a three-stage approach to full-mouth rehabilitation

8 Compendium—Volume 29 (Special Issue 1)

Posture, temporomandibular disorders (TMD), mus-cles in the neck, back, pelvis, legs, and the wholecraniomandibular complex are all intimately re-

lated to the bite or how teeth interdigitate. An improperbite can predispose and/or directly cause malfunction of thetemporomandibular joint (TMJ) (internal derangement),which can result in one or more of the following symptoms:

headaches, pain behind the eyes, facial or throat pain, dizzi-ness, earaches, clenching or grinding of the teeth, neck pain,clicking, popping or grating sounds in the jaw joints, andtired jaws. These problems can be caused by the joints, themuscles of the face and jaw, or a combination thereof.

Structures that make it possible to open and close themouth include bones, joints, and muscles. The teeth are in-serted into the jaw bone. The TMJs connect the jaw to theskull. Muscles attach to the bones and joints of the stomatog-nathic system. Improper muscle function creates musclespasm, which has a direct correlation with displaced discswithin the jaw joints. The muscles that manipulate the jawwith respect to the skull facilitate talking, chewing, breathing,and swallowing. A bite where the teeth do not come togeth-er properly directly impacts all of these physiologic functionsnegatively. If a nonphysiologic bite continues on a chronicbasis and is further disrupted by trauma, clenching and grind-ing, a poor airway, and/or numerous dental restorations, anadverse effect on the overall physiology of the patient is likely.

Treatment of a patient to optimal dental physiology takesinto consideration these situations and diagnoses the majorcontributions of the problem, ultimately correcting the im-proper bite, which facilitates healing and relief of the pa-tient’s adverse symptoms. Optimal dental physiology is a

Abstract: A case study is used to illustrate the intimate relationship of the interdigitation of teeth to the whole

body and a new approach to diagnosing it. The patient, suffering from jaw joint clicking and popping, jaw joint

pain, headaches, and an unpleasing smile received three phases of treatment over 2.5 years, resolving her physio-

logic chief complaints, enhancing her orthopedic arch form, straightening her teeth, and prosthetically restoring

her entire mouth. The treatment plan was developed using radiographic, computerized electrodiagnostic methods

and by mounting models on an orthopedic articulator, all of which directly influenced the course of treatment

selected for this patient. The completed treatment was subjectively and objectively very successful, with the

patient continuing to do well 3 years after completion of treatment.

Continuing Education 2

Learning Objectives

After reading this article, the reader should be able to:

n recognize the necessary components involved withrecord gathering that precedes treating a patient tooptimal dental physiology.

n appreciate the important diagnostic aspects thatseveral different radiographic views provide.

n explain the three phases of treatment necessary totreat a patient to optimal dental physiology.

n develop an awareness of the state-of-the-art diag-nostic and treatment modalities available to aid intreating a patient to optimal dental physiology.

A Three-Stage Approach to Full-Mouth Rehabilitation

Jim K. Beck, DDS

Private Practice, Pueblo, ColoradoFeatured Speaker at the 2009 BioRESEARCH Annual Conference

Compendium—Volume 29 (Special Issue 1) 9

treatment philosophy that diagnoses existing teeth, peri-odontal, maxillary/mandibular orthopedic, airway, and over-all stomatognathic functioning conditions realizing that theyare related intimately. The treatment philosophy recognizesthat pathology in any or a combination of the above men-tioned areas contributes to a negative impact on several phys-iologic considerations of the patient’s well-being and health.

A THREE-STAGE COMBINATION CASE STUDYA 57-year-old woman presented with the chief complaints ofjaw joint clicking and popping, jaw joint pain, and head-aches. She felt that she had a bad bite and that her mouth didnot close properly. Further, she disliked the appearance ofher teeth. An initial screening examination revealed that shehad been involved in an accident and suffered a traumaticblow to the mandible. She had a hard time closing her mouthtogether for several weeks following the accident. The pa-tient stated that her jaw joints were sore on awakening. Shewas aware of daytime and nighttime clenching, and her jawpopped on opening and closing. She had several old fillingsand crowns, and her teeth were becoming sensitive. She didnot like the way her teeth looked and wanted to be happywith her smile (Figure 1 and Figure 2). The patient was givena consult to take diagnostic records.

