Features of Examination and Treatment of Patients with Complete Dentitions and Occlusal Disorders

In modern specialized literature, the issues of diagnosis and treatment of patients with cephalalgias of various etiologies are widely discussed. Disorders of the temporomandibular joint function and masticatory muscles are often accompanied by pain sensations of varying intensity. The role of occlusal discrepancies and other factors in the development of pain syndrome is assessed ambiguously by domestic and foreign authors. There are publications that present the results of randomized controlled trials proving that changes in occlusal relationships do not lead to dysfunction of the temporomandibular joint and masticatory muscles. An analysis of the examination results of patients with orthognathic occlusion and intact dental arches showed that occlusal disorders occur in 84.9% of cases, and signs of temporomandibular joint dysfunction were identified in 84.8%. The high prevalence of occlusal discrepancies in patients with orthognathic occlusion necessitates the systematization of factors contributing to occlusal disorders, the development of tactics for early diagnosis, and a comprehensive treatment plan.

Observations conducted by us from 2008 to 2014 confirm that recently there has been an increase in the number of patients visiting dental clinics with complaints of intense pain in the area of the temporomandibular joint (TMJ), accompanied by clicking, crepitus, and disturbances in the smooth movements of the lower jaw, radiating to the occiput and temporal region. Analysis of the examination results of patients with such complaints showed that 84% of patients have intact dental arches, an orthognathic bite, and a physiological (at first glance) occlusion of the dental arches. In such situations, many specialists find themselves powerless, and the use of traditional treatment plans does not yield a lasting positive result. When examining patients with intact dental arches and an orthognathic type of bite, who do not present any complaints from the stomatognathic system, static and dynamic occlusal disorders of varying severity were identified in 64% of cases during a comprehensive examination. There is a possibility that occlusal interferences in such patients, upon reaching a certain degree of decompensation in the stomatognathic system, may subsequently lead to dysfunctions of the TMJ and masticatory muscles, accompanied by painful symptoms.

Research Objective: to improve the effectiveness of examination and treatment methods for patients with occlusal disorders of intact dental arches with orthognathic occlusion.

Research Tasks

1. To develop a system of diagnostic measures that allow for the early identification of factors influencing the formation of occlusal disorders in patients with intact dental arches and orthognathic occlusion.

2. To develop a treatment strategy for patients with orthognathic occlusion depending on the degree of compensation for occlusal disorders.

Materials and Methods of Research

A comprehensive clinical examination was conducted on 210 patients with intact dental arches and orthognathic occlusion. The age of the patients ranged from 22 to 45 years. The examination included a clinical examination, analysis of occlusal status, surface electromyography of the masticatory muscles, and extraoral registration of lower jaw movements. The control group consisted of 45 individuals with orthognathic occlusion and intact dental arches, without identified occlusal disorders and pathology of the TMJ and masticatory muscles.

The results of the study were statistically processed on a personal computer using statistical formulas from the MS Excel program.

Results of the study and their discussion

According to our observations, occlusal disorders, TMJ dysfunctions, masticatory muscle disorders, and periodontal diseases are most often accompanied by pain phenomena of varying intensity and nature – in 88% of cases, and noise manifestations during the opening and (or) closing of the mouth (cracking, clicking) – in 100% of cases. Occlusal disorders in the form of supercontacts in central, anterior, and lateral occlusions are also frequently found in patients with TMJ dysfunctions – in 99% of cases.

Occlusal supercontacts lead to a decrease in the bioelectrical activity of the masticatory muscles, an increase in the share of activity of the temporal muscles compared to the masticatory muscles, and a significant increase in the bioelectrical activity of the lateral pterygoid muscles, as well as asymmetry in the degree of bioelectrical activity of the masticatory muscles on the right and left sides.

Patients with occlusal disorders were arbitrarily divided into two groups. In the first group, occlusal correction was performed through selective grinding and removable TMJ joint trainers, myobraces were used. In the second group of patients, treatment was carried out using removable tooth-gum caps with an open occlusal surface, made on the Bio-Art or Schulte apparatus.

In patients who underwent selective grinding and used TMJ joint trainers, myobraces, a statistically significant increase in the area of occlusal contacts (281 ± 23 mm²) was determined, a temporary and force balance of occlusal contacts was achieved, improvement in the parameters of the balance of bioelectrical activity of the masticatory muscles, and a decrease in the degree of tooth mobility.

Planning and constructing relaxation, stabilizing caps (splints) for the treatment of patients with TMJ dysfunctions and masticatory muscles were carried out in an individual jaw articulator (IJA), on diagnostic models taking into account the individual movements of the lower jaw relative to the upper one. Individual occlusal caps were modeled from wax, forming multiple contacts in the central, anterior occlusion, canine guidance or guiding group function in lateral occlusions.

The degree of separation of the dental arches using a splint was determined individually, using data from the EPA test, electromyography, and radiographic analysis of the condition of the TMJ. The thickness of the splint varied from 3 to 5 mm. An individual occlusal splint was made from dental plastics "Sinma", "Ftoraks".

