Functional Treatment: Based on Disease Status and Risk. Treatment R needs increase in intensity and A. as disease is more advanced and risk

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1 Low Low Low Low Low At At At At At \\Server\central form fi les\sec 9 Forms At LOW MODERATE HIGH LOW MODERATE HIGH LOW MODERATE HIGH LOW MODERATE HIGH 3/14/2010 Dysfunction k Functional Treatment: Based on Disease Status and H I G H M O D E Treatment R needs increase in intensity and A aggressiveness T as disease is more advanced and risk E is higher. These two factors, risk and disease, need to be considered together when determining treatment. L o w Low Moderate Severe Disease Status Functional Recognition Joint Health questionnaire /exam Muscle Tenderness Wear, Fremitus, Shifting of teeth Type of diet Existing bite relationship / Deep overbites/anterior open bites Position of teeth in face Large masseters / Brachycephalics Cause of existing tooth loss/ History 9 Questions Interview FOR DISCUSSION TODAY T.M.J. STANDS FOR: TEETH MUSCLES JOINTS THESE ARE THE COMPONENTS OF OUR CHEWING SYSTEM. THIS ENTIRE SYSTEM MUST BE IN HARMONY AND FUNCTION TOGETHER Teeth that are stable : not wearing,moving breaking Muscles that are healthy,stable and work in harmony with the dental envelope Joints that have a proper codyle/disc/bone assemby, can accept load and are stable Smiles by design PERIODONTAL RISK ASSESSMENT Past History of Periodontal Disease PERIODONTAL PROGNOSIS GOOD FAIR POOR Bone Loss (AAP > II) Smoker Medical Conditions (Diabetic Pts: Increases with >7% H1AC Levels) Family History Pregnancy Furcation Involvement Mobility Pocket Depths Recession(if yes check erosion) Oral Hygiene Bleeding on probing (prognostic) Short Roots (Not a "risk factor" but, prognostic indicators) Genotype DNA Pathogen Testing CARIES RISK ASSESSMENT LOW MODERATE HIGH Low ERO/ABR RISK ASSESSMENTLOW MODERATE HIGH Active Decay Erosive / Arbasion Lesions Rough White Spot Lesions Recession Caries Restored in the Past 3 Years Abrasivity of toothpaste Interproximal Enamel Lesions tooth brush hardness Visible Plaque Diet: Frequent Intake of Acidic Food/Beverages Frequent Sugary/Starchy Snacks Salivary Characteristics/xerostomia Ortho Appliances of Partial Dentures Medical Conditions/gerd i.e. Xerostomia Medications / Supplements Exposed Root Surfaces Attrition (see function) Family Members/Significant Other with Decay Deep Pits/Fissures, Developmental Defects Non Fluoridated Water CariScreen Test Results STRUCTURAL RISK ASSESSMENT Isthmus Width of Restoration Tooth Location in Mouth Masseter Muscle Size Past History of Tooth Fractures (Reason for existing crowns) Sensitivity to Bite/ craze lines Diet Habits Root Canal Treated Teeth, Full Coverage / Large Direct Restorations Opposing Teeth Functional Diagnosis FUNCTIONAL RISK ASSESSMENT Trouble chewing a small piece of gum Trouble chewing bagels or dry chewy foods Teeth changing in the last 5 years (wear, shorter/thinner, mobility, new spaces) More than 1 bite, clenching Trouble with sleep Popping, clicking, joint sounds Jaw pain, soreness, exhaustion, tension headaches Grinding, own/wear a occlusal guard BRUXING DYSFUNCTION NOT DETERMINED Existing Wear(if yes check erosion) ACTIVE NON ACTIVE NOT DETERMINED YET Bite Relationship (OPEN CONSTRICTED OTHER) ESTHETIC RISK ASSESSMENT Smile Line Bone Crest Biotype Tooth Shape 15 years old g Low At FUNCTIONAL RISK ASSESSMENT LOW MODERATE HIGH Trouble chewing a small piece of gum Trouble chewing bagels or dry chewy foods Teeth changing in the last 5 years (wear, shorter/thinner, mobility, new spaces) More than 1 bite, clenching Trouble with sleep Popping, clicking, joint sounds Jaw pain, soreness, exhaustion, tension headaches Grinding, own/wear a occlusal guard BRUXING DYSFUNCTION NOT DETERMINED Existing Wear(if yes check erosion) ACTIVE NON ACTIVE NOT DETERMINED YET Bite Relationship (OPEN CONSTRICTED OTHER) L At

