Biomimetic Occlusion Part 2: Abfractions and Full-Mouth Cases

Daily dentistry, the cases you see every day, usually involves minor occlusal adjustments that can be treated quickly and predictably using the Six Lessons Approach, but biomimetic techniques can benefit more advanced occlusal cases too. In this episode, Dr. David Alleman discusses the cause of abfractions, how complex temporaries are a thing of the past and options for doctors seeking more advanced occlusal training beyond everyday cases.

Articles referenced in this episode:

• Magne P,  Belser  U. Rationalization of Shape and Related Stress Distribution in Posterior Teeth A finite Element Study Using Nonlinear contact Analysis. J Periodontics Restorative Dent. 2002;22-425-433
• Pintado M, Et al. Variation in tooth wear in young adults over a two-year period. J Prosth Dent. 1997(77)3. 313-320.

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Transcript

0:33

All right. Welcome to season two, episode ten of the Six Lessons podcast. We're very excited to have you join us. And we hope that everybody's enjoyed the two seasons so far. We wish everyone to get to the highest level of knowledge of the six lessons approach. This biomimetic restorative dentistry is gaining traction all over the world. We're getting contacts every day for more interest from more countries. And, we know that you'll enjoy being able to implement these as you find mentors in deep dive into the the literature. This episode will be a follow up of the last episode was chosen occlusion. And the general introduction to occlusion in the Six lessons is prioritized as the sixth most important thing. Now, in the six lessons, all lessons are important. But the sixth lesson, which we will deal with, a little more detail today, has to be founded on the first five lessons to have long lasting, pain free, restorative dentistry. So we want you to become masters of lesson one before you come. Masters of lesson two in lesson two. Before three three. Before four four. Before five five of four six. My mentor in occlusion was John Kois. I studied for a year with John Kois in 1998. We went through. Two notebooks, and these notebooks were chock full of references and illustrations and concepts. And of course, if one lesson fills two notebooks, six lessons, fills 200 notebooks. And when we published the 2012 article, John Kois personally reached out to me and thanked me for that. The important contribution to restorative dentistry. Because caries detection and caries diagnosis and treatment of deep caries, which we dealt with in detail in the 2012 article that I wrote with Pascal Magne John Kois recognized it immediately as a very important contribution, that important aspect of restorative dentistry. But as we go through each of the lessons, each of the lessons contribute, questions that need to be answered. And, for example, in lesson six, when we talk about occlusal forces, how does that manifest? In lesson two we talk about cracks and the cracks and gaps that are manifestation of stress to the tooth or the tooth restoration complex. And so in lesson two, we specifically talk about dealing with the diagnosis of cracks and gaps and treatment of restoration. So I have no gaps and no cracks in the part of the tooth that's holding the restoration side to side, front to back and top to bottom, which we call the peripheral seal zone. But in less than six, if we have everything perfect as far as reconstructing the tooth. But we don't have the occlusal, anatomy in the occlusal scheme. Quite perfect. Then we have stresses into the tooth that are distributed in a non-ideal way. An ideal way of stress distribution was first, published in 2002 by Urs Belser and Pascal Magne. And it showed that a vertical ization of occlusion always distributes the stress throughout the tooth without concentrating stresses in certain area, but that same article showed that if you had a one point contact on a sliding inclined from a cusp, if you have a cusp but an incline, and you have a contact here, all of a sudden the tooth is being talked instead of compressed. If we have the contact in the fossa, then the compression is distributed throughout the whole tooth. Well, the manifestation of these stresses can be, as we said, cracks into enamel, cracks into dentin, and restoration that fail. But this idea of vertical eyes, the occlusion. What if we don't vertical ize the occlusion? How many patients come in with a verticalized occlusion where the teeth are under ideal compression? Well, just a rough estimate would be 50% and 50% of the patients to come in with a normal force relationship and anterior guidance where the cusp builds are helping the mandible know where to go and go up and down like a rat or a dog, and not sideways like a cow. And so these concepts of a lateral envelope of function, John Kois thought that is chewing like a cow and that causes more stress on the tooth and the tooth restoration complex. And so if we don't vertical eyes the occlusion with anterior guidance, and we have what's called group function, where the teeth are more prone to having these sliding contacts on the cusp and inclines, what's the manifestation? Well, the manifestation is ab fractions. When I went to dental school, fractions were still being. Discusses multifactorial. They didn't know if it was tooth brush. Brazen. You're brushing your teeth too hard or they didn't know if it was. You're drinking acidic sports drinks, you know, that were eroding. Or perhaps it was occlusion. And this, fraction. Well, the first, researcher who did the best accumulation, the data was named Grippo and Doctor Grippo publishing his articles theorize that, this group function, put more stress and did not have an ideal, cusp fossa relationship. The Pankey-Mann philosophy that we talked about last lesson had a lot of, ways to ideally make cusps relationship usually goes with waxing up gold onlays, a conservative restorative technique. But again, you're talking about, 20 or 24 units that might be involved in these golden onlays in this reconstruction in a badly worn dentition. And of course, that's a specialty that a prosthodontist would take on for a general dentist. Take those cases on. You need advanced training. That's