consequence #1 bone loss - brian palmer, dds - exceptions.pdf · consequence #5 b71. fractured...
TRANSCRIPT
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Consequences of not meeting all the requirements.
Consequence #1Bone loss
B1
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Some of the reasons for bone loss.• Bone weak / unhealthy. Smoking can impact.• Position of the tooth in the bony dental arch.• Poor oral hygiene.• Low pivot center within the tooth. • Whole tooth moves in the socket. Similar to
rocking post in the ground to loosen it.• Thickened periodontal ligament.• Periodontal pockets deepen and get increased
invasions of micro-organisms.
B2
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Simple illustration demonstrating how by just taping a post lightly on the side over a long period of time can eventually loosen the post. The same thing can happen to a tooth.
B3
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Bone loss illustration
Thickened periodontal ligament.
Small lateral forces hitting the tooth from
many different directions, in a tooth
with a low pivot point, may eventually
loosen the tooth.
B4
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Bone loss cases
Case #1
B5
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Anterior view. Very shallow bite.B6
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Right side (reflective). Note tongue thrust & recession #5.
Mirror#5
Tongue thrust
B7
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1983 FMX. Note bone level around #s 5 and 18.
#5
#18
B8
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1990. FMX. Note bone level around #s 5 and 18.
Most significant bone loss on these 2 teeth.
#5
#18
B9
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Bone around #18 in 1983.
#18
B10
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Bone around #18 in 1990.
B11
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#18
1983
#18
1990
Bone loss that occurred over 7 years was the result
of traumatic occlusion.
B12
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Case mounted on semi-adjustable
articulator in Centric Relation.
B13
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Note posterior contact on #18 during excursion.
#18
B14
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Close up of contact on #18.B15
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Bone level on #5 in 1983.
#5
B16
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Bone level on #5 in 1990.
#5
B17
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Bone level on #5 in 1983.
#5
Bone level on #5 in 1990.
#5
B18
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Note contact between #s 5 & 29.
# 5
# 29
B19
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Reason why maxillary first bicuspids most prone for breakdown.
1) First bicuspid is usually the first tooth that hits, or guides, if there is no cuspid rise.
High cuspid.
2) First bicuspid usually has a weak root structure
3) First bicuspid usually has a proximal concavity that also makes it a weak tooth.
4) Maxillary bone less dense than mandibular bone.
B20
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High cuspid.
High cuspid.
Drawing somewhat depicting the situation.
Bicuspid rise instead of cuspid rise.
B21
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Note markings on #s 5 and 15.
#5
#15
B22
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Note markings on #s 18 and 29.B23
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Maxillary model equilibrated.B24
It can be determined where a tooth was adjusted and by how much by staining the teeth on
the model first.
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Mandibular model equilibrated.B25
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Mandibular flat-planed hard acrylic splint fabricated demonstrating
centric stops (dots) and cuspid rise guidance (green line),
B26
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Bone loss
Case 2
B27
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Panoramic radiograph. Note bone loss around #15.
Do not have that extensive bone loss in rest of mouth.
#15
B28
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Bone loss around #15.B29
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Mounted case demonstrating interference during excursion.B30
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Interference cause by contact between #s 15 & 18.
#15
#18
B31
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Close up of interference.
#15
#18
B32
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1 mm 3 mm.
Reason for more breakdown around maxillary second molars.
1) Closest tooth to the TMJ fulcrum. Less chance for error - about 1:3 ratio to anterior teeth.
2) Receives strongest force on it because of muscle position.
3) Maxillary bone less dense than mandibular bone.
B33
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Maxillary lingual cusp tip below the curve of Wilson. Interferes during excursions.
Curve of Wilson
Curve of Wilson
B34
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Mandibular model equilibrated.B35
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Maxillary model equilibrated.B36
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Mounted models equilibrated. Note anterior contact.
Anterior contact.
B37
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#15
#18
Mounted models equilibrated so as to have anterior contact before
equilibrating in the mouth..
Anterior contact.
Original posterior interference between 15 and 18 during excursion..
Correction of posterior interferences.
Anterior open.
B38
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Perio chart.
Because of equilibration and
improved oral hygiene, teeth have stabilized and are
healthy.
B39
Progression of disease.
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Abfractions
Consequence #2
B40
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Definition of an abfraction
Grippo J. Abfractions: A new classification of hard tissue lesions of teeth. J Esthetic Dent. Jan/Feb 1991:14-18
Due to the stresses resulting from biomechanical loading forces exerted on the teeth (static, as in swallowing and clenching or cyclic, as in chewing) both enamel and dentin can chip or break away. This loss of tooth substance, which shall be termed Abfraction, is dependent on the magnitude, duration, direction, frequency, and location of the forces. These abfractive lesions are caused by flexure and ultimate material fatigue of susceptible teeth at locations away from the point of loading.
B41
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Lines of stress directed down to apical area.
Lines of stress concentrating in area of cervical
region.
Tooth bends or flexes around
pivot area.
A B
A - Ideal loading on teeth.
B - Traumatic forces.
B42
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Forces that can be working on teeth at any time.
Green arrow - only non-destructive force.
Blue arrow - lateral force from tongue.
Pivot Point
B43
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Reasons for abfractions, cervical erosion, clefts, recession.
