Patient with Bruxism: How to Restore the Implant?

I have a 30-year old male patient without any systemic disease and is a non-smoker.  He had #36 (left mandibular first molar) extracted about 1 year ago because it was non-restorable. I have treatment planned for a 4.5x10mm implant to replace it.  The bone quality is average.  The main problem  is that the patient has bruxism.  There is much occlusal wear on many teeth, especially on the mandibular anterior teeth.  What is the best way to restore the implant crown? Should I design a crown with a flat occlusal surface? Narrow occlusal table? Minimal occlusion? Would a night guard help?

39 thoughts on: Patient with Bruxism: How to Restore the Implant?

  1. Walt Mick says:

    1…Would this individual consider full mouth rehab to include orthodontics to correct Class II Div 2 occlusion?
    2…If not, then small flat occlusal table. Shimstock slips when holding bite, holds when squeezing bite. NIGHTGUARD!!!!!!

  2. z says:

    This patient is 30? That’s not a typo? Looking at the models first I would have guessed late 60s. Massive anterior wear and no opposing crowns means something is up. Some sort of weird parafunctional habit, clinical anxiety? In any case, best thing for the patient is a full prosthetic rehab. Orthodontics to correct the class 2 and deep bite then place and restore the implant.

    From what it looks like now with the deep plunger DB cusp of #14, you’re going to have a lot of working and non-working interference on your new implant crown, which means extreme lateral forces and implant failure. Also, without correcting the anterior issues, it looks like you have an anterior open bite which means even more occlusal forces on the implant crown. You could crown #14 to raise it up so that it doesn’t interfere as much which would probably make the implant last longer, regardless of the implant crown design.

    However, this patient is 30! They are going to crush the rest of their teeth into nothing and eventually that prosthetically corrected #14 is going to supererupt and bonk into the implant.

    It’s a much more complicated case than just the implant itself, in my opinion. Also, night guard at the end for sure.

    • vnt says:

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

      • Yahya Mansour DDS MS DICOI says:

        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

        • vnt says:

          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?

  3. z says:

    By the way, good for you in taking articulated models and looking at this stuff beforehand. Most of the time the implant is placed and restored and these questions are asked once the implant has failed.

  4. mpedds says:

    I agree with the above comments about occlusion. Try to achieve a level occlusal plane by enamelplasty on # 14. There is plenty of thick enamel here for you to adjust without need for a crown. Then narrow occlusal table on the crown with centric occlusion only, no lateral contacts. Longer implant would be better if possible. You should be fine.

    • Ed Dergosits D.D.S. says:

      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.

  5. Joseph Guarino says:

    I agree with all the suggestion previously stated. Restore the lost bone vertically and horizontally[autogenous,BMP…], since more than 30% is lost due to resorption the first year…
    You may want to use awide implant and a longer implant.
    Construct a Dawson type occlusal appliance with relief in the intaglio surface over the implant supported crown .
    Check and adjust the occlusion for years to come….A lot to do…But very rewarding…
    Take care….Be well

  6. Yahya Mansour DDS MS DICOI says:

    Great job reaching out. For once, I agree with what everyone else is saying. Narrow occlusal table, mono plane cusp, enameloplast on opposing tooth or possible crown. But also make long proximal contacts on adjacent teeth. Night guard is a must and pt needs full mouth rehab. So if he is game
    For it, need to
    Start there before doing this crown or your vdo is going to be shot. Good luck!

  7. Matt Helm DDS says:

    This advanced lower anterior abrasion in a 30 year old is indicative of nighttime AND daytime bruxism, occurring 80% on the anteriors. Patient may have other bad habits also, like constantly chewing lemons or tobacco. (Carefully inspect his soft tissues, specially in the lower posterior mucco-buccal fold and cheek.) This is the kind of abrasion seen in a 65+ year old. At this rate his lower anteriors will be worn down almost to the gingiva in less than 15 years, and by then a ton of other occlusal problems will exist, along with a diminished vertical dimension (and its resulting migraines), and perio due to continued deterioration.

    How to restore the implant now is the least of your (and his) problems. No matter what you do — whether you restore him completely or not, and even if you make the implant crown’s occlusal table narrower and with shallower cusps — this implant is going to get blown out of the bone in no time, specially with only average bone. In fact, I tend to doubt that an implant is the right treatment choice here, now. A bridge is more appropriate. It would’ve been nice if you had included a pano, since you didn’t mention anything about his perio status.

