Chapter 47 7 Criteria for Success of Occlusal Treatment PRINCIPLE Without specific treatment goals, treatment success cannot be measured.596 Part Ill Treatment MEASURING SUCCESS OBJECTIVELY Al occlusal treatment should have specific goals. We often hear claims of success, but we rarely hear how success is ‘measured objectively. Having specific criteria for measuring the results of occlusal treatment is the only way any claim of suevess can be validated. In addition, specific goals are the only way treatment can be planned with the end in mind, Criteria for success are an essential requirement for achiev= ing successful complete dentistry because they: 1, Define a desired end point for treatment 2. Are an objective measurement for treatment success, partial success, or failure 3. Are a guide for whether treatment has been performed correctly 4. Are a guide for determining if treatment has been ‘completed 5. Are a guide for evaluating different clinical approaches ‘The following criteria for occlusal treatment success have stood the test of time in clinical practice. Every clini- cal result should be evaluated on the basis of these criteria, But the criteria are also the basis for diagnosis. These same criteria should be used in evaluating new patients or in re- evaluation of patients of record, If any criterion is not satis fied, iti indicative of a problem that needs to be diagnosed, Let’s look at each criterion for success. Understand the rationale for why itis a valid standard for judging, and learn hhow each criterion is tested In addition (0 occlusal success, there is always the pri- ‘mary requirement for periodontal health. It should go with- cout saying that the most perfected occlusal result falls short if the supporting structures are not optimally healthy.Chapter 47 Criteria for Success of Occlusal Treatment 597 IMPORTANT CONSIDERATIONS ‘Testing for success ‘Whether treatment has been successfully completed can be ascertained by the following seven criteria: 1. Load testis negative, This means complete absence of any sign of tension or tenderness in either temporomandibular joint (TMJ) when joints are firmly loaded. 2. Clench testis negative. This means complete absence of any discomfort in either TMJ or in any tooth when the pa- tient clenches with maximal muscle contraction (empty mouth). 3. Grinding test: No posterior interferences. This testis to verify that all excursive contact is on the anterior guidance only Posterior teeth must separate the moment the mandible moves from centric relation, 4, Fremitus testis negative, This testis to ensure that there is no sign of fremitus on any anterior tooth during firm tap- ping or grinding excursions. 5. Stability testis positive. This testis to verify that there are no signs of instability in either TMJ, in any tooth, or ‘within the total occlusal relationship. 6. Comfort testis inclusive. The patient should have complete comfort of the teeth, lips, face, masticatory musculature, and speech. 7. Esthetics testis inclusive, Both the patient and the dentist should be completely happy with the appearance of the smile and its relationship to the functional matrix. tis not always a realistic expectation to achieve 100 percent success in all ofthese goals. The problems in some pa- tients have progressed too far to expect complete correction. When this happens, there should be a reasonable explana- tion for the compromised treatment result.598 Part Ill Treatment [criterion #1: Load Test Is Negative A long-term successful result requires the fulfillment ofthis criterion. tis the first criterion for success because complete fulfilment ofall the other criteria is dependent on satisfying, this first criterion, Ifthe TMIs cannot comfortably accept firm loading, it in- dicates that either the condyles are braced by the lateral plerygoid muscles (an unacceptable positioning for the TMJs that leads to musele incoordination and potential hy’ peractivity of the masticatory musculature) or there is an in- tracapsular disorder that has a probability of instability of the TMJs. Treatment that does not end up with complete comfort of the TMJs during maximal loading by the elevator muscles cannot be considered a completely successful treatment. A negative load testing result indicates that the TMJs can be successfully positioned into a verifiable centric relation or adapted centric posture, the essential starting point for successful treatment. It cannot be considered a successful occlusal result if the TMJs are unstable or uncomfortable. [criterion #2: Clench Test Is Negative One of the simplest yet most effective tests for determining if occlusal interference is a factor in orofacial pain is to have the patient close and squeeze the teeth together (empty- ‘mouth clench). Ask the question, “Do you feel any sign of discomfort in any tooth or in either TMJ when you squeeze hard?” A patient with perfected occlusion cannot cause any sign of discomfort in any tooth or in either joint regardless of how hard he or she bites, Discomfort in & tooth is a cer~ tain sign that atleast one tooth has a premature or deflective contact. If the clench test also produces discomfort in the ‘masticatory musculature, itis a positive indication for an oc- cluso-muscle disorder, and it cannot be considered a suc cessful occlusal treatment result If occlusal treatment is