8 CompendiumVolume 29 (Special Issue 1)

P
osture, temporomandibular disorders (TMD), mus-
cles in the neck, back, pelvis, legs, and the whole
craniomandibular complex are all intimately re-
lated to the bite or how teeth interdigitate. An improper
bite can predispose and/or directly cause malfunction of the
temporomandibular joint (TMJ) (internal derangement),
which can result in one or more of the following symptoms:
headaches, pain behind the eyes, facial or throat pain, dizzi-
ness, earaches, clenching or grinding of the teeth, neck pain,
clicking, popping or grating sounds in the jaw joints, and
tired jaws. These problems can be caused by the joints, the
muscles of the face and jaw, or a combination thereof.
Structures that make it possible to open and close the
mouth include bones, joints, and muscles. The teeth are in-
serted into the jaw bone. The TMJs connect the jaw to the
skull. Muscles attach to the bones and joints of the stomatog-
nathic system. Improper muscle function creates muscle
spasm, which has a direct correlation with displaced discs
within the jaw joints. The muscles that manipulate the jaw
with respect to the skull facilitate talking, chewing, breathing,
and swallowing. A bite where the teeth do not come togeth-
er properly directly impacts all of these physiologic functions
negatively. If a nonphysiologic bite continues on a chronic
basis and is further disrupted by trauma, clenching and grind-
ing, a poor airway, and/or numerous dental restorations, an
adverse effect on the overall physiology of the patient is likely.
Treatment of a patient to optimal dental physiology takes
into consideration these situations and diagnoses the major
contributions of the problem, ultimately correcting the im-
proper bite, which facilitates healing and relief of the pa-
tients adverse symptoms. Optimal dental physiology is a
Abstract: A case study is used to illustrate the intimate relationship of the interdigitation of teeth to the whole
body and a new approach to diagnosing it. The patient, suffering from jaw joint clicking and popping, jaw joint
pain, headaches, and an unpleasing smile received three phases of treatment over 2.5 years, resolving her physio-
logic chief complaints, enhancing her orthopedic arch form, straightening her teeth, and prosthetically restoring
her entire mouth. The treatment plan was developed using radiographic, computerized electrodiagnostic methods
and by mounting models on an orthopedic articulator, all of which directly influenced the course of treatment
selected for this patient. The completed treatment was subjectively and objectively very successful, with the
patient continuing to do well 3 years after completion of treatment.
Continuing Education 2
Learning Objectives
After reading this article, the reader should be able to:
I recognize the necessary components involved with
record gathering that precedes treating a patient to
optimal dental physiology.
I appreciate the important diagnostic aspects that
several different radiographic views provide.
I explain the three phases of treatment necessary to
treat a patient to optimal dental physiology.
I develop an awareness of the state-of-the-art diag-
nostic and treatment modalities available to aid in
treating a patient to optimal dental physiology.
A Three-Stage Approach
to Full-Mouth Rehabilitation
Jim K. Beck, DDS
Private Practice, Pueblo, Colorado
Featured Speaker at the 2009 BioRESEARCH Annual Conference

