Craniomandibular Dysfunction (CMD) after Dental Implant Restorations

Last Updated: Nov 13, 2005

Osseonews was pleased to have the opportunity to speak with Dr. Alvaro Ordonez, a general practitioner and Director of TMJ Dental Consultants Inc, in Coral Gables, Florida. Dr. Ordonez has over a decade of experience treating patients who have developed CMD (Craniomandibular Dysfunction) after restoration with dental implants. Dr. Ordonez shares with us some of his observations and recommendations for treatment.

Osseonews: Dr. Ordonez, What is the incidence of CMD (Craniomandibular Dysfunction) in patients who have been restored using implants?

Dr. Ordonez: The true incidence is unknown. CMD is a relatively new and not well defined area of diagnosis and treatment. The biggest problem in forming an accurate estimate of the incidence of CMD would be to first implement a standardized system for evaluating these patients. This has not been accomplished yet and owing to the complexities and differences of opinion in this field, may never happen.

Our patients come to us usually because they have an existing CMD problem and we are a CMD\Facial Pain Center. We often use implants to restore the patient after we have ameliorated the CMD problems. We really are not seeing a true picture of the normal range of TMJ function for these patients simply because our patient population is very heavily weighted with patients with CMD.

If is very difficult to generate reliable data for the kinds of studies that we really need in the area of CMD. Perhaps creating as specific a questionnaire as possible to evaluate cases and enlisting multiple sites for inclusion in the collection of data would give us an idea of the actual condition of the patients before implant restoration. The same patients would need to be evaluated years after implant treatment to evaluate for potential problems. Personally, I believe that the combination of missing teeth and parafunctional habits can predispose a patient to CMD that meets an academically acceptable definition.

Osseonews: Is there a greater incidence of CMD associated with a particular kind of implant restoration?

Dr. Ordonez: That has not been my observation. In the early days of implant dentistry, not having a periodontal ligament in between the implant and the bone was considered a major problem because of the lack of proprioception. This proprioception deficit was believed by some to be a potential cause of CMD. In other words, since the implants lack proprioception, they fail to generate the kinds of nervous impulses or information that trigger self-protective reflexes. This was thought to lead to unbalanced force distribution on the implants which generates CMD. Without protective reflexes the jaws would in a sense, malfunction.

We did not observe this in our patients. We did not observe a precipitous increase in CMD cases after major implant restorations. So what happened here? And by the way, this is not just my observation but the observation of many researchers and experienced clinicians.

I believe a CMD problem in any patient could be caused by or related to so many different factors that include: the presence or absence of parafunctional habits, the type of parafunctional habit, the presence or absence of stress related factors (anxiety and or depression), mandibular position (whether deviated to the sides or anteriorly or posteriorly), macro- or micro-trauma, variable adaptation response, and so on.

Any restoration, including implant restorations could be a predisposing or precipitating factor for CMD if not done properly from the craniomandibular aspect. The advantage of implants again is that they can be use to restore missing teeth, enhancing the distribution of forces and restoring mandibular position which in turn affects neuromuscular mechanics. This is especially true for the patient with posterior bite collapse. If implant restorations are managed properly they should enhance stability and assist in the dispersion of forces.

Osseonews: How does the treatment of patients with CMD involving dental implants differ from patients who do not have dental implants?

Dr. Ordonez: There really is no difference between the ways we diagnose and treat patients with natural teeth and patients with implants. The point is that patients with CMD usually have multiple problems including: muscle disorders, joint related problems or internal TMJ derangements, Cervical Spine dysfunction, postural problems and complications from systemic medical problems. It is very rare to find a single problem; we usually find multiple problems that collectively produce the CMD.

After we arrive at a diagnosis, we often find that we have to work with other health care professionals because of the complexity of the many factors involved. All the parts of the body are linked together and often one pathosis can have repercussions on other structures and functions. Treatment may involve splints, physical therapy, spray and stretch, manipulation, electromyography, Botox, and other therapies.

Osseonews: What type of treatment would you recommend if a patient develops CMD after implant restorations? How does this differ from CMD caused by the restoration of natural teeth?

Dr. Ordonez: The first thing the dentist has to do is to assess the situation, is it primarily muscular? Is it primarily articular? Are we dealing with multiple factors? Once the dentist determines the etiology of the problem, he should inform the patient and proceed with the treatment.

Splint therapy is often used, especially for muscular problems. Being familiar with multiple designs of splints is extremely useful. Although there are many schools of thought, this would often be your initial therapy. If the primary component is muscular, use a muscle relaxant temporarily or medications like cyclobenzaprine or even diazepam at night, to relax the muscles and induce the patient into a deep phase of sleep (which will decrease the incidence of parafunctional habits). If the problem is articular, then analgesics and anti-inflammatory medications are even better. Our experience suggests that there is a higher incidence of muscular disorders as a primary causative factor than articular.

Your best friend and your best strategy will always be a good splint (a night guard) right after treatment (it is like buying insurance). It will work as a shock absorber and it will distribute the forces even better and more precisely and it will wear down rather than the restorative material, natural teeth, bone or the implant and its components.

We recently conducted a study in which we recalled our CMD patients from 1999, 2000 and 2001 that were finished with dental implants and implant restorations. The results and conclusions of our study were very interesting.

