Takami Hirono HOTTA1
Luiz de Jesus NUNES1
Anderson Hayaxibara QUATRINI1
Osvaldo Luiz BEZZON2
1Departamento de Odontologia Restauradora
2Departamento de Materiais Dentários e Prótese, Faculdade de Odontologia de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
Braz Dent J (2000) 11(2): 147-152 ISSN 0103-6440
Introduction | Material and Methods | Results | Discussion | Conclusions | Resumo | References
The authors report a clinical case that presented tooth wear and absence, with painful muscular and articular symptomatology, and also alteration in deglutition, mastication and speech. The clinical procedures used were re-establishment of vertical dimension of occlusion, mandibular centric relations, and occlusal contacts through therapeutic removable partial dentures. The condyle position was analyzed in habitual occlusion and in occlusion with dentures, through transcranial radiographs of the temporomandibular joints. Oral rehabilitation was achieved with dental restoration and removable partial dentures.
Key Words: overlay removable partial denture, vertical dimension of occlusion, tooth wear, transcranial radiographs.
The loss of dental elements or even severe tooth wear may be a contributing factor to masticatory system dysfunction. The position of the remaining teeth in the dental arch is altered, as well as in relation to the antagonist teeth. Associated with other factors, this may cause muscular and articular dysfunction, characterized by signs and symptoms such as: pain in the mastication muscles, restriction in mandible movements, pain and sounds in the joints, migraine, etc.
Since occlusion, as an etiological agent of temporomandibular dysfunction, is controversial in the literature, there has been much research with a reversible focus, rather than invasive ones (Brown, 1980; Palmer and Nitola, 1992). Occlusion also has an influence on deglutition, mastication and speech, thus, when there is tooth loss, it is important and necessary that the oral condition is re-established, so that the patient can execute these functions properly (Okeson, 1995).
Radiographic images of the joints are complementary resources that have been studied intensively for years (Weinberg, 1972; Rozencweig, 1975). Transcranial radiographs, for example, were used in several studies (Weinberg, 1972, 1985), in order to verify the condyle position in different clinical situations.
The present study reports the clinical procedures, overlay removable partial dentures, transcranial radiographs and dental restoration used in a clinical case of tooth wear and loss, with painful muscular and articular symptomatology, that affected functions and esthetics.
Material and Methods
This 43-year-old white female patient was seen at the Occlusion Service and Temporomandibular Joint Dysfunction (SODAT), School of Dentistry of Ribeirão Preto, USP. The symptomatic areas were examined by manual palpation, and the pain intensity was classified, according to the patient's sensibility: not much pain (+), some pain (++), and a great deal of pain (+++) (Nowlin and Nowlin, 1995). The most affected muscles were: the masseters, pterygoids, temporalis, the posterior ones of the neck, sternocleidomastoids and the supra- and infrahyoids, most of them on the left side. The patient had only a few teeth in the maxilla and the mandible with moderate or severe tooth wear (Figure 1). Thus, there was dimensional alteration of the facial inferior third, as well as the absence of posterior occlusal support.
For a better analysis and diagnosis, the casts were placed in a semiadjustable articulator in centric relation position. Then, the re-establishment of the clinical crown size and of the missing teeth was started, according to the appropriate dimensions of vertical occlusion, using overlay removable partial dentures (Hotta et al., 1997). The dentures were properly adapted for the patient, and the occlusal adjustments were made in the centric relation position (Figure 2), left and right laterality and protusion, always monitoring the painful symptomatology.
As the symptoms decreased and the points of occlusal contacts became stable, transcranial radiographs of the right and left temporomandibular joints were taken, with and without dentures (Figures 3 and 4). These radiographs were visually compared and also compared using the Bataglion (1994) method, where the condyle position could be evaluated by dividing the articular space in quadrants, using mathematical calculation that gives the values of the condyle displacement angles and modulus.
The satisfactory clinical and radiographic results permitted the re-establishment of the oral condition, through dental restoration, removing the incised complements of the dentures, as the natural teeth were restored. In the maxilla, two screw pins were placed in the left incisor (STP, restorative pins, 0.71 mm, Maillefer, Ballaigues, Switzerland), and an intracanal pin (Unimetric, 1 mm, Maillefer) in the left canine. In the mandible, prepara- tions were made in the anterior mandibular teeth so that they could surround the teeth and create an extension of approximately 3 mm on the occlusal- cervical position, without removing the interproximal contacts. The hybrid compound resin, Z100 (3M, St. Paul, MN, USA) was used for restoration. Oral rehabilitation was then started, with removable partial dentures (Figure 5) and an interocclusal splint for night wear.
The treatment re-established the vertical dimension of occlusion, the occlusal contacts, that were distributed in a simultaneous and homogeneous way, the condyle position, the muscular condition and the extension of the mandible movements, with a consequent significant reduction of pain. However, there remained a few areas of pain in the pterygoids.
The maximum opening increased from 32 mm to 51 mm; the laterality to the right from 4 mm to 11 mm; the laterality to the left from 9 mm to 11 mm, and protusion from 3 mm to 10 mm.
The transcranial radiographs of the left and right temporomandibular joints, in habitual occlusion and with dentures, were analyzed by visual comparison and by the mathematical method. The condyle position clearly changed when the patient used dentures. It was different in habitual occlusion. The mathematical method showed the values of the condyle displacement angles, in habitual occlusion, on the right side (RS) = 6.40 and on the left side (LS) = 5.48. The values of the condyle displacement angles with dentures were RS = 6.40 and LS = 9.74. The method also showed the values of the condyle displacement modulus in habitual occlusion: RS = 0.5566 and LS = 0.9590, and with dentures: RS = 0.7014 and LS = 1.0000.
