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Implementing A Risk Assessment Strategy In Clinical Practice: Emphasis on Occlusion

John C Kois, DMD, MSD

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2Implementing A Risk Assessment Strategy In Clinical Practice: Emphasis on Occlusion

1

ALWAYS 1 of 1

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Diagnostic Opinion

DIAGNOSTIC OPINION

Medium

Normal

AcceptableAcceptable

Low

Flat

ModifyModify

High

High

Medium

Normal

ModifyModify

High

High

AcceptableAcceptable

Low

Flat

Acceptable Modify

RISK ASSESSMENT Acceptable May require further att enti on Requires immediate att enti on

DATEAGENAME

LOW HIGHMODERATE

PERIODONTAL

BIOMECHANICAL

FUNCTIONAL

DENTOFACIAL

Risk Assessment

Risk Assessment

Risk Assessment

Risk Assessment

LOW

LOW

LOW

LOW

Mild (AAPII)

Minimal

Minimal

Moderate (AAPIII)

Moderate

Moderate

Severe (AAPIV)

Severe

Severe

HIGH

HIGH

HIGH

HIGH

MODERATE

MODERATE

MODERATE

MODERATE

Gingiviti s (Gum) (AAPI) Modifi ed By:Att achment Loss / Chronic Periodonti ti s (Bone Loss)

Posterior Bite CollapseRecessionSecondary Occlusal Traumati sm

Defecti ve Restorati ons

Abnormal Att riti on / Bruxism / Excessive Force

Abfracti on

Abrasion

TMD

Missing Teeth

Erosion

Compromised Occlusal Verti cal Dimension

Other

Developmental Disturbances

Other

Pati ent’s Vision

Missing Teeth

1. Maxillary Incisal Edge Positi on

6a. Gingival Tissue Assessment MAXILLARY

6b. Gingival Tissue Assessment MANDIBULAR

Lip Dynamics

Lip Dynamics

Scallop / Form

Scallop / Form

Positi on / Horizontal Symmetry

Positi on / Horizontal Symmetry

2. Maxillary Posterior Occlusal Plane

3. Mandibular Incisal Edge Positi on

4. Mandibular Posterior Occlusal Plane

5. Intra-arch Tooth Positi on (Arrangement & Form)

Midline

Rotati ons

Diastema

Crowding / Overlap

COLOR

FACIALLY RELATED TOOTH POSITION

Aggressive Periodonti ti s

Caries

XerostomiaQuesti onable Restorati ons

Att riti on / Normal Force

Enamel Decalcifi cati on

Primary Occlusal Traumati sm

Crown Margin Locati on ConcernsDefecti ve Root Canal Treatment Concerns

ACCEPTABLE FUNCTION

NEUROLOGIC DISORDERS

PARAFUNCTION (SLEEP BRUXISM)

OCCLUSAL DYSFUNCTION (OSA, UARS)

CONSTRICTED CHEWING PATTERN

Structural Compromises

Abnormal Neuromuscular Habits

Missing Teeth

Left Right Axially Inclined

Other

Oral PathologyImpacti onMissing TeethOther

EXCELLENT GOOD FAIR POOR HOPELESS

EXCELLENT GOOD FAIR POOR HOPELESS

EXCELLENT GOOD FAIR POOR HOPELESS

PROGNOSIS

Specifi c (Individual Teeth)

Generalized (Remaining Teeth)

PROGNOSIS

Specifi c (Individual Teeth)

Generalized (Remaining Teeth)

PROGNOSIS

Specifi c (Individual Teeth)

Generalized (Remaining Teeth)

PROGNOSIS

Specifi c (Individual Teeth)

Generalized (Remaining Teeth)

Acceptable

Acceptable

Acceptable

Acceptable

Acceptable

Acceptable

Acceptable

Acceptable

Modify

Modify

Modify

Modify

Modify

Modify

Modify

Modify

Site Specifi c (Infrabony)Horizontal Bone Loss

EXCELLENT GOOD FAIR POOR HOPELESS

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FRICTIONAL

Pulpal Pathology

Diagnosis is a determination of the “cause.”

