Examining the occlusion
Tooth wear patterns, can indicate both functional and non functional interferences. This a really good indication of muscle hyperfunction. As in the case of the bruxer. When you see evidence of hyperfuntion do not be quick to reshape enamel. Better to quiet the muscles first, in all cases. You can accomplish this by separating the teeth with a pencil, credit card, anterior jig.. anything that will keep the teeth from touching.
Excursive interferences are best evaluated by using occlusal marking ribbon and dental floss or tape. The ribbon I prefer is made of mylar. Be careful using mylar. The wax can be rubbed off on the ribbon yet will not mark the teeth. Excessive forces can do this. As in, “I want you to grind your teeth on this ribbon.” When I suspect this is happening, I have the pt close on the ribbon lightly, just enough to catch it. Then as I pull gently on the ribbon, I have the pt “let go”. If there was adequate resistance, the wax will be left on the enamel at the point of contact. To check for F and NF interferences, use a loop of dental tape or floss. For example, if you are checking a left lateral excursion, loop the tape around #31/32, grab both ends of the floss and have the patient perform slowly, while you put very light tension on the floss. Have them move in increments so that you can determine where and when the floss is catching. As you Identify these interferences remove them. This is a good time to apply the “BULL” rule. Do the same with protrusive movement. Look to see if the contact is an interference or a guiding plane before you adjust.
Using ribbon in the mash and gnash technique. Do not use a heavy inked paper for this. Use mylar keeping in mind that the wax may not adhere to very heavy contacts. To perform this procedure successfully you must know how to “read” the markings on the occlusal table. You have to be able to distinguish FI and NFI from guiding planes and occlusal stops. I don’t recommend doing this unless you are experienced.
Tongue positioning, especially during swallowing
I have a case in which some errors in diagnosis have occurred due to the lack of understanding of occlusal function and tongue habits.Yesterday afternoon, Female probably mid sixties, CC pain “somewhere on the lower right side”. Already had recent endo, by endodontist, on #31. No relief. The endodontist says” it is probably the one in front of it”. The GP has no ideas. I examined this case carefully from an occlusal perspective.
1. She knows that she is a “heavy bruxer”. 2. she has pain during the day and no pain during the night and upon awakening. Because she wears a “night guard”. This night guard is “cracked and she WANTS a new one, she does not want this one repaired, interesting. The crack is on the right side,3. Exam of teeth shows flat occlusal surfaces on the right and excessive faceting on a gold crown on # 18 which is inclined mesially (maybe this is really #17) and no wear on posterior teeth anterior to the gold crown.(Curious) . 4. I ask her to close. With the exception of the gold crown, no contact on the left posterior, approx 1 + mm gap anterior to the gold unit. In my thinking, from an occlusal perspective, How was this not taken into consideration. 4. The only way that this condition can exist is if the TONGUE has suppressed the teeth on the left side. 5. While “closed” I had her swallow. There was the TONGUE filling the inter-occlusal gap. I gave her a mirror and had her watch. It did not happen. I told her that I was not sure about the tongue and I was perplexed because there was no other explanation. Then she told me she was not able to swallow although she was trying. So lesson learned. Do not trust everything you think you see at first, repeat the procedure, make sure. Funny but frustrating at times.
Summary and diagnosis
1. Wearing the night guard eliminates the pain! No pain on awakening. Only during the day when pain “builds” and the night guard is left in the medicine cabinet. This is KEY.
2. Lack of balanced forces due to minimal and poor quality contact on the left side causing very heavy forces on the flat posterior teeth on the right side which are bearing all of the stress from bruxing.
3. Pain seems to be diffuse, ill defined. Not likely a tooth. There are no reactions to temperature changes,( ice or hot beverages) Pain is relieved by taking nsaids. (excedrine)
Diagnosis: Pain is resulting from trauma to the periodontal ligaments caused by excessive forces applied during bruxism. The right side is bearing most of this force.
Treatment: Wear the night guard full time. To be removed only for eating. Allow complete healing of the ligaments.
Keep the tongue away from the teeth on the left side
Return after healing for occlusal therapy and further observation of the tongue position and the eruption of the teeth on the left side. Occlusal equilibration is anticipated at a proper time.
With proper knowledge of gnathologiy, examination from an occlusal perspective and observation of tongue position during swallowing, this “traumatic event” could have been avoided.
All of the above is correct assuming that my diagnosis is correct. I will update this case if I get the opportunity to do so.
9/27/2014 This woman has not yet returned.