2 15 years old g Low At FUNCTIONAL RISK ASSESSMENT LOW MODERATE HIGH Trouble chewing a small piece of gum Trouble chewing bagels or dry chewy foods Teeth changing in the last 5 years (wear, shorter/thinner, mobility, new spaces) More than 1 bite, clenching Trouble with sleep Popping, clicking, joint sounds Jaw pain, soreness, exhaustion, tension headaches Grinding, own/wear a occlusal guard BRUXING DYSFUNCTION NOT DETERMINED Existing Wear(if yes check erosion) ACTIVE NON ACTIVE NOT DETERMINED YET Bite Relationship (OPEN CONSTRICTED OTHER) L At "Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things to help, or at least to do no harm. Hippocrates Epidemics, Bk. I, Sect. XI. Function Assessment Trouble chewing a small piece of gum Trouble chewing bagels or dry chewing foods Teeth changing in last 5 years (wear, teeth appear shorter, thinner, loose or mobile, new spaces between teeth) More than 1 bite Trouble with sleep Popping, clicking, joint sounds Jaw pain, soreness, exhaustion Clenching, grinding Existing wear Bite Relationship UNDERSTANDING OCCLUSION IS CRITICAL TO THE LONG TERM SUCCESS OF OUR DENTISTRY. HOW DO WE LOWER OUR PATIENT S RISK TO OCCLUSAL DISEASE? WE HAVE TO DIAGNOSE IT FIRST! Functional Diagnostic Categories Acceptable Function Constricted Chewing Pattern Occlusal Dysfunction Parafunction Neurologic Disorders Terminology of Occlusion Border Movements Penwalt s Envelope Dental Envelope dictated by anatomy Envelope of teeth of Inside Function out or Neuromuscular Envelope OUTSIDE IN and Includes: Acceptable Restricted Dysfunctional Based on the work of John Kois, DMD 2

3 Significant Concepts About the Envelope of Function Border movements are wider than functional zone. Clinical evaluation of the functional zone is related to postural position. Dysfunction is characterized by a larger envelope of function. As the home position becomes more precise and refined the functional zone narrows. Other than true parafunction refining the home position may help a patient clench less. Bilateral simultaneous and equal intensity contact is the goal. Envelope of Destruction (Occasionally Dysfunction) Parafunction Neurologic TOOTH WEAR WHAT DOES IT MEAN? TOOTH WEAR CAN BE AGE AND DIET APPROPRIATE AND PART OF A NORMAL OCCLUSION TOOTH WEAR IS NOT LINEAR THE WEAR YOU SEE TODAY MAY HAVE OCCURRED YEARS EARLIER AND THE PATIENT HAS ADAPTED TOOTH WEAR CAN ALSO DEMOSTRATE THAT THE CHEWING SYSTEM IS OUT OF BALANCE AND THE STRESS IS BEING SEEN IN ABNORMAL WEAR TOOTH WEAR WHAT DOES IT MEAN? OCCLUSAL TOOTH TRAUMATISM (mobility) WHAT DOES IT MEAN? WHAT ARE SOME OF MY TAKE HOME MESSAGES FOR TODAY CAN BE CAUSED OR MODIFIED BY CHEMICAL PROCESSES CAN BE CAUSED BY MECHANICAL FORCES SUCH AS TOOTHPASTE OR TOOTHBRUSH ABRASION OUR JOB IS TO DETERMINE IF THE WEAR IS ABNORMAL FOR THE AGE OF THE PATIENT AND IS IT DAMAGE AS A RESULT OF THE PATIENT S OCCLUSION AND CHEWING (MASTICATORY) SYSTEM OR A CENTRAL NERVOUS SYSTEM PROBLEM( NEUROLOGIC OR TRUE PARAFUNCTION) DEFINED AS THE MOBILTIY OF THE TEETH RELATIVE TO THE ADJACENT TEETH. OUR TEETH ARE HELD IN PLACE IF THE PERIODONTIUM HAS NOT BEEN COMPROMISED BY OCCLUSAL FORCES OR PERIODONTAL DISEASE. PRIMARY OCCUSAL TRAUMATISM IS DEFINED AS LOOSENESS CAUSED BY EXCESSIVE FORCES ON A NORMAL PERIODONTIUM SECONDARY OCCLUSAL TRAUMATISM IS DEFINED AS LOOSENESS CAUSED BY NORMAL FORCES ON A REDUCED PERIODONTIUM (BONE LOSS). RECOGNIZE THAT WEAR ON TEETH IS NOT ALWAYS BRUXISM. RECOGNIZE THAT HOW YOU CHEW CAN CREATE TOOTH WEAR AND DESTROY YOUR DENTISTRY. UNDERSTAND THAT IF OUR CHEWING SYSTEM IS OUT OF BALANCE IN EITHER THE TEETH, THE MUSCLES, OR THE JOINTS, THE RESULT IS INCREASED RISK FOR OCCLUSAL DISEASE IN ONE OR MORE OF THE COMPONENTS WHAT ARE SOME OF MY TAKE HOME MESSAGES FOR TODAY UNDERSTAND WHAT IS A PHYSIOLOGIC ACCEPTABLE OCCLUSION AND HOW UNDERSTANDING THIS AFFECTS THE DENTAL TREATMENT YOU WILL PROVIDE Functional Diagnostic Categories Acceptable Function Constricted Chewing Pattern Occlusal Dysfunction Parafunction Neurologic Disorders Based on the work of John Kois, DMD Acceptable Function Physiological Wear Efficient Use of Masticatory Muscles Healthy or Stable Joints Envelope of Function is WNL, HOWEVER h l d f Pathologic conditions exist if Extrinsic localized (i.e. dietary factors) create premature tooth structure loss. Intrinsic localized (i.e. developmental disturbances, GERD) create premature tooth structure loss. Iatrogenic 3

