Patient with Bruxism: How to Restore the Implant?

thanks for everyone advice, now i wonder, which one better screw retained or cement retained crown on the implant?

Depends on how much inter occlusal space and your technique for cementing crowns. Cemented crowns that have cement induced peri implantitis because of the margins being way too subG. Make your margin 0.5mm subG and make a vent hole and do a good clean up and you’ll be fine. Screw retained is a great option as well but have a higher incidence of screw loosening. If you have 7 mm of interoccluala space do a cement retained. IMO

what do you think if i use roxolid? u know roxolid tagline is "more than solid" i assume it will more durable to stand against bruxism force, will roxolid make significant difference?

I did not see any articulated pre op casts of this patient. Where they deleted?

I am curious why you believe an implant longer than 10 mm would improve the clinical outcome for this patient. Implants are stabilized by the crestal bone. The only time I place an implant longer than 10mm is when I am placing an immediate implant into an extraction site and need to achieve primary stability in the apical bone. In healed sites any implant longer than 8.5 mm is not needed.

thank for ur input doc, im familiar with the hard acrylic splint but never heard of MORA, should i restore the implant crown first and use MORA? or MORA first and then implant crown? i assume MORA wont fit if i made it before the implant crown?

My pleasure vnt! And yes, you assume right. MORA is always made last normally, or else it wont' fit. And the difference between the MORA and all the other appliances is that it leaves the anteriors completely uncovered. On the lingual it has either a bar placed below the cervical, on the gingival (like a cast partial denture) that connects the left and right sections, or is simply made of acrylic placed on the lingual of the anteriors way below the incisal edge and a little on the gingiva too. In this way it is completely invisible to the outside world, enabling the patient to wear it during the day. I would use a bar in this case because the spaces between his lower anteriors would make it visible and also because it's more comfortable and affects speech much less. BUT, having said that, this case is an exception to the "MORA last" rule. I fully agree with the other posters that before you even embark on treating this patient, you should make sure that you have educated him, that he complies with your instructions, and that he takes a serious interest in his condition. You should therefore make the MORA first, see if he pursues his further treatment that you advise (restoring his anteriors, his posteriors and occlusion, psych therapy, and biofeedback), and then place the implant. (By the way, by using a lingual bar on the MORA you will be able to make the anterior crowns and not even affect the fit of the MORA.) You can then make him another MORA when all is said and done, if need be. (It is also possible to adjust a MORA post-treatment, by reaming out the inside of the modified posterior teeth and relining it in the mouth with clear ortho acrylic. But that's a very finicky job so let the lab do it, because you might have a tough time with all the undercuts, and might not be able to remove it from the mouth once the acrylic sets.) I wouldn't treat this any other way. Approached in the right way, there is no reason this case can't be very successful. Oh, and document it, I mean the whole case, start to finish, every restoration. Not just for risk-management, but more for posterity and presentation reasons. I've done soooo many interesting cases that I regret not documenting at the time. I could write a book with many unusual cases, which taught many lessons. Good luck man!

Almost forgot, vnt: I remain of the opinion that an implant is not the best idea at this time. I would do a bridge now. You can always place an implant at a later date, in some years. By then you will have a much better handle on the patient's condition, other things may happen, other teeth may fail, and you'll know much more about an implant's chances for success.

And even if you do an implant crown now, do it LAST. Do all the other restorations FIRST, specially his lower anterior crowns! You'll have a much better, integrated occlusion and better chances to have better occlusion on the implant crown.

I went to a course that showed slides of bilateral lower intrusion cases using mora 24/7 Pt now had no posterior occlusion only anterior contact. Longer than 8-12 hrs use of guards/day can alter bite.

LSDDDS, it is true that intrusion (it's actually called ingression) can happen with 24/7 MORA use, and this has been known for decades. I did mention it in my first, very long post above. But it is the exception, not the rule. In my 30+ years I've never seen a case personally, and I've had enough patients who initially needed daytime and night-time MORA use. Constant MORA use is always limited to no more than a year, usually. Additionally, should that happen, there are two alternatives: one can wait for the posteriors to egress again, which they will naturally; or one can restore the posterior occlusion either with composite onlays or with a cast partial denture that restores the cusped occlusals until the posteriors re-erupt, that the patient uses only to eat. Besides, anyone who knows anything about TMJ treatment and MORA's will instruct the patient to take breaks from wearing it a couple of hours a day, precisely to prevent this ingression. It is also hoped that, with proper treatment and patient education, control of excessive bruxism can be obtained so that the patient can be weaned off daytime use and be limited to night-time use only. And this usually does happen, whether it's because the patient actually got control of their excessive bruxism or, as it happens in most cases, the patient exists a critical period of their life and the excessive stress factors that caused the bruxism cease to exist.