why I was trained with John Kois in 98, 99, 2000. I did larger cases, and I understood the challenges. And I also came to understand why precedent is generally charged three times as much as general dentists. When you talk about how much a tooth is going to cost to get it restored, if it's a restoration that's just one tooth or two or a quadrant, then you're not changing the occlusion. But the precedent is to see worn dentition and TMD where a joint would be involved. Again, they have more diagnosis and usually involves, diagnostic wax ups, temporarization, usually several sets of temporaries over a treatment, might be involved. So there's a lot involved in a full mouth case, and only those who have done them can really appreciate the challenges. But the fraction issue once the group was identified, this and finite elemental analysis like Belser and Magne put forward were in a clinical trial in vivo, totally validated by Maria Pintado Now, Maria Pintado is not a name that hardly anyone knows unless they've gone to the University of Minnesota. At the University of Minnesota, they had a whole floor dedicated to dental research. It was the 14th floor. Dave Wold can correct me if it was only the 11th floor, but I visited Moose Tower, in Minneapolis. University of Minnesota Dental School went to the 11th or 14th floor. I can't remember exactly which one it was, and met Maria Pintado and I had heard the name Maria Pintado from this article, and I also heard it from Pascal Magne who had spent over a year at Minnesota doing postgraduate research that led to the publication of his first book under the direction of William Douglas. William Douglas, headed up the research lab. Ralph DeLong was another important, person there. Anthony Versluis was there for a number of years. Just had a top notch, team of dental researchers. And a lot of the research was focused on micro movements and teeth, and simulations through 2D and 3D, simulators. But, when I first read Pascal's book in 2002, the thing I remember the most were that he had some strain gauges. Now, no dentist knows what a strain gauge is unless they've been mentored by somebody who has some connection with, engineers and engineers learn about strain gauges because they know that things fail not from usually big catastrophic events, but from small Micro movements that are jiggling the molecules in ways that eventually start cracks. And so the strain gauges that Pascal, shows in his 2002 book and his other books that were published a couple years ago, show these small movements and how teeth under function make these small movements and that these small movements, although they're not visible to the naked eye, have an effect on the substructures or the micro structures of a tooth, mainly enamel. so they decided to do an in vivo to test and follow it over three years. And so the test had a group of patients that had AB fractions. And the group was divided into two groups. One got no treatment. The evaluation of the occlusion was that it was in group function, did not have bicuspid disillusion or bicuspid guidance, but the inclines of the. Usually the buccal comes from the lower and the lingual curves of the upper, or the ones that hit these, inclines on the cusp. The cusp inclines first, and these teeth manifested these, ab fractions. Now the ab fractions, once they are there, can be aggravated. There's no enamel covering the dead end. And so again, erosion and abrasion, acid attack of these dental surfaces now can become increasingly, destructive of two structure. But Maria Pinto though without restoring these ab fractions, measured them with a very sophisticated measuring technique. And then they followed them over three years, half of the group, they restored bicuspid guidance, so they added composite to the lingual of the upper custards and composite to the buckle of the lower cusp. Kids. They vertical ize the occlusion. So now the mandible wasn't moving. This horizontal envelope of function. It was moving more up and down. Vertical ization. Well, the half of the patients that had the cusp guidance restored to an ideal vertical ization of their envelope of crunching the ab fraction stopped because after three years they measured very specifically how much to structure was missing. And there was and the patients had been told not to drink a lot of acid and not to brush hard. You know, they used soft toothbrushes. They tried to control for those other two confounding variables, this top research lab at University of Minnesota that the main cause, the initiation, for sure, of the abfraction was, occlusal related. And so the desirability of verticalizing occlusion, which prosody using non adhesive techniques for years knew that their cases held up better if they had this anterior guidance, this cusp of protection. Later on John Kois and others, Francesco Vailati have shown that the anterior guidance, although it may be a little more sensitive, can also the same function can be happened on molars on posterior teeth, as long as the brain gets contact from the nerve, stimulation of the molars, then it can program, the mandible to go up and down, even if there are no interior teeth. So posterior guidance is another piece of, science we have now that we didn't have 20 years ago. Phasing treatment is something that, is important to realize. If you have a person who really is under the need of restoring occlusal surfaces on 20 teeth, just economically, it's usually not a very easy way to go. I remember, the example of Matt Nejad we used to teach together, and Matt Nejad was one of Pascal's best students at USC, and he took on his senior year a full mouth case. Now, the full mouth case, of course, posteriorly, was being treated, biochemically using Pascal's protocols. course, there were interior, cosmetic considerations for the patient. The patient was a dental student. You know, she wanted perfect teeth on the back in the front, but, the long and the short, the story is that, it's a very time consuming situation to document and treat this case, but they got it done in a year. But they only had the final restorations on the top So the patients happy. She got her veneers. She got her on lace on the back, but on the bottom they were all