4 ACCEPTABLE FUNCTION Chemical Erosion? Is This Acceptable Function? Malocclusion Occlusal Interference Occlusal Discrepancy Excessive Slide Lack Of Guidance Steep Guidance Etc, Etc Diagnostic Opinion /99 Diagnosis of Acceptable Function Influences Material Choice And Prep Design Post Op Expectations And Need For Night Guards Decrease Need For Posterior Restorative Dentistry Predictability of the restorations 8 Year Follow-up 10 year follow-up What are the requirements of an acceptable function? 10/2007 FOR AN OCCLUSION TO BE STABLE, WE MUST BE ABLE TO BUILD OR MAINTAIN A MAXIMUM INTERCUSPATION THAT THE BRAIN CAN FIND AND IS COMFORTABLE. IF WE DO, THE PATIENT WILL BE ABLE TO CHEW COMFORTABLY AND NOT DESTROY YOUR DENTISTRY.. 4

5 So If we do not have a stable occlusion, HOW DO WE START TO BUILD A BITE (MAXIMUM INTERCUSPATION) THAT THE BRAIN CAN FIND AND IS COMFORTABLE? WE START WITH THE THREE P S OF OCCLUSION The most Important things That I have learned at the Kois Center that have changed the way I approach clinical practice and patient care: The Diagnostic Opinion / Assessment The 10 Step Management Principles 3 P s of Occlusion Keep This In Mind When evaluating different concepts, their similarities may be more important than their differences. John C. Kois THE THREE P S OF OCCLUSION P1 POSITION : Orthopedic position of the mandible must be acceptable or must be established first P2 PLACE : Home position, the Maximum intercuspation of the teeth(mip) or how the teeth fit together at closing. P3 Pathway : Driveway into the Home, the working anterior guidance (outside /in) or guidance into maximum intercuspation. P1 Position TMJ P2 Place Home P3 Pathway Guidance P1 Objective Functional Occlusion Position (Orthopedic Position of mandible) CR /Adapted Centric Posture Myocentric M.I.P Technique Reference / Starting Point Concerns Flawed M.I.P - Remaining Dentition CR - Manipulation Techniques NM - Muscles, Head Posture, Neurologic system Place (Home) Bilateral Equal Intensity Simultaneous Contact P2 Objective OVD? (Step 2 and 4) Technique Vertical Support / Posterior Teeth or Anterior Platform Articulation Paper Shim Stock T - Scan Digital Palpation Concerns Mandibular Flexure Worn Teeth Periodontal Ligament Pulpal Status P Pathway (Driveway) 3 Objective Steepness vs. Flatness Minimize Friction Avoid Chewing Interferences 7 P1 = Position P2 = Place (home MIP) By J. Derango DDS 2006 Kois Center, LLC 5