completely successful, maximal clenching pressure should produce no discomfort in either TM} or in any tooth. Criterion #3: Grinding Tes No Posterior Interferences This is another simple test to do, but a very reliable one for determining if there are posterior interferences. Ithe patient can feel contact on any posterior tooth while grinding the {eeth through any or all excursions, itis a positive indication that posterior diselusion has not been achieved, and the re- sult Falls short of optimal success.Chapter 47 Criteria for Success of Occlusal Treatment 599, ‘Remember that posterior interferences hyperactivate the ‘muscles while posterior disclusion shuts off all the elevator _muscles except the anterior temporal motor units. ‘This test has great importance for long-term stability of the occlusion because excessive wear of the posterior teeth ccan only occur if they interfere in excursive jaw movements, ‘This test must be modified in certain occlusions that do not have anterior contact in centric relation. In such cases, posterior group function on the working side may be neces- sary. In such cases, firm grinding should not cause discom fort in any posterior tooth If posterior teeth interfere with the anterior guidance, ‘the result is incoordinated, lyperactive musculature and potential attrtional wear, It cannot be considered successful treatment. [criterion #4: Fremitus Test Is Negative Lightly contact the labial surface of each upper anterior tooth using the edge of your fingernail. Have the patient tap the tecth together lightly, then firmly, Then grind in all di- rections. Any movement of any anterior tooth is an indica- tion thatthe tooth is in interference, The interference can oc- ccur from a restrictive envelope of function or failure to provide a needed “long centri” The most common cause, however, is a dellective posterior incline that forces the ‘mandible forward into hard contact with the anterior teeth, which is an unacceptable occlusal result. Harmonious contact through the full range of anterior ‘guidance is critical for long-term stability of the dentition because interferences tothe anterior guidance affect the neu- romuscular harmony and cause overload on the anterior teeth. The result is excessive wear, hypermobility, or move~ ‘ment of the anterior teeth, A perfected occlusion produces no sign of fremitus ‘on any anterior tooth, even with firm clen« srinding. [criterion #5: Stability Test Is Positive ‘The criterion that is often missed or ignored is this test for stability. This refers to stable TMJs and stable dentition. If both the joints and the teeth are stable, there should be no need for readjustment ofthe occlusion for a period of at least three months (Figure 47-1). It often takes awhile 10 achieve occlusal stability be- ccause of the rebound of the teeth and/or remodeling of the TMI structures following occlusal correction. In some structural TMJ deformation, we may not be able to com= pletely satisfy the stability test because the damage to the joint has progressed too far, That must be considered compromised result, The treatment goal then becomes one of “manageable stability.” Bone-to-bone TMJ contact that results from osteo-arthritie breakdown of the condyle and eminence is a classic example. The occlusion cannot be ‘made completely stable, but if all other requirements for a perfected occlusion can be achieved, the stability of the dentition is “manageable.” Signs of instability in the dentition 1, Excessive wear of teeth 2, Hypermobility 3. Shifting of tooth position If any of these conditions persist after treatment, the ‘oatment result must be considered as less than optimal suc- cess. When there is doubt about the stability of the TMJs, re versible treatment utilizing a full occlusal splint can test for joint stability, Until the occlusion on the splint is stable for three months or more, there can be no claim for a com- pletely successful result, Final treatment should produce the ‘same result without the splint. Note that long-term stability is not always dependent on Class I textbook occlusion. There are “physiologic maloc- clusions” that are stable. Even though they do not look like the ideal, they can still pass all the tests for stability. Unless there are esthetic concerns, treatment is not necessary. Every occl regular intervals. [criterion #6: Comfort Test ‘The patient should have complete comfort of the teeth, the lips, and the face. Speech should be comfortable and not ccause tiredness in the facial and masticatory muscles. ‘A perfected occlusion results in a peaceful neuromuscu- lar system (Figure 47-2). That is the goal of all occlusal ther- apy. The masticatory system is also the organ of speech. Disharmony within the system can affect speech in different ‘ways. If changes in the occlusion result in speech changes or Tead to muscle Fatigue when speaking, the occlusion should bbe carefully re-examined including the position and contour of the anterior teeth. 11s important for the clinician to prod the patient re- ‘garding the comfort issues, I routinely asked every patient to be “very fussy” about the total comfort of the face, lips, and teeth and to let me know if there were any problems ‘with speech. 