Dr.noble Occlusion Ii

Front 1

List the potential problems which may be aggravated by or associated with bruxing?

Back 1

Excessive wear (including abfracture)
Tooth fracture
Restoration failure
Aggravate periodontal problems: pockets and mobility
Muscle tenderness
Joint disturbances

Front 2

4 components of history taking:

Back 2

Medical History:
Family History:
Social History:
Dental History:
----Include Screening Questions for Potential occlusal problems:
-------More Detailed Questions for Positive Answers to Screening Questions

Front 3

What is the purpose of asking the question: "Does your jaw ever lock open or closed, get stuck, or go out?"

Back 3

Jaw ever lock: it’s the hinge is locked while it’s open. On the other hand if they can’t open it may be muscles

Front 4

What is the purpose of the question: Have you noticed any recent changes in your bite?

Back 4

Recent changes in bite: acromegaly.
Trauma: change in the bite due to jaw fracture.
Muscles can cause change in disc

Front 5

What are you looking for when you palpating the Muscles and TMJ?

Back 5

pain, deviation, displacement, clicks, crepitus, limitation

Front 6

What are the anatomical structures palpated in an exam?

Back 6

TMJ, temporalis (origin, insertion, anterior, middle and posterior portion), coronoid process (contains temporal tendon), Masseters(internally, and externally),
Both temporalis and Masseters should be palpated

Front 7

What is the Normal range of motion of the mandible?

Back 7

53-58mm (for class I incisial relationship)

Front 8

At what point is the range of motion of the mandible considered restricted?

Back 8

<40mm

Front 9

What does a hard stop and soft stop suggest in a patient with restricted opening

Back 9

hard stop=joint issue
soft feel=muscle problem

Front 10

What is the normal range for lateral and protrusive excursions?

Back 10

8 mm + laterally and protrusively
< 8 mm = restricted

Front 11

Distinguish between deviation and deflection

Back 11

DEVIATION: As the mandible opens, if it goes towards one side, then returns to centre as it continues to open.
DEFLECTION: If it does NOT return to the midline after opening

Front 12

What do Deviation and Deflection indicate?

Back 12

Deviation and deflection are often indicative of joint disturbances.
The condyle on the side the mandible is moving towards may be unable to translate during opening, resulting in movement towards the affected side.
In the case of deviation, the return to the centre/midline on further opening may be accompanied by a click in the TMJ on the affected side.

Front 13

How do you record a joint sound?

Back 13

Record the vertical dimension between incisors when you hear click

Front 14

What is a click?

Back 14

Clicks are a single sound of short duration

Front 15

When do clicks most often occur

Back 15

Clicks occur most frequently as the mandible opens beyond the range of rotation of the condyles, i.e. during the translation portion of mandibular opening.

Front 16

What is a reciprocal click?

Back 16

A click that happens on both opening and closing

Front 17

what's a pop?

Back 17

A pop is a particularly loud click

Front 18

What's crepitation?

Back 18

, is a series of sounds, often described as “gravelly” or “grating”. It suggests the sound of two dry bones rubbing together. Sounds terrible but not often painful
-> Associated with disk deterioration and osteoarthritis

Front 19

What should you see clinically if the the pterygoid muscles are the source of pain?

Back 19

If a muscle is a source of pain, both stretching and contracting the muscle should elicit pain, or increase existing pain.

Front 20

What should you see clinically if the the INFERIOR lateral pterygoid muscles are the source of pain?

Back 20

Contraction:
Protruding the mandible against resistance should cause pain (muscles have to work harder to open)
Stretching:
Biting maximally in MI should cause pain
Biting on separators should not be painful or reduce pain

Front 21

What should you see clinically if the the SUPERIOR lateral pterygoid muscles are the source of pain?

Back 21

Contraction:
Biting maximally in MI should cause pain.
Biting on separators will also cause pain.
Masseter & Temporalis will give same result
Stretching:
Biting maximally in MI should cause pain (same as Masseter & Temporalis.
Opening the jaw wide will NOT cause pain in the Superior Lateral Pterygoid.

Front 22

What is the test that distinguishes the source of pain is due to superior lateral pterygoids and NOT the masseter and temporalis?