6 P3 = Pathway (driveway anterior guidance) P1 Position WHAT DO WE USE???? MIP The P1 position of the Existing bite:. Teeth are KING Centric Relation /Adapted CR or Deprogrammed position: Joint is KING Neuromuscular Position myomonitor guided position: Muscles are KING P1 Position When can we use the P1 position dictated by MIP (the existing bite)? When we have a diagnosis of acceptable function, are not at risk for developing occlusal problems and are not changing the vertical dimension of occlusion(ovd) KEY: The P2 position is dictating the P1 position The P1 position With an effective P2 P1 may not be the most important and safe of P3 the 3 P s P3 Smiles by design KEY: When the Home/Place(P2) is correct and you have an effective and safe Driveway/Pathway (P3) then the Location/Position(P1) is not always the most important of the 3P s. This is why many dentist can do ok by just treating to MIP.This is also why many orthodontist are successful with the teeth set up with good posterior contact P2 and correct overjet and overbite P3 P1 Position When do we use Centric Relation, the deprogrammed position? When our diagnosis is not acceptable function, when we are changing the vertical dimension i of occlusion(ovd) or when we have the at risk patient needing extensive single tooth dentistry(many teeth to be done one or two at a time) KEY: The P1 position is dictating the P2 position P1 Established from the Deprogrammed position 6

7 WHEN DO YOU NEED CENTRIC RELATION AS YOUR P 1? ANYTIME YOUR TREATMENT WILL AFFECT OR REMOVE YOUR PATIENT S EXISTING HOME OR PATHWAY. ANYTIME YOUR PATIENT HAS DIFFICULTY IN FINDING HOME P2 AND YOU ARE PLANNING TREATMENT. THEN REMOVAL OF ONE CONTACT CAN CAUSE THE PATIENT NOT TO BE ABLE TO FIND HIS BITE ANYTIME YOU CHANGE A PATIENT S VERTICAL DIMENSION BY OPENING OR CLOSING HIS OVD. I P1 Position When do we use Myocentric Position? I use rarely P2 Place This is not just how the teeth fit together. But fit together in harmony with the envelope of chewing Our goal is equal intensity, bilateral, simultaneous contact of the posterior teeth. GOAL OF ALL OCCLUSAL CAMPS P2 sets the VDO The VDO is based on esthetics, functional, periodontal and biomechanical requirements P3 Pathway Our guidance or pathway to where the teeth fit together. How do we get to home(p2) THE DRIVEWAY We have to look at the steepness vs flatness of the pathway. Goldilocks Principle too steep chance of CCP, to shallow chance of Occlusal Dysfunction. Must be just right Training tool to find P2? P3 Pathway We normally check anterior guidance from the inside out but the chewing pathway occurs from the outside in. We need to re-evaluate our methods of checking guidance 3P s Summary If Occlusal problems are present then one or more of the three P s is not in balance P2 simultaneous, equal intensity, bilateral contacts are common to all occlusal philosophies P1 may not be an exact point but an area maintained by a healthy joint disc assembly P3 is an outside-in guidance not inside-out P1 and P3 may serve as training wheels to help find a newly established bite FUNCTIONAL OCCLUSION NOW LET S LOOK AT HOW WE DIAGNOSE OCCLUSION CONCEPTS OF FUNCTIONAL OCCLUSION WHAT ARE THE DIFFERENT POSSIBLE DIAGNOSIS? Let s look at each of these individually so we can learn to identify these clinically and use them in our treatment planning, risk assessment, development of our prognosis Prognosis Decreases Diagnosis Decision Process Functional Concerns ACCEPTABLE FUNCTION (all 3 p s acceptable) VS CONSTRICTED CHEWING PATTERN VS OCCLUSAL DYSFUNCTION VS PARAFUNCTION VS BASED ON THE WORK OF JOHN KOIS, D.M.D. NEUROLOGIC DISORDERS Based on the work of Dr John Kois Kois Center Seattle Wa 2006 Kois Center, LLC 2006 Kois Center, LLC Smiles by design 2006 Kois Center, LLC 7