Record Gathering and ExaminationUpper and lower models were made and mounted on anarticulator at her existing habitual bite. A series of full-mouthbitewing, periapical, and panoramic radiographs were made.In addition, right and left corrected-angle tomograms were

taken at her maximum intercuspation, rest, and full-openingposture. Also, a cephalogram, right/left anterior/posteriorcoronal tomograms, frontal skull, Towne’s view, and lateralskull radiographs were taken. The biometric records takenincluded joint vibration analysis (JVA), resting and function-al electromyograms (EMGs), range of motion jaw tracking,and opening and closing mandibular velocity trace. Intraoral,extraoral, and postural photographs were taken. The patientwas given a comprehensive questionnaire to complete.

The mounted models revealed an uneven occlusal pat-tern with a high uphill roll pattern to the left. The bite-wing and periapical radiographs showed extensively failingrestorations with recurrent decay and various isolated peri-apical lesions. There was generalized stage III bone loss asa result of chronic occlusal trauma, determined because thepatient’s home care was excellent and there was no bleed-ing or evidence of periodontal disease.

The panoramic radiograph revealed teeth Nos. 1, 13, 16,17, and 32 were missing. There was bilateral antegonialnotching, resulting from chronic excessive masseter musclehyperfunction. The nasal septum was relatively straightwith no turbinate obstruction noted.

The right and left tomograms revealed excessive posteri-or and superior displacement. Excessive orthopedic bend-ing was noted bilaterally and the right tomogram showedosseous degeneration. Both joints exhibited hypertrans-lation,1 which represents excessive stretching in the bilam-inar zone of the posterior ligament.

The cephalogram showed lack of normal lordotic curva-ture, with inadequate spacing between the C1 and C2 ver-tebrae. The antigonial notching was again noted, and the

Figure 1 The patient was unhappy with the esthetics of

her smile. Note the uphill cant to the left.

Figure 2 Several occlusal flags included crowded anteriors

and abfractions.

double border of the mandible was consistent with the previ-ously noted uphill cant to the left of the occlusal table. Thiscervical orthopedic relationship was also consistent with theforward head posture observed on the postural photographs.

The anterior and posterior coronal tomograms showednormal osseous contour on the left, and osseous degenera-tion of the right lateral pole. The frontal skull radiographwas traced for a triplanar analysis. The three planes tracedran through the frontosphenoid sutures of the orbits, themastoid processes, and the gonial angles of the mandibles.By tracing these three planes, cranial orthopedic problemscan be diagnosed.2 The frontosphenoid plane and the mas-toid process plane were parallel. The gonial angle planeconverged to the left side. Gonial angle plane discrepanciescan be corrected with a mandibular orthopedic reposition-ing appliance (MORA), which will make the gonial anglelevel with the other planes. Cases with orthopedic and TMJ

issues, as presented here, initially can be treated with a biteregistration and construction of a MORA appliance. Thepatient wears the MORA during all waking hours and re-moves it only to brush his or her teeth.3-8

The Towne’s view radiograph showed no fracture ofthe condylar neck. This is always a concern when dealingwith TMD and orofacial pain patients. Final full-openingposture was straight and symmetrical.

The lateral skull radiograph is excellent for diagnosingcervical degeneration in C5 through C7.9,10 This is im-portant because TMD patients often require multidisci-plinary treatment. This patient had a normal C5 throughC7 lateral skull radiograph.

BioJVA™ (BioResearch Associates Inc, Milwaukee, WI)is a diagnostic aid that objectively detects pathology in thejaw joints during function. It can be used to aid the detec-tion of TMD at an accuracy rate greater than 90%.11-14

According to the American Dental Association, every den-tist is required to diagnose jaw joint pathology. This patientpresented with a Wilkes stage II internal derangement (discdisplacement with reduction, Figure 3).