that's what's bothering me, why most of the wear on the anterior? there's a big difference between anterior tooth wear and the posterior cusp

vnt, all good posts here. I posted a very long post last night about how I think you should handle this case. If you have very little experience with TMJ and bruxism it will be worth your read, as it includes detailed instructions. I think an implant is definitely contraindicated now as it will definitely be headed for failure fast. A fixed bridge will be much better. As for the wear being more advanced in the anteriors that is normal for daytime bruxing and is a result of how this patient grinds his teeth. In any case the anterior wear is a moot point, except perhaps that it's actually fortunate, since his occlusion would have collapsed with his kind of very aggressive bruxism. Of much more concern is the very advanced wear on the lower anteriors because it indicates not only a very aggresive type of parafunction, but also other possible bad habits. Please wait for my post to be approved and you'll have a better understanding of how to treat this case.

Class II Div 2 occlusion and parafunctional habits!

Hi Ed, nice to see you again. You are essentially right, because everyone has a different perspective, education, and experience. Remember that old joke about "get 5 Doctors in a room and you'll never hear two identical opinions"? I break it down from the standpoint that there are constants and there are variables, i.e. there are non-negotiable issues, and there are issues that are debatable. Indeed, we can all differ about the merits of an implant vs a bridge, or we can differ about restoring or not restoring the occlusal surfaces of the molars, or even about the constant MORA use. However, what remains non-negotiable here is an absolute need to restore those lower anteriors, equilibrate the occlusion, and control the excessively aggressive bruxing, IMHO.

Actually, if you look at most opinions in these comments, most are in agreement that this patient's excessive and very aggressive bruxism should be brought under control -- and the patient should be educated and brought into compliance -- before any serious treatment is commenced. I agree and said as much myself. )