Back 22

Opening the jaw wide will NOT cause pain in the Superior Lateral Pterygoid. Masseter & Temporalis will be painful during this exercise. Superior lateral pteryoid is relaxed in this state, but the other two are being stretched.

Front 23

What should you see clinically if the the MEDIAL pterygoid muscles are the source of pain?

Back 23

Contraction:
Biting maximally in MI should cause pain.
Biting on separators will also cause pain.
Masseter & Temporalis will give same result

Stretching
Opening the jaw wide will cause pain in the Medial Pterygoid. Masseter & Temporalis will be painful during this exercise.

Front 24

What would you observe in a patient with Intracapsular (Joint) Disorders?

Back 24

Movement of the Condyle and increased loading will cause pain, or an increase in pain:
Biting maximally in MI.
Opening widely.
Protruding against resistance .

Decreasing the loading on the condyle may cause a decrease or elimination of pain:
Biting on a unilateral separator.
Protruding against resistance with a separator on painful side

Front 25

What teeth are used to measure Overbite?

Back 25

Distance between Incisal Edges of 11 and 41, measured VERTICALLY

Front 26

What landmarks are you using if your over jet value consists of one number?

Back 26

Horizontal Distance between Facial Surfaces of 11 and 41, measured at incisal edge of 11

Front 27

What landmarks are you using if your over jet value consists of two numbers?

Back 27

1st number: Facial of 41 to Lingual of 11, measured at incisal edge of 41 (black lines). Indicates if there is contact between the two incisors.
2nd number: Horizontal Distance between Facial Surfaces, measured at incisal edge of 11 (red lines)

Front 28

Why is it important that the patient be upright when trying to locate MI contacts?

Back 28

Places the patient in Alert feeding position. (More accurate)

Front 29

Why is it important to note if wear facets are flat or cupped?

Back 29

Flat: Wear is still on enamel
Cupped: Wear is into Dentin and needs to be restored (Class VI). Dentin wears much faster, potential to be carious

Front 30

How do we check for Fremitus?

Back 30

Check for FREMITUS in excursions and MI by placing finger over root and sliding sideways, forwards, and tapping teeth together. Feel for vibrations or movement.

Front 31

What is Total Cross-Bite? What is the biggest problem with this?

Back 31

Overtime there is over eruption of both teeth, creating a heavy interference

Front 32

Other names for Occlusal Splints?

Back 32

Bite Plane
Nightguard
Bruxism Splint
Orthotic

Front 33

What are the 3 categories of splints?

Back 33

Diagnostic
Preventative
Therapeutic

Front 34

Features of a maxillary nightguard

Back 34

Flat Plane
No cusp indentations
Freedom of movement

Front 35

When is a mandibular nightguard useful?

Back 35

Some patients with Class III occlusion
Some posterior cross-bites
Daytime use
Some patients who find maxillary splint hard to wear.

Front 36

What's the purposing of rinsing before inserting impression?

Back 36

This removes excessively thick saliva, which can interfere with impression accuracy for fine detail

Front 37

Why is it important to protect opposite teeth with a finger on the handle of the impression tray when you're removing the impression?

Back 37

You can chip an incisor during the "snap" removal action.

Front 38

List the criteria for a good impression:

Back 38

Adequate tissue roll
All teeth in impression
No voids or bubbles
No “burn-through” to metal
CHECK FOR PERIPHERAL DISTORTION !
If you see metal rim, alginate may have distorted.

Front 39

List some problems that can make taking a impression hard

Back 39

Gagging
Orthodontic hardware
Bridges (use block out wax)
Exostoses and Tori (Use a plastic tray and cut out the sides)

Front 40

Alternate names for Jadestone and Microstone

Back 40

Jadestone: Densite
Microstone: Hydrocal

Front 41

What's the problem of leaving the cast in the alginate for more than an hour?

Back 41

If you let it sit more than an hour, the stone will start absorbing water from the alginate. Hard to remove and increases risk for breakage

Front 42

What is the purpose of using a knife to trim retromolar areas on the stone cast?

Back 42

Prevent interferences when we are occluding the casts

Front 43

What are the function of keyways?

Back 43

Keyways allows lab to separate the cast from the plaster and then remounted in the same manner at a later time.

Front 44

What is the purpose of Jaw relation records?

