MW efficacy in DSP

Dicle Dişhekimliği Dergisi / Dental Journal of Dicle ISSN 1308-0903

EXTREME ANTERIOR OPEN OCCLUSAL RELATIONSHIP

Emrah AYNA ve ark.

*AŞIRI ANTERİOR OKLUZAL AÇIK KAPANIŞ İLİŞKİSİNE SAHİP BİR HASTANIN OKLUZAL REHABİLİTASYONU: BİR VAKA RAPORU OCCLUSAL REHABILITATION OF A PATIENT WITH EXTREME ANTERIOR OPEN OCCLUSAL RELATIONSHIP: A CASE REPORT 1

Emrah AYNA, 2Köksal BEYDEMİR, 2Suat ALTUN, 3Zelal SEYFIİĞLU Doç.Dr. Dicle Üniversitesi Dişhekimliği Fakültesi Protetik Diş Tedavisi AD. Diyarbakır. Prof.Dr. Dicle Üniversitesi Dişhekimliği Fakültesi Protetik Diş Tedavisi AD. Diyarbakır. Yrd.Doç.Dr. Dicle Üniversitesi Dişhekimliği Fakültesi Protetik Diş Tedavisi AD. Diyarbakır.

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Abstract Introduction: An extreme anterior vertical overlap, an horizontal overlap greater than 6-7 mm, an opening between the intercuspal position and retrusive contact position of greater than 2 mm, the loss of five or more posterior teeth and the presence in children of unilateral maxillary-lingual cross-bite have been reported as being possibly related to temporomandibular dysfunction. Purpose: This case report presents occlusal rehabilitation of a patient with extreme anterior open occlusal relationship and temporomandibular dysfunction symptoms.Methods: The treatment plan was established on the basis of distributing the occlusal forces evenly over all the teeth and establishing maximum contact of the mandibular and maxillary teeth by eliminating the early contact of the right and left mandibular and maxillary second molar teeth which obstructed the maximum intercuspidation of the maxillary and mandibular teeth.Results: At check-up one month later, it was observed that there had been a 50% reduction in the patient’s pain complaints, and an 80% reduction at check-ups three and six months post-treatment. Conclusion:In the end of the treatment, the distribution of occlusal forces over the teeth with an increased number of teeth in occlusion provided the patient with a relatively good aesthetic appearance and masticatory function. Key words: Temporomandibular dysfunction, anterior vertical overlap, temporomandibular joint, Magnetic Resonance, fixed partial denture Özet Giriş: 6-7 mm’ den daha büyük bir aşırı anterior vertical overlap ve horizontal overlap, interkuspal pozisyon ve en geri pozisyon arasında 2 mm’den daha büyük bir açıklık, uzun süreli beş veya daha fazla posterior diş kaybı ve çocuklarda unilateral cross-bite gibi durumların temporomandibular rahatsızlıklarda yüksek oranda ilişkili olduğu bildirilmektedir. Amaç: Bu vaka raporu aşırı anterior oklüzal açıklık ilişkisi ve temporomandibular rahatsızlık belirtileri bulunan bir hastanın oklüzal rehabilitasyonunu sunmaktadır. Gereç ve yöntem: Alt ve üst çene dişlerinin maksimum kapanışta olmasını sağlayacak, alt-üst ve sağ- sol ikinci molar dişlerin erken temaslarını ortadan kaldırılması ile alt ve üst çenedeki tüm dişlerin maksimum teması ile oklüzal kuvvetlerin tüm dişler üzerinde dağıtılmasını amaçlayan tedavi planı hazırlandı.Bulgular: Bir ay sonundaki kontrollerde, hastanın ağrı şikayetlerinde %50, üç, altı ve oniki ay sonundaki kontrolerde ise %80 oranında azalmalar olduğu tespit edildi. Sonuç: Tedavi sonucunda, oklüzyona katılan dişlerin sayısının artması ile oklüzal kuvvetlerin tüm dişler üzerinde dağıtılması sağlanarak, nispeten iyi bir çiğneme fonksiyonu ve estetik görünüm sağlanmıştır. Anahtar kelimeler: Temporomandibular rahatsızlıklar, anterior vertikal overlap, temporomandibular eklem, Manyetik Rezonans, sabit bölümlü protez.