    Regardless, be careful! While apparently simple at first glance, this is the kind of case that can turn into a long-term nightmare. You should approach it as a full mouth reconstruction, even though he has most of his teeth.

    You should:

    1. Since we treat patients, not just teeth or implants: Educate the patient on his condition, its excessively advanced state in his case, its dire consequences, and the reasons for your treatment plan. Emphasize strongly that his advanced attrition is more than double his age, accent the severity of the situation, and try to get to the bottom of his excessive bruxism (and other possible bad habits) i.e: how long he’s been doing it, why so acutely, and why he thinks he’s doing it. What stress factors he has in his life (is he a stock broker on the floor?), or anxieties. Question him about headaches, specially if he awakens with them, and if so, how often. You may want to refer him for some psychological therapy, and possibly biofeedback, but handle that suggestion with kid gloves and bring it around gradually. Some people with this kind of bruxism are very anxious and frail emotionally deep down, possibly even “closed off”, and he may react very negatively to your suggestion of psych therapy. Also, be mindful (and educate him too) that this kind of excessive, intensive bruxism leads to internal TMJ damage, and most often to severe migraine headaches in the long term. Most importantly at this stage, ascertain if you have a cooperative, compliant patient. If he is reluctant to cooperate with you, you should refer him out to a prosthodontist or a TMJ specialist. Don’t get involved with this case if he’s uncooperative! IF he’s cooperative you can proceed through point 4, which is by far the most essential KEY to success.

    2. At the very least restore all his lower anteriors (canine to canine) with crowns, preferably of a strong lab-processed composite (like Cristobal or Artglass), or if you’re going to use a porcelain, use e-max crowns (lithium disilicate, not as hard as regular porcelain) . Stay away from standard feldspatic porcelain (or Procera or Empress) because it will abrade his upper anteriors and destroy them in short order.

    3. Also at the very least, restore the abraded existing fillings on the lower molars, preferably with lab processed composite onlays (or also e-max) to rebuild the worn cusps and recreate an equillibrated occlusion with proper guidance and no interferences. Some of the big names out there (like Dickerson) would crown everything. Personally I prefer the more conservative approach I stated.

    4. Lastly, this is THE KEY, the imperative MOST IMPORTANT element to all your treatment! Even if you give this patient no other treatment, you should at least do this, and you can also use it as an indicator of his compliance level. Fabricate a MANDIBULAR appliance (nightguard) known as a MORA (Mandibular Orthopedic Repositioning Appliance), aka Gelb appliance in some TMJ circles. If you’ve never made one, your lab (or a lab like Glidewell in California) will know it. It covers only the posteriors (including the cuspids), it has a completely flat occlusal surface, and is made of HARD clear orthodontic acrylic! That hard acrylic is essential! DO NOT make him any other kind of appliance (certainly not an upper and NO soft acrylic, like some might advise) because you will set off a whole cascade of negative events. A soft nightguard will cause a world of problems in this case! Adjust the occlusal contacts (and excursions) on the MORA (and only on the MORA, do not touch the upper cusps yet) to be of equal force on all teeth that are in contac with it. Try to keep the occlusal of the MORA as thin as possible, but not less than .5 mm at it’s thinnest point.

    This MORA leaves the lower anteriors uncovered and is invisible to the outside world when the patient smiles, so he can comfortably wear it during the day also. Instruct the patient to wear the MORA all the time, not just at night, and teach him to monitor himself as to the amount of daytime grinding he does and to try to control it. He will wear it all the time until you (and he) are sure that he can control his daytime bruxism. (Yes, that daytime cycle can be broken, but it takes a long time and a very willing patient.) You must also see him periodically because extended constant use of a MORA can occasionally cause ingression of the lower posterior teeth in the long term (upwards of a year).

    I’ve been treating TMJ for over 30 years and saw someone this young with this advanced level of attrition maybe only a few times. It is very dangerous, and its long-term effects can be devastating when untreated and/or improperly managed, and specially when the patient doesn’t follow instructions to wear the MORA during the day also.

    I therefore cannot emphasize enough constant wearing of the MORA (minimum a year), fabricated exactly as I described it. And good luck!

    • vnt says:

      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?

      • Matt Helm DDS says:

        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!

        • Matt Helm DDS says:

          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.

          • Matt Helm DDS says:

            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.

    • LSDDDS says:

      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.

      • Matt Helm DDS says:

        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.

