Contemporary ortho chap18 part2

CHAPTER 18Special Considerations in Treatment for Adults, 623William R. Proffit, David M. Sarver

Adjunctive vs Comprehensive Treatment,

624

Goals of Adjunctive Treatment, 624

Principles of Adjunctive Treatment, 624

Adjunctive Treatment Procedures, 627

Comprehensive Treatment in Adults, 637

Special Aspects of Orthodontic Therapy for

Adults, 661

Diastema Closure and Space Redistribution The major indication for adjunctive orthodontic treatment to correct malaligned anterior teeth is preparation for buildups, veneers, or implants to improve the appearance of the maxillary incisor teeth. The most frequent problem is a maxillary central diastema, which is often further complicated by irregular spacing related to small or missing lateral incisors (Figure 18-20). A "diagnostic setup" is very helpful in planning the correction of such problems. For this procedure, the study casts are duplicated and the malaligned teeth are carefully cut from the model, repositioned, and then waxed back onto the cast in a new position. If digital casts are available, a modern alternative is to do this on a computer screen (see Figure14-1), and this is part of routine treatment planning when a sequence of clear aligners will be used in comprehensive treatment (see below). This allows evaluation of the feasibility of the orthodontic treatment in light of the crown and root movements required, the anchorage available, the periodontal support for each tooth, and the possible occlusal interferences.

Alignment of Anterior Teeth

If spacing of maxillary incisors is related to small teeth and a tooth-size discrepancy, composite buildups are an excellent solution, but satisfactory esthetics may require redistribution of the space before the restorations are placed, as in this patient who was concerned about his large central diastema. A and B, Before treatment, age 48. C and D, Redistribution of the space using a fixed appliance with coil springs on a 16 mil steel archwire immediately before removal of the orthodontic appliance and placement of the restorations (to be done the same day). A17.5 mil multistrand steel wire was used for initial alignment before the coil springs were placed. Eand F, Completed restorations (composite buildups). G, Note the fixed retainer of bonded 21.5 mil multistrand wire on the lingual of the central incisors to prevent partial reopening of the midline space. Surgical revision of the frenum was not performed, partially in deference to the patient's age. H, Appearance on smile before and (I) after treatment.636

FIGURE 18-20




FIGURE 18-20

Ortho. Closure ?

Restorations ?




FIGURE 18-20

Ortho. Closure ?

Restorations ?

Diagnostic Setup




FIGURE 14-1

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Pre-Tx. Dx. Setup or Digital simulation

Pre-Tx. Dx. Setup or Digital simulation




FIGURE 18-20




FIGURE 18-20

16 mil steel




FIGURE 18-20




FIGURE 18-20

21.5 mil

Crowded, Rotated, and Displaced Incisors As a rule, spacing is the problem when maxillary incisors need realignment to facilitate other treatment. Crowding usually is the problem when alignment of lower incisors is considered to provide access for restorations, achieve better occlusion, or enable the patient to maintain the teeth. In some cases, alignment of incisors in both arches must be considered. The key question is whether the crowding should be resolved by expanding the arch, removing some interproximal enamel from each tooth to provide space,8 or removing one lower incisor. Expansion of a crowded incisor segment can be done with clear aligners, but if only the lower arch is to be treated, the esthetics of the appliance is not a consideration, and a partial fixed appliance is more efficient and cost-effective (Figure 18-21). A segment of A-NiTi wire, with stops to make it slightly advanced, usually is the best way to bring the teeth into alignment (see Figure 14-5).