8 Functional Diagnostic Categories Acceptable Function Constricted Chewing Pattern Occlusal Dysfunction Parafunction Neurologic Disorders Based on the work of John Kois, DMD Constricted Chewing Pattern Anterior tooth position is constricting the functional envelope You may have wear and mobility of the anterior teeth. TMD May contribute to the problem or be the result. Constricted Chewing Pattern Can be broken down into two types: First type is NON DISTALIZING. The problem is demonstrated in the teeth wear, fremitus, sore teeth. Second type is DISTALIZING. The problem is the constriction forces the condyle back and results in TMD issues. Smiles by design Constricted Path of Closure Slides courtesy Of Dr Don Jayne? Constricted Path of Closure Slides courtesy Of Dr Don Jayne Possible Signs Of Constricted Chewing Pattern Typical Wear Patten Lingual Maxillary Anterior Teeth And Facial Mandibular Anterior Teeth Mobility Of Anterior Teeth No Posterior Mobility Anterior Open Spaces Fast Chewing Fewer Cycles Smiles by design Possible Signs Of Constricted Chewing Pattern Tender Joints / TMD Tired Muscles When Speaking A Lot Absence Of Wear On Posterior Teeth* *Depends On Timing Of Problem NOTE: Anterior Initial Contact Following Deprogramming Appearance And Position Of Teeth In Face What Can A Restricted Envelope Look Like Clinically? i ll 8

9 Post-Ortho Mandibular Growth? Smiles by design Restricted Envelope Of Function Distalization Of The Condyle? Wear On The Linguals Of Max Incisors/Lower Buccals? Fremitus Or Flaring Of Anteriors? What If The Dental Envelope Constricted The Functional Envelope?? 9

10 Ortho Literature This paper looks at Chewing Envelope issues and how Anterior Guidance affects wear and dtmd It is this clinician's opinion that the concept of anterior interferences has not received adequate attention in our clinical management of orthodontic patients. Much has been written on the subject of Occlusal interferences in the posterior teeth during Occlusal function. This article will deal with the impact that anterior interferences have in the possible causation of specific Temporomandibular disorders and the impact of this information on how orthodontic cases should be finished. The effect of anterior interferences on Occlusal l dysfunctions is discussed. d Finally, we will review the possible control of anterior interferences during fixed appliance mechanics. Five specific clinical sequela are identified, and their clinical implications in orth odontic treatment are reviewed. (Semin Orthod 2003;9: ) 2003 Elsevier Inc. All rights reserved. The Five Known Consequences of Anterior Interferences It is this clinician's observation and experience, having studied the clinical implications of ante rior interferences, that five distinct clinical sequela can be identified. They are listed here in no particular order, and will be discussed sepa rately in detail. 1. Anterior spacing and diastemas 2. Fremitus 3. Areas of excessive incisal wear 4. Periodontal damage- gingival recession 5. Intracapsular derangements of the Temporomandibular joints Smiles by design Figure 10. The initial contact between the maxillary and mandibular dentitions during the closing movement of the mandible (A). Poster superior distraction of the mandible to establish posterior intercuspation (B). Figure 12. Corrected axis tomogram, demonstrating concentric position of the right condyle at the point of initial contact (A). Corrected axis tomogram, demonstrating poster superior displacement of the right condyle as the patient establishes maximum intercuspation (B). Immediate post ortho SMILE age 13 Immediate post ortho Age 13 Class III Tendency: RISK May be acceptable function now but at risk for CCP(P3 problem) and / or Dysfunction(P2 problem) 2005 Age Age 18 Continued Mandible Growth Pre-Ortho Post-Ortho 10

11 Can we achieve her esthetic desires, longer 4 incisors (correct reverse smile) and stay within her envelope of function? Can we achieve her esthetic desires and stay within her envelope of function? Adjusting the envelope of function Move Maxillary Anteriors Forward Move Lower Anteriors Back Procline Maxillary Anteriors Retrocline Lower Anteriors Surgical corection Open Vertical Dimension of Occlusion Use Centric Relation P1 position Zone of high risk New Diagnosis Chipped incisal edges bonded rebonded NC rebonded NC and nite guard new bonding agent rebond NC New Diagnosis Reverse smile created by wear from constricted envelope Full Composite Mock Up Preparation/Temporization System Mock up for Dr. -Patient communication of desired results preservation of existing Incisal edge and contour 11