CompendiumVolume 29 (Special Issue 1) 9
treatment philosophy that diagnoses existing teeth, peri-
odontal, maxillary/mandibular orthopedic, airway, and over-
all stomatognathic functioning conditions realizing that they
are related intimately. The treatment philosophy recognizes
that pathology in any or a combination of the above men-
tioned areas contributes to a negative impact on several phys-
iologic considerations of the patients well-being and health.
A THREE-STAGE
COMBINATION CASE STUDY
A 57-year-old woman presented with the chief complaints of
jaw joint clicking and popping, jaw joint pain, and head-
aches. She felt that she had a bad bite and that her mouth did
not close properly. Further, she disliked the appearance of
her teeth. An initial screening examination revealed that she
had been involved in an accident and suffered a traumatic
blow to the mandible. She had a hard time closing her mouth
together for several weeks following the accident. The pa-
tient stated that her jaw joints were sore on awakening. She
was aware of daytime and nighttime clenching, and her jaw
popped on opening and closing. She had several old fillings
and crowns, and her teeth were becoming sensitive. She did
not like the way her teeth looked and wanted to be happy
with her smile (Figure 1 and Figure 2). The patient was given
a consult to take diagnostic records.
Record Gathering and Examination
Upper and lower models were made and mounted on an
articulator at her existing habitual bite. A series of full-mouth
bitewing, periapical, and panoramic radiographs were made.
In addition, right and left corrected-angle tomograms were
taken at her maximum intercuspation, rest, and full-opening
posture. Also, a cephalogram, right/left anterior/posterior
coronal tomograms, frontal skull, Townes view, and lateral
skull radiographs were taken. The biometric records taken
included joint vibration analysis (JVA), resting and function-
al electromyograms (EMGs), range of motion jaw tracking,
and opening and closing mandibular velocity trace. Intraoral,
extraoral, and postural photographs were taken. The patient
was given a comprehensive questionnaire to complete.
The mounted models revealed an uneven occlusal pat-
tern with a high uphill roll pattern to the left. The bite-
wing and periapical radiographs showed extensively failing
restorations with recurrent decay and various isolated peri-
apical lesions. There was generalized stage III bone loss as
a result of chronic occlusal trauma, determined because the
patients home care was excellent and there was no bleed-
ing or evidence of periodontal disease.
The panoramic radiograph revealed teeth Nos. 1, 13, 16,
17, and 32 were missing. There was bilateral antegonial
notching, resulting from chronic excessive masseter muscle
hyperfunction. The nasal septum was relatively straight
with no turbinate obstruction noted.
The right and left tomograms revealed excessive posteri-
or and superior displacement. Excessive orthopedic bend-
ing was noted bilaterally and the right tomogram showed
osseous degeneration. Both joints exhibited hypertrans-
lation,
1
which represents excessive stretching in the bilam-
inar zone of the posterior ligament.
The cephalogram showed lack of normal lordotic curva-
ture, with inadequate spacing between the C1 and C2 ver-
tebrae. The antigonial notching was again noted, and the
Figure 1 The patient was unhappy with the esthetics of
her smile. Note the uphill cant to the left.
Figure 2 Several occlusal flags included crowded anteriors
and abfractions.
double border of the mandible was consistent with the previ-
ously noted uphill cant to the left of the occlusal table. This
cervical orthopedic relationship was also consistent with the
forward head posture observed on the postural photographs.
The anterior and posterior coronal tomograms showed
normal osseous contour on the left, and osseous degenera-
tion of the right lateral pole. The frontal skull radiograph
was traced for a triplanar analysis. The three planes traced
ran through the frontosphenoid sutures of the orbits, the
mastoid processes, and the gonial angles of the mandibles.
By tracing these three planes, cranial orthopedic problems
can be diagnosed.
2
The frontosphenoid plane and the mas-
toid process plane were parallel. The gonial angle plane
converged to the left side. Gonial angle plane discrepancies
can be corrected with a mandibular orthopedic reposition-
ing appliance (MORA), which will make the gonial angle
level with the other planes. Cases with orthopedic and TMJ
issues, as presented here, initially can be treated with a bite
registration and construction of a MORA appliance. The
patient wears the MORA during all waking hours and re-
moves it only to brush his or her teeth.
3-8
The Townes view radiograph showed no fracture of
the condylar neck. This is always a concern when dealing
with TMD and orofacial pain patients. Final full-opening
posture was straight and symmetrical.
The lateral skull radiograph is excellent for diagnosing
cervical degeneration in C5 through C7.
9,10
This is im-
portant because TMD patients often require multidisci-
plinary treatment. This patient had a normal C5 through
C7 lateral skull radiograph.
BioJVA

(BioResearch Associates Inc, Milwaukee, WI)

is a diagnostic aid that objectively detects pathology in the
jaw joints during function. It can be used to aid the detec-
tion of TMD at an accuracy rate greater than 90%.
11-14
According to the American Dental Association, every den-
tist is required to diagnose jaw joint pathology. This patient
presented with a Wilkes stage II internal derangement (disc
displacement with reduction, Figure 3).
Resting and functional EMGs recorded with the Bio-
EMG II