temporaries. Now in a biomimetic approach, your temporization becomes so much more manageable than a traditional crown bridge approach approach, because on the bottom you have bio bases. And so if your temporary enamel replacements wear over time because of the, length of time it takes for treatment, then you might lose some temporaries, but you still have a totally sealed dentin component of your tooth, and the bio base is pain free. It just doesn't function very well. But like we teach in the six lessons, we want to heal the teeth first and then restore function second. So the healing of the pulp is less is one through four. The restoration of the function or less than five and six. And so we always put priority on allowing the pulp to heal. And Matt injured he did that. But as things happened after graduation the patient was left town. she didn't get finished, you're not going to believe this. She really, actually didn't finish the lower arch. Final restoration. All the teeth in the lower for ten years. So talk about phasing in treatment. I believe in an earlier broadcast, they referred to a patient that we had to phase of the treatment because he disappeared from the practice for 26 months because he had a brain aneurysm, and that he had to deal with to try to keep his life going. Before we got the tops on these three, on orderlies that we had taken and presents for Temporaries. But then he disappeared from the practice for 26 months and finally came back. Aneurysm had been successfully treated by neurosurgery, and he came back in. The orderlies that were composite, unfortunately, were on the shelf. We submitted, quite a bit of adjustment, but 20 years later I saw him a couple of weeks ago. They're still doing fine. But this idea of phasing treatment in a traditional approach without immediate debt and sealing resin coating, it's a problem we, Davey and I once taught a course on biomimetics in Tulsa, Oklahoma, and in Tulsa, Oklahoma. There were ten dentists that we were training in. As we spoke about this difference between a temporarization of a biomimetic approach in the temp position on a traditional crown and bridge where you would prep the tooth, take an impression, and then, cement your temporary crown with, usually zinc oxide based, cement to try to give it some, pain relief. We knew that zinc oxide helped, the dental tubules seal, a little bit, but that was what I learned in dental school. But And then during this part of the lecture, one doctor got this really sick look on his face, and I noticed it. I looked at Davey and he kind of noticed that. I said, Brad, you look like you're you've had experience with this. And he said, my second wife has just got a full mouth temporarization by another dentist. She didn't want to come to me to get her teeth done, but she got in this other dentist. She's got all these temporary crowns, and they're all sensitive. we said, boy, we do feel your pain. And hopefully your wife will trust you enough to at least do immediate sealing on these teeth that have already been prepped. And of course, once you prep it, you have different biomechanical challenges with that of biochem. But, the philosophy was being there use there was, called the bio simulation philosophy Bob Lee championed. Then he was very big into occlusion, very big into customer relationship, a very big into and to your guidance. He was like the ultimate traditional nephrologist, but he did not have, a biologic, healing approach to the, the pulps. but unfortunately it's been documented by ended on a stand. Precedents, high number of root fractures over the years. In these post and core anatomically treated teeth, with crowns on Sophie Schwartz is one of the main, experts that was published on this, teach from in the in the six lessons. occlusion. Yes. Is important if you want more details of larger cases, restoration, how to do that? Like I say, Francesca Vailati is kind of spearheading that now around the world in her teaching center. Proceed on occlusion oriented courses that are based on biomimetic dentistry in Europe. So we always recommend, doctors who want to get more information and more techniques and decide whether to do these larger cases based on modifying the occlusion. We recommend, Francesca Vailati’s course John Kois’ course is still a good one to take. There's two courses, a basic and advanced occlusion course. You learn a lot, other people like Frank Speer obviously teach, a modified situation, but has, retired. And so Frank Spear is not, teaching at the Spear Center now, but there are others that have, advanced prosthodontic training. And I believe that almost every person who's studying seriously occlusion now has the idea that going down on forward is ideal. Another one we should mention is, Clayton Chan for decades have been teaching an approach to occlusions based on little sophisticated, diagnostic, technology called the male monitor. And again, the myo monitor, Jenkelson and his son, been teaching that for decades. And when we get the muscles, with these TENS machines, that are giving small electric currents into the masters and into the temporal muscles, you'll see that that relaxing TENS stimulation again brings the jaw down to forward. The down and forward that we use, we like to stabilize that with a doll appliance. John Kois uses a deprogramner The deprogramming that happens, with the, the myo monitor, usually, results in an impression taken in that down, forward place. And then we, they make a night guard. But the disadvantage, the night guard, it gives you in the right position. But if you do have a joint that is deteriorating from adhesions, it will not solve the problem less. The night guard is where worn 24 seven 365. But these again you know the differences. The John Kois versus Clayton Chan versus Francesca Vailati versus Dave Alleman, there would be 80% agreement, probably 20% options on treatment. Again, there's a lot of pieces to the puzzle that will probably be our last piece of the occlusal puzzle we'll talk about. But we would invite everyone to join the six lessons so that you can get all the research that we use in teaching occlusion if the six lessons approach. until next time, we just always say get bonded first, stay bonded second.