Resting and functional EMGs recorded with the Bio-EMG II™ (BioResearch Associates Inc) were used to diag-nose how the muscles of the stomatognathic system werefunctioning with the existing occlusion and also how wellthey relaxed at rest.14-24 Muscles that function abnormallyoften do not rest normally either. This can cause pain andtension in the TMD patient. This patient presented withextremely high resting EMGs for the temporalis, masseter,and sternocleidomastoid muscles. This illustrated that thechronic malfunctioning of this patient’s occlusion, along



Figure 3 Joint vibration analysis showing stage II anterior

disc displacement with reduction.

Figure 4 Pretreatment upper study model. Crowded

maxillary anteriors and “V”-shaped arch form.

Figure 5 Pretreatment lower study model. Crowded

mandibular anteriors, “V“-shaped arch form, and blocked

out tooth No. 22.

with a chronic history of clenching and forward head pos-ture, was creating a pathological situation that did not allowthe muscles to rest adequately. The muscles, joints, andwhole body posture were being affected negatively, creatinga dwindling spiral that ultimately broke down the wholestomatognathic system and affected this patient’s entirebody. The functional EMG recordings indicated the tem-poralis and masseter muscles had poor left–right symmetryduring clenching. This muscle pathology is consistent withpoor orthopedic and occlusal schemes where the patient isforced to go through “muscular gymnastics” to facilitatechewing, swallowing, and breathing.

The jaw-tracking range of motion and velocity tests(recorded with the JT-3D™, BioResearch Associates Inc)revealed a maximum opening of 41.4 mm. Left lateral ex-cursion was 7 mm, and right lateral excursion was 8 mm.Protrusion was 7 mm. This is considered to be at the lowend of a normal range of motion. However, the velocitytrace showed an opening speed of only 250 mm/sec and aclosing speed of 200 mm/sec, indicating bradykinesia (slow

movement). Normal opening and closing speeds should bein excess of 350 mm/second.25-28 A normal opening andclosing velocity is consistent with normal muscle and jawjoint function. When there is pathologic opening and clos-ing velocity, there is a potential for muscle and/or TMJ dys-function. Bradykinesia is slow movement and commonly isassociated with dyskinesia (erratic movement). It can be anindication of a disc that is reducing and displacing. In thispatient, there was a significant slowdown present right be-fore the teeth contacted at centric occlusion. This patholo-gy was consistent with intracapsular trauma and the body’ssensory proprioception protecting against additional trau-ma associated with tooth contact. Ultimately, this pathologyputs pressure on the condyle intracapsularly. When there isdamage intracapsularly, which is associated with inflamma-tion, the body braces to protect itself.28,29

Intraoral and extraoral photographs revealed a patientwith a large number of old failing restorations, includingfillings, root canals, crowns, and bridges. The occlusal pat-tern was irregular overall. There was generalized type III

Beck


Figure 6 The patient’s habitual bite. Note the anterior

overjet and the relationship of molars and cuspids.

Figure 7 Note the anterior/posterior and vertical change

from phonetic bite registration.

Figure 8 Left-side habitual bite condylar posture. Figure 9 Left-side phonetic bite registration posture from

which the MORA appliance was constructed.

bone loss. Also noted on the models and in the examina-tion was upper/lower loss of transverse arch form. Themaxillary arch form was anteriorly “V” shaped with centralincisor overlap. The mandibular arch form was also narrowanteriorly and had general anterior crowding with toothNo. 22 blocked out (Figure 4 and Figure 5). This orthope-dic condition significantly affects the TMJ because the

occlusion will displace the condyles posteriorly and superi-orly.30,31 This has a negative impact on joints, muscles, andairways. The blocked out tooth No. 22 and upper/lowercrowding directly impact the treatment process because ofthe limitations of crown-and-bridge alone. This patientrequired orthopedic and orthodontic treatment. The extra-oral photographs illustrated noticeable forward head pos-ture. This structural posture is a person’s adaptation tofacilitate swallowing, and/or is seen in someone who hasbecome a mouth breather. These functioning adaptationssignificantly affect diagnoses and treatment plans.