(BioResearch Associates Inc) were used to diag-

nose how the muscles of the stomatognathic system were
functioning with the existing occlusion and also how well
they relaxed at rest.
14-24
Muscles that function abnormally
often do not rest normally either. This can cause pain and
tension in the TMD patient. This patient presented with
extremely high resting EMGs for the temporalis, masseter,
and sternocleidomastoid muscles. This illustrated that the
chronic malfunctioning of this patients occlusion, along
Continuing Education 2
10 CompendiumVolume 29 (Special Issue 1)
Figure 3 Joint vibration analysis showing stage II anterior
disc displacement with reduction.
Figure 4 Pretreatment upper study model. Crowded
maxillary anteriors and V-shaped arch form.
Figure 5 Pretreatment lower study model. Crowded
mandibular anteriors, V-shaped arch form, and blocked
out tooth No. 22.
with a chronic history of clenching and forward head pos-
ture, was creating a pathological situation that did not allow
the muscles to rest adequately. The muscles, joints, and
whole body posture were being affected negatively, creating
a dwindling spiral that ultimately broke down the whole
stomatognathic system and affected this patients entire
body. The functional EMG recordings indicated the tem-
poralis and masseter muscles had poor leftright symmetry
during clenching. This muscle pathology is consistent with
poor orthopedic and occlusal schemes where the patient is
forced to go through muscular gymnastics to facilitate
chewing, swallowing, and breathing.
The jaw-tracking range of motion and velocity tests
(recorded with the JT-3D

, BioResearch Associates Inc)