Back 44

Allows mounting casts
Programming the articulator

Front 45

What is the purpose of the facebow record?

Back 45

records relationship between maxillary teeth and the TMJ

Front 46

What is the purpose of the CR record?

Back 46

Mandibular Teeth to Maxillary

Front 47

What is the purpose of the Protrusive record?

Back 47

Setting Condylar Guidance

Front 48

Features of the WhipMix 3000 series articulator

Back 48

Semi-adjustable
Adjustable Condylar Guidance
Average Anatomical Shape
Fixed Inter-condylar distance.
Arcon
Condyle on Mandible
Arbitrary facebow
Arbirary Hinge Axis

Front 49

What are the references that are used for the Arbitrary Hinge Axis Facebow?

Back 49

1. External Auditory Meatus (EAM)-Minimum 5mm error
2. Anterior reference point is the Nasion

Front 50

What other options can be used besides PVS to obtain the facebow record?

Back 50

Wax, White compound.

Front 51

Should the fossae be included when you are taking the facebow record?

Back 51

No! Just the cusp tips should indent the record. Including Fossae will cause inaccuracies. There should also be no rocking!

Front 52

List the articulator settings when you are mounting your cast

Back 52

Lock articulator in CR
Trapeze ON
Condylar inclination set at 30 degrees
Side Shift 0

Front 53

Describe operator guided Disc-oriented CR

Back 53

Patient reclined 30-45º
Bilateral pressure to seat disc
Downward pressure on the chin
CR taken at highest point when patient can rotate without pain or tenderness

Front 54

Describe Operator guided ligament-Dominated CR

Back 54

“Capture” a repeatable reference position
Patient seated upright
Patient closes with light chin-point guidance on softened recording material

Front 55

Power Centric

Back 55

Patient’s elevator muscles seat condyles
Patient upright
Anterior wax wafer stop
CR measured on posterior wax record with patient closing against anterior stop
*(ie. The deprogramming jig)

Front 56

Criteria for a good cast?

Back 56

No nodules
No grinding slurry
No interferences of soft-tissue/land area, esp. in posterior
Should be able to hand-articulate in a stable Maximum Intercuspation (MI)

Front 57

Why do you want to trim the buccal area of the CR record?

Back 57

You want the record to create as little interference with occlusion as possible

Front 58

Why do you not want the teeth to perforate the wax when taking the CR record?

Back 58

The teeth will have a natural tendency to want to slide into MI if this occurs

Front 59

How do you check that you've taken a accurate CR record?

Back 59

When you place the CR record in between the casts, the MANDIBULAR red line should be posterior to the maxillary red line

Front 60

Steps to mounting the cast using the CR record

Back 60

Lock centric latch
Condylar Inclinations set at maximum
Increase vertical dimension 3 mm at incisal guide pin, to allow for the thickness of the wax record.

Front 61

What are some better method of stabilizing casts for mounting

Back 61

Stabilize with popsicle sticks and sticky wax, or
Hold casts steady with hands (assuming wax record holds cast reliably).

Front 62

How far should the patient protrude when taking a Protrusive record?

Back 62

5-6mm

Front 63

Is perforation of wax a problem when taking a protrusive record?

Back 63

No. Unlike CR, you don't have to worry about slide.

Front 64

Steps for setting condylar inclination

Back 64

CR Latch OFF
Trapeze OFF
Pin UP
Condyle path inclines set to 0
Seat casts in record
Should be 5-6mm forward of CR
Loosen condylar Inclines and rotate until they touch condyles
Tighten Condylar Inclines

Front 65

Conditions for mounting in MI?

Back 65

There is no pathology related to the slide, just go with MI
If MI is small (<0.5mm)
IF there are a lot of teeth present to give stable MI
Most situations involve restoring natural teeth.
We still may have to deal with other occlusal problems in MI (like working And NW but not the slide.

Front 66

Conditions for Mounting in CR:

Back 66

For Dx to allow analysis of premature contacts and slides
For restorative situations where there is not a stable or measureable MI:
Complete dentures
Full mouth reconstruction
Multiple missing teeth
Flat plane occlusal splints (allow patient to go back into CR)
In therapeutic situations where it has been determined that the existing MI position is contributing to pathology and a decision has ben made to adjust the patient’s position of MI to one in CR, with no sldie present.