12 Use of flexi-model technique to create functional temps Flexi-Model System Multiple uses of flexi-models Alginate of choice Duloid impression and mach 2 silicone. 3 minutes from start of impression to model Original contours used to guide new lingual contours, facial contours and length Original dental envelope. Restored dental envelope. Provisionals to confirm esthetics, function and a laboratory guide for final restorations Restoratively moving incisal 1/3 of tooth facially to unrestrict envelope NOTE: ANGLE FROM PREP TO INCREASE ROOM FOR ENVELOPE 12

13 Laboratory Communication Laboratory Communication Laboratory Verification Mtht Match to this contour Mtht Match to this contour 7&8 final veneers in relation to temps 9-10 note facial contour match Pre-op Post-op Temps day 3 Constricted Chewing Pattern Summary o Anterior tooth position is constricting the functional envelope o You may have wear and mobility of the anterior teeth or have spaces developing o Typical Wear Pattern : Lingual Maxillary Anterior Teeth And Facial Mandibular Anterior Teeth o TMD May contribute to the problem or be the result. o Absence Of Wear On Posterior Teeth, No posterior Mobility o Previous ortho: Bicuspid extractions or early (before growth completed) and Class III tendency o Anterior Initial Contact Following Deprogramming o Appearance And Position Of Teeth In Face Smiles by design Constricted Chewing Pattern Summary : How to Treat Usually a problem of P3 Orthodontics Surgical Restorative: Open Vertical Dimension of Occlusion Centric Relation P1 position Functional Diagnostic Categories Acceptable Function Constricted Chewing Pattern Occlusal Dysfunction Parafunction Neurologic Disorders Based on the work of John Kois, DMD 13

14 Occlusal Dysfunction A Posterior tooth position, that can cause an interference or avoidance pattern in the functional envelope to MIP(P2) Possible Signs of Dysfunction Muscle Fatigue or Soreness More generalized wear facets can appear or confuse with bruxism Can have TMD Usually posterior contact after deprogramming Can see anterior wear and mobility if avoidance pattern Is this Acceptable Function? Dysfunction?? Trouble chewing a small piece of gum Trouble chewing bagels or dry chewy foods Teeth changing in last 5 years (active vs adapted (wear, teeth appear shorter, thinner, loose or mobile, new spaces between teeth) More than 1 bite Trouble with sleep MUSCLE ENGRAMS ARE LEARNED MUSCLE PATTERNS THAT YOUR BRAIN DEVELOPS TO FIND P2(Place) and Disease Your risk in doing restorative dentistry in these types of patients are removing their home position and putting your dentistry in a path that creates dysfunction. How to find your bite 3P s by Dr Kois Posterior Teeth / MIP Place P2 Anterior teeth / Anterior Guidance Pathway P3 Joint / CR / Neuromuscular Position P1 What do we use to help develop the engrams P1 P2 P3 How to find your bite 3P s by Dr Kois Posterior Teeth / MIP Place P2 Anterior teeth / Pathway P3 Anterior Guidance Joint / CR / Neuromuscular Position P1 Kois Deprogrammer Deprogram Muscle Engrams Aid in Diagnosis Establish a P1 Aid in Equilibration establishing P2 LUCIA JIG on a retainer 14

15 Married - Single - Divorced - Widowed DATE EMPLOYMENT/SCHOOL FAMILY to Restorative Discussion Biomechanical Structural Carries,tooth# Preliminary Treatment Definitive Treatment 3/14/2010 and Disease to Restorative Name: Referred by: L M H L M H L M H L M H Functional High risk to restorative Any tx to the bicuspids back face the risk of dysfunction a And not finding his bite. Check with shimstock Inform patient that he may need a deprogrammer And equilibration prior to any restorative tx or After treatment if problem with bite L M H Dentofacial Anterior open Class I bite flat anatomy Deep overbite Dysfunction acceptable constriction RISK TENDENCIES SCI and erosion/attrition Dysfunction/parafunction? Gummy smile 15

16 Goals of Ortho Intrude upper and lower anteriors to create room for restorative materials without additional tooth loss from preparation Question: Where do you want the orthodontist to position these teeth? Level posterior occlusal planes and align anterior gingival levels Create a stable posterior occlusion P2 in a deprogrammed d P1 position, reduce dysfunction Allow anterior room for an equilibration at end of ortho to create stable P2 position Position anteriors, uppers and lowers, to allow a proper P3,anterior pathway, to be developed restoratively Use transitional bonding during orthodontic treatment to help get the ideal position First layer is a very thin layer of bluish translucency to serve as a matrix for build-up and to allow for a natural translucency to the final restoration First layer is a very thin layer of bluish translucency to serve as a matrix for build-up and to allow for a natural translucency to the final restoration KEY: do every other tooth to complete finish and polish then build the other teeth right to the finished teeth Second layer is a dentin color to create lobes and preserve translucency between the lobes and at the incisal edge. Third layer is an incisal color to final contour 16

