Comprehensive Orthopedic Dentistry
Santa Rosa, San Francisco, Oakland, Vallejo - California
The Story of Neal Gates
jamesklim.com Case Review
Dentistry and Ceramics Completed by Dr James Klim
I would like to thank Dr. Neal Gates (neuro-chiropractor) for permission to share his comprehensive case review on my website. The narrative and photographs of this case will illustrate the current technological methods used to diagnose and treat temporomandibular disorder (TMJ), premature dentition wear, bruxing (grinding), aesthetic smile enhancement, and biological compatible restorations
Neal arrived to my office with an oral condition of premature tooth wear (bite) and TMJ symptoms. My first step of clinical assessment is a dental interview followed by a dental exam. By listening to Neal's priority objectives and dental story, many of the significant signs and symptoms were discovered.
Neal had premature wear on his teeth ahead of his chronological age. From the TMJ interview questions, we discovered a connection between the dental grinding, premature wear and the TMJ symptoms.
From the TMJ interview questions, we discovered a connection between the dental grinding, premature wear, and the TMJ symptoms. The TM joint is a unique joint. It is the only joint in the body that rotates and slides (translates). With technological advances in joint/skeletal imaging and muscle EMG measuring, dentistry has found a connection between skeletal, neck temporomandibular joint alignment, and muscle fatigue.
In most TMJ cases, the primary source of pain is muscle and neurological pain. Less than 10% of TMJ cases have the primary pain source originating in TM joint.
With technological advances in joint/skeletal imaging and muscle EMG measuring, dentistry has found a connection between skeletal, neck temporomandibular joint alignment, and muscle fatigue.
Grinding is usually indicative of alignment issues between the habitual bite, lower jaw postural position, and a neutral TM joint position. With this postural tension, the muscles have to work more for normal oral function such as chewing, speaking, and particularly swallowing. Every time we swallow, our jaw goes to the bite home base. When this position is not physiologically balanced, we subconsciously adapt a neck and jaw postural compromise (forward head position) and over worked neck and facial muscles. Chronic muscle fatigue eventually translates into sore cramping muscles leading to the TMJ pain. See the Profile Signs and Symptoms of TMJ PDF file.
Chronic muscle fatigue eventually translates into sore cramping muscles leading to the TMJ pain.
I have found from my 25+ years of training, teaching dentistry, and treating TMJ patients, that grinders are usually in a compressed (back) position from a neutral TM joint position to the cranial base. This is impacted by how the upper and lower teeth fit together. The physiological adaptive response to a compressed joint is to grind. When subject to psychological stress, the brain will process the information, which contributes to even more grinding.
Grinding over a period of time will create premature tooth wear. Not all people with accelerated wear and overactive muscle activity will experience TMJ. It is all about the neurological and muscle ability to adapt. When the physiological and psychological stress grows beyond the threshold of the brain and body to adapt, the signs and symptoms of TMD follow. This was Neal's problem.
Following the dental exam, we collected x-rays, study models, skeletal alignment, and muscle firing (EMG) records. From these records, it was determined that that Neal's bite was over-closed and the lower jaw drifting back due to bite collapse, creating a TM joint compression.
With the records and test results at hand, Neal and I discussed a workable solution to his primary dental objectives (rehabilitating the worn teeth, balancing the bite, and enhancing the smile).
In my practice, my initial primary focus before initiating comprehensive restorative care is to establish a comfortable bite and jaw relationship prior to any tooth refurbishing. This is accomplished by placing a fixed orthotic. In severe pain cases, I will initially use a removable splint to assess patient's symptoms response to jaw postural change first, and then move to a fixed orthotic when they are pain free.
Neal wanted to proceed directly to the fixed orthotic. The advantage of the fixed orthotic is the 24-hour wear continues bite positions. This will assist in a rapid physiological adaptive response.
The fixed orthotic stage will accomplish several important treatment objectives to optimize the physiological and anatomical position of the lower jaw to the cranial base.
- Muscle imprinting?most ideal working length and relaxed tone for jaw muscles.
- Non-retrusive jaw closing pattern
- Decompress jaw joints
- TM joint remodeling
Timeline for the fixed orthotic stage can vary 3-12 months depending on patient's initial condition and time needed for clinical resolution of symptoms and adaptive responsiveness. It will also assure physiological acceptance of proposed bite position providing certain evidence for the restorative phase.
Following dental records and muscle-skeletal assessment, it was determined that that Neal's bite was over-closed and the lower jaw drifting back due to bite collapse, creating a TM joint compression.
Following Neal's successful fixed orthotic phase, the upper arch was restored to optimize aesthetics and function. Metric aesthetic principles of tooth width/length ratio were used to establish tooth length/size. An aesthetic prototype was created to propose aesthetics and bite ratio of tooth length between the upper and lower arch.
Using the wax prototype as our guide, the upper arch is prepared for the final restorations. This is my favorite part of the process. Because I am my own ceramist and I design the wax-up, I can "fingerprint" the final restorations (front veneers and posterior crowns) for ideal functional and aesthetic results.
Technological advances in 3D imaging and virtual design now allow me to design the final restorations on a computer. Because I am my own ceramist and I design the wax-up, I can "fingerprint" the final restorations (front veneers and posterior crowns) for ideal functional and aesthetic results.
One way I assure final aesthetic success is to fabricate clinical transitional restorations before fabrication of the final restorations. The value of this stage is the clinical assessment for our aesthetic objectives. Adjustments can be made and then used as a guide for the final restorations. In addition, I will often see the need for emotional imprinting on the patient's part.
Lower teeth are bonded with a fixed orthotic to position bite/jaw in a neural bite favorable for swallow reflex and comfortable TMJ and jaw muscles.
This usually takes 2-3 weeks.
Technological advances in 3D imaging and virtual design now allow me to design the final restorations on a computer. I will scan in the wax-up prototype and use it as a guide for virtual tooth design.
The final restorations are then machined from a refined grade of ceramic that functions and appears like natural enamel. Studies affirm that the machined ceramic have better inherent functional properties (less likely to fracture) than traditional laboratory stacked or pressed ceramics.
The natural tooth gradation/color transition is already designed in the ceramic, so the aesthetic result is very natural. In addition, when these ceramics are bonded with precise clinical technique, they will surpass tooth strength and yet have wear properties that are as biologically compatible as enamel.
Artistic finishing techniques are used for the final texturing and superficial gloss. The artistic eye that I inherited from my mother shines through at this point.
Restoration bonding is critical for a successful outcome. I use biological "super glues" to adhere the ceramic to the tooth to create a biological seal. The gum tissue and body will recognize these restorations as ones of it's own. They are optimal for wear and biological compatibility.
The final phase is completing the lower arch and fine-tuning the bite. Since teeth are attached to the jawbone with very small ligaments, teeth will experience subtle movement. Following restoration placement the teeth and jaw joint will experience orthopedic settling. It is important to fine-tune the bite until physiological restorative settling is complete (usually 6-12 months). This will assure proper function of teeth for years to come.
As an assurance final step, maintenance retainers are made for nighttime use to stabilize bite and prevent grinding.
An aesthetic prototype was created to propose aesthetics and bite ratio of tooth length between the upper and lower arch.
An aesthetic prototype was created to propose aesthetics and bite ratio of tooth length between the upper and lower arch.
The patient is then placed on a proper hygiene protocol to maintain the gum health and given home care advice to prevent cavities and gum disease.
Dr. Klim is pleased to serve patients in the San Francisco, Santa Rosa, Sonoma, and Vallejo, California areas.
