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ePaper created 2018-05-16, 11:45:19 | version 1.38.0
Fig. 1 Pre-op view. Severe loss of tooth structure was noticeable, with functional and esthetic impairment. Fig. 2 Pre-op view. Dentin exposure and a wider incisal edge due to significant wear of dental tissue on the maxillary anterior teeth. The anterior guidance was lost and the patient occluded on anterior teeth as well. Fig. 3 Stabilization appliance for the mandible. The decis- ion on a maxillary or man- dibular appliance was exclusively based on the prosthetic needs. In this case, it was decided that the maxillary arch would be restored first. Besides controlling the enormous bruxing forces, the stabilization appli- ance would determine the musculoskeletally stable position. Fig. 4 Initial relationship of anterior teeth. The patient presented with a pseudo Class III relationship, as most bruxing patients do once anterior guidance has been lost and the mastica- tory anatomy of posterior teeth flattens. Fig. 1 Fig. 2 Fig. 3 Fig. 4 – How can the bruxism be controlled? The bruxing forces applied to the patient’s natural teeth will also be applied to the future restorations. This consideration also leads to the next question. – What is the material of choice to with- stand the bruxing forces? – Should the vertical dimension of occlu- sion (VDO) be changed? Usually in brux- ing patients, although the wear of the dental structures might be significant, the VDO remains normal owing to the continuous eruption of the teeth. – What should the treatment position be? The patient presented with several bites and a pseudo Class III relationship. Most dentists would feel more comfortable maintaining the maximum intercuspation that the patient presented with, since he was asymptomatic, although most prob- ably it was not the one that the patient had when his dentition was still intact. Determining the 3-D position of the mandible and where it is resting against the rest of the stomatognathic system should be a priority. – Is digital dentistry an option? How can the bruxism be controlled? Bruxism is an involuntary parafunction- al movement that often occurs without the patient even realizing it. The etiolo- gy is not fully understood; therefore, there is no treatment that can stop brux- ism from happening. Once the patient has been informed about the parafunc- tional habit and how it affects the struc- tures of the stomatognathic system, he or she should be educated on how to avoid grinding and clenching of his or her teeth. We as dental professionals can and should control the parafunctional forces applied to the teeth, masticatory muscles and temporomandibular joints with the use of a stabilization appliance during sleep and by educating the pa- tient (Fig. 4). The appliance protects the teeth from wearing down while allowing the rest of the stomatognathic system to determine its most stable relationship dictated by the rest position of the mas- ticatory muscles. Therefore, the stabili- zation appliance not only controls and redistributes the parafunctional bruxing forces, but also dictates the musculo- skeletally stable position that will be the treatment position of choice. What is the material of choice to withstand the bruxing forces? Ceramic restorations are popular because of their excellent esthetic properties. However, failures are still a major concern, and dentists fear that sleep bruxism may be associated with an increased frequency of ceramic restoration failures due to oc- clusal overload. Nevertheless, there is a lack of data to support this clinical fear. Within the limitations of the existing studies, there is no association between higher failure of ceramic restorations and bruxism. Monolithic restorations present better results, but it is important to provide adequate material thickness. Lithium disil- icate glass-ceramic is often the material of choice owing to its mechanical properties and high esthetic value. Article Clinical Mentoring issue 2018 — 77