This patient presented with a concern about his bite. A first look at the top image would not alert the observer to the fact that he was incredibly uncomfortable unless his mandible is positioned forward and down on the appliance he has been wearing.



My patient CAN be seated and actually loaded, but it is on a psuedo-disc, tissue that has become avascular and enervated; a type of scar tissue that can function very well against load but may not position the condyle in a comfortable relationship within the fossa. There is also the possibility that the remodeling of the condyle and the fossa throughout the adaptive process have made that “seated position” one at which the patient cannot function.

Because he is comfortable with the appliance but uncomfortable at times after eating without it, my goal is to mimic the appliance occlusion with a bonded plastic occlusion that the patient can now test in actual function. He wore these overlays without incident for five months before we created definitive restorations. The three images below show the overlayed occlusion bonded to the mandible after that five months.



This technique can also be used to create a provisional stage in a case which must be phased. Altering one arch to a final design permits treatment of the opposing arch to the ideal finish and then completion of part or all of the provisionalized arch when appropriate for the patient.


The concept of Facially Generated Treatment Planning can greatly simplify treatment planning for wear patients. You can find more information about treatment planning, esthetics and occlusion within the Spear Digital Suite. Download the free resource:
The 8 Steps Checklist-Facially Generated Treatment Planning.


 

Comments

Commenter's Profile Image Cary Dunne
October 8th, 2013
Hey Gary: Are you confident that this is a stable enough joint to restore both arches? Are you planning ortho expansion or restorations for the maxillary teeth?
Commenter's Profile Image Gary DeWood
October 8th, 2013
Hey Cary! Thanks for the comment. I am very confident in the stability of his joints although I do not plan to restore both arches. The appliance and the subsequent overlays served to clarify that this position is one that is comfortable for him. He has anterior coupling and guidance on the anterior teeth from this position. He did not create any wear facets on the second molars over an 8 month period and was completely symptom free. The upper occlusal plane will not be changed as it is esthetically acceptable and the patient must now choose between orthodontic movement of the lower posterior occlusal plane or restorative movement of it to engage the upper occlusal plane as the overlays do. He chose restorative. Good to hear from you Cary!
Commenter's Profile Image Mark Venditti
October 8th, 2013
Hi Gary, Looks great. What material did you use for the bonded plastic occlusion overlays? Thanks Mark
Commenter's Profile Image Gary DeWood
October 9th, 2013
They were milled in the CEREC machine from a 55mm Telio acrylic block in 4 tooth sections.
Commenter's Profile Image Daniel Bergeron, DDS
May 14th, 2015
Good Morning Gary, I first learned this technique of doing overlays to test opening vertical dimension back at the Pankey Institute sometime after C5. Usually I've done the wax up on an articulator and made a splint and then formed temporary crown material overlays onto existing occlusion. I am about to start a new case and I have had a CEREC machine for about one and a half years. I am intrigued by this article that I could do this quickly on a CEREC. Can the program be modified to open the bite? Or is there a jig to use to open the bite? Or would you do a biocopy from a wax up. At this point the patient is asymptomatic after 6 months in a 2 mm removable appliance. I see this as the next progressive step. Could you give me some pointers? BTW, I took C2 from you at Pankey about 1999 or 2000. Regards, Dan Bergeron