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Partial toothlessness, lately or wrongfully compensated, are at the origin of prosthetics problems often difficult to solve. We shall explain the importance of dental grooves in the prosthetics process, through different cases of temporomandibular dysfunction.
Out of 3159 patients referred to a specialist clinic of stomatognathic physiology, 1297 patients started treatment because of temporomandibular disorders. All those patients were divided into subgroups of patients with mainly muscular or TMJ symptoms, respectively. A prediction of the treatment outcome as good or dubious was also made. This prediction was based on the patient's history and the clinical findings. A total of 989 patients (76%) completed the treatment. They all graded the degree of improvement of their initial symptoms using a Numeric Rating Scale. An improvement of initial complaints of 50% or more was judged to be a relevant change. In 85% of the patients with mainly muscular symptoms, the treatment was predicted to have a good outcome. The corresponding figures for those patients with mainly TMJ symptoms were 93%. Not less than 88% of all the patients reported an improvement of 50% or more of their initial complaints. The possibility to predict the treatment outcome as good in patients with mainly muscular symptoms was very good: 90% fulfilled the criteria of a positive treatment result. For those with a dubious prognosis, 56% had a positive outcome of treatment. The possibility to predict treatment outcome as good in those with mainly TMJ symptoms was also very good: 94% responded positively on the treatment. Almost the same figure, 88%, of those with a poor prognosis had a positive treatment outcome.
With recent interest in sleep apnoea, oral devices have been proposed and used increasingly to treat patients suffering from snoring and obstructive sleep apnoea (OSA). Numerous case reports have been published and studies have been carried out to determine the efficiency and mechanism of action as well as evaluate side effects, complications and costs of different oral devices in the treatment of habitual snoring and OSA. A summary of the scientific basis and current opinions regarding oral devices in the treatment of habitual snoring and obstructive sleep apnoea is presented in this article. The selection of papers was based on a computerised search of published clinical and associated studies identified by MEDLINE from 1980 to November 2000. Although there is not yet enough scientific evidence for the clinician to determine which appliance is most likely to improve symptoms for a given patient, it appears from the literature that dental devices may have a place in the treatment of habitual snoring and mild and moderate cases of OSA. However, most of the studies are case series, raising questions on validity, and few studies use appropriate control groups. The general opinion is that these patients should not be treated without a sleep study as the OSA must be diagnosed before beginning treatment with oral devices to identify patients at risk and to provide a baseline to establish the effectiveness of the treatment. The main advantages of oral devices is the relative simplicity of the treatment, its reversibility and cost-effectiveness, and the fact that they can be used as an alternate treatment in patients who are unable to tolerate nasal continuous positive airway pressure (nCPAP) or who are poor surgical risks. Side effects occur in a significant proportion of patients using the MAD. In most cases these are minor and their importance must be balanced against the efficacy of the MAD in treating snoring and OSA. n.
This case report describes management of a 3-year-old child with early childhood caries and anterior crossbite. Restorative care was postponed until after crossbite correction to eliminate occlusal interferences associated with premature contact and a functional shift of the mandible. Crossbite correction was performed with a fixed anterior bite plane appliance, and comprehensive restorative care was performed under general anesthesia.
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In part I of this article, the evolution of bruxism from childhood was discussed. Further, the different types of anterior tooth wear were reviewed. Specifically, the type of wear noted in bruxed-braced or cross-over position was pointed out. Examples were illustrated to allow the practitioner to recognize the type of parafunction in advance of treatment. This article will continue the discussion of cross over with moderate to extreme examples. Suggestions for treatment are discussed depending on the severity of the problem. Restorative failure and the implications for implant dentistry are noted.
