Functional Diagnosis and Treatment Planning
by Allison Watts, DDS
For the last several Mondays, we have been walking through the steps of a full – mouth reconstruction. I have enjoyed putting all the pieces of this complex process together and simplifying them to make them easy to implement. That is my goal here. The trick is whether it comes across in print and whether I’ve included enough or too much information…
Here’s a review of what we’ve covered so far:
- Phone call/First encounter
- NP experience/First appointment
- Data collection/Records
- Treatment planning and sequencing
- Setting fees – Just a reminder that much of fee-setting is mindset—how comfortable are we with the value of what we do and do we believe that what we do is a commodity or a highly valuable service (the more training and skill we have, the more valuable).
- Last week, we took a closer look at diagnosing and treatment planning esthetics.
- This week, we are going to focus on Function:
Occlusion is such a big part of the long-term predictability and stability of what we do. Completing a comprehensive evaluation of the TMJ, muscles and the occlusion is essential to evaluating and treating complex cases. Most of what I am sharing, I learned from Pankey, Spear and Dawson, though there are pieces from other teachers.
Remember, our occlusal diagnosis comes from information we get from the examination and records. We want to gather information first, identify the condition (make a diagnosis), decide on the desired outcomes and then decide how we are going to help the patient get to the desired outcome (treatment plan and sequence).
Before we make create the occlusal treatment plan and sequence, we need to have an excellent esthetic diagnosis and treatment plan that includes where we want the teeth to be esthetically. Through esthetics you can figure out where the upper and lower teeth look good in the face, but then you have to figure out how they are going to fit together for proper function—function that works well for the patient and helps the dentistry last as long as possible. We want to know where the envelope of function is and make sure we put the teeth in harmony with it.
During the functional exam, there are many things we want to figure out:
1. Is the occlusion physiologic or pathologic?
2. Does the occlusion need to be altered (Is it pathologic)?
3. Am I doing dentistry that will destabilize the occlusion? The answer is definitely yes in a full-mouth reconstruction, but we can destabilize the occlusion by altering one tooth if it’s a guiding tooth or first contact!
4. How do we design the occlusion so that it works?
It’s important to analyze the current occlusion to see if it’s working or if it’s not. Often, when I’m doing large cases, the occlusion has not been working well and that is one of the reasons they need a lot of dentistry. To analyze the current occlusion, we need:
a. Exam – If you’d like copies of my occlusal, TMJ, muscle exam, let me know.
b. Photos – If you’d like ideas on photo analysis, let me know.
c. Mounted models – We get so much information from mounted models. From esthetic information to occlusal information, most cases I treat require and benefit greatly from mounted models. Full mouth rehabilitation definitely requires mounted models.
To properly mount models, you need:
- Relaxed/deprogrammed lateral pterygoids, so the condyle will properly seat in the fossa in the uppermost position (with the disc in place)
- An articulator (I like the Sam 3 or Artex)
- A ”corrected” facebow (for questions on a corrected facebow, please contact me)
- Accurate, diagnostic models (2 uppers and 2 lowers)
- Properly trimmed centric relation bite records (2)
- Protrusive bite record
The models are very helpful to know what the patient does with their teeth. Do they go out edge to edge? Crossover? Which direction? Protrusive?
d. Appliance therapy – If the muscles and or joints are dysfunctional and in need of stabilization (or deprogramming) to get correct mounted models, this process should be done.
e. Waxup –It’s important to know where the teeth go esthetically and then figure out the vertical dimension, overjet, overbite, and eccentric contacts (canine guidance vs. group function and when each is appropriate, how steep or shallow to build the guidance, etc). It’s also helpful to have trial therapy (appliance, composites, and provisionals) in your toolbox and feel confident in that as a diagnostic tool. Leaving this up to the lab is usually not a good idea. A tool that is helpful is an incisal guide table, which we can make or the lab can make to know the patients current envelope of function.
I find that some of the most common challenges for us (dentists) in the area diagnosing and treating occlusion are:
- We don’t understand the value of it
- We don’t know how to make an accurate diagnosis
- We don’t know how to properly treat occlusal / TMJ / muscle problems
- We don’t know how to talk to patients about it
There are many ways to design the occlusion; some patients can adapt to almost any occlusion we give them and some patients will destroy their teeth no matter what we do.
Something I believe important to mention before we close is how important it is to understand is where our responsibility lies and where it does not lie. Once we touch a patient’s occlusion, we “own” it if we haven’t had the appropriate conversations ahead of time to help them “own” it. Much of my learning on this has been painful and I have redone many cases and lost sleep over many teeth and patients because of poor boundaries and taking way too much responsibility for things that weren’t my responsibility. I’d love to be able to reduce this learning curve for you.
If you’d like help in any of these areas, I’d be happy to help you or recommend a place for you to go to get an excellent education in occlusal diagnosis and treatment. Contact me at insights@allisonwatts.com.
Functional diagnosis and treatment planning is only part of the whole picture, but it seems to be one of the most challenging. When I help dentists with treatment planning, occlusion and esthetics are the areas that seem to be most difficult. I think this is because those are the areas we’ve had the least amount of training in and they are “big picture” diagnoses with a lot of little diagnoses within them.
I hope this helped clarify things a little. Let me know if there’s something you want to hear more about. You can leave a comment or question below, or connect with me on my Facebook Page. I will be more than happy to assist in any way that I can!
Best wishes creating excellent function,
Have to tell you Dr. Watts .. I am NOT a dental professional. However, I LOVE the way you so simply explain and detail all of your information! Thanks so much – I cannot even begin to tell you how much I have learned from reading this series and how much my respect for you has grown!!