Occlusion in a Modern World 2016

Transcription

1 Occlusion in a Modern World

2 Peter & Phil Occlusion in a Modern World Occlusion, Occlusal Restoration, TMD & Vertical Dimension 2

3 3

4 Learning Aims in a Modern World Occlusal Function the need to replace missing teeth Patient views on treatment Loss of teeth over-eruption and tooth movement Update on TMJ and various management options relevant for 2015 Creation of space - vertical dimension change in 2015 and beyond 4

5 Do we always need to treat and restore loss of teeth? How many teeth and how good an occlusion do we need? 5

6 Do we always need to treat and restore loss of teeth? 6 classes c =11-12 c = 6-8 c = 4-5 N = number of teeth C = number of premolar units (molar occluding unit counts as two premolars) n = 28 n = 19 n = 18 c = 7-8 c = 3-4 c = 0-2 n=18 n=16 n=19 6

7 Do we always need to treat dental disease and restore loss of teeth? Relationship between oral function and shortened dental arches We could argue that the biggest drop off in oral function is between 2 & 0 OUs 7

8 Do we always need to treat dental disease and restore loss of teeth? Conclusion (Solution) Sufficient (85%) patient adaptive capacity in SDAs where 4 occlusal units are left, preferably in a symmetrical position not a disaster if down to 2 occlusal units (65% function) and none (38% function) 8

9 So we do not seem to need to fill in all the gaps for function in my view it is usally more about what is shown avoid risk if you can 9

10 There s enough risk out there without going looking for it 10

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12 Number of Claims 1 Endodontics 2 Crown & Bridge 5 Implants 6 Orthodontics 7 Veneers 8 Oral Surgery 3 Periodontics 4 Nerve Damage 12

13 Who wants to manage this patient? 13

14 Claims by value 2015 Riskwise Dental Protection Ltd. 14

15 Patient Reported Outcome Measures what do they think? PROMS What do patients make of it all? 15

16 Patient Reported Outcome Measures what do they think? Patient-Centred Outcomes 16

17 Patient Reported Outcome Measures what do they think? Patient-Centred Outcomes PROMs / PREMs 17

18 What happens when teeth are lost? So functional drop-off of SDA is quite limited What about movement / over-eruption of the teeth left behind? 18

19 What happens when teeth are lost? Honest messages to patients What is the truth about over-eruption, tilting and rotation when space(s) is/are left un-restored? Kiliaridis S, Lyka I, Friede H, Carlsson G E & Ahlqvist M. Vertical position, rotation, and tipping of molars without antagonists. Int J Prosthodont 2000; 13:

20 What happens when teeth are lost? POLL - when and how much? 20

21 What happens when teeth are lost? Kiliaridis S, Lyka I, Friede H, Carlsson G E & Ahlqvist M. Vertical position, rotation, and tipping of molars without antagonists. Int J Prosthodont 2000; 13: If it is going to happen it will do so in the first 12 months 18% of teeth do not over-erupt at all the rest (majority 82%) do move Only 24% of teeth over-erupt more than 2mm 21

22 What happens when teeth are lost? Conclusions Very rare that we need to replace posterior teeth for functional reasons In honesty it is managing cosmetic expectations 22

23 Update on TMJ and various management options TMJ 23

24 Update on TMJ and various management options When would you prescribe a bite splint (and what type) in 2015? 24

25 Update on TMJ and various management options Pity, Great Pity 25

26 Update on TMJ and various management options Pity, Great Pity 26

27 Update on TMJ and various management options level 4 evidence Beard & Clayton (1980) - PRI 27

28 Update on TMJ and various management options level 4 evidence Beard & Clayton (1980) - PRI 28

29 Update on TMJ and various management options level 4 evidence PRI where does this fit in with patient symptoms i.e. complexities of pain? 29