Usually, the signs and symptoms reported by patients can be so many that they are induced to a peregrination in the search for an appropriate professional to solve their problems. It is very common to see patients with temporomandibular dysfunction be sent to an otolaryngologist, a neurologist or an orthopedist. Unfortunately, the professionals tend to find some kind of problem concerning their own area and prescribe treatments that will not solve the problem, because it was not the real one and does not act on the real cause. This causes a great deal of insecurity for patients. Perhaps, that is one reason why every health professional should also have some general knowledge, besides his/her specific area knowledge, in order to recognize other pathologies and be able to instruct the patient properly.
The data obtained with the anamnesis, clinical and complementary examination are of great importance not only for diagnosis but also for the planning of treatment. In order to plan treatment in a case that shows tooth wear, it is important to verify the cause and remove it, before any definitive dental restoration (Mahonen and Virtanen, 1991). In the present case, the patient showed accentuated tooth wear in the anterior teeth, mainly in the maxilla, probably due to the loss of bilateral posterior teeth that caused an overload on the anterior region. Thus, before oral rehabilitation, it was necessary to first re-establish the maxillomandibular relations, making use of overlay removable partial dentures. Through periodic analysis of the function of these dentures, it was possible to verify that the integrity of the incisor surface was maintained. This being the case, it was decided to re-establish the clinical crowns through dental restoration, in order to preserve the dental structure as much as possible, avoiding more radical operations. Even though the use of the hybrid resin Z100 is indicated for posterior teeth, it was chosen to restore the anterior teeth, due to its high resistance to functional overloads.
The fact that the initial pain was quantified in a way to compare it to the symptomatology at the end of the treatment may suggest some subjectivity. However, it was a means of analyzing the symptomatological effectiveness, in the professional's point of view as well as the patient's. One must consider that the professional with clinical practice will develop a pattern for the adopted procedure. The measurement of mandible movements is considered an acceptable resource to evaluate the evolution of masticatory musculature conditions, during the proposed treatment.
Concerning the condyle position, once the angles and modulus values were close to 1, suggesting condyle centralization, it may be concluded that a) laterality in habitual occlusion: when analyzing the modulus values RS = 0.5566 and LS = 0.9590, and the angle values RS = 6.40 and LS = 5.48, the right side was the most displaced, concerning the extension quantity and the displacement direction. However, the left side was displaced upward and to the back which probably is the reason why there was a greater symptomatology on this side; b) laterality with dentures: when analyzing the modulus values RS = 0.7014 and LS = 1.0000, and the angle values RS = 6.40 and LS = 9.74, the right side presented more displacement concerning quantity and extension, and the left side presented no displacement. However, the displacement direction was altered on both sides, mainly on the left side; c) laterality in habitual occlusion to laterality with dentures: when analyzing the RS modulus values in habitual occlusion and with dentures, and the angle values on both sides and positions, with dentures there was an extension displacement that brought the right condyle closer to centralization, without, however, changing the displacement direction. When analyzing the LS modulus values in habitual occlusion and with dentures, and the angle values on both sides and positions, with dentures the left condyle was centered, without extension displacement, even with direction alteration.
In brief, with dentures, the displacement extension and quantity were closer to a centric reference value, including the left side with the exact value of 1.0000. Concerning the displacement direction, the right side showed no changes, however, the left condyle displacement direction changed more with dentures. Correlating these data and the final symptoms, one can consider that the dentures led to a better mandibular position and most of the signs and symptoms presented before treatment were eliminated.
According to the results obtained through this methodology application, it is concluded that the symptomatological and therapeutic treatments were effective, because they not only solved the pain and dysfunction problem, but also worked as a parameter for the definitive oral rehabilitation. By analyzing the condyle position on the transcranial radiographs, it was possible to verify that the condyles were in a better position, in relation to the mandibular fossaes, at the end of the treatment than they were initially (Hotta, 1998).
Hotta TH, Nunes LJ, Quatrini AH, Bataglion C, Nonaka T, Bezzon OL: Desgastes e perdas dentais: tratamentos sintomatológico e reabilitador. Braz Dent J 11(2): 147-152, 2000.
Os autores estudaram um caso clínico que apresentava desgastes e ausências dentais, com sintomas de dor muscular e articular, e também, alterações na deglutição, mastigação e fala. Os procedimentos clínicos utilizados foram restabelecimento da dimensão vertical de oclusão (DVO), relações cêntricas da mandíbula e contatos oclusais por meio de próteses parciais removíveis terapêuticas. As posições dos côndilos foram analisados em oclusão habitual e em oclusão com as próteses, por meio de radiografias transcranianas das articulações temporomandibulares (ATMs). A reabilitação oral foi realizada com restaurações dentais e próteses parciais removíveis convencionais.
Unitermos: próteses parciais removíveis terapêuticas, dimensão vertical de oclusão, desgastes dentais, radiografias transcranianas.
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Correspondence: Dra. Takami H. Hotta, Departamento de Odontologia Restauradora, Faculdade de Odontologia de Ribeirão Preto, USP, Av. do Café, s/n, 14040-904 Ribeirão Preto, SP, Brasil. Tel: +55-16-602-4020. e-mail: firstname.lastname@example.org
Accepted April 18, 2000
Eletronic publication october, 2000