Occlusal therapy incorporates those treatment modalities available to the dentist to manage occlusal abnormalities that can cause damage to the teeth and periodontium. Tooth-related reasons for treatment include severe tooth wear, abnormal occlusal planes, malposed teeth, occlusion- related periodontal attachment loss, and parafunctional
habits, such as bruxism, clenching, or nailbiting. Patients
with temporomandibular disorders (TMDs) affecting either the muscles of mastication or the TMJ itself may be candidates for occlusal therapy both to diagnose and to treat the problem. Individuals who engage in contact sports or other physical activities that place the teeth at risk for blunt trauma are good candidates for protective occlusal (athletic) guards. Often instituted before pros- thodontic rehabilitation, occlusal therapy may include adjunctive orthodontic treatment. Occlusal therapy may also precipitate the need for additional dental procedures, including root canal therapy, crown lengthening proce- dures, and/or crown placement.
Procedures for Treating Occlusal Problems Occlusal Adjustment Occlusal adjustment, also referred to as occlusal equilibration, involves selective grinding of tooth surfaces with the goal of improving tooth contact patterns. The treatment can be an adjunctive therapy used to alleviate symptoms of temporomandibular dysfunction or, more commonly, to complement comprehensive prosthodontic reconstruc- tion. Treatment goals for selective grinding include developing an acceptable centric relation contact position for the patient, providing for acceptable lateral and pro- trusive guidance, and establishing an acceptable plane of occlusion with adequate interarch space for any prosthe- sis replacing missing teeth.
Occlusal adjustment is an irreversible procedure and the dentist must carefully study the patient’s existing occlusion before removing any tooth structure. This includes analyzing mounted diagnostic casts and care- fully observing the patient’s occlusion intraorally. Artic- ulating paper and occlusal indicating wax are valuable tools for identifying occlusal patterns. Before performing the procedure, the dentist should inform the patient that grinding the teeth may cause tooth sensitivity in some individuals. The patient also needs to be aware that when gross occlusal reduction is used to correct an occlusal plane discrepancy—such as that caused by a hyper- erupted or extruded tooth—root canal treatment, surgi- cal crown lengthening, and/or a crown restoration also may be required.
Table 8-2 Treatment Alternatives for Malocclusions and Related Problems
Condition Treatment Options Keys to Decision Making
Angle’s Class I malocclusion No treatment Patient not interested in correction; limited financial resources or presence of active oral disease precludes treatment
Limited tooth movement Patient wants limited care only; goals of limited tooth movement are feasible and meet patient expectations; no systemic or oral
contraindications to treatment are present; no financial, motivational, or other psychosocial barriers to care
Comprehensive orthodontic Patient consents to comprehensive care; no contraindications to treatment treatment by generalist or barriers to care; generalist has the training, expertise, and desire to
provide the care
Comprehensive orthodontic Same as above except generalist does not have the training, expertise, or treatment by orthodontist desire to provide the care
Impacted or partially erupted No treatment Patient has no motivation to correct the problem; systemic disease maxillary canines suggests contraindications to surgery or orthodontics; presence of active
caries or periodontal disease precludes orthodontics
Surgical removal of canines Impacted canines and poor prognosis for successful forced eruption; no contraindications to surgery; orthodontic treatment is precluded by lack of financial resources or motivation, or presence of active oral disease; retention of canines may jeopardize the long-term well-being of the adjacent teeth
Extraction of first premolars Patient seeks correction; root form and tooth position of canines conducive and comprehensive to forced eruption; orthodontics without extraction is not a feasible orthodontics option (insufficient space available for good alignment if all teeth are
retained)
Comprehensive orthodontics Patient seeks correction; canine root form and tooth position conducive to forced eruption; orthodontics without extraction is a feasible option (sufficient arch space exists to allow good alignment when all teeth are retained)
Anterior open bite No treatment Patient has no interest in treatment; no phonetic or functional deficiency Correction of tongue thrust Primary tongue thrust must be corrected before initiation of any surgical
habit or orthodontic treatment (management of secondary or acquired tongue thrust can be deferred until after orthodontic or surgical therapy) Orthodontic correction Patient seeks correction; skeletal relationship is adequate to support an
all-orthodontic solution
Surgical and orthodontic Patient seeks correction; the skeletal relationship is insufficient to support correction an all-orthodontic correction
Skeletal malocclusion No treatment Patient not interested in correction; no significant phonetic or functional problem exists; health, financial resources, or presence of active oral disease preclude treatment
Orthodontic treatment Patient seeks esthetic improvement but lack of motivation, presence of alone (camouflage) systemic disease, or other reasons preclude surgical-orthodontic
treatment; camouflage option is feasible, practical, and likely to yield desired result
Comprehensive orthodontics Patient seeks comprehensive, ideal solution; good surgical candidate (ASA in conjunction with I or II); oral disease under control; patient has satisfactory oral hygiene; orthognathic surgery patient is cooperative, motivated, and has adequate time and financial
resources; professional support from competent specialists is available
Occlusal Appliance Therapy An occlusal appli- ance, also referred to as a bite guard or bite splint, is a custom-fabricated hard or soft acrylic device that fits over the occlusal and incisal surfaces of either the maxillary or mandibular teeth (Figure 8-9). Occlusal appliances have several uses. For patients with symptoms of TMD, the appliance promotes a more orthopedically stable TMJ position and reorganizes the neuromuscular reflex activity. Along with providing some measure of relief
from pain symptoms for the patient, use of the appliance may also confirm the diagnosis of TMD. Occlusal appliances are commonly used to prevent tooth wear caused by bruxism. The dentist also may use the appli- ance to assess the patient’s tolerance for an increased vertical dimension of occlusion before prosthodontic rehabilitation.
A major advantage to occlusal appliance therapy is that the treatment is reversible and noninvasive. The
therapy requires patient cooperation, however, since the splint is only effective when the patient is wearing it. To gain maximum benefit from the therapy, the dentist must carefully adjust the appliance at the time it is delivered and periodically thereafter.
Athletic Guards A soft, plastic removable appliance, the athletic guard is designed to protect teeth from blunt injury trauma (Figure 8-10). Most frequently prescribed for younger patients who engage in contact sports, such as football and wrestling, the athletic guard can benefit adults too, particularly those who play basketball and racquet sports. If used consistently, the athletic guard effectively protects the teeth from damage. Unfortunately, for many patients compliance can be a problem.
Patients can make their own guards, using kits avail- able in sporting goods stores, or the dentist can fabricate a custom-fitted appliance by vacuum-forming the guard material onto a plaster cast of the patient’s maxillary arch. To maintain an adequate fit for children, the guard may need to be remade periodically as deciduous teeth are lost and new teeth erupt.