In an adult with a damaged lower incisor (in this case, the left central incisor with a crown fracture) and incisor crowding, there are two treatment possibilities: extract the damaged tooth and use the space to align the remaining teeth, or align the teeth with arch expansion and restore the damaged one. The decision has an esthetic component because the lower incisors are visible on smile in older individuals. In this patient, aligning the lower incisors without extraction would also require aligning the upper incisors, but this expansion would increase lip support and improve the overall facial appearance as well as the dental appearance. A, Smile before treatment, after loss of one corner of the lower right central incisor. B, Mandibular occlusal view. C, Frontal view. Note the moderately deep bite and lack of overjet. The restorative dentist sought orthodontic consultation, thinking that extraction of the damaged tooth might be the best plan. The patient wanted the best esthetic result and accepted a period of treatment with a fixed appliance on both arches, after which the incisor would be restored. The orthodontic alignment required 5 months. 0, Mandibular occlusal view after alignment. E, Frontal view. F, Smile after restoration was completed.

637

FIGURE 18-21

FIGURE 14-5




637

FIGURE 18-21

FIGURE 14-5

Ext. ? Expansion?

Inter-proximal Reduction (IPR)?




637

FIGURE 14-5FIGURE 18-21




637


No ext. of one lower incisor !!No braces on upper !!

Only 5 month tx. time !!It seems no IPR !!




637


No ext. of one lower incisor !!No braces on upper !!

Only 5 month tx. time !!?It seems no IPR !!




637


Crimped stop




637


Crimped stop Open coil first

Crowded, Rotated, and Displaced Incisors Stripping the contact points of the teeth to remove enamel can provide space for alignment of mildly irregular lower incisors, and either a fixed appliance or a clear aligner sequence can provide the tooth movement. This should be undertaken with caution, however, because it may have an undesirable effect on overjet, overbite, posterior intercuspation, and esthetics.9 In severe crowding, removing one lower incisor and using the space to align the other three incisors can produce a satisfactory result and can be managed with clear aligner therapy if bonded attachments are part of the treatment plan (Figure 18-22). The treatment time and difficulty, whatever the type of appliance, put this at or across the border of comprehensive treatment. Neither stripping nor incisor extraction should be undertaken without a diagnostic setup to verify feasibility. Remember that stretched gingival fibers are a potent force for relapse after rotations have been corrected, and that good long-term stability may require a fiberotomy (see Chapter 16). Whether clear aligners or a fixed appliance was used, retention is necessary until restorative or other treatment is completed. This can be the final aligner in a sequence (though this may be too flexible to be a good retainer), a molded thermoplastic retainer after a fixed appliance is removed, a canine-to-canine clip retainer, or a bonded fixed retainer. 10


This 24-year-old patient had a congenitally missing mandibular right lateral incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C, Mandibular occlusal. The plan was extraction of the primary incisor and closure of the extraction site, using a series of Invisalign aligners and bonded attachments to produce the necessary rotation and root movement. Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-to-see bonded attachments on the maxillary right canine and incisors and on the mandibular right canine and central incisor. The original plan called for 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F, After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used along with the aligner to further rotate it. New records were taken, and four upper and five lower revision aligners, with three revision overcorrection aligners, were fabricated. G to I, Completion of treatment. A bonded canine-to-canine mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completion of treatment. Total treatment time was 19 months (which included 2 months waiting for revision aligners). (Courtesy Dr. W. Gierie.)

637

FIGURE 18-22




637

Neither stripping nor incisor extraction

should be undertaken without a diagnostic setup.

FIGURE 18-22




637

FIGURE 18-22




637




637

Inter-arch Tooth Size Discrepancy




637




637

Wedjet® (Coltène Whaledent, www.coltene.com)

Dental Dam Stabilizing Cord

http://www.coltene.com/




637




Addition or Reduction ?Addition or Reduction ?




Local Treatment or not ?Local Treatment or not ?




450450

530475

250240

280270

190200

230170

Anchorage ValueAnchorage Value

250240




4545

5348

2524

2827

1920

2317

Anchorage ValueAnchorage Value

2524




Mobile & Non-mobileMobile & Non-mobile




Center of RotationCenter of Rotation




Apply Bone ScrewApply Bone Screw




Rehearsal on ModelRehearsal on Model

Segmental Tech.