Most of the problems were related to patients that stopped wearing their splints after the fifth year of maintenance, and the most common complication was fracture of the prosthetic ceramics. Think about it, low fusing ceramics fracture very easily. In fact, I have heard Gerard Chiche mentioned that these ceramic systems are still undergoing re-invention! Well, it is an advantage in these cases since I would rather see ceramic fracturing than implants and components fracturing and bone lost. â€œIt is easier to replace the ceramic on top rather than the titanium under the ceramic.â€ The actual concepts of Dr Carl Misch have been tested in our patients, and results have been extremely interesting, since our implants are abused by clenchers and grinders every day of their lives.

Progressive loading in patients that have a history of CMD is a must! When we donâ€™t progressively load, organizing the occlusion is really hard, and becomes problematic, especially if they have dual bite. Having a progressive transition from temporary restorations to permanent restorations is the way to go, especially in the posterior segment.

Developing the implant site from the beginning with atraumatic extractions and then enhancing the site by bone grafting is a must, so you may place the widest and longest implant for that specific site. Always extend the restoration and your implants to the second molar because the second molar absorbs and protects a great deal of forces that otherwise would be transferred to the TMJ.

Reject the concept of First Molar Occlusion. First Molar Occlusion is a very sad concept in the times that we live; this might create some controversy, but think about it. Where does this concept come from? It comes from the times of lack of resources to elevate sinuses and graft bone. It used to be tough to do sinus elevations and bone grafts. We didnâ€™t know as much then as we know today about regeneration. Today I strongly recommend that if you want to plan your case considering the TMJ and biomechanics and occlusion, do everything you can to include the second molar, and try to create occlusal tables that resemble that of the original dentition. If wide implants are not possible, then plan for a Premolar looking type of crown. I want to be sure I am understood on this critical point. If you cannot use wide implants to support a Second Molar Occlusion, switch to a Premolar design for your second molar crown. This should be your standard operating protocol.

For the patients with a history of CMD, you want to wait long enough for osseointegration before you initiate temporary or permanent restoration. We have immediately loaded a good number of them, but we have used Botox in the masticatory muscles to decrease the applied parafunctional forces and this works well. Remember Planning, planning, planning!

There is a significant advantage of using single dental implants, since the forces would not rest only on the remaining natural teeth and so the remaining teeth would not be overloaded, so distribution would be better with dispersion of forces. We could now extend the occlusal span by adding a restoration in the first and second molar areas.

Osseonews: What is the success rate in treating patients with CMD and dental implant restorations compared to patients with natural teeth?

Dr. Ordonez: That is a very complicated question to answer but we have been analyzing the data that we have been collecting in comparing the two scenarios. I can also tell you that I know of at least another group looking at that too. Success is very high, similar to normal patients; complications are more related to the implant prosthetics.

We recently recalled 50 patients in September with more than 6 years of implant placement (47 showed up) a total of 141 Wide Diameter Implants. Most of these patients had Wide Diameter Implants with an external hex. We lost 4 implants in this group, 3 in the sinus areas and I have to blame it on the technique I used since at the time we were developing a modified supracrestal technique for sinus elevation that was presented as a clinical innovation last year at the Academy of Osseointegration. The other implant was lost about six month after placement and I believe it was also my fault since it was placed in an area with a severe apical lesion that was grafted and we waited 4 month when I believe we should have waited longer. The decisions and technique played a negative role greater than the parafunctional forces.

Now, what we have seen in that group is a more extensive amount of fracture and micro-fracture of the ceramics as I mentioned before after the fifth year and it was greater in the patients that stopped wearing their splints. We recalled these patients since we were planning a lecture at the Consensus Conference in success criteria in Pisa and we wanted to give the results. We were looking for crestal bone loss that some clinicians have reported on Wide Diameter Implants. We had two implants with major crestal bone loss in the same patient (it was an early bone loss with major threads exposure), and I truly believe it was related to my management at the time of that case. I donâ€™t think it was the implants, it was my technique. We are processing and analyzing the data now.

These patients were or are heavy clenchers and or grinders and the percentage of success was similar to the other patients who are not CMD patients. I have to admit that the percentage of porcelain breakage was tremendous, higher than non-CMD but implant success was similar (based on the new success criteria that will be published soon). So expect to have complications that are mainly prosthetic due to maldistribution of forces. My point would be that we should translate this to our regular everyday patients who are probably not from a CMD population with such elevated forces. Therefore we should calculate our biomechanic tolerance in excess to what we usually see.

The teaching, again, is planning, case selection, case management and applied biomechanics. In Contemporary Implant Dentistry by Dr Misch, you have everything you need to manage these cases (e.g., implant biomechanics). The Textbook of Occlusion by Mohl, Zarb, Carlsson and Rugh has most of what you need to know on occlusion. Clinical Management of Temporomandibular Disorders and Orofacial Pain by Pertes and Gross has up to date information on comprehensive evaluation of CMD (Facial pain patients). Myofascial Pain and Dysfunction: The Trigger Points, by Travell and Simons provides the best information on muscle mechanics and muscle physiology. I strongly encourage you to get familiar with splints. I think that the Pankey institute has the most balanced program available to dentists that practice every-day dentistry and implant dentistry.