30 Update on TMJ and various management options level 4 evidence Solberg et al (1975) - EMG 30

31 Update on TMJ and various management options Cochrane level 1 evidence Zaid Al-Ani et al (2009) 31

32 Update on TMJ and various management options Cochrane level 1 evidence Zaid Al-Ani et al (2009) 32

33 Update on TMJ and various management options Cochrane level 1 evidence Zaid Al-Ani et al (2009) - Pain reduction 33

34 Update on TMJ and various management options Cochrane level 1 evidence Zaid Al-Ani et al (2009) - movement 34

35 Update on TMJ and various management options Cochrane level 1 evidence However, there is NO Stat difference that SSs are any more effective at reducing TMD pain than most other active treatments Zaid Al-Ani et al (2009) 35

36 Update on TMJ and various management options Level 2 evidence Intra Oral Orthopaedic appliances for Rx of TMD Hard bite stabilisation splints when adjusted properly have good evidence of modest efficacy for Rx of TMD compared to non-occluding appliances (Fricton et al, 2009 meta analysis of RCTs) Other types of appliances to include: repositioning and anterior partial coverage appliances also have some evidence but are prone to adverse effects (Fricton et al, 2009 meta analysis of RCTs) 36

37 Update on TMJ and various management options Conclusions - Management of TMD (Durham et al 2015) First line reversible conservative Education Self - care CBT Simple NSAIDs (systemic or local) Physiotherapy Splints MDT referral 37

38 Update on TMJ and various management options Level 2 evidence Short RCT Stabilisation splint v NTI 38

39 Update on TMJ and various management options Cochrane level 3 evidence TMJ (2015) Use of local or systemic NSAIDs are first line Rx for joint pain secondary to inflammation. Topical delivery as good as systemic for superficial joint pain (4 times a day based on BMJ meta analysis) (Sidebottom J 2009) 39

40 Update on TMJ and various management options Conclusions Need to distinguish muscular (Myogenic) pain from joint (Arthrogenic) pain and patients with Psychological Overlay issues very different (Sidebottom 2009) 40

41 Update on TMJ and various management options Conclusions splint type Cochrane evidence (Al-Ani et al, 2003) does not suggest that any occlusal bite splint is better than any other. Therefore more expensive ones should not be used initially 41

42 Update on TMJ and various management options TMJ Conclusions - adjustment Cochrane evidence confirms that there is no evidence for occlusal modification / adjustment First do no Harm (Sidebottom J 2009) 42

43 Update on TMJ and various management options TMJ American Academy of Orofacial Pain (2008).no clinical evidence between occlusal irregularities and temporomandibular problems. 43

44 Update on TMJ and various management options T Scan surely para-function and facial / myogenic / arthrogenic / headache pain the enemy? - will this type of thing not attract nutters? 44

45 Update on TMJ and various management options Other things to look out for in TMD patient group Burning discomfort in the gingival third around teeth can be an itch, electric, wooley, fluffy etc.. Persistent dry mouth (despite adequate saliva) Taste disturbance Persistent uncomfortable occlusion 45

46 Update on TMJ and various management options Phantom Bite (Marbach 1978) Uncomfortable occlusion Often appears to follow some iatrogenic / dental change but characteristically is made worse by attempts to improve situation Patient has seen many clinicans but doesn t let you know Has strong views how teeth should meet and what needs to be done Often want to be restored to their habitual position Often hidden life events in the background 46

47 Update on TMJ and various management options Conclusions TMJ Orthodontics 47

48 Update on TMJ and various management options TMJ Conclusions - Botox Botulinum toxin has been shown to be effective where muscle spasm pain with third of patients gaining long term or much improved relieved. Repeated injections do not get the same improvement (Sidebottom 2009) 48

49 Update on TMJ and various management options TMJ Conclusions acute closed lock Therapeutic Arthoscopy should be considered early for closed lock. Pain in joint suggest presence of inflammation TMJ / Pain manage in MDT environment (Sidebottom J 2009) 49

50 Update on TMJ and various management options TMJ Conclusions In the light of evidence should we be using Michigan splints to manage TMD? Are we happy using SBG for TMD with associated parafunction? Who should see TMD patients (and why?) What is the role of a TMD MDT how would patients get on to this clinic? What is the role of acupuncture, physiotherapy and CBT? 50