Yes Ed, you're right. I've been treating TMJ-related injuries and bruxism all my 32+ years in practice. As a diagnosis term, TMJ is actually a misnomer that comprises ALL the TMJ injuries, internal derangements, AND all the head and neck muscular injuries (which can also result in TMJ problems). As a premise, do keep in mind that, by definition, bruxism does constitute a PERPETUAL injury to the TMJ, and to the head-and-neck musculature, just as much as momentary physical trauma to the head and neck does. Proper treatement depends on proper training regarding the TMJ, a good understanding of its structure, function, and dysfunction, and what the injuries are to it (permanent or not), as well as the injuries to the head and neck musculature, and their manifestations. As such, TMJ dysfunction is also closely tied to another dysfunction known as MDP: Myofascial Pain Dysfunction Syndrome, which is a fancy name for the muscular dysfunction caused by bruxism OR, by motor vehicle accidents and other accidents that result in trauma to the head and neck, or even by a grossly altered vertical dimension of occlusion. In the case of accidents muscular dysfunction spasms are always the result of the severe momentary muscle-bracing caused by sudden trauma (generally known as a whiplash-type injury), and is most common even in the slightest fender-benders, but it can also occur in even common falls, like skiing. In bruxism, muscular spasms are caused by constantly overworking of the masticatory muscles, resulting in straining and, ultimately muscle spasms, which can be acute or chronic. (Long story in both instances, that I don't have room for here.) In an altered VDO, the culprit is the modified working length of masticatory musculature. Unfortunately TMJ (and whiplash and the like) is one of those gray areas that is never really properly taught anywhere and, therefore is understood very little. It is certainly not taught in dental school, and unfortunately it's not taught in orthdontics post-grad courses either. TMJ is by no means the realm of orthodontists! It is generally the realm of Dentists who have been schooled in it, at least in general terms. I had a very close friend who was an orthodontist (a good one), and I was totally flabbergasted that after more than a decade in practice he knew and understood absolutely nothing about TMJ and the permanent injuries that can result to it after accidents AND after some ortho treatment as well. I would have thought that at least orthodontists would be given training about this important, but little understood area, because meniscus displacement, or other TMJ dysfunctions, can occasionally result after some ortho treatments also. One classical example of muscle-induced TMJ internal derangement which you may have occasionally encountered is this: did you ever have a patient whose jaw remained locked open after being treated in the chair? Did you ever have to close that jaw by grasping the mandible and pushing down on the second molars bilaterally with your thumbs to close it? THAT's caused by "meniscus lag", i.e. the meniscus doesn't stay on the condyle (and doesn't slide with it) as the patient opens, but lags behind it and actually comes off the condyle (remaining behind it) when the patient opens a little more widely, like for dental treatment. Then, when the patient tries to close his mouth, the meniscus bunches up behind the condyle instead of just slipping back onto it, thereby blocking the condyle from completing its posterior travel all the way into its posterior-most position in the glenoid fossa (=centric). By pushing down on the mandible in the posterior-most area you're only pushing the condyle down a little, facilitating its glide back onto the meniscus. This situation is usually caused by muscular spasm that doesn't allow full travel of the meniscus via the posterior meniscal ligament. It can occur bilaterally, or unilaterally. (It's actually a little more complicated but again, no room here for a whole "book".) Sadly, the only so-called training out there are continuing education courses, but even those don't provide sufficient training. It takes many hours of training to explain the whole TMJ and related conditions and issues. In my book, it should be a one semester-long course in Dental school. That lack of education is a problem, because every small change we make to an occlusion during treatment can result in a cascade of events that can lead to bruxism. Integrating the WHOLE TMJ "story" (AND all the effects of occlusion on the TMJ) into Dental education is long overdue, and it's still not being done. I was fortunate enough to learn TMJ in detail early on, from the nr 1 Dr on it on the East Coast. The MORA is actually the best appliance for bruxism therapy, because it's the ONLY appliance that really works properly and does what it's meant to do. Unfortunately I can't give you any links regarding successes, because I doubt there is on the net that much detailed info about this gray and less understood area. Success in bruxism (and in TMJ management altogether) is not as clearly defined as it is for all other dental treatment. because bruxism is one of those nebulous "conditions" that can appear and disappear, to varying degrees, throughout a patient's life. And, contrary to apparent logic, the headaches are not always directly tied clinically to bruxism, oftentimes persisting long after bruxism has supposedly stopped -- though there is no way to verify that bruxism has ceased either. Bruxism is directly stress and anxiety related (and INDUCED), and even a seemingly innocuous event, or situation, in a person's life can trigger intense nocturnal bruxism, and sometimes daytime bruxism as well, like in the present case -- this patient has been bruxing very heavily and very constantly for years, if not a decade or more. It is all very subjective, as each person has their own threshold. It is generally said that 98% of people are bruxers, at least periodically! The undetected ones (usually upwards of 50%) either are sub-clinical (meaning they have no symptoms) or are never diagnosed even when they do have symptoms, because few dentists are really trained to spot it. MD's even less so. I can't tell you how many patients I've seen who had gone to their general MD's for severe, protracted headaches, and even had cranial CAT scans or MRI's, plus a whole bunch of other tests, only to be told to take aspirin or Tylenol, because their Dr had no clue what was causing their headaches. In each and every case the cause was either long-standing bruxism, or a history of some accident (most often motor vehicle, or a serious fall) in the prior 2 years. Some of the headaches were even caused by dentures with improper (increased or decreased) VDO's, without any bruxism at all. As soon as I corrected the VDO the headaches disappeared. Since bruxism is mostly nocturnal, most patients don't even know they're doing it, and will initially vehemently contradict the Dentist when they are first told that they are grinding their teeth in their sleep. Unfortunately, most Dr's believe the patient, and not the clinical evidence -- the wear facets on cusps, which even when smallest, are the definitive clue! (No amount of chewing and NO other cause generates those wear facets! Only bruxism does!) Essentially, "success" of treatment being impossible to quantify, it is defined merely as the disappearance of headaches and other TMJ symptoms, if they exist. This does not mean that the bruxism has ended, only that the MORA worked! BUT -- and here is the answer to your question -- I can tell you without a doubt that the reason your patients had muscular problems after delivering a MORA was that you most likely made the MORA much too thick on the occlusal, thereby greatly increasing the VDO abruptly, thereby increasing the normal working length of the masticatory muscles, suddenly straining them. This leads to headaches that can be quite severe and seemingly intractable -- at least until the muscular spasms are brought under control by eliminating the cause. And you would be greatly surprised at the severe consequences that can ensue from even the slightest change in VDO, of only a couple of mm, because the habitual working length of masticatory muscles has been modified. For instance, I'm sure you know that when restoring dentition in a patient with a collapsed VDO, when you need to increase a long-standing reduced VDO, you must increase it gradually, no more than 1-2 mm every 3-4 months so as not to cause headaches. Likewise, as a general rule, the thickness of a MORA should be kept, as much as possible, within the confines of VDO at-rest -- VDO being defined as the Vertical Dimension of Occlusion in maximal intercuspation (aka "centric"), while rest-VDO being 2-3 mm higher. This means making a MORA as thin as possible in centric occlusion. Mind you, it will always be thinnest over the molars (0.5-1 mm) and gradually thicker anteriorly towards the canines. Ideally, thickness over the bicuspids should not exceed 2-3 mm. ALL upper posteriors must have contact with the MORA when the patient bites on it, with EQUAL pressure on all contact points as much as possible! I could probably write you a whole book on all of the above, but the essence of TREATING bruxism is to interrupt not the bruxism itself -- that isn't really possible -- but, to interrupt the nefarious effects of grinding, and that is: the lower and upper teeth interlocking and "pulling and pushing" on each other, thereby greatly straining the head and neck musculature, specially all the masticatory and cranial muscles, overworking them to death and causing muscular spasms, which invariably leads to headaches. (There is also an explanation why muscular spasms are a self-perpetuating, closed cycle, which goes back to the Krebs cycle and aerobic and anaerobic metabolism within the musclar mass. Did you know that a muscle is working when at rest also?) This is why the MORA is hard and smooth, to prevent the uppers and lowers from interlocking in occlusion and to facilitate the easy "gliding" of the mandible in all directions. This is also why ALL other appliances are totally inadequate for bruxism. Any appliance that has indentations for the cusps, or any soft appliance (the worst of all), will not allow the mandible to glide and move completely freely and easily during nocturnal (or daytime) bruxing and, will actually exacerbate the muscle spasms and, therefore, the headaches. I've had scores of patients come to me with all kinds of "nightguards" (mostly uppers, the soft ones being the worst offenders) complaining that their headaches actually got worse after they started wearing the nightguard. But your question did make me curious, and I will search Pub-Med, and other sources, for actual studies or some quantification of results in TMJ treatment. Frankly I doubt that quantified studies really exist, because the effects of bruxing and TMJ symptoms are, on the one hand, mostly subjective and nearly impossible to quantify. (EMG (electro-myography) has been tried, but that still only tells you if the muscular activity is symetrical.) And on the other hand, most dentists (including dental school professors) never really payed enough attention to TMJ-related problems. But I will search.