Osseonews: What are the best strategies to prevent CMD in implant patients?

Dr. Ordonez: Identify: Find out during your initial exam if this patient has parafunctional forces or habits that are present or at some point have been present in the system. If they are present then they should be controlled and managed. If they were present at some point, then they can come back at any time so you have to prepare for it by creating mechanisms to disperse them well and to withstand them.

Differentiate: There many types of parafunctional habits and they all work differently and have different behaviors, patterns and clinical signs and symptoms. A common mistake I see in top speakers is that they relate to clenching and grinding the same way! That is a major mistake that is affecting treatment planning and case management and even the way we look at patients and conduct research! Clenching and grinding are two separate entities, that are different and they have different manifestations, and different signs and symptoms; so they also need different clinical management. We in dentistry have paid more attention to the grinder and very little attention to the clencher.

The grinder is often the easier patient to treat. Most of the dental protocols in occlusion design are created to protect the restorations from grinding. We have paid more attention to the grinder since it is very destructive dentally while the clencher is the silent enemy and itâ€™s the habit that causes the worst problems and the symptoms that mimic medical problems. Clenching is very hard to diagnose since there is no noise, no teeth wearing. An even more serious condition is when the patient grinds and clenches.

Interestingly about long term clenchers is the fact that they very often have vertical lines of micro fractures known as craze lines. They can also have abfractions, elongation and widening of the coronoid process and muscle tenderness of the deep portions of the masseter muscle and anterior temporalis muscle. We need to use these to identify these patients as early as the first appointment so we can plan for treatment modifications that ameliorate this problem.

Another habit that is especially dangerous is known as abnormal posturing of the jaw or sometimes known as â€˜crossoversâ€™ where the patient goes out of centric into odd eccentrics that makes no sense. This habit is very difficult to diagnose and whenever using immediate loading, special care should be taken to make sure the patient doesnâ€™t do it since they can end up banging on the recently placed and loaded implant.

Conditioning: Conditioning means creating a healthy environment in which the implant can succeed by modifying the existing abnormal occlusal set-up, eliminating the trigger points (if any) and placing the implant in accordance with the fundamentals and principles of an appropriate protective occlusal design.

Protecting: Always, after a case has been successfully loaded, the best insurance you can provide to your new implant case is the protection by the use of occlusal splints. Remember that splints can be used as preventive devices whenever you feel that occlusal forces can be a problem. Treatment guiding devices produce precise mandibular positioning which may be required in some cases to reduce symptoms. They can also help us confirm a diagnosis.

Botox is successfully being used to decrease the muscle activity of the masticatory muscles therefore eliminating applied forces to a certain degree. When used in cases of patients with parafunctional habits we decrease the applied forces and facilitate the normal process of osseointegration.

OsseoNews: Thank you Dr. Ordonez for a very enlightening discussion.
Interview conducted by:
Gary J. Kaplowitz, DDS, MA, M Ed, ABGD
Editor, Osseonews.com

36 Comments on Craniomandibular Dysfunction (CMD) after Dental Implant Restorations

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ImplantPros

11/13/2007

You state: "Dr. Ordonez has decades of experiencing treating patients who have developed CMD", yet he finished his dental school training in 1991. Does a decade and 6 years make for "decades"? I don't argue that he may have significant experience treating CMD as a general dentist but I do think it is important to stick to the truth when documenting about someone's clinical experience on sites that are of public access. The fact that you have a significant amount of knowledge on a topic does not add to the number of years you have been practicing.

osseonews

11/13/2007

Thanks for your comment. There was a typo in this interview and it has now been corrected.

Ihde

11/14/2007

Implants add several reasons for additional TMJ-problems. Here are two major reasons: 1. The aditional surgery leads to a tremendous overall remodelling of the jaw bones.(Attkinson 1977) Directions of remodelling are uncertain, however if unilateral or anterior patterns of chewing are present and left in the patient, the remodelling proces will be directed by this wrong/unwanted function. Bones will be bent the wrong way, with the TMJ having to cope with the effects. If augmentations will prevent or ease this problem has not been investigated. 2. Unilateral implant placements face the fact, that the operated side will undergo stronger shrinkage through remodelling than the non-operated side, where extrusions of teeth are likely to happen. Other than teeth, implants do not extrude. This may lead to an unlevelled plane of bite.

Buddy Shafer

11/14/2007

I can easily see how many full arch implant restored cases would end up with occlusal/muscle pain (characterized as TMJ, TMD, or CMD) considering how many cases are restored forward of centric relation. With full arch cases, and without verified CR bite records,the occlusal records are often down and forward, so if the case is restored like that in the lab, it will be down and forward in the mouth. This could easily result in occluso-muscle pain. Also, if the "night guard" is made in that same down and forward position the muscle pain will likly continue. As was mentioned by Dr. Ordonez, implants lack the mechanoreceptors found in teeth, so the body looses much of the adaptive response capability. With comprehensive implant restorations, it is more critical than ever, that the condyle/disc assembly be properly aligned and condyles fully seated to provide coordinated muscle function and occlusal stability. Buddy Shafer

mwsc

11/14/2007

The Textbook of Occlusion by Mohl, Zarb, Carlsson and Rugh has most of what you need to know on occlusion. Clinical Management of Temporomandibular Disorders and Orofacial Pain by Pertes and Gross has up to date information on comprehensive evaluation of CMD (Facial pain patients). Myofascial Pain and Dysfunction: The Trigger Points, by Travell and Simons provides the best information on muscle mechanics and muscle physiology. Where can I buy these books, if you can help. Thank you.