Segmental Tech.




ImplantImplant

GPGPOrtho.(Adjunctive Tx.)

Ortho.(Adjunctive Tx.)

CHAPTER 18Special Considerations in Treatment for Adults, 623William R. Proffit, David M. Sarver

Adjunctive vs Comprehensive Treatment,

624

Goals of Adjunctive Treatment, 624

Principles of Adjunctive Treatment, 624

Adjunctive Treatment Procedures, 627


Special Aspects of Orthodontic Therapy for

Adults, 661


Special Aspects of Orthodontic Therapy for Adults, 661

Psychologic ConsiderationsTMD as a Reason for Ortho. Tx.Perio. ConsiderationsProstho-implant interactions

Esthetic Appliances in Tx. of AdultsApplications of Skeletal AnchorageRetraction and Intrusion of Protruding IncisorsFinishing and Retention

637

Psychologic Considerations A major motivation for orthodontic treatment of younger patients is the parents' desire to do the best they can for their children. The typical child or adolescent accepts orthodontics in about the same rather passive way that he or she accepts going to school, summer camp, and the inevitable junior high school dance: as just another in the series of events that one must endure while growing up. Occasionally, of course, an adolescent actively resists orthodontic treatment, and the result can be unfortunate for all concerned if the treatment becomes the focus of an adolescent rebellion. In most instances, however, children tend not to become emotionally involved in their treatment. Adults in both the younger and older groups, in contrast, seek comprehensive orthodontic treatment because they themselves really want it. For the younger group who are trying to improve their lot in life, exactly what they want is not always clearly expressed, and some young adults have a remarkably elaborate hidden set of motivations. It is important to explore why an individual wants treatment and why now as opposed to some other time to avoid setting up a situation in which the patient's expectations from treatment cannot possibly be met. Sometimes, orthodontic treatment is sought as a last-ditch effort to improve personal appearance to deal with a series of complicated social problems. Orthodontic treatment obviously cannot be relied on to repair personal relationships, save jobs, or overcome a series of financial disasters. If the prospective patient has unrealistic expectations of that sort, it is much better to deal with them sooner rather than later.

637


Why & Why now ?

For Adult patients

637


Why & Why now ?

For Adult patients

Unrealistic Expectation?

638

Psychologic Considerations Most adults in both the younger and older groups, fortunately, understand why they want orthodontics and are realistic about what they can obtain from it. One might expect those who seek treatment to be less secure and less well-adjusted than the average adult, but for the most part, they have a more positive self-image than average.11 It apparently takes a good deal of ego strength to seek orthodontic treatment as an adult, and ego strength rather than weakness characterizes most potential adult patients. A patient who seeks treatment primarily because he or she wants it (internal motivation) is more likely to respond well psychologically than a patient whose motivation is the urging of others or the expected impact of treatment on others (external motivation). External motivation is often accompanied by an increasing impact of the orthodontic problem on personality (Figure 18-23). Such a patient is likely to have a complex set of unrecognized expectations for treatment, the proverbial hidden agenda. One way to identify the minority of individuals who may present problems because of their unrealistic expectations is to compare the patient's perception of his or her orthodontic condition with the doctor's evaluation. If the patient thinks that the appearance or function of the teeth is creating a severe problem, while an objective assessment simply does not corroborate that, orthodontic treatment should be approached with caution.

FIGURE 18-23 Dentofacial deformity can affect an individual's life adjustment. Fortunately, most potential adult orthodontic patients fall into the "no problem" category psychologically. Afew highly successful individuals (who nevertheless may seek treatment) can be thought of as almost overcompensating for their deformity with their exceptional personability, but they tend to be personable and very pleasant to work with.For some individuals, however, the orthodontic condition can become the focus for a wide-ranging set of social adjustment problems that orthodontics alone will not solve. These patients fall into the "inadequate personality" and "pathologic personality" categories, who are difficult and almost impossible, respectively, to help. An important aspect of orthodontic diagnosis for adults is understanding where a patient fits along this spectrum.