The subjective questionnaire revealed that the patient’schief complaints were headaches, jaw clicking, shoulderpain, neck pain, pain when chewing, and appearance. Thepatient was healthy overall. She had had her tonsils and wis-dom teeth removed. She had right-sided frontal, temporal,and back-of-the-head headaches. She was aware of daytimeand nighttime clenching. She had a previous accident whereshe was struck violently on her mandible. Her history indi-cated that her pain patterns started thereafter and she hadbeen in chronic pain for many years. She had experiencedoccasional numbness in her fingers. She experienced chron-ic vertigo. She wakened with a dry mouth in the morning.

DiagnosisThe patient was diagnosed with bilateral Wilkes stage II an-terior disc displacement with reduction, bilateral capsili-tis, bilateral myalgia, right-sided headache/facial pain, andchronic clenching.

Treatment PlanThe treatment plan consisted of three phases.

Phase 1:n Clean up existing dentistry, removing all dental and peri-

odontal pathologyn Realign mandible (condyles) orthopedicallyn Reduce adverse joint loadingn Improve functionn Improve myalgian Reduce pain

Phase 2:n Transversely develop upper and lower arches orthopedicallyn Rotate, level, and align dentition on upper and lower

arches (braces)



Figure 10 Tripod transfer established from Phase I orthotic

after MMI was established.

Figure 11 Hyrax transverse expansion appliance with

rectangular wire to establish proper torque.

Figure 12 Upper-arch clean up, orthopedic expansion, and

orthodontics completed.

Phase 3:n Full-mouth prosthetic reconstruction to the correct

orthopedic and functional relationshipn Improve cosmetics

ConsultationIt was explained to the patient that her problems were associ-ated predominantly with soft-tissue issues of the jaw jointwith early degeneration. Her other problems were overworkedmuscles, which were not getting adequate rest. Finally, it wasexplained to her that the maxillary and mandibular dentaland orthopedic arches needed to be developed transversely.The patient was informed that the total treatment time wouldbe approximately 2.5 years, start to finish. The patient agreedto treatment and signed informed consent forms.

Phase 1The patient was sent to a periodontist for bone graftingand general periodontal treatment. After the completion of

periodontal treatment, the author removed all of her existingdental work, with the exception of old conservative fillings.These fillings were not a liability of later needing root canals,and they would be removed in Phase 3 when the teeth wereprepped for the full-mouth rehabilitation. Through thecourse of cleaning up the existing dentistry, teeth Nos. 19,29, and 30, which had old failing crowns and advanced de-cay, were treated by extraction. The remainder of the teethwere restored with healthy restorations, buildups, and tem-porary crowns. The teeth and periodontia were then healthyand could support the complete treatment.

Orthopedic realignment of the condyles started with abite registration. Because the patient had bilateral retrodiscitis(TM inflammation) and disc displacements, and neededanterior/posterior correction, the phonetic bite registrationtechnique was used.32-34 The phonetic bite technique pro-vides the limit of anterior/posterior movement of the man-dible (Figure 6 and Figure 7). Additionally, the phonetic biteachieves significant improvement in the airway. From the

Beck


Figure 13 Note the rectangular wire used to create ideal

torque.

Figure 14 Lower-arch clean up, orthopedic expansion, and

orthodontics completed.

Figure 15 Removable retention that was used for 6 months. Figure 16 Final upper and lower waxup, maintaining the estab-

lished position. The temporary stent was made from the waxup.

phonetic bite registration and upper and lower impressions,a neuromuscular demand appliance (NDA) was made for thepatient to wear during all of her waking hours. This orthotic,in essence, resets the jaw orthopedically to enable the condylethe opportunity to recapture the disc. In addition, the orthot-ic, by moving the condyle in a down and forward position,

decompresses the joints allowing for healthy blood flow, andthe elimination of pressure on retrodiscal nerves and bloodvessels35-37 (Figure 8 and Figure 9). Ultimately, the NDA aidsin eliminating inflammation of the joint capsule, which pre-viously was caused by occlusal and parafunctional trauma.