51 Update on TMJ and various management options TMJ Conclusions Harris et al

52 Vertical Dimension Change in 2015 Vertical Dimension Change in the Modern World 52

53 Vertical Dimension Change in 2015 My evolution on this one My revolution on this one 53

54 Vertical Dimension Change in 2015 It became clear in the late 80s and 90s that dentate patients with tooth wear did not lose face height with tooth wear nature maintains natural tooth contact with alveolar compensation 54

55 Vertical Dimension Change in 2015 Vertical Dimension comparison between a young patient group without tooth wear and older patients with tooth Wear Crothers and Sandham (1993) Compared the face heights of young dentate patients in Newcastle Dental Hospital without TSL to middle aged patients with significant TSL. Conclusion: They found no signif difference between the two groups. why? 55

56 Vertical Dimension Change in 2015 So dentate patients with tooth wear and natural tooth stops do not lose face height their teeth shorten! It is very rare - in my view - that tooth wear rapid enough to overcome the compensatory mechanisms Crothers and Sandham (1993) 56

57 Vertical Dimension Change in 2015 So can we open up and increase VD? If yes, what will can be tolerated? 57

58 Vertical Dimension Change in 2015 What is the first thing that we all think of doing for patients with TMJ dysfunction? Constructing a splint and increasing the interincisal VD by approx 4-6mm 58

59 Vertical Dimension Change in 2015 What historical studies guided us on this? 59

60 Vertical Dimension Change in 2015 EMG Carlsson, Ingervall & Kocak Effect of Increasing vertical dimension on the masticatory system in subjects with natural teeth. J Pros Dent (1979) 41: In all cases the increase of VD exceeded the freeway space The fitted splints brought about a reduction in postural activity. No sign of increased muscle activity to restore the original VD were observed. No clinically demonstrable symptoms were found at the end of the 7 day experiment. 60

61 Vertical Dimension Change in 2015 EMG masseter (Manns et al (1985)) 61

62 Vertical Dimension Change in 2015 PRI Garnick and Ramfjord Clinical investigation using PRI J Prosthet Dent 12: 895, (1962) found no signs of either symptoms or muscle dysfuntion until the VD had been increased (by a Michigan splint) by more than 11-12mm! 62

63 Vertical Dimension Change in 2015 Freeway Space The re-establishment of freeway space in dentate patients - they put in splints of differing thickness and got them to bite together once and assessed adaptability of patient to learn freeway space Hellsing (1984) 63

64 Vertical Dimension Change in 2015 Hellsing,

65 Vertical Dimension Change in 2015 Hellsing G. Functional adaptation to changes in vertical dimension. J Prosthet Dent 1984 Dec;52(6): The traditional concept of PP stability defies neurophysiologic explanation. Conversely, the hypothesis presented to explain the rapid adaptation of jaw elevator postural tonus to sudden change of vertical dimension is in accordance with research of automotized motor behavior. Furthermore, there is no logical reason to believe that maladaptive reactions develop after prolonged procedures that increase the vertical dimension of occlusion. Rather, Goldspink reports that within a few weeks complete normalization probably occurs. Jaw muscle motor behavior is more dynamic and adaptable to environmental changes than has been believed. 65

66 Vertical Dimension Change in 2015 So - it seems that we have a fair bit of space and vertical height to play with 66

67 Vertical Dimension Change in 2015 TMD Therapy: Manns et al 1983 splints at VD increase of 4.42mm (Grp II) and 8.15mm (Grp III) improved myofacial paindysfunction more effective than an 1mm increase (Grp I) 67

68 Vertical Dimension Change in 2015 The next bit of the puzzle came from the work of Bjorn Dahl in the 80s / 90s the placement of a flat anterior bite plane in a non-growing adult patients 68

69 Vertical Dimension Change in 2015 Baseline evidence The Dahl Appliance The evidence using a cobalt chrome anterior removable bite plane to create interocclusal room Dahl BL, Krogstad O & Karlsen K. An alternative treatment in cases with advanced localized attrition J Oral Rehabil 1975; 2: Dahl B & Krogstad O. The effect of a partial raising splint on the occlusal face height. An X-ray cephalometric study in human adults. Acta Odontol Scand 1980; 40: Dahl BL & Krogstad O. The effect of a partial bite-raising splint on the inclination of upper & lower front teeth. Acta Odontol Scand, 1983; 41: Dahl BL & Krogstad O. Long-term observations of an increased occlusal face height obtained by a combined orthodontic prosthetic approach. J. Oral Rehabil., 1985; 12:

70 Vertical Dimension Change in 2015 What he did - the Dahl Appliance He inserted a removable anterior palatal bite platform in 22 non-growing adults with localised TSL They wore them full time for 6 months. At completion of the study the posterior occlusion had re-established. He found no evidence of associated TMJ symptoms, pulpal pain, root resorption or function problems. 70

71 Vertical Dimension Change in 2015 The Dahl Appliance The evidence using a cobalt chrome anterior removable bite plane to create interocclusal room Dahl BL, Krogstad O & Karlsen K. An alternative treatment in cases with advanced localized attrition J Oral Rehabil 1975; 2: Dahl B & Krogstad O. The effect of a partial raising splint on the occlusal face height. An X-ray cephalometric study in human adults. Acta Odontol Scand 1980; 40: Dahl BL & Krogstad O. The effect of a partial bite-raising splint on the inclination of upper & lower front teeth. Acta Odontol Scand, 1983; 41: Dahl BL & Krogstad O. Long-term observations of an increased occlusal face height obtained by a combined orthodontic prosthetic approach. J. Oral Rehabil., 1985; 12: Space was created by Intrusion & over-eruption. The younger the patient the greater the over-eruption and opposite with older patients The initial increase in VD returned to pre-op values at 5 years No change in inter-incisal angulation, no TMD or root resorption. Some cases took longer than others (3-16 weeks). 4% non-responder This clinical study involved Clinical examination and Cepthlometric assessment with Tantilum balls inserted in the A & B points prior to the study couldn t be done now! 71

72 Vertical Dimension Change in 2015 Development of what we now know as the Fixed Dahl Concept Clinical teams within the UK have described and evaluated fixed evolution techniques of the original Dahl Appliance. It is interesting that Prof Bjorn Dahl did not drive these developments 72

73 Vertical Dimension Change in 2015 UK teams initially described the use of fixed techniques as an alternative to the original removable Dahl Appliance. It is interesting that Prof Bjorn Dahl himself did not drive these developments 73

74 Vertical Dimension Change in 2015 UK teams then published the results of clinical evaluation of both fixed and removable modifications to the original removable Dahl Appliance mostly level III evidence Briggs PFA, Bishop KA, Djemal S The Clinical Evolution of the Dahl Concept. Br Dent J (1997); 183: Darbar UR, Hemmings KW. Treatment of localized anterior tooth wear with composite restorations at an increased occlusal vertical dimension Dent Update (1997) Gough, M. B. Setchell D. J. Br Dent J (1999); 187: A retrospective study of 50 treatments using an appliance to produce localised occlusal space by relative axial tooth movement Hemmings KW. Darbar UR. Vaughan S. J Prosthet Dent (2000); 83: Tooth wear treated with direct composite restorations at an increased vertical dimension: Results at 30 months Chana H. Kelleher MGD. Briggs PFA. Hooper R. J Prosthet Dent (2000);83: Clinical evaluation of resin bonded gold alloy veneers 74

75 Vertical Dimension Change in 2015 What was their conclusions? They also worked No evidence of resorption No evidence of significant TMD problems Could Dahl individual teeth Around a 4% non-responder rate but reduced with time Composite predictable on anterior teeth 75

76 Vertical Dimension Change in 2015 Bringing us right up to date Gulamali et al level III evidence 76

77 Vertical Dimension Change in 2015 Poyser et al 2007 split mouth randomised (level II) 77

78 Vertical Dimension Change in 2015 Al-Khayatt et al 2013 level II evidence 78

79 Vertical Dimension Change and Use of Direct Resin in TSL 2015 Occlusion and the use of direct resin restorations to manage TSL (2015) 79

80 Vertical Dimension Change and Use of Direct Resin in TSL 2015 Prospective Observational Cohort study level III evidence - Used a hybrid composite Spectrum (DentsplyDeTrey) for all restorations One specialist operator (AM) placed all restorations Patients recruited as offered secondary care at Liverpool Dental Hospital 80