Prognosis is a prediction of the probable cause and outcome of disease.

Sign is an objective indication of a medical fact or characteristic.

High blood pressure is a sign, not a diagnosis!Mobility is a symptom, not a diagnosis. Primary or secondary occlusal traumatism is a diagnosis.

Wear is a sign. Attrition is a diagnosis.Bone loss is a sign. Aggressive periodontitis is a diagnosis.

Symptom is a departure from normal, which is noticed by the patient.

PRINCIPLES Diagnosis Prognosis

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3Implementing A Risk Assessment Strategy In Clinical Practice: Emphasis on OcclusionMINI ME 2 of 27

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Periodontal Medicine Diagnostic Opinion |

Periodontal Medicine

• Patient Specifi c: Genetics (Ethnicity), Smoking, Diabetes

• Tooth Specifi c: Secondary Occlusal Traumatism

• Site Specifi c: Infrabony Component

PRINCIPLES Periodontal Risk Assessment

Low Moderate High80%10% 10%

AAP II AAP IVAAP III Radiographic Bone Loss

>3 – ≤5 mm Horizontal PatternMobilityClass I–II

Furcation InvolvementGrade II-III

Probing DepthInfra Bony ≥5 – <7 mmBleeding on Probing

YesClinical Attachment Loss

3 – 4 mmIsolated Infrabony Defects

ModerateShared Risk Factors

Minimal

Radiographic Bone Loss ≥2 – ≤ 3 mm Horizontal PatternMobilitySlightFurcation InvolvementGrade 0–IProbing DepthSupra Bony >3 – <5 mmBleeding on ProbingYesClinical Attachment Loss1 – 2 mmInfrabony DefectsNoneShared Risk FactorsNone

Radiographic Bone Loss > 5 mm Horizontal PatternMobilityClass II–IIIFurcation InvolvementGrade II–IIIProbing DepthInfra Bony ≥7 mmBleeding on ProbingYesClinical Attachment Loss≥5 mmInfrabony DefectsSevereShared Risk FactorsMore Significant

PERIODONTALRISK ASSESSMENT

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4Implementing A Risk Assessment Strategy In Clinical Practice: Emphasis on OcclusionMINI ME 12 of 27

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Biomechanical Diagnostic Opinion |

Biomechanical

Tooth Structure Loss• Biofi lm Mediated Diseases

– Caries Risk Assessment – Shared Risk Factors*

• Environmentally Mediated Concern – Erosion – Abrasion

Load Based Mediated Problems• Friction

– Attrition Shared Risk Factors (Abrasion) – Abnormal Attrition

• Bite Force – Abfraction – Cracked Tooth Syndrome (CTS) – Pulpal Vitality?

PRINCIPLES Biomechanical Risk Assessment

Low Moderate High80%10% 10%

Biofilm Mediated Diseases Caries – Pit and Fissure System• Premolars Only

– Proximal• Posterior • Maxillary Anterior

– Cervical (Coronal to CEJ) – Shared Risk Factors

Environmentally Mediated ConcernsModerate

Load Based Mediated Problems – Attrition – Abfraction – Cracked Tooth Syndrome (CTS)

Biofilm Mediated Diseases Caries – Pit and Fissure System• Molars Only

Environmentally Mediated Concerns Minimal Load Based Mediated Problems – Friction – Bite Force

Biofilm Mediated Diseases Caries – Proximal − Mandibular Anterior – Apical to CEJ – Shared Risk Factors – Xerostomia

Environmentally Mediated Concerns – Shared Risk Factors – Xerostomia

Load Based Mediated Problems – Abnormal Attrition

BIOMECHANICALRISK ASSESSMENT

*Shared Risk Factors (i.e. Diet, Saliva, Tooth Structure, Oral Hygiene)

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5Implementing A Risk Assessment Strategy In Clinical Practice: Emphasis on OcclusionMINI ME 16 of 27

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Functional Diagnostic Opinion |

Functional

• Attrition

• Primary Occlusal Traumatism (Mobility)

