeth should contact only in the
closed position and not during any eccentric
movement.
 The posterior contacts must provide stability.
 Accomplished by developing
 A tripodization contact pattern for the centric
cusps or
 A centric cusp tip–to–flat surface contact
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Tripod contact:
 In tripod contact the tip of the
cusp never touches the
opposing tooth. Instead,
contact is made on the sides
of the cusps that are convexly
shaped.
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 Lateral and protrusive disclusion of posterior teeth is
essential whenever tripod contact is used.
 Tripod contact is extremely difficult or impossible to
equilibrate without losing tripoidism and ending up
with contact on inclines.
 Main reason for the popularity of tripoidism is the
impression that it is so stable if it is properly done.
One should thoughtfully evaluate its
practicality
10/21/2022
66

Cusp tip-to-fossa contact:
 If cusp tips are properly
located in the most
advantageous fossae, this
type of occlusion offers
excellent function and stability
with the flexibility to choose
any degree of distribution of
lateral forces that is
warranted.
 It is the easiest occlusion to 10/21/2022
67

 With cusp tip-to-fossa contact, it is not
necessary to restore upper and lower teeth
together .
 It serves the goal of function rather than form.
 It can be accomplished with the aid of
gnathologic instrumentation, functional path
procedures, or a myriad of other
instrumentation techniques 10/21/2022
68

Waxing technique for maxillary 1st
Molar
Prepared Die Buccal view
Lingual view Wax coping
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69

BO,LO & CF lines are drawn
Step1: Centric Cusp(lingual) tips
Step2: MMR &DMR (Blue wax)
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70

Step 3 : Centric Fossa Contact Area(Blue)
Step 4 : Lingual cusp ridges (Red wax)
Step 5& 6: ML & DL cusp ridges (green)
Lingual cusp triangular ridges
Step 7 : Non-Centric
Cusp tips (Ivory)
Step 10 : Buccal Cusp
triangular ridges (Red )
Step 8 : Buccal cusp ridges (Red )
9: MB & DB ridges (green)
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Final wax pattern when colored waxes are used. The cusp
tips are
in ivory wax. The other areas are red (R), blue (B), and green
(G)
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Criteria for Success of Occlusal Treatment
 Load test is negative.
 Clench test is negative.
 Grinding test:
No posterior interferences.
 Fremitus test is negative.
 Stability test is positive.
 Comfort test is inclusive.
 Esthetics test is inclusive.
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Post-operative care of Occlusal therapy Patients
 Three “No’s”: No smoking, no hard candy & no
more than two soda drinks per week.
 The patient should learn to accomplish:
Cleanability, Cleanliness, Occlusal & TMJ
stability.
 Patients who are unable or unwilling to follow
hygiene
recommendations should be encouraged to come
in for more frequent recalls.
 Dietary counseling should be a part of any recall
appointment. 10/21/2022
74

 Patients should be told to report any of the
following indications of occlusal disharmony:
1. Any discomfort in the teeth when chewing.
2. Any indication of a “high” tooth or any sign that
one
or more teeth contact before the rest when
closing;
any tooth that can be made to hurt by biting on it.
3. Any sign of tooth hypermobility.
4. Any discomfort in the TMJ area.
5. Any limitation of function.
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Review of Literature
Turp JC, Greene CS, Strub JR
(2008)
 Reviewed the past, present and future of the
subject of occlusion.
 They described the importance of occlusion &
the importance of therapeutic occlusion and
its concepts and also the interrelation of
occlusion with TemperoMandibular
Disorders.
Turp JC, Greene CS, Strub JR. Dental occlusion: a critical reflection on
past,present
and future concepts. Journal of Oral Rehabilitation 2008; 35: 446-453.
10/21/2022
76

Forrester SE et al (2010)
 Measured neuromuscular function for the
masticatory muscles under a range of occlusal
conditions in healthy, dentate adults.
 He concluded that maximum masticatory
muscle activity requires bilateral posterior
contacts and the mandible to be in a stable
centric position, whilst with anterior teeth
contacts, both the muscle activity and the
degree of symmetry in muscle activity are
significantly reduced.
Forrester SE, Allen SJ, Presswood RG, Toy AC, Pain MTG. Neuromuscular funct
in healthy occlusion. Journal of Oral Rehabilitation 2010; 37: 663-9.
77

Abduo J, Tennant M, Mcgeachie J
(2013)
 Reviewed the prevalence of naturally
occurring lateral occlusion schemes.
 They summarized that the canine-guided
occlusion tends to be more frequently
observed during complete excursion and
group function occlusion is more frequent
during partial excursion.
 The studies revealed no relationship between
the lateral occlusion schemes and TMD
development.
Abduo J, Tennant M, Mcgeachie J. Lateral occlusion schemes in natural and
minimally
restored permanent dentition: a systematic review. Journal of Oral Rehabilitation
2013;
78

References
 Okeson JP: Management of
Temporomandibular Disorders and Occlusion.
St Louis, CV Mosby Co., 1989.
 The Glossary of Prosthodontic Terms, 8th
Edition (GPT-8). J Prosthet Dent. 2005; 94:10–
92.
 Dawson PE: Evaluation, Diagnosis, and
Treatment of Occlusal Problems. St Louis, CV
Mosby Co., 1961.
 Malone FP etal. Tylman’s theory and practice
of fixed prosthodontics. St Louis, CV Mosby
Co., 8th edn, 1997. 10/21/2022
80

 Rosenstiel FS, Land FM, Fujimoto J.
Contemporary fixed prosthodontics. St Louis,
CV Mosby Co., 4th edn, 2011.
 Dawson PE. A classification system for
occlusions that relates maximal intercuspation
to the position and condition of the
temporomandibular joints. J Prosthet Dent
1996; 75: 60-6.
 Wiens JP, Priebe JW. Occlusal stability. Dent
Clin North Am. 2014; 58(1): 19-43.
10/21/2022
81

 Turp JC, Greene CS, Strub JR. Dental occlusion:
a critical reflection on past, present and future
concepts. Journal of Oral Rehabilitation 2008; 35:
446-453.
 Forrester SE, Allen SJ, Presswood RG, Toy AC,
Pain MTG. Neuromuscular function in healthy
occlusion. Journal of Oral Rehabilitation 2010; 37:
663-9.
 Abduo J, Tennant M, Mcgeachie J. Lateral
occlusion schemes in natural and minimally
restored permanent dentition: a systematic review.
Journal of Oral Rehabilitation 2013; 40: 788-802.
10/21/2022
82

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