81 Vertical Dimension Change and Use of Direct Resin in TSL 2015 Distribution of restorations placed 81

82 Vertical Dimension Change and Use of Direct Resin in TSL restorations placed in 164 patients 71 of the 1010 restorations failed during follow-up. 5.4% failure in first year 82

83 Vertical Dimension Change and Use of Direct Resin in TSL 2015 Mean restoration follow up time: 33.8 months! 83

84 Vertical Dimension Change and Use of Direct Resin in TSL 2015 How many restorations are at risk at 8 years? Number of Restorations Months at risk 84

85 Vertical Dimension Change and Use of Direct Resin in TSL 2015 Criteria of success? Seems from the paper to be complete loss of restoration all or nothing how does this affect interpretation? No partial loss, chipping, staining, wear etc. No variables compared & contrasted 85

86 Lack of posterior support associated with greater severity of TSL 86

87 Vertical Dimension Change and Use of Direct Resin in TSL 2015 Lack of Posterior Support or not? half number of restorations placed with LOPS 87

88 Vertical Dimension Change and Use of Direct Resin in TSL 2015 Occlusion important? - Type of tooth wear Attrition, Erosion or Multi-aetiology 88

89 The significant differences (as relevant to our Occlusion Seminar) Time to failure greater in older patients (SD / 0.005) Greater failure with Lack of Posterior Support (SD 0.004) Multiple TSL aetiology (SD 0.007) 89

90 The non-significant differences (as relevant to our Occlusion Seminar) Erosion (NS) Class III more failures (NS) than I & II Vertical dimension change (NS) Lower Arch (NS) 9.5% failure compared to upper jaw at 6% 90

91 91

92 Vertical Dimension Change in 2015 The Dahl Concept allows the best to be made of the mechanical properties of composite resin Pre -op Immediate post op The restorations can be placed in some bulk 3 years post op 92

93 Vertical Dimension Change in 2015 Major conclusions Direct composite build-ups seem to work on top and bottom anterior teeth more success in top? Direct Resin De-novo survival of 5.8 years and re-do restorations 4.75 years Generally no difference with use of preparation or nonpreparation High patient cosmetic and functional satisfaction even when repair needed With lower anterior teeth - the thicker the composite the better 93

94 Vertical Dimension Change in 2015 level 2 evidence 94

95 Vertical Dimension Change in 2015 Hall Technique SS crowns increasing occlusal height in growing patients 95

96 Vertical Dimension Change in 2015 So what does this mean to us in 2016? Attention rather than an Obsession to detail in Prosthodonics We can think again about approach to increasing inter-occlusal space We can think more additively with our treatment plans We can create space in individual areas and not involve teeth that do not require restoration 96

97 Understand and explain to patients the +/-s of conventional - v - additive restorations 97

98 Vertical Dimension Change in 2015 Findings over 10 years (cumulative survival estimates) 62% for direct restorations 74.5 % for indirect Direct Anterior RBCs = 58.9% Anterior Indirect CMCs = 70% Composites mostly failed due to fracture and indirect CMC from complete loss Long-term survival of direct and indirect restorations placed for the treatment of advanced teeth wear Smales and Berekally Eur J Prosthodont Restor Dent :2-6 98

99 Vertical Dimension Change in 2015 Findings over 10 years (cumulative survival estimates) At failure - composites mostly failed due to fracture most could be repaired or crowned At failure indirect CMC from complete loss many could not be re-restored or involved complex procedures to include RCT / Posts / Xla and replacement Long-term survival of direct and indirect restorations placed for the treatment of advanced teeth wear Smales and Berekally Eur J Prosthodont Restor Dent :2-6 99

100 Vertical Dimension Change in 2015 Gold standard = Acid Etched Enamel (for optimum bond strength & control of leakage) Rings of confidence Anterior Erosion: tailor-made for composite resin - we must get over message of diagnostic etching prior to planning adhesive restorations 100

101 Vertical Dimension Change in 2015 I know there are alternative views on the restorative management of erosive TSL & I don t want to start an argument here but surely If further damage occurs isn t the repair straightforward? 101