alvaro ordonez

11/14/2007

To MWSC Go to Amazon.com you will find them there, or go online to the publishing companies (pertes book and Mohl's book are by quintessence; travells book is by williams and wilkins). To Ihde 1. In 1977, the surgery most likely would create some degree of bone loss! in 2007 the surgeries are done to develop and enhance the surgical sites; it is part of the evolution of science. 2. You are assuming based on the same concept you mentioned in your point #1, now, you mention that "Other than teeth implants dont extrude" you are assuming that you are going to have a passive eruption effect, I wonder why? if you organize the occlusion and redistribute the forces most likely the passive eruption mechanism and the anterior component of forces will be neutralized. To control the forces you need to apply techniques like biofeedback, you could use splints at night time and you could use botox, etc. To Buddy: I agree with you that if the mandibular position is not right and bite registration is not right and occlusal splint is not right then you have a mess. Splints have to be adjusted periodically since occlusion in patients with parafunction and poor neuromuscular functioning is not stable; the patient needs to be out of pain and functioning well before you go into any finishing technique, call it implants, call it orthodonticas or whatever you suggest for your patient.

Albert Hall

11/18/2007

GP placing implants and solving TMJ problems? That is the State of the art in Implants....probably this doctor will come out with the implant for TMJ disorders soon. Who knows?

alvaro ordonez

11/19/2007

Dear Dr Hall This Gp did a full time university program at Tufts University at the Gelb Craniomandibular pain center in Boston and have also placed more than 3000 implants. I wont even get in to my continued education after that. I also teach in different well recognized institutions educating all kind of GPs and specialist including U. of Florida and Veterans Hospital. I would like to invite you to go search the literature for published articles and search for our clinical innovations in implants presented and published at the American Academy of Osseointegration 2005- 2006- 2007, hopefully you also have done a few. If you feel you are so good and you feel that a GP could not place implants as good as you could, then I respectfully invite you to get together to compare our cases, I would be happy to travel wherever you are with my computer and my videos on surgical techniques and lectures and here what you have to say. Shame on you, hopefully you are a good and clean practicioner and not just somebody leaving up to a degree. It is not funny to still finding people with such prejudice, most people have forgotten now that the field of implant dentistry was created by general dentists who got under heavy criticism and attacks in the process of developing the techniques that we take for granted today in this field. I was so impressed with the lecture of Dr Linkow at the ICOI winter meeting in Sandiego 2006 when he showed a slide with a pioneer going in to indian territory and then the pioneer full of arrows in his back in his way out. I think if you have some criticism on the content of the interview then bring it forward for discussion but it is funny to see that something created with the intention to guide Drs into more careful management of implants and TMD patients is used just to diminish the work of somebody. Probably in your specialty program you had more intensity in this area than I had in mine (I doubt it) but to my knowledge, the area of implant dentistry and soft tissue management have to be learned by most practicioners in courses since in the past it wasnt part of the curriculums of the specialty programs, and that is why I see so many perio and oral surgeons taking the same courses with the GP'S. Funny no? The youngest specialist have more intensity now in this area than in the past. Lets dont even get into the intensity of TMD in the university programs (some schools dont even have it in their curriculums) and the ridiculous things that people do to this patients; a few days ago I was seing a patient that was ready to be "scoped" in the joints since the Dr wanted to get a better idea of what was going on. Scope what? the patient had a temporal tendinitis, a muscle disorder, due to heavy clenching. What good would scoping a patient with a perfectly healthy functioning joint would have done to that patient? Ignorance to diferential diagnosis create situations like that, and I wonder why a GP like me was able to fix the problem? In reality, any one should know diferential diagnosis, specialists as well as GPs, but most people dont care. That is what this interview is about, it is with the purpose to create awareness, not to say that the editor made a mistake when he wrote "decades" in the beggining of it about my experience in CMD, I am 39 years old it is impossible that I have practiced for decades, but most likely I have place more implants than a great number of specialist and lets not even get into TMD and the heavy number of complicated cases we see and manage here in our practice, by the way, it is very wearing to do this kind of work mentally and physically. This interview has been used by you to criticize a GP that have respond to the questions on the interview with nothing more than what is really happening in the field. Perhaps you have some constructive comments to make in this field of dentistry and those are welcomed since this blog is used for people all over the world, specialist as well as GPs to cover topics of interests and bring answer to questions in this field. Perhaps you should have been interviewed right? By the way, I am not inventing any implants at this point, but I could tell you which ones work better to disperse the forces, and which ones behave better mechanically in the presence of forces. I could also tell you the ones that dont behave as good. It is not a single one, there are many in the market; but you wont be interested in knowing that since I am a GP, somebody that should talk about implants right? so I wont tell you. Sicerely Dr Ordonez

alvaro ordonez

11/19/2007

By the way Dr Hall (hopefully that is your real name) To make something constructive of all this, I suggest you contact the editor of osseonews about posting an interview on "Why GPs shouldnt place implants". Let me remind you, about the magnificent job of Marius Steigmann on soft tissue management (a GP), Adi Palti, A great number of the big names in italy are GPs and counting. Grow up sir.