Selective grinding, conducted on diagnostic models according to the methodology of Hyman Smukler, in an individually adjusted articulator AICH, allowed for more balanced occlusal contacts on the right and left in central, anterior, and lateral occlusions. The use of AICH and the methodology of Hyman Smukler in patients with intact dental arches and an orthognathic bite type, with identified occlusal disorders in 89.2% of cases, allowed achieving an area of occlusal contact closure of 280 ± 54.2 mm², in two to three visits. Achieving a higher treatment efficiency was impossible without replacing existing composite restorations and orthopedic constructions that restore defects in hard tissues with more rational occlusal constructions.

Restoration of occlusal relationships prosthetically using crowns and inlays made with modern computer CAD/CAM technologies from durable materials is more acceptable from the perspective of creating adequate occlusal contacts (OC) compared to the direct restoration method of hard dental tissues with composite materials. Research results demonstrate an improvement in functional indicators within 6 months after comprehensive treatment.

In 210 patients with an orthognathic bite and intact dental arches, occlusal interferences were identified in 84.9% of cases, signs of temporomandibular joint dysfunction were found in 84.8% of cases (178 patients), and signs of masticatory muscle dysfunction were identified in 15.2% of cases (32 patients).

Occlusal disorders in patients with an orthognathic bite and intact dental arches were found in central occlusion in 31.9% of cases, in anterior occlusion in 84.9% of patients, in right lateral occlusion on the working side in 38.0%, and on the balancing side in 44.7% of cases. In the position of left lateral occlusion, patients with an orthognathic bite and intact dental arches showed premature contacts on the working side in 28.0% of cases and on the balancing side in 74.7% of cases. Thus, in lateral occlusions, premature contacts on the balancing side were most frequently found in patients with an orthognathic bite and intact dental arches, and more often in the position of left lateral occlusion than in right.

Most often – in 64.7% of cases (136 patients out of 210 examined with an orthognathic type of bite) – premature contacts on the balancing side in the lateral occlusion position occurred on the supporting cusps of the first molars, in 15.2% of cases (32 patients) premature contacts were found on the supporting cusps of the third molars.

In the anterior occlusion position, premature contacts on the anterior teeth were determined in 68.0% of cases (143 patients out of 210), on the anterior buccal cusps of the lower third molars in 32.8% of cases (69 patients).

The examination of patients with an orthognathic type of dental arch closure and intact dental arches using the T-Scan 3 device allowed for results that confirm that the data obtained during the oral cavity examination, characterizing neutral occlusion, are not so unambiguous. During the examination of patients, supercontacts, temporary and force imbalance of dental closure on the right and left sides, and disruption of the balance of occlusal force between the anterior and lateral groups of teeth were identified.

It is necessary to distinguish three forms of occlusal disorders: compensated, subcompensated, and uncompensated.

The compensated form of occlusal disorders is characterized by the absence of signs of dysfunction of the TMJ, masticatory muscles, periodontium, and high chewing efficiency without patient complaints.

The subcompensated form of occlusal disorders is characterized by the presence of one or more signs of dysfunction of the TMJ, masticatory muscles, periodontal diseases without patient complaints, with a slight decrease in chewing efficiency, determined by objective examination methods.

The uncompensated form of occlusal disorders is characterized by the detection of signs of TMJ dysfunction, manifested by degenerative processes in the cartilage layer of the mandibular condyles and meniscus, parafunctions of the masticatory muscles, cephalalgias, glossalgias of unclear etiology, and postural disorders.

The average area of the occlusal contact in patients with intact dental arches in the control group, visualized using the T-Scan 3 device, was 274 ± 11.24 mm². The average occlusal contact area in patients with an orthognathic bite and occlusal disorders was 124 ± 76.5 mm², which is 45.2% of the average occlusal contact area of patients with intact dental arches, orthognathic bite, without identified occlusal disorders.

The analysis of the occlusal status of 210 patients with an orthognathic bite and intact dental arches showed that the presence of third molars, especially their non-simultaneous eruption and non-physiological position in the dental arch, is most often a factor leading to the development of occlusal disorders.

The use of modern methods of occlusal diagnostics has allowed for the acquisition of objective qualitative and quantitative characteristics for the assessment and analysis of the occlusion of dental arches in patients with intact dental arches. The application of the occlusal diagnostic method using the T-scan device and the method for determining the area of occlusal contacts has made it possible to determine the average values characteristic of patients with intact dental arches and an orthognathic bite.

Conclusions

1. Examination of patients with intact dental arches and an orthognathic bite should include an analysis of the occlusal status and the method for determining the area of occlusal contacts.

2. In patients with intact dental arches and an orthognathic bite, occlusal disorders are identified in the form of supercontacts in central, anterior, and lateral occlusions in 99% of cases.

3. The use of selective grinding techniques, removable splints that neutralize occlusal disorders in the treatment of patients with occlusal disorders, temporomandibular joint dysfunctions, masticatory muscle issues, and periodontal diseases allows for improvements in the indicators of electromyographic activity of masticatory muscles and parameters of occlusal analysis.

Authors: Bragin E.A., Dolgalev A.A., Bragareva N.V.

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