638



Internal Motivation

External Motivation

638



Internal Motivation

External Motivation

I want this? or You want me to do

this?

638

Dentofacial deformity can affect an individual's life adjustment. Fortunately, most potential adult orthodontic patients fall into the "no problem" category psychologically. A few highly successful individuals (who nevertheless may seek treatment) can be thought of as almost overcompensating for their deformity with their exceptional personability, but they tend to be personable and very pleasant to work with. For some individuals, however, the orthodontic condition can become the focus for a wide-ranging set of social adjustment problems that orthodontics alone will not solve. These patients fall into the "inadequate personality" and "pathologic personality" categories, who are difficult and almost impossible, respectively, to help. An important aspect of orthodontic diagnosis for adults is understanding where a patient fits along this spectrum.

FIGURE 18-23

641

Psychologic Considerations

FIGURE 18-22

Even highly motivated adults are likely to have some concern about the appearance of orthodontic appliances. The demand for an invisible orthodontic appliance comes almost entirely from adults who are concerned about the reaction of others to obvious orthodontic treatment. In an earlier era, this was a major reason for using removable appliances in adults, particularly the Crozat appliance in the United States. All of the possibilities for a better appearing appliance, however, lead to potential compromises in the orthodontic treatment. Plastic brackets create problems in controlling root position and closing spaces. Ceramic brackets, though much better, inevitably make treatment more difficult because of the problems outlined in Chapter 11. Lingual appliances have been greatly improved since the turn of the twenty-first century and now make all types of tooth movement quite possible but still are technically difficult for the doctor to use efficiently and can be difficult for patients to tolerate. Clear aligners manage some types of tooth movement quite well (especially tipping) but have difficulty with others (especially extrusion, rotation, and root positioning). Small bonded attachments on teeth that require complex movements give the aligner a better purchase, partially overcoming this difficulty (see Figure 18-22).

638


Dentofacial deformity can affect an individual's life adjustment. Fortunately, most potential adult orthodontic patients fall into the "no problem" category psychologically. Afew highly successful individuals (who nevertheless may seek treatment) can be thought of as almost overcompensating for their deformity with their exceptional personability, but they tend to be personable and very pleasant to work with.For some individuals, however, the orthodontic condition can become the focus for a wide-ranging set of social adjustment problems that orthodontics alone will not solve. These patients fall into the "inadequate personality" and "pathologic personality" categories, who are difficult and almost impossible, respectively, to help. An important aspect of orthodontic diagnosis for adults is understanding where a patient fits along this spectrum.



641

FIGURE 18-22




FIGURE 18-22

641



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Although there is nothing wrong with using the most esthetic appliance possible for an adult patient, the compromises associated with this approach should be thoroughly discussed in advance. It is unrealistic for a patient to expect that orthodontic treatment can be carried out without other people knowing about it. The whole issue of the visibility of the orthodontic appliances is much less important, at least in the United States, than many patients fear. Orthodontic treatment for adults is certainly socially acceptable, and one does not become a victim of discrimination because of visible orthodontic appliances. In a sense, the patient's expectations become a self-fulfilling prophecy. If the patient faces others confidently, a visible orthodontic appliance causes no problems. Only if the patient acts ashamed or defensive is there likely to be any negative reaction from others. The question of whether an orthodontic office should have a separate treatment area for adults, separated from the adolescents who still constitute the bulk of most orthodontic practices, is related to the same set of negative attitudes. Most comprehensive orthodontic treatment for adolescents is carried out in open treatment areas, not only because the open area is efficient but also because the learning effect from having patients observe what is happening to others is a positive influence in patient adaptation to treatment. Should adults be segregated into private rooms, rather than joining the group in the open treatment area? This is logical only if the adult is greatly concerned about privacy (more true of Europeans than Americans), or vaguely ashamed of being an orthodontic patient. Sometimes, for some adults, treatment in a private area may be preferable, but for most adults, learning from interacting with other patients helps them understand and tolerate the treatment procedures. There are positive advantages in having patients at various stages of treatment compare their experiences, and this is at least as beneficial to adults as to children, perhaps more so.