At night a separate orthotic was used, which was a night-time deprogrammer with a palatal ramp. This appliance, ananterior discluder, keeps the condyles, mandible, and mus-cles in a posture that is consistent with the occlusal trajectoryestablished with the day appliance. In addition, the posteri-or teeth do not touch, significantly eliminating night clench-ing.38-40 Finally, by holding the jaw in position at night andcombining this with patient functioning in the NDA or-thotic in the daytime, the musculature will reprogram to thisposition and the TMJ capsules will adapt to the condyles’new posture. These two orthotics, worn over a period of 3 to4 months, set the foundation for the subsequent Phase 2 andPhase 3 treatments.

In addition to wearing the appliances, the patient had sub-sequent trigger point, ligament insertion, and prolotherapyinjections. She also had the chiropractor do some cervicaladjustments. After 8 weeks of therapy, the patient reachedmaximum medical improvement (MMI). All of her pain is-sues were gone. The final Phase 1 records were taken, includ-ing new tomograms, cephalograms, bitewing and perioapicalradiographs, JVA, EMGs, and jaw-tracking records. Therecords showed objectively that she had reached MMI.

Phase 2The orthopedic position established in Phase 1 was main-tained in Phase 2 by constructing anterior composite incisalramps/blocks for the lower anterior incisor occlusion. In theposterior, occlusal blocks were built on the occlusal surface ofthe second molars. This tripod (Figure 10) maintained thejaw and bite trajectory, which was established in Phase 1through the NDA and the nighttime deprogrammer withpalatal ramp. With this functional tripod established, thePhase 2 goals of orthopedic expansion could be accom-plished as well as the orthodontic goals of rotating, leveling,and alignment. The upper-arch orthopedic developmentwas accomplished through a fixed Hyrax expansion appli-ance (Figure 11 and Figure 12). The lower arch developmentwas accomplished along with the upper arch and throughuse of straight wire techniques (Figure 13 and Figure 14).Final coupling of the dentition was accomplished throughverticalization with eruption of the teeth through elastics.



Figure 17 Completed case, right-side view.

Figure 18 Completed case, left-side view.

Figure 19 Completed case. The patient was pleased with

her final smile.

Phase 2 took 13 months. The patient then was placed inretention for an additional 6 months (Figure 15).

Phase 3With the completion of Phase 2, the patient was ready tostart Phase 3, full-mouth reconstruction to optimal dentalphysiology. This process started by constructing the upperand lower arch bite-registration stent out of Sil-tech (IvoclarVivadent Inc, Amherst, NY). This bite registration stentwas constructed from the upper and lower models mountedon the articulator. The mounting was from the currentcomplete orthopedic/orthodontic relationship establishedin Phase 2. The bite-registration stent allowed the author toprepare the teeth and then put a wash in the stent for theupper and lower prepped teeth, which maintained the rela-tionship established in Phase 1 and Phase 2. After con-struction of the bite-registration stent, the upper and lowermodels were prepped and both dental arches were waxedup in an ideal relationship (Figure 16).

From this waxup, a triple-tray temporary stent was con-structed. The design of the temporary stent enabled thepreparation of both arches in a single visit. The temporiza-tion of the occlusion maintained the relationship estab-lished in Phase 1 and Phase 2. The patient had both archesprepped and temporized. After 3.5 weeks, the permanentrestorations were placed. The following day, the final res-torations were fine-tuned with computerized occlusal analy-sis. The laboratory constructed a new nighttime depro-grammer with a palatal ramp for the patient to wear everynight. This appliance would protect against nighttime para-function and maintain a healthy airway.

The patient returned 1 month later for computerized oc-clusal analysis. The analysis objectively confirmed that theocclusion was balanced and right and left cuspid disclusionas well as protrusion were immediate and measurable to lessthan 0.2 seconds. The patient was reevaluated at 6 months,1 year, and 3 years posttreatment. Her symptoms have notreturned. Follow-up examinations using biometric instru-mentation objectively show normal healthy muscle function,normal jaw function, normal swallowing, and a normal air-way. The patient is ecstatic with her final result (Figure 17through Figure 19).