satish joshi

11/19/2007

HERE WE GO AGAIN!!!!!!!!!!!!!!!!!!!! Specialists against GPs. I thought this topic was over with the consensus among us that" It is not speciality but dentist's knoweldge and skill make a better implant dentist." I do not condone a GP or specialist(older generation without implant training in curriculam) doing implant dentistry with education of weekend courses, but at the same time I do resent when some obnoxius specialist thraw insults at GPs for being GPs. I am a proud GP, I have worked very hard,spent enough time and money to acquire knoweldge and skill. I teach in university implant program, surgical as well as retorative phases. When I did my first bilateral sinuses 10 years ago.My patient was hypertensive and very anxious and so I decided to do it in hospital so patient can have IV sedation. Then chief resident at Brookdale Hosptal's implant dept. Dr. Michael Katz was assisting me and Dr. Norman Cranin (one of the fathers of implant dentistry)then chairman of dept. was standing next me, watching me. After I finished elevation of membrane, as I have learned from Dr. Hilt Tatum to place colatape under elevated membrane, I started opening package of colatape. Dr.Cranin asked me " What are you doing Dr. Joshi?" I told him I am placing colatape in case if there is a perforation" He said" you do not need colatape, you did not perforate a membrane. you are an accomplished surgeon". What a confidence building that sentence was. Instead of puting other people down, try to lift them.You will have more satisfation in your life.

CL Koay.

11/20/2007

Syabas to you Drs.Alvaro Ordonez and Satish Joshi. Well said. Continue the good work. Whether you are a GP or a specialist does not matter. If you do not know what and how to do a procedure, what difference does it make?. Let us all help to hoist the flag of dentistry up high and be counted worthy to be in the big team of the health practitioners and the bigger family of mankind. Your Brother from Malaysia, Koay.

11/20/2007

Albert Hall is right.GPs should not be doing implant surgery.Even if they want,they should be restricted to ant. mandible.

perioplasticsurgeon

11/20/2007

M, You have been named the winner for the sillest comment of the year. First off I have no problem with GPs placing implants, and I'm as specialist, and it doesnt bother me. There are alot of great implant programs/fellowships out there such as NYU, Loma Linda and many others that teach many dentists to provide comprehensive implant care. I have a problem when there are people placing implants that aren't qualified. A weekend course doesnt qualify one to place implants, do sinus lifts or graft bone. I have seen many comments on these site to show unqualified dentists placing implants (I especially like the one on the dentist asking how should his flap be done and should he one or two stage for a case of 8 implants in the maxilla and 6 in the mandible that he was doing). To me a person taking a weekend course will do more harm to our profession than good. We aren't working on animals, we are working on people. Dr. Ordonez has clearing demonstrated that he has both the training and ability to place implants and he should be commended. But I think even Dr Ordonez will agree that there are alot of GPs that are doing implant surgery that aren't qualified and dont have the proper training.

dr s sharma

11/21/2007

i need to know what happens if while doing an indirect sinus lift one feels that the membrane has not been perforated,one places the graft and the implant thereafter but the membrane was actually perforated and no collagen membrane was placed to seal the defect. the area was the upper first molar area and the x-ray post implant placement showed a generous amount of bone graft material around the apices of the implant. the patient was asymptomatic for the first three days but developed slight pain and swelling post that.she has been put on analgesics and is comfortable. is this normal and if the perforation has actually happened what is the prognosis considering that the area itself is sealed with the implant in place.

alvaro ordonez

11/21/2007

The sad part of this whole part is that we have created a good content related to TMD and occlusion, something very hard to find in the literature, and nobody seems to be paying that much attention to that. In the mean time, we are immediate loading, we are creating occlusal spans that might not have the appropriate foundations, and we are using restorations, occlusal designs, materials and implants that might no respond well to the specific demands of a patient. Lack of interest for detail is what it seems to be happening here and a lot of interest for screwing a screw! Well, I have seen good implants and bad implants done by GPs, by specialists of all kind etc; but that its not the topic here. Lets talk here occlusion and forces applied to our implants, to our bone and stop being superficial, there are two comments that are personal criticism and seem to be from people that knows me, and I know exactly one of the people behind it since that guy said the same to me a few years ago and that stayed in my mind. I will tap on his shoulder next time I see him. On the other hand, lets get back on track. This is the space for questioning occlusion, design, protection for the implant restoration number of implants with and lenght, timing for placing the implants, medications, differential diagnosis etc. sorry, this is not the space for sinus complications, we could answer but there are other discussions about it in osseo news that cover that. If you have a comment and is personal, and want to take advantage of the fact that I have contributed to this blog, then go ahead, be a coward publically and even more, use a nick name or an alias and not your own to hide yourself. OK DOC?

