Use of the Kois Deprogrammer

with Smile Design

By
Mau Nguyen DDS, MAGD
August 21, 2012
“I’d like to fix my Smile”
• 54 year old male
• Health History:
– Diabetic
– Recent Gastric Bypass surgery, lost 50 pounds in the
last 6 months
– Reports Previous History of Acid Reflux (pt has a very
hoarse voice)
– After Stomach Surgery, no longer has reflux
– NKDA
 Dental History
• Missing: 1, 16, 17,19,32
• Existing Restorations:
– Amalgams: #2 OL, #4 DO, #12 O#15OL, #18 O, #31 MO (with composite)
– Ceramic Onlay: #3 MOL, #20 MOD
– Ceramic Crown: #30
– RCT: #30, #10
– Recent RCT #30 and ceramic crown, after bite adjustment, pt stated LR area felt much better
– Possible Root FX distal #30, did not probe deep, though 6 mm pocket
– Facial Composite #10
PHOTOS
Photos at age 22 yrs-pt on left
 Periodontal- Diagnostic Opinion

• Attachment
Loss/Chronic
Periodontitis- AAP
II Mild
• Site Specific -#30
Distal
• Missing Teeth
#19
• Recession
• Risk - Low to
Moderate
Prognosis-Fair
• Treatment-
Scaling and Root
Planing, Perio
Maintenance,
Watch #30 D
• Pt reported
previous dentist
said #30 had a
crack so tooth
was crowned
 Biomechanical – Diagnostic Opinion

• Questionable Restorations -#31 MO

• Erosion –dentin exposed #7-#10, #22-#27–
History of acid reflux
• Missing Teeth - #19
• Recurrent Decay #10 Facial
• Risk – Moderate
• Prognosis-Fair
• Treatment – control caries, MI paste, ceramic onlay
#31 MO to replace questionable restoration
(amalgam/composite)
FUNCTIONAL-Diagnostic decision process
• Acceptable function (20%) vs

• Constricted Chewing Pattern (10%) vs

• Occlusal Dysfunction vs.

• Parafunction (8%) vs.

• Neurologic Disorder
FUNCTIONAL-Diagnostic decision process
• Acceptable function -20%
– Efficient Use of Masticatory Muscles
– Envelope of Function is WNL
• However – Pathological Conditions Exist if:
– Extrinsic localized (i.e. dietary factors) create premature tooth structure
loss
– Intrinsic localized (i.e. developmental disturbances, GERD) create
premature tooth loss

• Constricted Chewing Pattern 10%

– Anterior tooth position is constricting envelope
clinical hint: initial point of contact on anterior teeth
with patient sitting up
– TMD –may contribute to problem or be the result
FUNCTIONAL-Diagnostic decision process
• Occlusal Dysfunction
– Inefficient use of masticatory muscles
• Aberrant chewing pattern
– Posterior interferences into maximum intercuspal
position (MIP) create avoidance patterns
– TMD creates avoidance patterns
• Parafunction (bruxism) – 8%
– Destructive use of the system (No Functional
Purpose), Excessive Grinding Triggered by Brain
• However
– Normal mastication may occur
– Pathological conditinos of normal function may develop
as adaptive (compensation) mechanisms occur
– Occlusal dysfunction may exacerbate pathological
problems
FUNCTIONAL-Diagnostic decision process

• Neurologic Disorder
– Destructive use of the system (No Functional
Purpose
– However
• Extrinsic systemic factors (i.e medication, drugs)
create etiology
• Intrinsic systemic factors (i.e basal ganglia) create
etiology, basal ganglia initiates movement (e.g.
parkinsons, tardive dyskinesia
 Bite and Jaw Joint Questions
• Any problems chewing gum? NO
• Any Problems Eating Bagels? NO
• Teeth changed last 5 Yrs, become shorter, thinner, worn?
YES
• Are your Teeth Crowding or Developing Spaces? YES
• Do you have more than one bite or do you clench
(squeeze) to make your teeth fit together? YES
• Do you have any problems with sleep or wake up with an
awareness of your teeth? YES
• Do you have problems with your jaw joint? (pain, sounds,
limited opening, locking, popping) NO
• Do you have tension headaches or sore teeth? YES
• Do you wear or have ever worn a bite appliance? NO
 Functional – diagnostic opinion
• Any Yes answer to questions rules out
Acceptable function
• Patient Findings
– Abnormal attrition – moderate
– Excessive force – large masseters
– Missing Teeth - #30
– No systemic medications that can contribute
to Neurologic Disorder
 Functional – diagnostic opinion
• Consider Constricted Envelope or Occlusal
Dysfunction
– Constricted Envelope
• Tender Joints/TMD (Patient Answered NO to Joint Question)
• Tired muscles when speaking a lot
• Tired muscles with difficulty in nasal breathing
• Absence of wear on posterior teeth
• Typical Wear pattern –lingual maxillary anterior teeth and facial mandibular
anterior teeth (Not observed in Patient)
• Mobility anterior teeth
• No mobility posterior teeth (clinical finding in patient)
• Open spaces Anterior teeth
• Fast Chewing –fewer cycles
– Note: Anterior initial contact –following deprogramming
– Key – there is a greater discrepancy in the orthopedic position of the
lower jaw when the patient bites on the deprogrammer between laying
back and sitting up
 Functional – diagnostic opinion
• Consider Constricted Envelope of Function or
Occlusal Dysfunction
– Occlusal Dysfunction
• Muscle Hypertrophy (knots) –Inefficient system
• Masticatory muscle fatigue (Pt answered Yes to tension headaches
sore teeth)
• Generalized wear facets (A Patient Finding)
• Wear on Incisal Edges, maxillary and mandibular teeth (Patient Finding)
• Generalized mobility pattern
• Avoidance of chewing certain foods
• TMD with distalizing vectors
• Unilateral muscle symptoms more common
– Note: Posterior Initial Contact following deprograming
• More than one bite (Pt. answered Yes to this question)
 Functional – KOIS DEPROGRAMMER
from Jayne, Don DDS. A Deprogrammer for Occlusal Analysis and Simplified Accurate
Case Mounting. The Journal of Cosmetic Dentistry. Vol 21 Number 4. Winter 2006.