This article reports the results of a clinical study that evaluated adjunctive teeth-associated signs and symptoms before and after nonsurgical temporomandibular disorder therapy. Eighty-nine patients were referred to a private prosthodontic practice in the Washington, DC metropolitan area. Of the 89 patients, 75 were selected for the clinical study after completing the interview, history, and clinical examination. The major signs and symptoms were recorded, along with adjunctive teeth-associated signs and symptoms. The treatment included an anterior programming device, a centric relation occlusal device, and, when indicated, a selective occlusal equilibration. The results were recorded after five treatment visits. Of 75 patients, 67 made good-to-excellent improvement in the signs and symptoms of their major temporomandibular disorder. Patients with adjunctive teeth-associated signs and symptoms demonstrated a marked reduction in these signs and symptoms as assessed by their mental perception and verbal feedback. The symptoms of perceived awareness of malocclusion were not resolved with centric relation occlusal device therapy in 22 of the 24 patients with this symptom. However, excellent improvement was noted in this symptom when occlusal device therapy was followed by a selective occlusal equilibration. Thirty-eight patients in this study had difficulty in making lateral gliding articulation movements with the occlusal device out of the mouth. This problem was resolved in 36 patients after removal of eccentric occlusal interferences. It is suggested that adjunctive teeth-associated signs and symptoms be initially recorded and addressed in patients, especially if extensive or invasive dental therapy is planned. Although this clinical study in a private practice was carefully performed, it does not meet the criteria of evidence-based research, because a control group was not included.
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In order to investigate the effectiveness and the mechanism of action of oral appliances (OA) on obstructive sleep apnea syndrome (OSAS), a series of studies including overnight polysomnography, both ultrafast MRI and measurement of intraesophageal pressure during daytime naps and cephalometric analysis while awakening were performed on 19 OSAS patients before and during the treatment. In all cases, a significantly decreased apnea hypopnea index (AHI), shortened apnea duration, and a significant elevation in the lowest value of nocturnal arterial oxygen saturation, in comparison with the pretreatment values, were recognized during treatment with OA. The number of patients who responded to OA treatment, i.e., those whose AHI decreased by more than 50% of the pretreatment value, was 13 (68.4%). In cases with an AHI of 30 per hour of sleep or more before treatment, the number of arousals decreased and the percentage in stage 3 + 4 increased significantly during the use of OA. Cephalometric analysis revealed the anteroinferior advancement of the mandible, the anterosuperior movement of the hyoid bone and increase of upper airway area with OA in the cases studied. An MRI of the upper airway during sleep showed that glossopharyngeal obstruction disappeared with the use of OA in all cases, and velopharyngeal obstruction disappeared in nearly half of the cases. Moreover, the fluctuation of the intraesophageal pressure during sleep decreased significantly with OA. There were no differences in clinical background (e.g., age, body mass index, pretreatment value of AHI, and upper airway characteristics) in patients who AHI had decreased to less than 50% and those in whom it remained over 50%. These results confirmed the effectiveness of the treatment with OA. OA can be recommended for OSAS patients with not only glossopharyngeal obstruction, but also velopharyngeal obstruction, which is the most common cause of OSAS.
Nearly every practitioner in dentistry, no matter what his or her specialty or special interest, may have a potential role in the management of patients with a sleep disorder, particularly snoring and sleep apnea. More important, every dentist as a practitioner in the health care field should be able to assist the patient who is identified with a potential sleep disorder by making recommendations, referrals, or participating in the overall management. Sleep is essential to life and to overall health. Involvement by dentists is another step in the development of a closer relationship between dentists and their medical colleagues. The treatment of sleep apnea may be more successful, both in efficacy and compliance, if dentists and sleep specialists collaborate closely. The importance of this collaboration is certainly indicated by the creation of a Section on Oral Appliances within the American Academy of Sleep Medicine (AASM), which further unifies dentistry and medicine. Many dentists are not familiar with sleep medicine, its magnitude, and the prevalence of sleep disorders. To assist those looking to expand their knowledge, the pertinent organizations are listed in Appendix A, and a number of sleep-related organizations and websites are listed in Appendix B. It is up to each individual practitioner, in medicine and dentistry, to develop a better awareness of the field of sleep, its effect on a person's overall health, and how a person's quality of life can be improved by a better night's rest.