1 instructed patients that if the restored teeth did not feel completely natural it would be an indication that some further adjustment would be necessary. This is a should be evaluated for stability at600 Part Ill_Treatment FIGURE 47-1 A, peefectad ocluson that fully all the exiteia fo success is amazingly stable and may reqie ony minimal austen over ‘many Yous By If asi contact not achieved, the aightine use of at appliance can effectively subst forthe unfulled eteria, A comely ‘ade spline should also be stabi. practical approach if all the details are refined in provi- sional restorations whenever changes are made. Final restorations should not be completed until the provisional restorations can pass all the tests described here. ‘A perfected occlusion results in a peaceful, comfort- able neuromusculature. [criterion #7: Esthetics Test ‘The patient should be happy with the appearance of the smile Tt is & consistent finding that functional harmony is dependent on anatomic harmony. When functional harmony is achieved, the result will also produce the most natural ‘beautiful smile design. That is why we designed and teach the concept ofthe anterior functional matrix. This matrix de- fines the outer contours of anterior teeth and makes every es- thetie decision an objective decision, kis important to recognize that patients are not tained in what makes a smile naturally beautiful. They will generally accept results that improve their appearance but fll far short of an achievable ideal result Thus itis important for the den- tist to also approve every restorative result only alter a criti- cal appraisal of all esthetic guidelines. This should include the relationship ofall tooth contours to the outline form es- FIGURE 47-2 ‘The comforts should include comfonable, unstrained speech, the mark of comeetiy place incisal edges, an harmony withthe neutral one tablished by the matsix of functional anatomy for anterior teeth (see Chapter 16). It is also important to realize that some patients have a biased expectation for an appearance that is not conformative with natural beauty. This is why essential to require approval of provisional restorations be- fore proceeding with final restorations. It is during the provi- sional stage that the clinician can resolve misdirected expec tations if they conflict with functional requirements. The most naturally beautiful esthetics is in conforma- tion with anatomic and functional harmony. [the Goal: Functional Esthetics Ifall of the criteria for success are fulfilled, the result will be an esthetic result that is also functional, comfortable, and stable. The results shown in Figures 47-3 to 47-7 are ‘examples of functional esthetics achieved by faculty mem- bers at the Dawson Center for Advanced Dental Study. Each of these cases fulfills every criterion for success in- ‘eluding the complete, long-lasting, and appreciative re- sponse from the patient. These results are achievable by any dentist who commits to understanding the principles, develops the skills, and avoids shortcuts: true examples of complete dentistry.Chapter 47 FIGURE 47-3 ,A complet reconstruction by Dr Michael Sesemann. [Note how perfécly the teeth late oan unstrained ip function, By Contour ‘nd inclination ofthe anterior teeth conform ideally oa functionl mai that ps the teeth in perfect funtional harmony with no requiements for guesswork FIGURE 47-4 By pertecting the relationship of the cease ration cones and peeinely determining a correct acvioe guidance the res is ‘ual-ntensty, simultaneous contac ofl teeth plus immediate dstasion fal posterior tect in excursions, thereby makig it impessible foe the pa tient to wear au the posterior cies hy atrton. erect comfort the et eesul Criteria for Success of Occlusal Treatment 601 Ys FIGURE 47-5. conservative resonsruction by Dr Dewit Wilkerson that included equation to esablih sable holding contacts before restoring only the teeth that needed it using bonded lumina restorations. ‘These acerior tet are sable Because they ae in perfect armony with & Light neual zone and lipelosure pat, forma That also resus in dhe ost ata sie. FIGURE 47-6 complete constuction by De Glenn DuPost that changed a very uncomfortable, anesthe denon into perfetly com fortable, stable, and functional Smile Alleria for success were fullled sn thin heal sie FIGURE 47-7 An excellent esthetic result achived by De. John (Cranbam using combination of bonded laminae restertions afl cow rage where needed. This aatual smile results also functional and stable because all ules were followed to mints teeth ns coret neal zone, perfected anterior guidance, and equal-itesity centric ration contac ot llth teeth602 Part Ill_Treatment SUMMARY Dentists have never been better equipped to serve their pa tients with the highest level of quality and predictability. If that ultimate level of master quality dentistry is 10 be achieved, dentists must truly become physicians of the total masticatory system, This cannot happen without a compre hensive understanding of the role of occlusion and its de- pendency on total masticatory system harmony. ‘The rules are clear. The goals are understandable and their fulfillment is achievable if treatment planning always starts with the end in mind. Any dentist who commits to learning the rules and de- veloping the necessary skills for achieving cach specific eri- terion for success wall have the most essential foundation for an exceptional dental practice and a very fulfilling life.