satish joshi

11/21/2007

I admire anybody who admires person's knowledge not just a 'paper diploma'. Perioplastic surgeon you are among them. I do not know Dr. Ordonez at all.I am not trying to do any favour to him. He dose not need it any way.He has shown his knowledge about TMD in the interview. I am just trying to educate those ignorant specialists who think additional few years of schooling make them super GODs. Yes ther is a problem. No body can deny it. There are poorly trained dentists: GPs as well as specialists, doing poor implant dentistry. I have come across few of them. GPs as well as specialists. In one case an OFMS with very large multiple prctices used to advertise very cheap implants in printed and air media and was in fact doing very bad dentistry. I have come across periodontists who totally disregard treatment planning as a whole, disregard patient's mutilated occlusion,disregard adjacent teeth with active periapical problems and just extract teeth and place immidiate implants. I have come across prosthodontist who had never done a surgical extraction in life before and now places implants. So one must look at a whole picture of ineffciency in implant dentistry, not just target GPs. I sincerely hope this topic ends here for ever. Let us go back to our more important discussons.

satish joshi

11/22/2007

I get many e-mails inquiring about good courses on bone grafting and advanced implant dentistry as a whole, particularly from India. There are many good courses available thru-out world including AAID maxi courses even in India. But any foreign dentist who really want to be an expert,at NYU we have wonderful International program in Implant dentistry under leadership of renowned Dr. Tarnow and Dr. Elian. It is two year full time course.You will learn from basics to latest advancements in Implant dentistry. Believe me you will not regret. It is money and time well spent.You will learn from great periodontits and prosthodontists who are cross trained.You will walk tall when you go back to your country.

Dr. Kimsey

11/27/2007

Getting back to the subject. If a patient is an extreme clencher with a bruxism component can you still place a couple of implants to replace mising teeth posteriorly or do you think that this patient should best avoid implant dentistry?

satish joshi

11/27/2007

It is a situation of overload. Implant restorations can be performed successfully provided all other factors are normal: with increase in nos.and size of implants and macro/micro roughness of implant's surface. Narrow occlusal table and less inclined planes,metal occlsal contacts and cuspid guidance should be norm. Occlusal guards, night time for night grinders and 24 (it is difficult) hours for clenchers should be prescribed.

alvaro ordonez

11/27/2007

Dear Dr Kimsey Those are actually the patients that can benefit from wide diameter implants providing that a nice site development and preparation of the apropriate buccal and lingual tables have been performed. In such patient, again, surface area is the key component in addition to selecting the widest implant the ridge can accept biologically. When designing the occlusal tables, you can build true molars in the first and second molar areas but be in control of the extension of the occlusal tables to avoid a mini cantiliber effect. Use botox if possible to create some degree of atrophy of the masticatory muscles in relationship to volume which will also affect applied forces (usually 4 applications in a year will have a nice effect in the applied forces) and always use a nice splint, if the patient is a clencher I suggest you use a hard splint, clenchers dont respond well to soft or intermediate splints since you have a dynamic tension effect due to resiliency of the material. Keep in mind that the patient you mention is "a clencher with a bruxism component" so you will have vertical applied forces as well as excentric forces due to the nature of the habit. therefore keep this in mind when designing the final crowns, I mean, check the apropriate occlusion in centric, in excentric and in the position where you identify the tendency to clench, clenching and or grinding usually follows and individual pattern whitin a patient. DR Kimsey, thanks a lot for a smart question related to the subject. hopefully this will help some people here!

11/30/2007

I have patient 60 years old with fixed PFM bridge from 6-11 in good condition.and all post upper and lower teeth are missing.Bite is collapsed and lower ant teeth are only 1mm to 3mm high due to severe bruxism. Should I open the bite before I place posterior upper and lower implants? Do they use Botox at NYU for bruxism patients?

alvaro ordonez

11/30/2007

Dear Jb, without seen your patient, and not knowing specifics, this is what I would suggest: You mention your patient only have pretty much anterior teeth and posterior segment is missing in the upper and lowers. I would create an upper splint with distal bilateral extensions (just as you would make an RPD)and would try to create a perfect plane of occlusion with perfect bilateral curve of spee, and then I would create a lower splint following the same recomendations; this lower splint would articulate with the upper. It is called a twin splint. That way the posterior segment would be restored, the vertical would be also restored and you would have room for anterior teeth. You could use RPDS, functional appliances, thanks god there are options. Now, depending on the desired treatment plan, I assume you are considering implants, you could create stents, place the implants. let them integrate, and then remove the posterior third of the splints (lets say from molar area to first premolar) and restore, then you do the other side the same way, and once you have a solid functioning posterior segment you build your anteriors. This is the most precise technique for restoring this type of patients since the splint will guide your mandibular position. I learned that at Tufts from Noshir Mehta my mentor and Rustram Divitry. There are options and modifications but as I say I would need more specifics, also budget is an issue. You ask for botox, botox would help you with the degree of parafunction if placed the right way, in specific site and or sites needed at the concentrations and ammounts needed. and it could work from 10 to 14 weeks. then you would need to use it periodically, but botox is not the cure, it is a strategy that you use as part of a comprehensive treatment if needed and if indicated. Hopefully this helps!!