The last 4 decades have seen the emergence of a new medical specialty, sleep medicine. In response to an unfulfilled clinical need, and fueled by better understanding of the significance of sleep disorders, sleep medicine developed medical solutions for age-old problems with sleep and wakefulness. Sleep-disordered breathing has played a central role in this story. Therapy and management offered by the dentist has become recognized as an important aspect of care for patients with SDB. Dentists who offer this service need to become acquainted with the multifactorial nature of sleep medicine to serve their patients better and to facilitate their interaction with other sleep medicine clinicians.
Obstructed sleep apnea syndrome and UARS are often missed in clinical practice. The pediatric population presenting with UARS or mild OSAS is the most commonly ignored because the symptoms are insidious. Often, their craniofacial morphology is not as altered as in the adult population because the effects of airway obstruction may not have been fully established. This is, however, the group in which trials aimed at redistributing bone growth and functional readaptations may be attempted. Dentists and orthodontists have the greatest opportunity to see these young individuals and may help identify them and participate in treatment options. Undoubtedly, functional appliances are not the ideal solution, but if used appropriately with the goal of enlarging the upper airway, they may obviate the need for aggressive surgical treatments later in life. Orthopedic palatal and transverse expansion appliances can widen the jaw bases at the level of the basal bone. Orthodontically uprighting lingually tipped teeth to widen the alveolar bone housing the teeth can help improve the oropharyngeal space indirectly by altering the resting posture of the tongue. These measures in conjunction with other simultaneous, noninvasive modalities may prove to be effective.
Many patients with upper airway sleep disorders can be successfully treated with oral appliance therapy. It is necessary for dentists to recognize these patients and refer them to a physician for further evaluation. Dentists must not become the primary care providers for these patients or attempt to treat a medical problem with an oral appliance without a proper diagnosis, which usually requires a sleep study and can only be diagnosed by a physician. Dentists must also be able to treat the patients referred by physicians and to follow accepted procedures when fabricating, inserting, titrating, and providing follow-up care for oral appliance therapy. In addition, the dental community needs to continue to heighten the awareness in their local medical community and in their patient population as to the possible contribution of oral appliance therapy to the management of snoring and some of the sleep-related breathing disorders.
Upper airway imaging techniques have significantly advanced the understanding of the pathogenesis of obstructive sleep apnea and the biomechanical mechanisms by which therapeutic interventions for this disorder exert their effects. Both static and dynamic imaging studies have been used to examine the structure and function of the upper airway during wakefulness and sleep. These studies have highlighted the importance of the lateral pharyngeal walls in addition to the tongue and soft palate in modulating changes in upper airway caliber. Upper airway imaging has also been used to understand the changes in upper airway anatomy associated with weight loss, mandibular repositioning devices, and upper airway surgery. At present, upper airway imaging should be considered in patients undergoing upper airway surgery and possibly in patients being evaluated for oral appliances. MR imaging and nasopharyngoscopy are the imaging modalities of choice in patients undergoing a UPPP. Cephalometrics should be considered in patients being treated with mandibular repositioning devices. Upper airway imaging has provided an important framework to examine the pathogenesis of airway closure, and these investigations may, in time, lead to more effective treatment options for patients with sleep apnea.
Occlusive SDB is common in childhood and is most frequently associated with adenotonsillar hypertrophy, congenital syndromes associated with craniofacial malformations, oropharyngeal dysfunction, and chronic neuromuscular disorders. Sleep-disordered breathing has a significant effect on the performance, behavior, and health of children and often results in significant lifestyle abnormalities for the entire family. Comprehensive, technician-attended polysomnography is the gold standard for diagnosis and assessment of occlusive SDB. Significant involvement of dental professionals in the assessment and management of this common childhood disorder is essential.
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