Front 67

Why do I have the same point of prematurity on the articulated models as I found in the mouth, but the articulated models do not close into a proper MI on the articulator, even after I unlatch the condyles?

Back 67

The articulator is only an approximation of the mouth.

Front 68

What are the regulations concerning keeping casts?

Back 68

Study models: used in diagnosis only. Need to be kept as part of patients clinical record
Clinical records need to be kept at least 10 years after the last visit of the patient, or 10 years after the patient has attained the age of 18

Front 69

Potential problems that Bruxing may cause or exacerbate

Back 69

Excessive wear (including abfracture)
Tooth fracture
Restoration failure
Aggravate periodontal problems
Muscle tenderness
Joint disturbances

Front 70

Causes of Bruxism?

Back 70

Occlusal interferences-No good evidence that this is a factor
Emotional stress:
Type “A” people (Dr. Noble thinks this is a issue)
“Hurry and Worry”
Other factors:
Some medications
Genetic factors
CNS disturbances

Front 71

Name some characteristics of Normal Functional Activity

Back 71

Vertical Forces
Normal amount of force
Normal Muscle contraction/relaxation (Isotonic) – good blood flow
Protective Reflexes
In or near MI
Forces distributed over many teeth
Condyles in stable position
Food between teeth

Front 72

Name some characteristics of Normal Functional Activity

Back 72

Horizontal Forces
Amount of force> 3x normal
Sustained Muscle contractions (Isometric) –poor blood flow
No Protective Reflexes
Eccentric positions
Forces distributed over few teeth
Condyles in unstable position
Tooth – Tooth contact

Front 73

Variables in Occlusal Splint Design?

Back 73

Purpose / Uses:
Function / Mode of Action:
Material
Arch: which arch?
Full Arch or Partial Arch:

Front 74

Benefits of coverage of occlusal surfaces?

Back 74

Cuspal coaverage.
Places material between teeth which is softer than teeth= less force being exerted on teeth and supporting structures including periodontium, muscles and joints.
-allows control of intercuspation

Front 75

Which situations may require a splint with intercuspation?

Back 75

1) If the Mandible needs to be held in MI
2) Repositioning splint

Front 76

When would you want to hold the mandible in MI with a occlusal splint?

Back 76

May be used in surgical positioning splints used in orthognathic surgery, and treatment of maxillofacial trauma.

Front 77

What is a repositioning splint and when should you prescribe one?

Back 77

Orthopedic device altering normal jaw closure.
Has the potential to cause permanent changes in a patient’s TMJ function or occlusion, requiring further extensive and expensive restorative treatment and occlusal therapy.
Generally we SHOULD NOT MAKE REPOSITIONING SPLINTS

Front 78

What is a Flat plane occlusal splint and what are the benefits?

Back 78

Flat Plane, no cusp indentations.
Disengages teeth from normal MI position.
Allows freedom of movement of mandible.
Used more for preventative splint to protect teeth and other structures from bruxing.
Can also be used as a therapeutic splint.
Can be useful as a diagnostic aid in the diagnosis of TMD, because it eliminates occlusal factors.

Front 79

When is it most important to allow retrusive movement?

Back 79

-> Any Flat plane splint should allow mandible to go into CR (along with protrusive without interference).
-->This is especially important for diagnostic splints, and patients with large CR-MI discrepancies.

Front 80

What is the main benefit of increasing vertical dimension with splints?

Back 80

Tends to decrease muscle tension.
Some feel this is the most important part of therapeutic splints.
Useful as part of full-mouth rehabilitation, esp. in the diagnostic and treatment stages.
Useful for treating cases of restricted jaw-opening.

Front 81

Benefits of Canine Ramps?

Back 81

Discluding ramps in canine area will cause separation in lateral and protrusive movements.
This will protect posterior teeth in excursions (mutually protected occlusion).
Thprois also reduces Muscle Force, which means potentially less damage, and possibly less muscle pain.

Front 82

What some potential problems if Canine Ramp isn't placed properly?

Back 82

may tend to force mandible posteriorly, creating pain in retro-discal tissues
and interfering with freedom of movement, especially in patients with long “slides” and mounted in CR. Pushes mandilbe posteriorly

Front 83

What is the occlusal disengagement theory of occlusal splints?