Introduction Most etiological factors leading to temporomandibular dysfunction (TMD) problems are risk factors. One part are causally-based in the true sense. The remainder are dental complaints that can lead İletişim Adresi Dr. Emrah Ayna Dicle Üniversitesi Dişhekimliği Fakültesi Protetik Diş Tedavisi AD. Diyarbakır E-mail: [email protected] Tel: 0.412.2488101-3465 Fax: 0.412.2488100 *Ankara Ortodonti Derneği 1. Uluslararası TME Sempozyumu,Ekim 1999, Antalya’ da poster olarak sunulmuştur.

Cilt / Volume 10 ∙ Sayı / Number 1 ∙ 2009

to such problems.1-6 Etiological factors have been classified as predisposing, initiating and perpetuating, and these have been reported to play a major role in the progress of TMD2. Predisposing factors have been reported to include structural, metabolic and/or psychological conditions and to significantly increase the risk of TMD by opposing the functioning of the masticatory system.1,2 Although it has been claimed by some researchers, with clinical support, that occlusion is a predisposing factor, there are also researchers who suggest that the relationship between TMD and malocclusion has not yet been scientifically proven.3,4 Researchers stress the difficulty of establishing a cause and effect relationship between TMD and occlusion as the latter includes a great many variables.2,3 In addition, an extreme anterior vertical overlap, Sayfa 7


an horizontal overlap greater than 6-7 mm, an opening between the intercuspal position and retrusive contact position of greater than 2 mm, the loss of five or more posterior teeth and the presence in children of unilateral maxillarylingual cross-bite have been reported as being possibly related to TMD. However, it has also been reported that the first three findings may only influence TMD, but not represent its main cause. 4-11 A new occlusal condition resulting in closure defect is described as cross support and anterior-posterior support. Cross tooth support is expressed as contacts on the side providing the balance. Anterior and posterior support is described as the presence of early centric contact in posterior or anterior teeth. 3,4 This case report presents occlusal rehabilitation of a patient with extreme anterior open occlusal relationship and TMDs.


Emrah AYNA ve ark.

time, the mandibular left first premolar was also observed to incline distally. In addition, the presence of the maxillary right primary first molar was also observed. Interocclusal distance was 6 mm in the anterior region and 3 mm in the posterior region. At temporomandibular joint (TMJ) auscultation neither clicking nor crepitation could be determined in any of the border movements of the mandible in both joints. Maximum mouth opening was measured as 48 mm, right and left lateral movement levels as 6 mm, and protrusive movement levels as 7 mm. The patient performed all these movements with the guidance of the second molar teeth (Figs. 2,3).

Case Report A 19-year-old female patient presented at the Dicle University, Dental Faculty, Department of Prosthodontics complaining of pain in the masticatory muscles, head-neck, and joint region, and of teeth failing to close fully. Extraoral examination revealed that postural face height had increased. At intraoral examination it was observed that the right and left mandibular and maxillary third molars were in contact and that there was an open occlusal relationship rising from these towards the anterior teeth (Fig. 1).

Figure 2. Right lateral border movement.

Figure 3. Left lateral border movement. No dental or bone pathology was encountered on the panoramic radiography. (Fig. 4)

Figure 1. Anterior open-bite. The right and left mandibular first molars had previously been extracted. It was observed that the right and left mandibular second molars bordering on these edentulous regions inclined mesially and the right and left mandibular second premolars inclined distally. At the same


Figure 4. Panoramic radiography. Sayfa 8


Magnetic Resonance (MR) images were used to determine whether or not there was a pathology in the TMJ (Figs. 5,6).

Figure 5. MRI (Left TMJ).

