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ePaper created 2018-05-16, 11:45:19 | version 1.38.0
REDEFINING FUNCTION IN A COMPLEX BRUXING CASE — Treatment position and occlusal considerations Dr. Ilia Roussou, Greece — Dr. Ilia Roussou, Greece Occlusion confusion is common among dentists. Occlusion is one of the most important considerations in dentistry, but also most controversial. The balance and the restoration of function of the stomatognathic system is often an every- day challenge during many dental treat- ments. For these distinct reasons, the dentist needs to study and fully under- stand the normal function of the temporo mandibular joints, how the man- dible rests against the cranium in the most favorable position, and of course how occlusion and any dental prosthetic res- torations should be adjusted without jeopardizing the stability of the stomatog- nathic system. Severe wear, missing teeth and perio- dontal disease over the years change the maximum intercuspation the patient had when his or her teeth were intact. For example, it is very common for patients with severe wear of their dentition to present with contacts of their anterior teeth in a Class III tendency relationship, which can also be described as a pseudo Class III malocclusion according to An- gle’s classification. Determining the treatment position during full-mouth prosthetic reconstruction or ortho- dontic treatment is a challenge. Dentists often choose to maintain the occlusal relationship the patient presents with. This clinical decision can lead to occlusal discrepancies upon delivery of the final restorations, temporomandibular pain symptoms and discomfort of the patient. Therefore, it is essential to register and maintain the orthopedic stability of the stomatognathic system during the treat- ment and determine the musculoskeletal- ly stable position during the dental proce- dures. In this case presentation, several common clinical problems that the dentist often has to deal with in everyday practice will be presented and the treatment se- quence to maintain the stability of the stomatognathic system will be presented. A 57-year-old male patient presented to a private clinic with his chief complains related to functional difficulties and con- siderable esthetic impairment created by the appearance of his teeth. Owing to severe wear of his dentition, the dentin was exposed on all of his teeth (Fig. 1). The patient was aware of his parafunction- al activity of bruxism that had never been addressed. Although the wear was signif- icant, he complained of no sensitivity to chemical and thermal stimuli. He also complained of no pain or other symptoms related to a temporomandibular disorder. During clinical examination, a clicking sound was detected at the right temporo- mandibular joint during opening and clos- ing, indicating a disk displacement with reduction in this joint that was however asymptomatic. The range of movement was within normal limits, and the left and lateral movements were 12 and 15 mm, respectively. Intraorally, the effects of bruxing on the dental tissue were significant. The masti- catory surface of the posterior teeth was completely flat, without any cusps and/or physiological anatomy (Fig. 2). Dentin exposure was present on all of the posterior teeth. The anterior teeth also presented with severe wear and dentin exposure. Because of the lack of physiological anatomy and the flat masticatory surfaces, no stable maximum intercuspation was present. The patient, as already mentioned, had a pseudo Class III relationship (Fig. 3), since his most comfortable bite was in an edge-to-edge anterior relationship while all the posterior teeth were also in occlu- sion. Nevertheless, the patient described feeling like he had several bites, none of which were comfortable. Important clinical dilemmas arise in such a case. The diagnostic questions that need to be answered before the treat- ment plan are as follows: 76 — issue 2018 Clinical Mentoring Article