• Fairly high pivot point.• Root solid in the bone.• Crown flexes.• Enamel rods split and fracture off.• Thinness / health of bone in the area.• Key point: Abnormal lateral forces that
tooth was not designed to withstand flex and eventually fracture off parts of tooth. B44
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Extracted tooth with abfraction. Note size of abfraction and marked indent. Tooth was unrestorable because of sub gingival depth of defect and patient’s desire not to spend any money on the tooth.
Indent
B45
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Same tooth prior to extraction. Abfraction TOTALLY SUBGINGIVAL. Tooth brushing could not have caused it!
Same indent
Tongue thrust
B46
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Abfractions are seen on a daily basis in dental offices today. Abfraction on right was only tooth I could find during research at Smithsonian.
B47
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Similar to other case but with multiple abfractions. Note tongue thrust.
B48
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Multiple abfractions. Note different angulations of each defect.Tooth brushing could not have caused these defects. The abfraction was so deep that one tooth actually fractured in half.
B49
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These abfractions were due to the traumatic lateral forces created by this tongue thrust.B50
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Abfractions: in summaryAbfractions are due to the traumatic lateral forces created by either a malocclusion or a tongue thrust - or both.
There is a complete presentation and two articles on abfractions elsewhere on this website.
The reason abfractions are rarely found on prehistoric teeth is due to the fact that prehistoric humans did not have any other choice of nurturing their young other than breastfeeding. Breastfeeding was responsible for better occlusions and lack of tongue thrusts in prehistoric times.
B51
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Flattened occlusions
Consequence #3
B52
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Flat occlusion.
B53
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Reason for flattened occlusion.• Root - Crown - Bone - are all solid.• Bruxing is major contributor to flat teeth.• Attrition of the enamel just due to wear over
time.• Chewing of coarse foods.
B54
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Prehistoric skull illustrating a flat occlusion.B55
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An example of flat occlusion.B56
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Another example of flat occlusion. Have a slight reverse curve of Wilson.B57
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Close-up of previous mouth.B58
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Tori
Consequence #4
B59
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Tori Non pathologic outgrowths of bone.
‘compression ionization’
B60
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Reasons for tori• Similar to a flattened occlusion in that the root, crown
and bone are all solid.• There is ‘compression ionization’ or some form of
stimulation through the bone that causes more bone to be laid down. The bone is laid down as a ‘support system’ to help prevent the teeth from rocking in the bone and causing damage.
• Tori are most prevalent in clenchers, bruxers, worriers, nervous individuals and those who have a driver-type personality.
• They are non-pathologic outgrowths of bone.
B61
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1998
1994
Same individual.
B62
Example of tori growth over 4 years.
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1995
2004
Same individual.
(Post whitening.)B63
Example of tori growth over 9 years.
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Example of mandibular lingual tori.B64
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Example of mandibular buccal tori.B65
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Massive buccal and lingual tori.
B66
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Massive tori take up tongue space. Lady had OSA.
B67
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Large palatal torus.B68
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Another massive palatal torus. B69
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See full presentation on tori elsewhere on this website.
B70
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Cracked teeth
Consequence #5
B71
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Fractured teeth are sometimes difficult to see and cracks do not always show up on radiographs.
One diagnostic tool that can sometimes be used is finding
one significant pocket like this around a tooth when
most of the other pockets are within normal limits.
B72
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Panoramic of 1987.
Bite-wings of 2004.
4 cracked teeth that needed root canals and crowns.B73
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Heavy bruxing at night caused these deep
grooves. This splint used to be very flat, had no grooves and had fine
cusp tip contacts.
B74
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Heavy bruxing at night caused these deep
grooves. This splint used to be very flat, had no grooves and
had fine cusp tip contacts.
B75
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Tight bites
Consequence #6
B76
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A B
Ideal bite. Tight bite.
Incline (flat) contacts and damaging lines of force.
Point contacts and forces directed down long axis of tooth.
B77
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Tight bite• Inclines (broader surfaces) of opposing teeth are
in contact. Contacts between teeth are much broader than ‘point contacts’. This may cause flat wear facets.
• Can be due to discrepancy in arch width and/or teeth having incorrect angulation or slant, or missing teeth (which can cause shifting or drifting of teeth).
• Results in forces being directed in the wrong directions within the tooth (black arrows) and not in the direction of the long axis.
B78
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Heavy ‘wear’ facets and tori are due to tight bite.B79
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Tight bite. Nearly end-to-end malocclusion.B80
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Tight bite and tongue thrust (green arrow) caused these abfractions. See next slide.B81
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Abfractions restored.B82
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Inward slant of upper anteriors locks bite in causing recession.
B83
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Mal-alignments
Consequence of
B84
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Mal-aligned cuspid.
Root tip angled distally.
Longitudinal forces are running in the wrong direction. Should be running in direction of dotted arrow.
Too angled.
B85
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Too upright.
Mal-aligned cuspid.
Interferes with the “Envelope of Function”.
B86
Should have position of dotted tooth.
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Mal-positioned cuspid.B87
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Cuspid too upright.B88
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Another cuspid that is too upright.B89
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Cuspid and bicuspid have wrong angulations.B90
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Cuspid too upright and bicuspid too angled.B91
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Bicuspid damaged because these was no cuspid rise and bicuspid too angled.B92
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Recession on bicuspid result of forces generated by excessive lean.B93
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Post ortho case. Teeth crowded and have bad angulation
B94
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End of section B
Brian Palmer, D.D.S. Leawood, Kansas December 2004.