CONCLUSIONThis case study illustrates the intimate relationship betweenhow teeth interdigitate and the impact interdigitation has

on the whole body. The patient presented with chief com-plaints of jaw clicking and popping, jaw joint pain, head-aches, bad bite, and dislike of the appearance of her teeth.The patient went through three phases of treatment over aperiod of approximately 2.5 years. The phases dealt with herphysiologic chief complaints, enhanced her orthopedic archform, straightened her teeth and, finally, prosthetically re-stored her entire mouth.

The entire treatment plan was established by using ex-tensive record gathering through radiographic and comput-erized electrodiagnostic modalities. In this patient, manydifferent sources of record gathering were used to diagnosethe cause of the patient’s chief complaints before treatmentand ultimately to direct the course of treatment. The occlu-sion was examined by mounting models on an orthopedicarticulator. This mounting showed the relationship of theocclusal plane of the teeth to the maxilla, mandible, and jawjoints. The function of the joints was assessed objectively byJVA. The function of the muscles was assessed objectivelyby EMG. These assessments illustrated pathologic muscleresting and functional activity.

The functional activities assessed were clenching, chew-ing, and swallowing. The degenerative and pathologic bonyorthopedics were diagnosed from various craniomandibularradiographs. These radiographs illustrated improper neckcurvature in the cervical vertebra, bony apposition associat-ed with clenching, and displaced TMJ posture bilaterally.All of the observed diagnostic modalities directly influencedthe course of treatment selected for this patient. The com-pleted treatment was subjectively and objectively very suc-cessful, with the patient doing well 3 years after treatment.

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1. A panoramic radiograph can reveal:a. antegonial notching.b. posterior displacement.c. cervical degeneration in C5

through C7.d. joint translation.

2. Right and left tomograms can reveal:a. antegonial notching.b. superior displacement.c. spacing between the C1

and C2 vertebrae.d. condylar neck fracture.

3. A cephalogram can show:a. lordotic curvature.b. cervical degeneration in C5

through C7.c. joint translation.d. all of the above

4. A lateral skull radiograph is excellent for diagnosing:

a. failing restorations.b. periapical lesions.c. cervical degeneration in C5

through C7.d. spacing between the C1

and C2 vertebrae.

5. What can be used as a diagnostic aid to objectively detect pathology in the jaw joints during function?

a. stethoscopeb. palpation of the jaw jointc. patient interview, during which joint

popping and clicking can be heardd. joint vibration analysis

6. What can be used to diagnose how well the musclesof the stomatognathic system relax at rest?

a. palpation of the jaw jointb. electromyogramsc. sonogramsd. right and left tomograms

7. The jaw tracking range of motion test can reveal:a. maximum opening.b. left lateral excursion.c. right lateral excursion.d. all of the above

8. In Phase 1, what was used to limit anterior/posteriormovement of the mandible and achieve significantimprovement in the airway?

a. neuromuscular demand applianceb. separate nighttime deprogrammerc. phonetic bite techniqued. prolotherapy injection

9. The orthopedic position established in Phase 1 was maintained in Phase 2 by:

a. constructing anterior composite incisalramps/blocks.

b. wearing a new nighttime deprogrammer.c. orthopedic expansion with the straight wire

technique.d. vericalization with eruption of the teeth

through elastics.

10. In Phase 3, what was used to maintain the relationship established in Phase 1 and Phase 2?

a. a wash in the bite-registration stentb. temporization of the occlusionc. a new nighttime deprogrammer with a

palatal rampd. all of the above

Continuing Education 2 Quiz 2

Ascend Dental Media, now operated by AEGIS Communications, provides 1 Continuing Education credit hour for this article for those who wish to document their continuing education efforts. To participate in this CE lesson, please log onto www.compendiumlive.com, and click on ”Continuing Education,” where you may further review this lesson and testonline. The deadline for submission of quizzes is 24 months after the date of publication. Participants must attain a scoreof 70% to receive credit. If you are not currently enrolled in the CE program, the fee for one exam completed is $16.00,for two exams completed $26.00. For more information, please call 877-4-AEGIS-1 and ask to speak to the CE department.

a three-stage approach to full-mouth rehabilitation

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