• TMD

• Stability

PRINCIPLES Diagnosis

Low Moderate High80%10% 10%

Acceptable FunctionMinimal Adaptation

Brain InitiatedLinear Lateral Movements

Aberrant EnvelopesAdaptive Mediated

Frictional Chewing Pattern

Constricted Chewing Pattern

Dysfunction

Acceptable – Chewing/Swallowing – Speaking – Breathing

Parafunction

Neurologic Disorder

FUNCTIONALRISK ASSESSMENT

Adaptive Mediated

Brain Initiated

Occlusion Stress Test

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6Implementing A Risk Assessment Strategy In Clinical Practice: Emphasis on OcclusionMINI ME 23 of 27

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Dentofacial Diagnostic Opinion |

Dentofacial

• Color

• Facially Related Tooth Position

– Intra-Arch Tooth Position

• Lip Dynamics/Tooth Display (Length)

• Gingival Architecture/Horizontal Position

PRINCIPLES Dentofacial Risk Assessment

* Ask Key Question: “Are we creating the smile you used to have or a smile you never had?”

*

Low Moderate High80%10% 10%

Color Natural White

Facially Related Tooth Position

Moderate DisplayLip Dynamics

Moderate - Gingival Display to Facial FGM

Gingival Architecture – Position• Tissue Exposes Normal

Anatomic Crown Length – Symmetrical – Scallop - Normal• Papilla Present

ColorNot CriticalFacially Related Tooth PositionMinimal DisplayLip DynamicsLow - No Gingival DisplayGingival Architecture – Position - Not visible• Tissue Conceals Normal

Anatomic Crown Length – Symmetrical - Not visible – Scallop - Flat• Papilla Present

Color Dark/UnevenFacially Related Tooth Position Excessive DisplayLip DynamicsHigh - Excessive Gingival DisplayGingival Architecture – Position - Visible• Tissue Exposes

Root Surface – Asymmetrical – Scallop - High• Papilla Loss

DENTOFACIALRISK ASSESSMENT

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7Implementing A Risk Assessment Strategy In Clinical Practice: Emphasis on Occlusion

ALWAYS 1 of 1

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Functional Occlusion � erapeutic Considerations

P1Position (Orthopedic Position of Mandible)

• MIP – Teeth• CR/Adapted Centric Posture – TMJ• Myocentric – Muscles

Objective• Reference/Starting Point

Technique• Flawed

Concerns• MIP – Remaining Dentition• CR – Manipulation Techniques• NM – Muscles, Head Posture, Neurologic System

P2Place (Occlusion, Esthetics)

• Bilateral Equal Intensity Simultaneous Contact Cuspids – Posterior• Esthetics – OVD?

Objective• Vertical Support/Posterior Teeth or

Anterior Platform?

Technique• Articulation Paper• Shim Stock• T–Scan• Digital Palpation

Concerns• Mandibular Flexure• Worn Teeth• Periodontal Ligament• Pulpal Status

P3Pathway vs. “Guidance”

• Steepness vs. Flatness

Objective• Minimize Friction and Load• Avoid Chewing Interferences

Technique• Articulation Paper – 200 microns• Digital Palpation• Assess Phonetics

Concerns• Envelope Retrained?• Overload Anterior Teeth

Normal Envelope - Upright Dysfunctional Envelope Constricted Envelope

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8Implementing A Risk Assessment Strategy In Clinical Practice: Emphasis on Occlusion

1. Position of Maxillary Anterior TeethAnatomic Reference Treatment Options:

• Orthognathic• Orthodontic• Restorative

2. Condylar Position

Slightly Back

Slightly Anterior

Orthopedic Position of the Mandible-Reference System:• Teeth • TMJ • Muscles

3. Position of Mandibular Anterior TeethAnatomic Reference - Treatment Options:

• Orthognathic• Orthodontic• Restorative• Limited

4. Alteration of OVDRationale:

• Facial Balance/Esthetics• Functional• Structural Concerns• Speech

Figure 1 Figure 2 Figure 3

Figure 4 Figure 5 Figure 6

Figure 7

Figure 8 Figure 9

Figure 10 Figure 11 Figure 12

Management of the Envelope of Function