Thanks for your reply Matt.

My pleasure Ed! Sincerely. Sorry it was so long but I hope it shed at least some light on the issues. By the way, after I posted it, I realized that I failed to mention that another possible reason you may have had trouble with the MORA was that, when you adjusted the occlusion on it, you made indentations for the upper cusps to go into, instead of grinding the MORA flat. As I stated above, this defeats the purpose of the MORA by not allowing the mandible to glide freely as the upper cusps get blocked into those indentations. Just another item to consider.

Thanks Debra for your comments

Thank you Larry! I'm very glad it was useful. I'm always willing to share, as much as I am always willing to also learn. And if I can be of any help with the case you're presently diagnosing, please don't hesitate to ask. I'll be happy to help you analyze, diagnose, and come up with a proper treatment plan. Diagnosing TMJ can still be a little daunting sometimes because, for all its modernization, present day radiology still doesn't allow us to fully explore the internal TMJ functionally during movement. Perhaps fluoroscopy might be the only method, but no one has tried it yet on the TMJ to my knowledge and I don't know if it can actually visualize the meniscus during function. Since we're talking about visualizing soft tissue, we would need an MRI equivalent to the flouroscope, but it does not exist as yet. Then of course, there is also the aberrant muscular activity/overactivity which is impossible to quantify against a fixed set of baseline parameters, since such baseline parameters were never really established by anyone. Nor do I think that such baseline parameters can actually be established for muscular activity (even in the digital age) because every patient's "build" and normal muscle length and activity is so individual in nature and different from everyone else's. Good luck with your case and please let me know if I can help.