641


Open Space ? or Private Space ?


641


If the p’t faces other confidently! Open space provide p’t to interact with

others.


641

Despite the fact that adults can be treated in the same area as adolescents, they cannot be handled in exactly the same way. The typical adolescent's passive acceptance of what is being done is rarely found in adult patients, who want and expect a considerable degree of explanation of what is happening and why. An adult can be counted on to be interested in the treatment but that does not automatically translate into compliance with instructions. Unless adults understand why they have been asked to do various things, they may choose not to do them, not in the passive way an adolescent might just shrug it off but from an active decision not to do it. In addition, adults, as a rule, are less tolerant of discomfort and more likely to complain about pain after adjustments and about difficulties in speech, eating, and tissue adaptation. Additional chair time to meet these demands should be anticipated. These characteristics might make adults sound like less desirable orthodontic patients than adolescents, but this is not necessarily so. Working with individuals who are intensely interested in their own treatment and motivated to take care of their teeth can be a pleasant and stimulating alternative to the less-involved adolescents. If the expectations of both the doctor and the patient are realistic, comprehensive treatment for adults can be a rewarding experience for both.


641


Explain more !

What happen & Why !

For Adult patients


641


Explain more !

What happen & Why !

Fight for the same Goal !!

For Adult patients




Psycho.Psycho.Ortho.Ortho.




Psycho.Psycho.Ortho.Ortho.

Explain more, Make a Positive environment

Explain more, Make a Positive environment

TMD as a Reason for Ortho. Tx.

642

Temporomandibular pain and dysfunction (TMD symptoms) rarely are encountered in children seeking orthodontic treatment, but TMD is a significant motivating factor for some adults who consider orthodontic treatment.12 The relationship between dental occlusion and TMD is highly controversial, and it is important to view this objectively.13 Orthodontic treatment can sometimes help patients with TMD, but it cannot be relied on to correct these problems.14 Patients need to understand what may happen to their symptoms during and after orthodontics.

In diagnosis of TMD problems, patients are classified as being in one of four large groups: masticatory muscle disorders, TM joint disorders, chronic mandibular hypomobility, and growth disorders. 15 From the perspective of potential orthodontic treatment in adults, differentiating between the first two groups is particularly important (Figure 18-24). Because muscle spasm and joint pathology can coexist, the distinction in many patients is difficult. Nevertheless, it is unlikely that orthodontics will relieve TMD symptoms in a patient who has internal joint problems or other nonmuscular sources of pain. Those who have myofascial pain/dysfunction, on the other hand, may benefit from improved dental occlusion.

Types of Problems

FIGURE 18-24 TMD symptoms arise from two major causes: muscle spasm and fatigue, which almost always are related to excessive clenching and grinding in response to stress, and internal joint pathology. As a general guideline, patients with symptoms of muscle spasm and fatigue may be helped by orthodontic treatment, but simpler methods should be attempted first. Orthodontics alone is rarely useful for patients with internal joint pathology.

Ortho. Tx.✔

?


642



Types of Problems

TMD symptoms arise from two major causes: muscle spasm and fatigue, which almost always are related to excessive clenching and grinding in response to stress, and internal joint pathology. As a general guideline, patients with symptoms of muscle spasm and fatigue may be helped by orthodontic treatment, but simpler methods should be attempted first. Orthodontics alone is rarely useful for patients with internal joint pathology.FIGURE 18-24

TMD symptoms:

painjoint noise

limited opening


642



Types of Problems


Muscle spasm and

fatigue

TMD symptoms:

painjoint noise

limited opening

Internal joint pathology


642



Types of Problems


Clenching, grinding(stress response)

Muscle spasm and

fatigue

TMD symptoms:

painjoint noise

limited opening



642



Types of Problems


Ortho. Tx.