17 3 months post -ortho Kois Deprogrammer Goal Deprogram Muscle Engrams Aid in Diagnosis Establish a P1 Aid in Equilibration establishing P2 LUCIA JIG on a retainer KOIS DEPROGRAMMER Maxillary Fabrication Instructions 1.Make impressions of maxillary and mandibular arches. 2.Maxillary and mandibular casts should be mounted in the maximum intercuspal position. Note: Bite records and facebow are not necessary 3.Fabricate labial bow to extend from the most distal tooth on each side of the arch. There should not be any wires to interfere with the occlusal surface. 4.Complete full palatal coverage with acrylic to allow complete intercuspation of all teeth initially. 5.Add a small anterior platform 3mm wide opposing the lower central incisors that slightly discludes all remaining teeth approximately mm Kois Deprogrammer to help determine P1 and establish a proper P2 17

18 GOAL Maximum intercuspation simultaneous and equal bilateral contacts First step is to adjust the anterior platform until the patient feels the first point of contact on the posterior teeth First point of contact after adjusting platform Keep adjusting the anterior platform and the posterior teeth as you continue to refine the bite Tooth contacts holding shim stock on all of the posterior teeth 18

19 Refining the Envelope ENVELOPE OF FUNCTION-- that creates harmony with muscle,joints and tooth loading and an ANTERIOR GUIDANCE that correctly guides (Goldilocks) into maximum intercuspation Envelope of Function has a Postural Component Correct patient position Not This Smiles by design Adjusted Lingual Contours And Retest Final restorative dentistry can now be done as single tooth dentistry, Quadrant dentistry or Full arches 9 months post ortho 19

20 Occlusal Dysfunction Summary Posterior tooth position that can cause an interference or avoidance pattern to MIP within the functional envelope resulting in wear and or TMD symptoms Muscle Fatigue or Soreness More generalized wear facets can appear or confuse with bruxism Most likely a problem of P2 Functional Diagnostic Categories Acceptable Function Constricted Chewing Pattern Occlusal Dysfunction Parafunction Neurologic Disorders Based on the work of John Kois, DMD Effect of a full-arch Maxillary Occlusal Splint on Parafunctional activity during sleep in patients with nocturnal bruxism and signs and symptoms of craniomandibular disorders Holmgren K J Prosth.dent. 1993; 69: The wear results facets revealed that the reappeared Occlusal in splint the same does not location stop the with habit the same of nocturnal pattern bruxism During eccentric bruxism the mandible moves far beyond the edge to edge contact relationship of the cuspids Parafunction / Envelope of Destruction Treatment Goals Concept of mutual protection The damage of horizontal excessive forces (bruxism) can be minimized not eliminated Eliminate interferences within the functional envelope Flatten anterior guidance Minimize lateral contacts Shallow the cuspid guidance pathway for lateral destructive patterns Shallow the anterior guidance pathway for front to back destructive patterns Parafunction Envelope of Destruction Excessive vertical forces (clenching) cannot be reduced Intercuspal Position / Stable Vertical Contact Relationships simultaneous equal bilateral contact Deflecting incline contacts must be eliminated Parafunction Parafunction Diagnosis High Red Sticker Patient Education And Communication Of THEIR NO GUARANTEE Altered Preparation Design Restorative Materials To Match Prep Design Flatten Guidance at expense of esthetics Continued Use Of Night Guard Forever Envelope of Destruction: Treatment Goals Concept of Mutual Protection The damage of horizontal excessive forces (bruxism) can be minimized not eliminated Eliminate interferences within the functional envelope Flatten anterior guidance Minimize lateral contacts Shallow the cuspid guidance pathway for lateral destructive patterns Shallow the anterior guidance pathway for front to back destructive patterns 20

21 Force Management Parafunctional Summary BREAK TIME Niteguard like occlusion Built With Force Management in Mind. Flattened Anterior Guidance and Equal Bilateral Posterior Contacts. High RED DOT Failure probable Force Management Principles Night Guards a must 21