satish joshi

11/30/2007

JB, I think first of all you have to find out whether this case is really a collapsed bite or bimaxillary extrusion(over erruption). If this case is a case of super erruption, you may not have collapsed bite and to restore lower anterior teeth you may have to do surgical crown lengthening with osseous resection to increase the coronal height of teeth atleast 5 mm for proper retention of restorations. You may need endos and posts and crowns.And still you will have poor crown/root ratio. If situation is so grave(financially and prognosis wise),I think it is wiser to extract lower anterior teeth, do osteoplasty( to increase inter arch distance)and place 5 to six implants in interforamina area which will allow you to make fixed prosthesis with up to bicuspid occlusion or hybrid kind of appliance. So most important thing is to find out about presence or abscence of collapsed bite. You should not take every attrition case as collapsed bite.Nature some times plays tricks. I think you might be missing a true picture of condition of maxillary teeth,as porcelain dose not wear out at the same rate as enamel,You might have extrusion and/or protrusion of maxillary teeth also, and they may have to be 'RE' restored or sacrificed depending upon situation. As far as bruxism is concerned,It may be a simple case of attrition due to opposing porcelain and missing posterior teeth (which causes patient to chew only with anterior teeth). NYU coolege of dentistry is a big institution.We have different research depts.which may be doing research on BOTOX, And we have different depts. dealing with bruxism,sleep apnea,snoring facial pain CMD/TMD etc. I am not aware of any faculty in dept. of Periodontia and Implant dentistry using BOTOX to releave bruxism during implant treatment.

12/1/2007

Alvaro and Joshi,you both are wrong. Splint therapy or extractions of good healthy teeth is rip off. Simple wax bite and new crowns for lower teeth is needed.Just like a patient had lost lower denture and wants only new lower denture. Few CE credits in TMJ does not make you specialist.

dr T

12/3/2007

to M. 3 mm isn't much for crownretention if you still have to drill them for the crown. Then some form of crownlenghtening is necessary, but you lose the crown-rootratio. A splint is a great way to see if a patient can adpat to a higher vertical demention and you can even translate that with composite fllings to make a more stabil splint. The effect described by Dahl let us see that most of the times we can do this without complications. But I think the crowns on the lower teeth aren't the only problems. Ãf i have read well then there are none occlusal contacts in de posterior region which causes probably the problem in the front region. So with just crowns on the lower anterior teeth the job isn't finished. I think this is a very good question which is the proper way to follow!

alvaro ordonez

12/4/2007

Of course extracting good healthy teeth would be nonsense, I wonder who would do that?! Some people might consider splint therapy a "rip off", I agree, if the splints are not the right one for the case. Since different splints have different actions and biomechanical effects, delivering a splint that has not been activated and adjusted and even monitored periodically is a rip off, no question about it! choosing a splint that is not the right one for a given condition could create a lot of problem, especially the patient loosing faith on the conservative therapy. Performing restorative therapy right away in the clinical situation mentioned by JB is an option, but I wouldnt do that, since very often we need to obtain apropriate 3d mandibular position, vertical dimention and stage this process to do it with precision. Of course you could do the work looking the other way (ignoring occlusion, ignoring muscle memory, ignoring precison work), but that is not the best most precise dentistry. But you can choose to work that way. Few CE credits or thousands of CE credits, or Years of studying TMD doesn't make anybody a specialist in TMD since in the USA TMD is not an ADA recognized specialty. But there are some of us that feel tremendous respect for this field and believe that it is worth studying and looking for answers on behalf of our patients and on behalf of the field. Integrating what we know in both fields (implants and TMD/ occlusion) about occlusion, mandibular positions, muscle physiology and implant dentistry helps build better and more solid cases. Anyone is free to look the other way, but thank God not everybody does.

satish joshi

12/4/2007

I did not see need to respond to post by M. But I feel I must respond to Alvaro's notion that,I suggested to remove GOOD Healthy teeth. I think you have misunderstood me or did not read my post properly. First of all, meaning of word TREATMENT in medicine means REMEDY FOR DISEASE OR INJURY. That means any thing which needs treatment IS not HEALTHY(GOOD). Obviously I would not called worn out '1mm high'tooth to be GOOD or HEALTHY.If you want,it is up to you. In my opinion patient's lower anterior teeth are injured and diseased not healthy at all and do need TREATMENT. Now keeping aside teratment of upper arch and splint therapy,let us compare your treatment plan against my 'NONSENSE' treatment plan of lower arch. First of all my treatment plan is for abscence of collapsed bite. I am sure you must agree with me that every case of worn out dentition is not necessarily a case of collapsed bite. If there is no collapsed bite, there is nothing to open.In fact you may 'over open' it, which may lead to TMD. To resore worn out teeth, you have to do crown lengthenening. It can be done two ways,1, coronally 2, apically. In case of normal bite you have to do apical lengthening,means surgical crown lengthening. In your plan for lower arch patient needs 6 RCTS,6 posts,6 PFMs,6 crown lengthening procedures,6 posterior implants (3 on each side), and may be bilateral ridge augmentation. My plan includes 6 extractions,socket graftings,6 implants in ant. mandible. Now let us compare costs. Alvaro's plan AVERAGE COST 6 RCTS X $650= $3900 6 Posts X $450= $2600 6 PFMs X $1000= $6000 6 Implants in post. mandible X $2000= $12000 6 Abutments X$500= $3000 6 PFMs X $1000= $6000 2 Ridge Augmentation If needed X $2000= $4000 Total cost US$37500.00 for lower arch. STILL THERE IS FUTURE POSSIBILITY OF FAILURE OF ENDOS, FRACTURES OF ROOTS,RECURRENT DECAY OF TEETH AND MOBILITY OF TEETH DUE TO POOR CROWN/ROOT RATIO. Alternative plan I suggested. 6 Extractions X$125= $750 Socket grafting $850=850 6 Implants in ant. mandible.X2000=12000 6 abutments X500= $3000 10 PFMs.X 1000= $10000 total cost US$23600.00 I think it is more predictable treatment plan.