Muscle spasm and

fatigue

TMD symptoms:

painjoint noise

limited opening



642



Types of Problems


Ortho. Tx.

✔


Muscle spasm and

fatigue

TMD symptoms:

painjoint noise

limited opening



642



Types of Problems


Ortho. Tx.

✔

?


Muscle spasm and

fatigue

TMD symptoms:

painjoint noise

limited opening



642

Almost all of us develop some symptoms of degenerative joint disease as we grow older, and it is not surprising that the jaw joints sometimes are involved (Figure 18-25). Arthritic involvement of the TM joints is most likely to be the cause of TMD symptoms in patients who have arthritic changes in other joints of the body. A component of muscle spasm and muscle pain should be suspected in individuals whose only symptoms are in the TM joint area, even if radiographs show moderate arthritic degeneration of the joint. Displacement of the disk (Figure 18-26) can arise from a number of causes. One possibility is trauma to the joint, so that the ligaments that oppose the action of the lateral pterygoid muscle are stretched or torn. In this circumstance, muscle contraction moves the disk forward as the mandibular condyles translate forward on wide opening, but the ligaments do not restore the disk to its proper position when the jaw is closed. The result is a click upon opening and closing, as the disk pops into place over the condylar head as the patient opens, but is displaced anteriorly on closure.

Types of Problems FIGURE 18-25 Three radiographic views of arthritic degeneration of a left mandibular condyle, from CBCT images. Note the flattening of the condylar head and the lipping posteriorly, which can be visualized in a view similar to what is seen in a panoramic radiograph (A) but are seen more clearly in the images that show the condylar area (B and C). With CBCT images it is possible to rotate the field of view as desired.

FIGURE 18-26

A, Computed tomography (CT) view of a displaced mandibular disk, which can be visualized (as a darker area) in front of the condyle. B, Magnetic resonance imaging (MRI) view of a displaced disk, with the anterior and posterior bands indicated on the adjacent sketch. There is evidence on this scan of a regenerating disk, as shown in the dashed area. MRI scans have largely replaced radiographic views for the diagnosis of disk displacement because the soft tissues can be seen more clearly and no ionizing radiation is required, while cone-beam CT (CBCT) is preferred for visualization of bony changes.

642

FIGURE 18-25

CT

642

FIGURE 18-25

CT3D condylar morphology

642

FIGURE 18-26

MRISoft tissue condition

Figure 4a. Morphologic features of the normal disk.

Tomas X et al. Radiographics 2006;26:765-781

©2006 by Radiological Society of North America


642

The click and symptoms associated with it can be corrected if an occlusal splint is used to prevent the patient from closing beyond the point at which displacement occurs. The resulting relief of pain influences patients and dentists to seek either restorative or orthodontic treatment to increase facial vertical dimension. However, orthodontic elongation of all posterior teeth to control disk displacement is not a treatment procedure that should be undertaken lightly. Often, the patient whose symptoms have been controlled by a splint can tolerate its reduction or removal, without requiring major occlusal changes. As a general rule, there are better ways of handling disk displacement than orthodontic treatment. Myofascial pain develops when muscles are overly fatigued and tend to go into spasm. It is all but impossible to overwork the jaw muscles to this extent during normal eating and chewing. To produce myofascial pain, the patient must be clenching or grinding the teeth for many hours per day, presumably as a response to, stress. Great variations are seen in the way different individuals respond to stress, both in the organ system that feels the strain (many problems besides TMD are related to stress) and in the amount of stress that can be tolerated before symptoms appear (tense individuals develop stress-related symptoms before their relaxed colleagues do). For this reason, it is impossible to say that occlusal discrepancies of any given degree will lead to TMD symptoms.