Figure 6. MRI (Right TMJ). In both joints the bone and disc relationship was irregular and the disc was in an anterior position. It was observed that the disc exposed to pressure between the mandibular condyle and the glenoid fossa had flattened out and lost its normal shape. Both joint discs possessed barely visible degenerative zones in the anterior. No appearance of fluid was determined inside the 2 joints. The patient reported that the right and left mandibular first molar teeth had been extracted at the age of 9 or 10 years of age, and the problems began subsequent to this. The patient also reported that clicking sounds and crepitation in the joints appeared at first, but these symptoms were absent for the last 2 years. The treatment plan was established on the basis of distributing the occlusal forces evenly over all the teeth and establishing maximum contact of the mandibular and



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maxillary teeth by eliminating the early contact of the right and left mandibular and maxillary second molar teeth which obstructed the maximum intercuspidation of the maxillary and mandibular teeth. It was determined that with the elimination of the existing early contact, the postural face height determined as being higher than normal by panoramic and MRI examinations could be adjusted and that the anterior mandibular condyle in the articular fossa could be brought to a normal position. In addition, it was thought that the pressure on the disc could be eliminated by distancing the mandibular condyle from the articular eminence. First the maxillary right primary first molar was extracted. After healing, impressions (Kettenbach, Eschenburg, Germany) were made and then plaster (Giludur, Fachbereich Dental, Hamburg, Germany) cast were placed on a semi-adjustable articulator (Dentatus, Novo Dental, Hägersten, Sweden) with the assistance of a face-bow with which occlusal records (Modelling wax, Cavex, Haarlem, Holland) were made. In order to ensure contact of all teeth in the intercuspal position, maximum contact of the teeth in the maxilla and mandible was established on the cast placed in the articulator by reduction from the occlusal of the right and left mandibular second molars which were then in contact. It was seen that the level of reduction reached the dentine level. The fact that the prepared teeth were adjacent abutments to the edentulous region permitted the application of fixed prosthetic restorations to these areas. After conducting the requisite tests on the articulator, treatment was initiated in the patient. Gradual preparation was performed from the occlusal of the right and left mandibular second molars with the assistance of diamond burs. Impressions were made after the reduction at the enamel level on the first day. An interocclusal splint was fabricated from heat-polymerized acrylic resin in order to provide oral rehabilitation was prepared on the plaster models installed in the articulator. Fluoride gel was applied to the prepared teeth. Two weeks after the first reduction it was seen that the patient had no new complaints, and progressed to the second reduction process. The dentin layer was reached in the second reduction process and a dentine protecting was applied to the reduced surface by performing the necessary adjustments on the interocclusal splint. When the third reduction process was applied 2 weeks later, maximum contact of the

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existing teeth was established and progressed to preparation for the fixed prosthetic restorations. The recession of the pulp chambers in these teeth which had been exposed to extreme vertical forces for a long time allowed us to increase the level of preparation. Fixed partial dentures prepared by traditional methods were cemented (Figs. 7,8,9).

Figure 7. Final Restoration.

Figure 8. Right lateral border movement after treatment.


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masticatory muscles to accustom themselves to the new occlusal position. In addition, physiotherapy and muscle relaxing medical agents when required were included in the treatment programme. Immediately after the reduction of the vertical dimension of occlusion and the cementing of the restorations, it was seen from the patient’s panoramic graphics (Planmeca Proline EC, Planmeca Group, Helsinki, Finland) that the joint assumed a slightly posterior position in the articular fossa (Fig. 10).

Figure 10. treatment.

Panoramic

A new occlusal splint was then prepared installed in order for the patient’s


after

It was also seen that that the patient’s joint and muscle pains had significantly decreased and that mandibular movement difficulties had also ameliorated. At check-up one month later, it was observed that there had been a 50% reduction in the patient’s pain complaints, and an 80% reduction at check-ups three and six months post-treatment. The following findings were observed in the patient’s MR images 6 months later: no irregularity was determined in the joint head cortex in either condyle; the disc was in an anterior position in both joints (anterior disc location without reduction); retrodiscal area dimensions had decreased and the disc had lost its normal shape (had flattened out). At the same time, the bilateral zone could not be distinguished. The joint was in a rather more posterior position compared to the pretreatment. The results from cephalometric orthodontic analysis also revealed this. (Fig. 11)

Figure 9. Left lateral border movement after treatment.

