Using a Relaxation System During Diagnosis and Full-Mouth Restoration
Functional stress is known to cause damage to almost any system of the body. But when it is in the stomatognathic system, the deleterious results can become painfully obvious. A colleague of mine referred this patient because he was constantly breaking restorations (Figure 1). She was looking for someone to evaluate the occlusion issues present in this case, and restore the patient to a functional position that would no longer cause him to grind his teeth. Given that I am an LVI Fellow, I got the call.
The patient suffered from a misaligned mandible. This misalignment created muscular stress, causing him to grind his teeth.
The ideal functional position for the mandible in all 6 dimensions of occlusion (vertical, anterior-posterior, lateral, pitch, yaw, and roll) was determined by TENSing the patient with the J5 Myomonitor (Myotronics) to relax the muscles of mastication and cervical musculature. During this process, the NuCalm patient relaxation system (Solace Lifesciences) was used to take the patient from an anxiety-laden sympathetic nervous system tone to a meditative and comfortable parasympathetic tone, allowing the patient to achieve complete relaxation.
The patient was then placed on the K-7 (Myotronics), which simultaneously monitors mandibular position and muscular activity via surface EMGs. The K-7 assisted in finding the mandibular position where the musculature was truly comfortable. The bite was registered in this position.
Correction of Occlusion
The case was sent to Williams Dental Lab (Gilroy, CA) for orthotic wax-ups. The vertical dimension change was 5 mm per arch, allowing for the creation of naturally sized teeth, and proper support for the facial muscles. The esthetic changes that we make are not only to the teeth—the age-defying changes to the face are often dramatic (Figures 2 and 3).
Venus Temp 2 (Heraeus Kulzer) orthotics were placed using BISCO products (Figure 4)—the SELECT HV Etch to spot-etch the teeth; Cavity Cleanser CHX to prevent bacterial growth under the orthotics; and All-Bond Universal to bond the orthotics to the etched enamel.
The orthotics were adjusted over a 9-month period utilizing TENS, NuCalm, K-7, and T-Scan (Tekscan) to create an occlusion that no longer caused the patient to grind his teeth. Because the patient had a history of destructive parafunctional habits, it was critical to fully refine his occlusion. Even with this history, he wore the orthotics for the entire 9 months without damage.
Oral sedation medications were used to relax the patient during the preparations. An important part of our oral sedation protocol is to simultaneously use the NuCalm system to potentiate the effects of the oral medications. Working on a patient who is on NuCalm is like working on a dentiform. They are relaxed, and the anxiety-induced mannerisms associated with a stressed-out dental patient are absent. This enables the dental team to be relaxed as well, allowing for the highest-quality care.
Using the techniques that I learned at LVI for prepping a full-mouth case, while maintaining the precise bite position determined during the orthotic phase, all 28 teeth were prepped, impressions taken, and provisionalized in approximately 4 hours. Integrity (Dentsply Sirona) was used for the provisional restorations.
The case was sent to Williams Dental Lab, where 28 IPS e.max (Ivoclar Vivadent) units were made in the exact functional position created by the orthotic. The Williams team provides an exceptional level of expertise that makes large cases very predictable. Delivery of the IPS e.max units was completed under rubber dam isolation using the BISCO products listed above, along with Bis-Silane and Variolink Esthetic (Ivoclar Vivadent) permanent cement (Figure 5).
While some may be concerned that IPS e.max units were placed in the mouth of a bruxer, I am confident in their long term success. Having practiced neuromuscular dentistry for 16 years, I have numerous cases that were restored with IPS Empress, a significantly weaker material, that are fi ne after many years. I am often asked why not put in a night guard to make sure? My answer to that is: (1) We have proven an ideal functional position with the undamaged orthotics; (2) We know that the patient is comfortable, and the K-7 shows that comfort. A night guard at this point would introduce an arbitrary factor that may cause more problems than it solves, especially if it encroaches on the tongue space and causes airway issues. As we have found, airway and tongue posture problems caused the occlusion problems in the first place, but that is a part of the story for another time.