Types of Problems

It is possible to demonstrate that some types of occlusal discrepancies predispose patients who clench or grind their teeth to the development of TMD symptoms. It must be kept in mind, however, that it takes two factors to produce myofascial pain: an occlusal discrepancy and a patient who clenches or grinds the teeth. Perhaps the most compelling argument against malocclusion as a primary cause of TMD is the observation that TMD is no more prevalent in patients with severe malocclusion than in the general population.16 The dictum "let your teeth alone" would solve myofascial pain problems if it could be followed by the patient.


642


Types of Problems


TMD is no more prevalent in p’t with severe malocclusion


642


Types of Problems


TMD is no more prevalent in p’t with severe malocclusion

Diagnosis TMD before Ortho. treatment

642

FIGURE 18-24


Muscle spasm and

fatigue

TMD symptoms:

painjoint noise

limited opening


642

FIGURE 18-24


Muscle spasm and

fatigue

TMD symptoms:

painjoint noise

limited opening


Occlusal discrepancy

642

FIGURE 18-24


Muscle spasm and

fatigue

TMD symptoms:

painjoint noise

limited opening



Ortho. Tx.

642

FIGURE 18-24

Ortho. Tx.


Muscle spasm and

fatigue

TMD symptoms:

painjoint noise

limited opening



+

642

FIGURE 18-24

Ortho. Tx.


Muscle spasm and

fatigue

TMD symptoms:

painjoint noise

limited opening



+

+/-

642

FIGURE 18-24

Ortho. Tx.


Muscle spasm and

fatigue

TMD symptoms:

painjoint noise

limited opening



+

+/-

Occlusal splint

642

FIGURE 18-24

Ortho. Tx.


Muscle spasm and

fatigue

TMD symptoms:

painjoint noise

limited opening



+

+/-

Occlusal splint

+/-+/-+/-

642

Ortho. Tx.


Muscle spasm and

fatigue

TMD symptoms:

painjoint noise

limited opening



+

+/-

Occlusal splint

+/-+/-+/-

Stress release IDT


643

From this perspective, three broad approaches to myofascial pain symptoms can be considered: reducing the amount of stress; reducing the patients' reactions to stress; or improving the occlusion, thereby making it harder for patients to hurt themselves. Drastic alteration of the occlusion, by either restorative dental procedures or orthodontics, is logical only if the less invasive stress-control and stress-adaptation approaches have failed. In that circumstance, orthodontic treatment to alter the occlusion so that the patient can better tolerate parafunctional activity may be worth attempting. In some instances, this may involve orthognathic surgery to reposition the jaws. The extent to which TMD symptoms in many adults disappear when comprehensive orthodontic treatment begins can be surprising and overly gratifying to those who do not understand the etiology of myofascial pain. Orthodontic intervention can appear almost magical in the way that TMD symptoms disappear long before the occlusal relationships have been corrected. The explanation is simple-orthodontic treatment makes the teeth sore, so grinding or clenching sensitive teeth as a means of handling stress does not produce the same subconscious gratification as previously; the parafunctional activity stops; and the symptoms vanish. The changing occlusal relationships also contribute to breaking up the habit patterns that contributed to the muscle fatigue and pain. The same benefit occurs with orthognathic surgery. No matter what the type of orthodontic treatment, symptoms are unlikely to be present while movement of a significant number of teeth is occurring, as long as treatment that produces strongly deflective contacts is avoided. Prolonged use of Class II or Class III elastics may not be well tolerated in adults who have had TMD problems and should be avoided (for that matter, prolonged use of elastics should be avoided in most other adult patients as well).