and

radiography

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Figure11. Cephalometric orthodontic analysis. Discussion In the literature regarding the occlusion treatment of patients with TMD it has been reported that as well as occlusal adaptation procedures based on definite and specific morphological concepts, planning based on the physiological and specific needs of the patient’s masticatory structures is also necessary. It is reported that when intercuspal position and the vertical dimension of occlusion are acceptable the TMD treatment programme needs to protect the functional balance. In addition, it has also been suggested that if intercuspal position and/or vertical dimension are not acceptable and if this balance needs to be established, then in order for occlusion to be ensured again centric relation position needs to be taken as the basis as a reference treatment position.1-4 In previous studies, the specific treatment aims for functional starting points newly established for TMD patients and to establish optimum structural needs are set out as follows: maximum symmetrical distribution of intercuspal contacts in previously determined jaw relationships, axial or semi-axial loading of teeth, an acceptable occlusal plane, guidance contacts must be established which permit free movement during gliding movements and mandibular closing, without allowing incorrect movements of the mandible or teeth, and an acceptable vertical dimension of occlusion and rest position. 3,4,6-11 In the light of all these data, the occlusal condition supported in a posterior direction which resulted in the patient’s closure defect led to both joints being in an anterior position and gradual disc abrasion. Since the vertical dimension decreased as a result of treatment, the joint moved towards the posterior and the



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pressure on the disc was alleviated. However, the anterior position of the disc persisted. With the alleviation of that pressure, the patient’s complaints of pain in the joint region and masticatory muscles decreased. Due to the inability to distinguish the bilaminal zone in the MR images it was impossible to determine whether there was post-treatment pressure on this region. However, the increasing reduction in the patient’s pain complaints in the examination periods was regarded as a welcome development. The elimination of the pressure on the disc which emerged posttreatment, despite the position of the disc not being ideal, and the distribution of occlusal forces over the teeth with an increased number of teeth in occlusion provided the patient with a relatively good aesthetic appearance and masticatory function. With splint treatment in subsequent periods the patient was easily able to adapt to this new occlusal state. Kaynaklar Bell WE. Classification of TM disorders. The presidents conference on the examination, diagnosis and management of temporomandibular disorders. Chicago. American Dental Association. 1982: 24-9. 2. McNeill C, Mohl ND, Rugh JD, Tanaka TT. Temporomandibular disorders; diagnosis management, education, and research. J Am Dent Assoc.1990; 120: 25363. 3. Mohl ND, McCall WD, Lund JP, Plesh O. Devices for the diagnosis and treatment of temporomandibular disorders. Part I: Introduction, scientific evidence, and jaw tracking. J Prosthet Dent 1990; 63: 198-201. 4. McNeill C. Management of temporomandibular disorders: Concepts on controversion. J Prosthet Dent 1997; 77: 510-22. 5. Mohl ND, Lund JP, Widmer CG, McCall VD. Devices for the diagnosis and treatment of temporomandibular disorders. Part II: Electromyography and sonography. J Prosthet Dent 1990; 63: 332-6. 6. Mohl ND, Ohrbach R. The dilemma of scientific knowledge versus clinical management of temporomandibular disorder. J Prosthet Dent 1992; 67: 113-20. 7. Ai M, Yamashita S. Tenderness on palpation and occlusal abnormalities in temporomandibular dysfunction. J Prosthet Dent 1992; 67: 839-45. 8. De Mot B, Casselman J, DeBoever J. Pseudodynamic magnetic resonance imaging in the diagnosis of temporomandibular dysfunction. J Prosthet Dent 1994; 72: 309-13. 9. Holmgren K, Shetikholeslam A, Riise L, Koop S. The effects of on occlusal splint on the electromyographic of the temporal and masseter muscles during maximal clenching in patients with a habit of nocturnal bruxism and signs and symptoms of craniomandibular disorders. J Oral Rehabil 1990; 17: 447459. 10. Kerstein RB, Wright NR. Electromyographic and computer analyses of patients suffering from chronic myofacial pain dysfunction syndrome: before and after treatment with immediate complete anterior guidance development. J Prosthet Dent 1991; 66: 677-86. 11. Kurita H, Kunashina K, Katani A. Clinical effect of full coverage occlusal splint therapy for specific temporomandibular disorder conditions and symptoms. J Prosthet Dent 1997; 78: 506-10. 1.

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