ALVARO ORDONEZ

12/4/2007

deAR SATISH JOSHI BY NO MEANS DID I IMPLIED THAT YOU SUGGESTED REMOVING HEALTHY TEETH, PLEASE FORGIVE ME IF I GAVE YOU THAT IMPRESSION, I KNOW WHERE YOU WERE COMING FROM. I AM RESPONDING TO THE INSTIGATING MANIPULATIVE STATEMENT OF M WHO DOESNT HAVE ANYTHING BETTER TO DO THAN WRITTING NONSENSE. HE WILL KEEP ON WRITTING NONSENSE AND MAKING FUN OF ALL THIS. WE WILL JUST TRY TO USE THE NONSENSE TO SEND THE MESSAGE ACROSS THAT GOOD DENTISTRY AND PRECISION DENTISTRY AND PLANNING IS A MUST. NO MATTER THE SPECIALTY AND FIELD OF ACTION.

Ihde

12/5/2007

To Ordonez 1. The effects of surgery on bone have not changed since 1977 :-). 2. We should not assumethat the relative position of teeth stays the same all over a lifespan. We know that during growth there are obvious changes and so a are chenges due to involution. Furthermore usage and especially unilateral usage leads to eruption or intrusion (Planas 1981). I don`t believe that it is possible to "organize" occlusion so that no changes will occur. It takes years, until the osteonal systems come back to "rest" (if the come back to rest at all) after each extraction or each implant placement or all perio-flap operations. If you use botox, you will get even more eruption, because you reduce the intruding forces and in this this case over-eruption is likely to happen. Every action which we take, interferes with the balance of bone and disturbs its rest. "Teeth and implants are like nutshells in the waves of the evolving bone".

Dr. Kimsey

12/5/2007

Our ability to treat teeth or replace teeth with implants should be predicated on what presents the best solution long term. While all of us were educated traditionally to keep teeth if at all possible that approach doesn't always make sense. We should focus more on saving bone. The best long term solution and possibly the least expensive is implant dentistry. This may be particularly true when treating the patient with a high caries index. However on this particular patient I would give strong consideration to working with temporization to establish a comfortable and stable occlusion prior to commiting myself and the patient to an expensive restoration whether implant based or not.

"A"non, Fl

12/5/2007

Dear Drs: I am not sure I fit into this category, but have exhausted every avenue for help with rt side facial pain after an implant in lower jaw for over a year. I found this website as a final effort before having implant removed and would really appreciate your collective knowledge and experience. I have had consults with numerous Doctors along with many forms of x-rays without being given a diagnosis, for the least of which to help deal with pain. After many office visits and x-rays I have been assured all is well with the implant. Does anyone have experiences with unusual cases where an implant is stable and looks healthy but could cause facial pain? What would be the symptoms? Thank you, CW

alvaro ordonez

12/5/2007

It could be referred pain very easily, coming from either the temporal tendon (temporal tendinitis) or the lateral pterigoid, I have seen it! but a good panorex and comprehensive exam would have to be performed. It is relatively easy to do the differential diagnosis and once Dx is done, then it could be possible to treat it!

"A"non, Fl

12/7/2007

Thank you for your reply. To be more specific, when head bent down for a time it evokes an inflammatory response. I am greatly frustrated that the source of pain can not be identified on film or exam. It is a very perplexing situation for such a simple problem. CW

alvaro ordonez

12/7/2007

what you describe now is a little different, it could also have a cervical spine component and even some sinus involvement but not knowing especifics is very hard. good luck!

"A"non, Fl

12/7/2007

Thank you again for your input. So far you are right on for not having any case history. Which I was hoping in this instance would be helpful for a fresh approach. A ct scan of lower jaw/neck region showed a degenerative disc issue that I attribute to a frontal impact car accident. (Btw, I was very touched that the Radiologist was concerned enough to call me in person. A simple unprompted phone call of concern can make a bigger impact than you can imagine.) A magnetic ct of neck and head showed sinus issues on right that is probably thickening due to scar tissue. However, the presence of either have not given significant discomfort until after surgery for a single implant on rt side of lower jaw. I was given a script for a high dose antibiotic that did greatly reduce inflammation. Since then have been looking for a natural anti inflammatory. So far fish oil capsules have been of great benefit. Although I was told there is no way they could generate any relief. I feel each of these conditions are due to a response generated by a common source that can not be identified. But so far I have not found the right field to present this dilemma. I have been advised to go to a University for evaluation. However, it strikes me as an uncomfortable arena where I will not find any different alternatives for treatment. I appreciate your time and interest in reading my posts. Sorry this one turned quite wordy. CW

harshika singh

12/29/2010

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Craniomandibular Dysfunction (CMD) after Dental Implant Restorations

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