Treatment Indications

Stress release


643

From this perspective, three broad approaches to myofascial pain symptoms can be considered: reducing the amount of stress; reducing the patients' reactions to stress; or improving the occlusion, thereby making it harder for patients to hurt themselves. Drastic alteration of the occlusion, by either restorative dental procedures or orthodontics, is logical only if the less invasive stress-control and stress-adaptation approaches have failed. In that circumstance, orthodontic treatment to alter the occlusion so that the patient can better tolerate parafunctional activity may be worth attempting. In some instances, this may involve orthognathic surgery to reposition the jaws. The extent to which TMD symptoms in many adults disappear when comprehensive orthodontic treatment begins can be surprising and overly gratifying to those who do not understand the etiology of myofascial pain. Orthodontic intervention can appear almost magical in the way that TMD symptoms disappear long before the occlusal relationships have been corrected. The explanation is simple-orthodontic treatment makes the teeth sore, so grinding or clenching sensitive teeth as a means of handling stress does not produce the same subconscious gratification as previously; the parafunctional activity stops; and the symptoms vanish. The changing occlusal relationships also contribute to breaking up the habit patterns that contributed to the muscle fatigue and pain. The same benefit occurs with orthognathic surgery. No matter what the type of orthodontic treatment, symptoms are unlikely to be present while movement of a significant number of teeth is occurring, as long as treatment that produces strongly deflective contacts is avoided. Prolonged use of Class II or Class III elastics may not be well tolerated in adults who have had TMD problems and should be avoided (for that matter, prolonged use of elastics should be avoided in most other adult patients as well).


Amount of Stress

Reaction to Stress

Occlusal Discrepancy


644

The moment of truth for TMD patients who have had orthodontic treatment comes some time after the orthodontics is completed, when the clenching and grinding that originally caused the problem tend to recur. At that point, even if the occlusal relationships have been significantly improved, it may be impossible to keep the patient from moving into extreme jaw positions and engaging in parafunctional activity that produces pain. The use of interocclusal splints in this situation may be the only way to keep symptoms from recurring. In short, the miraculous cure that orthodontic treatment often provides for myofascial pain tends to disappear with the appliance. Those who have had symptoms in the past are always at risk of having them recur. Occasionally, orthodontic treatment is made more complicated by previous splint therapy for TMD problems. If an occlusal splint for TMD symptoms covers the posterior but not the anterior teeth, the anterior teeth that have been taken out of occlusion begin to erupt again and may come back into occlusion even though the posterior teeth are still separated (Figure 18-27). Clinically, it may appear that the posterior teeth are being intruded, but incisor eruption usually is a greater contributor to the development of posterior open bite. In only a few months, the patient may end up in a situation in which discarding the splint has become impossible. Then the only treatment possibilities are elongation of the posterior teeth, either with crowns or orthodontic extrusion, or intrusion of the anterior teeth.


Occlusal relationships in a 24-year-old woman who had worn a splint covering only her posterior teeth for the previous 18 months. Note the posterior open bite when the splint was taken out. This was created by a combination of intrusion of the posterior teeth and further eruption of the anterior teeth. Discarding the splint had become impossible.

FIGURE 18-27


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Orthodontic intervention at this stage is difficult because TMD symptoms are likely to develop immediately if the splint is removed, and it is not possible to elongate the posterior teeth orthodontically without discarding or cutting down the splint. Placing orthodontic attachments on the posterior teeth and using light vertical elastics to the posterior segments can be used to bring the posterior teeth back into occlusion (Figure 18-28), if the patient can tolerate this treatment. Some re-intrusion of the elongated anterior teeth is likely to occur, but a significant increase in face height is often maintained. Although permanently increasing the vertical dimension to control disk displacement can be accomplished in this way, this treatment plan should be used with extreme caution.


FIGURE 18-28




TMDTMDOrtho.Ortho.




Take care TMD before Ortho. Tx.Take care TMD before Ortho. Tx.

TMDTMDOrtho.Ortho.

Contemporary ortho chap18 part2

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Transcript of Contemporary ortho chap18 part2