102 Vertical Dimension Change in 2015 This has led (in the UK) to an additive shift for the provision of Prosthodontics treatment (for both adhesive plastic and indirect (metal / ceramic /resin) restorations Pre-op 1995 It is something that we should all be proud of in year Post Op

103 Vertical Dimension Change in 2015 We can restore teeth simply that in the past were very, very difficult 103

104 Vertical Dimension Change in months later (2014) 104

105 Vertical Dimension Change in 2015 Finally we need to reflect on the ethical issues of how we developed these ideas / understanding would we be able to do it now? Human experimentation? Proper ethical approval? Enough evidence to allow change? Briggs PFA, Bishop KA, Djemal S The Clinical Evolution of the Dahl Concept. Br Dent J (1997); 183: Darbar UR, Hemmings KW. Treatment of localized anterior tooth wear with composite restorations at an increased occlusal vertical dimension Dent Update (1997) Gough, M. B. Setchell D. J. Br Dent J (1999); 187: A retrospective study of 50 treatments using an appliance to produce localised occlusal space by relative axial tooth movement Hemmings KW. Darbar UR. Vaughan S. J Prosthet Dent (2000); 83: Tooth wear treated with direct composite restorations at an increased vertical dimension: Results at 30 months Chana H. Kelleher MGD. Briggs PFA. Hooper R. J Prosthet Dent (2000);83: Clinical evaluation of resin bonded gold alloy veneers 105

106 Peter & Phil Occlusion in a Modern World Occlusion, Occlusal Restoration, TMD & Vertical Dimension, 106

107 The Beyonce Factor how high are you aiming? listen and watch - 107

108 Case Discussion discussion Case 1 108

109 Case discussion Case 1 Patient has had posterior bridges fitted problem is that patient cannot function on them they do not meet and never have.. 109

110 Case discussion Case 1..My teeth contacted before. Why do they not do that now.?..can you help me please? 110

111 Case discussion What is the clinical main error for this patient?? 111

112 Case discussion Assuming that none of the bridge(s) are de-cemented What are the issues Why are there occlusal gaps at the back? How would you tackle this case? What laboratory stages would you need? What would be your diagnostic stages? 112

113 What are the issues Why are there occlusal gaps at the back? How would you tackle this case? What laboratory stages would you need? What would be your diagnostic stages? 113

114 Case discussion Why did I use these first? 114

115 Case discussion Would you remove cores? How would you make the temporary with what would you cement it? 115

116 Case discussion How would you take off the bridges? 116

117 Case discussion Assuming you have taken off all posterior bridges Do you need a jaw registration? If so what technique would you use and why? How would you deliver the posterior bridges? 117

118 Case discussion Beauty wax Static Jaw Registration 118

119 One side at a time Thanks to: Walton Dental Arts 119

120 The three-legged Stool 1992 Take away one leg and it will fall down. I look at jaw registrations as returning one or more of the missing leg(s) to the stool. If the stool doesn t fall down at the start then you don t need a jaw reg! 120

121 How would you take your jaw registration to ensure that your chosen crown for LR6 is not high or shy of occlusal contact? 121

122 Beauty wax over the occlusal surface of distal molar refine with Temp-bond Kantor M.E. Silverman S.E. Garfinkel L. Centric relation recording techniques - A comparative study J Prosthet Dent 1972;28:

123 Occlusal record packaged within safe environment for the UK post system 123

124 How do I take a conformative Jaw Record? 124

125 Take Away Message Accurate Stable at mouth temp Reproducable Verifiable Cheap Simple to use Simple to use in lab Simple to transport No bounce solid material 125

126 No more use of the heated carding-wax sausage please from anyone in this room You need a material / wax that is absolutely firm at mouth temperature, dimensionally stable and allows simple verification 126

127 Learning point: If the stool falls down you need to put something between the teeth to prop-it-up when the natural teeth are together in ICP 127

128 Case discussion Do you need to use a face bow? Why? 128

129 Case discussion Provisional cementation of fixed restorations Salvageable and avoid Early Prosthodontic Lock In Thanks to: Walton Dental Arts 129

130 Peter & Phil Occlusion in a Modern World Occlusion, Occlusal Restoration, TMD & Vertical Dimension, 130