Have you ever had a patient ask you which one of their bites you want when you ask them to close? If so, you know that if there is any restorative work needed, you're in for some challenges managing their bite. The human bite is a complicated thing and while some individuals can adapt to changes in their bite, others respond poorly.

Patients who have multiple bites have the potential for bite issues. Take for example the different bites from the patient pictured below and the three different bites she showed me during her initial exam.


The best way to manage patients with multiple bites is to identify this fact as early as possible during your initial exam and before any restorative treatment. Once you know you are dealing with a patient with multiple bites it's critical to make sure you know how you plan to manage their bite prior to starting treatment. It's important to be sure that you and the patient realize and are accepting of the fact that no matter how you manage things, there will be increased risk in their treatment. The good news is that with the right training, knowledge and patience, you can often reduce the level of risk and make moving forward with these patients relatively predictable.

Typically my first step when treating these patients is to make them an occlusal orthotic. This is usually a lower full arch appliance fabricated from hard acrylic that simulates the desired post treatment occlusion. It's worth noting that sometimes you will have to go through several occlusal schemes to find the one that will work for your patient. Both you and your patient need to be ready to spend the time needed.

Once you find a stable treatment position and bite on the appliance, the next step is to mount models in that position. You then have to figure out what how to make the patient's teeth work the same way without the appliance in place. In some cases it may be as simple as an equilibration, while in others it may mean significant restorative work and/or orthodontics needs to be done.

The beauty about starting with an occlusal orthotic is that it's typically reversible. This means that if you can't get your patient to a stable, treatable point, if they simply stop using it they will typically (but not always) go back to their pre-treatment state. In many cases you will be able to find a predictable path forward with your patient; however, there are some cases where this may not be possible. Either way, the most important thing is to be as clear as possible with your patient about what to expect before you start treatment so that both you and your patient are comfortable.

John R. Carson, DDS, PC, Spear Visiting Faculty and Contributing Author [ www.johnrcarsondds.com ]


Commenter's Profile Image Jerry Zanni
April 14th, 2014
John Once you find the position that you want with the orthotic. How do you transfer that position to an articulator with out the orthotic in place so that you can treatment plan equilibration, ortho etc?
Commenter's Profile Image John Carson
April 15th, 2014
Great question Jerry! To do this what I do is take multiple bites, then verify that they are the same, if so I am typically comfortable that I have recorded the desired position. I will typically take at least 2 but sometimes 3. I typically take these bites using a leaf gauge and/or Lucia Jig. I hope this answers your question if not, let me know. John
Commenter's Profile Image Kevin Baker
June 27th, 2014
A little late on this conversation but how do you feel about a Lucia jig only versus a full orthotic? I took over an "old school" practice and patients are not very accepting of "extra" stuff that the dentist before never needed. Some of these patients are a disaster though. This assumes that you are charging for the orthotic? A Lucia jig can be easy to make in-house and less involved than an orthotic so this is why I ask.
Commenter's Profile Image John Carson
June 27th, 2014
Kevin, I think you are referring to having a patient wear an appliance such as an anterior deprogrammer. The short answer is yes this can be of benefit however it won't give the patient an "occlusal experience" and the information you can gather with this will be more limited since it only provides contact in the anterior. Additionally you need to be sure you are not using it on a patient with an internal joint derangement and I do not like for patients to wear it for more than 8 hours in a 24 hour period and that it is big enough that they cannot swallow or aspirate it should it come off while they are sleeping. That being said they can be very helpful in decreasing muscle pain and deprogramming muscles and are for sure way faster and simpler to make. Let me know if you have any more questions. John