Back 83

Use Flat plane splint to eliminate dental interferences

Front 84

What is the vertical dimension theory of occlusal splints?

Back 84

Use a Bite-opening splint to Increase vertical dimension reduces muscle tension

Front 85

What is the Joint repositioning theory of occlusal splints?

Back 85

Uses a repositioning splint to Places TMJ’s in more comfortable position (Not a good idea)

Front 86

What is the Cognitive awareness theory of occlusal splints?

Back 86

Similar to occlusal disengagement
Decreases “dental awareness”
Flat plane splint

Front 87

What are the different material options for occlusal splints?

Back 87

1)Hard Acrylic with clasps
2) Soft Flexible Acrylic (similar to sportsguard)
3) Thermoplastic Acrylic – softens when warmed
4) Hard Acrylic Occlusal bonded to Thermoplastic base (Dual Laminate)

Front 88

What is the benefit of a thermoplastic splint?

Back 88

Comfortable.
Flexible when heated in hot water but cools in mouth and becomes rigid.
Doesn't require clasps because it engages embrasures of teeth

Front 89

What is the advantages and disadvantages of Maxillary Dual-Laminate Splint?

Back 89

Hard Acrylic Occlusal surface (easy to adjust like dentures) on a thermoplastic base.
Biggest issue: Longitudinal cracks (last only 2-3 years)

Front 90

Advantages and disadvantages of maxillary occlusal splint

Back 90

+: all mandibular teeth contact on a flat surface
+:eccentric guidance easier to achieve
- : esthetics
- : Phonetics

Front 91

Advantages and disadvantages of mandibular occlusal splint

Back 91

+: phonetics
+:Esthetics
-:difficult to establish vertical occlusal contact with maxillary incisors (good for class three)

Front 92

What is the potential problem with partial arch coverage?

Back 92

Can have over eruption of the teeth that you didn't cover.

Front 93

List the things that should be on your night guard prescription

Back 93

Front 94

If an occlusal split does not seat properly during delivery, what is the most likely problem and how would you fix it?

Back 94

check acrylic in the embrasures – especially in the anterior.
This can be relieved with a straight-shank fissure or round bur in the slow speed handpiece.

Front 95

If you find your occlusal splint is lacking adequate canine ramp, what should you do?

Back 95

you can add cold-cure orthodontic resin (clear). You can use the same technique to add a "centric" contact
This technique is useful for repair future defects

Front 96

Why don't we want contacts on non-centric cusps on a night guard?

Back 96

they are the ones that tend to break (Buccal upper and lingual of lower)

Front 97

Patient has trouble sleeping or drooling. What are some solutions?

Back 97

Try wearing it earlier to start getting used to the drooling thing. Some may prescribe sleep medication…have to be careful because it can be habit and not real sleep.

Front 98

Patient notices tissue irritation. What do you do?

Back 98

Tell them to stop wearing it and bring it to you so you can relieve the impingement area

Front 99

Patient notices pressure from nightguard on teeth?

Back 99

Tell them to stop wearing it and bring it to you so you can relieve the impingement area

Front 100

Patient thinks teeth have moved?

Back 100

Stop immediately. Maybe have them leave it for a couple days until it returns to natural position. Then relieve it. Can’t see it but patient can know even it is a little bit off.

Front 101

Patient wakes up with pain in jaw joint?

Back 101

Stop wearing. It may be opening them up too much. May have to reduce it.
If it’s not completely flat. May have to relieve ramp for relief

Front 102

Patient says bite feel different in the morning. No pain. Feels normal again after about 30 minutes?

Back 102

Bite deprogramming. It allows the jaw to move back to their most relaxed position. So no need for occlusion correction!! Just get patient to come in to check if it’s a repositioning splint

Front 103

Patient needs a filling after splint is made

Back 103

Don't Forget that you made a splint for them! so if they need a filling, get them to bring their splint (and make a note that they have a splint in your records!!) so you can adjust afterwards. Hollow out where the filling/restoration is going to be, fill the hole with ortho resin, place vaseline on the filling and fit. If it fits ok, cure the ortho resin

Front 104

What are some considerations for patients for TMD?

Back 104

1) Short appointments
2) Use a Bite block/mouth prop