  8. Rick Weimar says:

    As an aside to these many worthy comments, posterior wear does not seem to match up with anterior wear. If I am not mistaken, anterior parafunction is associated with daytime parafunctional habits. I believe there is well documented research on this. Some behavior modification and resulting biofeedback may influence an overall treatment plan and keep patient from as much reconstruction as some may consider necessary. Fortunately or unfortunately my Pankey days still have me waxing some of these cases and doing some trial composite.

  9. LSDDDS says:

    I agree with Rick. First deal with the bruxism as he says but at this point we don’t even know if pt.
    will comply with a guard or anything else. Otherwise implant a risk here. Other options are leave it alone. Occlusion appears articulated unlikely to drift or extrude. All steel Nesbit removable as permanent or interim during therapy. Psychotherapy and/or Botox a possibility? Yes pt does ideally need rehab/ortho But again, a real risk if Bruxism continues not fully addressed or unabated.

  10. Bill McFatter says:

    Before you start have a sleep test. There appears to be violations of the neutral zone. The deep bite and wear could be the result of tongue position in an effort to breathe with the lowers being pulled lingually by the obicularis oris muscle as the tongue pushes up against the upper anterior teeth. This pattern will continue until you free up the anterior teeth to find a comfortable position If you restore where he you have done him no service. At his age he’s headed for a mess. I would walk away if he won’t do a more complete rehab. jMHO

  11. Ed Dergosits says:

    The vast assortment of opinions about this case is indicative that that there is not a consensus in our profession about how to treat such a patient.

    • Matt Helm DDS says:

      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.

    • Matt Helm DDS says:

      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. )

  12. Ed Dergosits says:

    Matt you obviously have experience using a Mora appliance . I have not delivered or considered prescribing one in more than 30 years . My experience was basically horrible and every patient that I delivered one to almost immediately had lots of muscle problems that were not present before I delivered the appliance. Some others were being treated by a local dentist that decided to specialize in orthodontics. Please post some links to success that I never saw when patients were given a Mora appliance. The orthodontist soon after disappeared.

    • Matt Helm DDS says:

      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.

        • Matt Helm DDS says:

          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.

  13. SMS says:

    Reason for failure of #19 to start with? Caries?, Perio?, Functional?, Biomaterial ?? Etiology has much to do with ultimate assessment an diagnosis and prognosis. How did natures own fail??

  14. Debra Enneking says:

    My advice is to have a diagnosis as to the cause of bruxism, erosion issues. But treating without diagnosis will be a disaster. Dentistry is not stronger then what nature provided. I would sit with patient and review all systems diet, reflux, sleep disorder( my heaviest bruxers often have sleep apnea) where he is employed( chemicals, grit, dust) pharmaceutical use ( legal illegal) . Once you have established a diagnosis then start a treatment plan. My first would be Ortho, then restore , you will want to be careful to increase VDO because of the mandible dropping down and back( we can cause sleep obstructive issues. I would also only restore patient with composites and biocryl to test treatment plan. If provisional fx don’t continue re eval treatment. A well known prosthodontics to taught me many years ago … “ a hand piece is not a diagnosis, start with a diagnosis then pick up the hand piece.

  15. SMS says:

    Good! It starts with the “D” word. There can be only one correct diagnosis with different treatment protocols based on YOUR individual patient. However, there are also multiple etiologies as to causation. by trying to know etiology will have a profound affect upon outcome. Example: Type of bruxism? Sleep, nocturnal or diurnal ” The Bruxil Triad” ETC….

  16. Larry J Meyer says:

    Matt Helm, thank you so much for the detailed explanations you gave. This was worth the long read and it will help me with a case I am still diagnosing. You have a wealth of knowledge and experience on this subject and thankfully you are willing to share it.

    • Matt Helm DDS says:

      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.

  17. Anon

    Matt Helm thank you for providing so much information regarding the mora appliance and the management of bruxism .It has been very insightful. Matt please can you explain why the upper night guards are not good? This is typically what is taught in most average dental schools that being a Tanner appliance with an anterior ramp to try and minimise muscular activity and provide some kind of equilibrated occlusal stops? For how long do you have the patient where the Mora appliance until you restore the lower 6 anterior teeth with composite and the posterior teeth on the lower? When you mentioned about gradually increasing the VDO by 1 to 2 mm at a time to avoid headaches do you measure the one to two millimetres in the posterior or the anterior teeth? Thank you very much for taking the time to educate us all! Did I understand it correctly when you said that aggressive anterior tooth wear is a symptom of daytime bruxism? Thank you once again

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