• Can be used as diagnostic tool if the mandible needs to move in

anterior or posterior direction to reach CR from MIP
• KD protocol breaks discoordination cycle by discluding teeth and
allows muscles to return to normal function. Also verifies muscles
of mastication are deprogrammed. This ensures that condyles are
allowed to “move” to CR position, being unaffected by
uncoordinated muscles, tooth interferences, or operator error.
• Also used to differentiate between:
– 1. CCP-constricted chewing pattern-
 pt. will not grind on KD since etiology of grinding has been removed once
pt. is deprogrammed
 Difficult to treat
– 2. Occlusal Dysfunction
 Will not grind on KD
 Removed interferences
– 3. Parafunction (bruxism)
 Will see wear facet on anterior platform of KD
 Managed with nightguard
Functional – KOIS DEPROGRAMMER
Functional – KOIS DEPROGRAMMER

Kois Deprogrammer worn for 3 weeks

• Pt report- found himself initially trying to clench on
anterior teeth, then resolved
• Reports sleeping better, waking up feeling more
relaxed
• During bite adjustment- posterior initial
contact between - #2 and #31 hit first
 Functional Occlusion -Goals
• Restore in CR
– Objective -Reference/Starting Point
– All movements and terminal closure must be compatible with
harmonious TMJ function
• Achieve bilateral simultaneous contact with equal
intensity – focus on premolars and 1st Molars
– Objective – Vertical Support/Posterior teeth or anterior platform
– MIP that the brain can find
– MIP that is precise (no slide)
• Flatter cusps for guidance
– Objective – Minimize Friction and Load; Avoid Chewing
Interferences
– Envelope of function that creates an efficient use of closing and
opening movements (muscles)
– Envelope of function that does NOT create premature loading of
teeth (wear, mobility and TMD)
 Occlusal Adjustment in CR
• Bilateral simultaneous contact with premolars
with equal intensity (shimstock) – pt reports bite
feels comfortable
– Posterior teeth hold shimstock
– Anterior teeth do not hold shimstock
– Pt sitting upright
– Pt reports 1 week post op bite feels good

MOUTH MOUNTED CASTS

MOUNTED CASTS AFTER
ADJUSTMENT -CR
 Simulated Chewing with Bausch
Horseshoe paper After Adjustment
• All posterior teeth
including cuspid
should have at least
one small contact
point- these should
hold Shimstock
• Bite should sound
crisp when pt. closes
on teeth
• Should be no lateral
marks or streaks on
any posterior teeth –
or incisors, only
cuspids
• Incisors should
never hold
Shimstock in MIP or
CO –Ever
• Pt. sitting upright
 DentoFacial
• Tentative Partial Treatment Plan-Veneers or crowns #5-#11, #22-
#27, after wax-up –added #12, #21, #8 veneers to tx plan
• Color – Modify
• Gingival Tissue Assesment-Maxillary and Mandibular
– Lip Dynamics: High
– Horizontal Symmetry: Modify
– Scallop/Form: Normal
• Intra-arch tooth position (arrangement and form)
– Midline: modify
– Crowding/overlap: Acceptable
– Diastema: modify
– Rotations: modify
• Maintain VDO
– Maxillary Incisal Edge Position: Modify
– Maxillary Posterior Occlusal Plane: Acceptable
– Mandibular Incisal Edge Position: Modify
– Mandibluar Posterior Occlusal Plane: Acceptable
• Missing teeth: Dental Implant #19
• Risk: Moderate, Prognosis: Fair
 Initial Proposal Mounted Wax-up
SMILE DESIGN
1. Length of Central
Incisors
2. Midline
3. Axial Inclination
4. Arch Form
5. Gingival Symmetry
6. Smile Arc
7. Biologic Width
8. Contact points
9. Embrasure form
10.Gradation
11.Buccal Corridor
12.Balance and
Symmetry
13.Golden Proportion
 Initial Proposal Mounted Wax-up
SMILE DESIGN
1. Length of Central
Incisors
2. Midline
3. Axial Inclination
4. Arch Form
5. Gingival Symmetry
6. Smile Arc
7. Biologic Width
8. Contact points
9. Embrasure form
10.Gradation
11.Buccal Corridor
12.Balance and
Symmetry
13.Golden Proportion
Preparation, Prep Shade, Bite Stick, Provisionals –
Uppers Completed First then Lowers
Cemented Uppers and Lowers Post Cleanup
Post-Ops
Post-Ops
Post-Ops
Thank You
 Bibliography

• John Kois Lecture/Notes from courses

Treatment Planning I and Functional
Occlusion I