revealed a maximum opening of 41.4 mm. Left lateral ex-
cursion was 7 mm, and right lateral excursion was 8 mm.
Protrusion was 7 mm. This is considered to be at the low
end of a normal range of motion. However, the velocity
trace showed an opening speed of only 250 mm/sec and a
closing speed of 200 mm/sec, indicating bradykinesia (slow
movement). Normal opening and closing speeds should be
in excess of 350 mm/second.
25-28
A normal opening and
closing velocity is consistent with normal muscle and jaw
joint function. When there is pathologic opening and clos-
ing velocity, there is a potential for muscle and/or TMJ dys-
function. Bradykinesia is slow movement and commonly is
associated with dyskinesia (erratic movement). It can be an
indication of a disc that is reducing and displacing. In this
patient, there was a significant slowdown present right be-
fore the teeth contacted at centric occlusion. This patholo-
gy was consistent with intracapsular trauma and the bodys
sensory proprioception protecting against additional trau-
ma associated with tooth contact. Ultimately, this pathology
puts pressure on the condyle intracapsularly. When there is
damage intracapsularly, which is associated with inflamma-
tion, the body braces to protect itself.
28,29
Intraoral and extraoral photographs revealed a patient
with a large number of old failing restorations, including
fillings, root canals, crowns, and bridges. The occlusal pat-
tern was irregular overall. There was generalized type III
Beck
CompendiumVolume 29 (Special Issue 1) 11
Figure 6 The patients habitual bite. Note the anterior
overjet and the relationship of molars and cuspids.
Figure 7 Note the anterior/posterior and vertical change
from phonetic bite registration.
Figure 8 Left-side habitual bite condylar posture. Figure 9 Left-side phonetic bite registration posture from
which the MORA appliance was constructed.
bone loss. Also noted on the models and in the examina-
tion was upper/lower loss of transverse arch form. The
maxillary arch form was anteriorly V shaped with central
incisor overlap. The mandibular arch form was also narrow
anteriorly and had general anterior crowding with tooth
No. 22 blocked out (Figure 4 and Figure 5). This orthope-
dic condition significantly affects the TMJ because the
occlusion will displace the condyles posteriorly and superi-
orly.
30,31
This has a negative impact on joints, muscles, and
airways. The blocked out tooth No. 22 and upper/lower
crowding directly impact the treatment process because of
the limitations of crown-and-bridge alone. This patient
required orthopedic and orthodontic treatment. The extra-
oral photographs illustrated noticeable forward head pos-
ture. This structural posture is a persons adaptation to
facilitate swallowing, and/or is seen in someone who has
become a mouth breather. These functioning adaptations
significantly affect diagnoses and treatment plans.
The subjective questionnaire revealed that the patients
chief complaints were headaches, jaw clicking, shoulder
pain, neck pain, pain when chewing, and appearance. The
patient was healthy overall. She had had her tonsils and wis-
dom teeth removed. She had right-sided frontal, temporal,
and back-of-the-head headaches. She was aware of daytime
and nighttime clenching. She had a previous accident where
she was struck violently on her mandible. Her history indi-
cated that her pain patterns started thereafter and she had
been in chronic pain for many years. She had experienced
occasional numbness in her fingers. She experienced chron-
ic vertigo. She wakened with a dry mouth in the morning.
Diagnosis
The patient was diagnosed with bilateral Wilkes stage II an-
terior disc displacement with reduction, bilateral capsili-
tis, bilateral myalgia, right-sided headache/facial pain, and
chronic clenching.
Treatment Plan
The treatment plan consisted of three phases.
Phase 1:
I
Clean up existing dentistry, removing all dental and peri-
odontal pathology
I
Realign mandible (condyles) orthopedically
I
Reduce adverse joint loading
I
Improve function
I
Improve myalgia
I
Reduce pain
Phase 2:
I
Transversely develop upper and lower arches orthopedically
I
Rotate, level, and align dentition on upper and lower
arches (braces)
Continuing Education 2
12 CompendiumVolume 29 (Special Issue 1)
Figure 10 Tripod transfer established from Phase I orthotic
after MMI was established.
Figure 11 Hyrax transverse expansion appliance with
rectangular wire to establish proper torque.
Figure 12 Upper-arch clean up, orthopedic expansion, and
orthodontics completed.
Phase 3:
I
Full-mouth prosthetic reconstruction to the correct
orthopedic and functional relationship
I
Improve cosmetics
Consultation
It was explained to the patient that her problems were associ-
ated predominantly with soft-tissue issues of the jaw joint
with early degeneration. Her other problems were overworked
muscles, which were not getting adequate rest. Finally, it was
explained to her that the maxillary and mandibular dental
and orthopedic arches needed to be developed transversely.
The patient was informed that the total treatment time would
be approximately 2.5 years, start to finish. The patient agreed
to treatment and signed informed consent forms.
Phase 1
The patient was sent to a periodontist for bone grafting
and general periodontal treatment. After the completion of
periodontal treatment, the author removed all of her existing
dental work, with the exception of old conservative fillings.
These fillings were not a liability of later needing root canals,
and they would be removed in Phase 3 when the teeth were
prepped for the full-mouth rehabilitation. Through the
course of cleaning up the existing dentistry, teeth Nos. 19,
29, and 30, which had old failing crowns and advanced de-
cay, were treated by extraction. The remainder of the teeth
were restored with healthy restorations, buildups, and tem-
porary crowns. The teeth and periodontia were then healthy
and could support the complete treatment.
Orthopedic realignment of the condyles started with a
bite registration. Because the patient had bilateral retrodiscitis
(TM inflammation) and disc displacements, and needed
anterior/posterior correction, the phonetic bite registration
technique was used.
32-34
The phonetic bite technique pro-
vides the limit of anterior/posterior movement of the man-
dible (Figure 6 and Figure 7). Additionally, the phonetic bite
achieves significant improvement in the airway. From the
Beck
CompendiumVolume 29 (Special Issue 1) 13
Figure 13 Note the rectangular wire used to create ideal
torque.
Figure 14 Lower-arch clean up, orthopedic expansion, and
orthodontics completed.
Figure 15 Removable retention that was used for 6 months. Figure 16 Final upper and lower waxup, maintaining the estab-
lished position. The temporary stent was made from the waxup.
phonetic bite registration and upper and lower impressions,
a neuromuscular demand appliance (NDA) was made for the
patient to wear during all of her waking hours. This orthotic,
in essence, resets the jaw orthopedically to enable the condyle
the opportunity to recapture the disc. In addition, the orthot-
ic, by moving the condyle in a down and forward position,
decompresses the joints allowing for healthy blood flow, and
the elimination of pressure on retrodiscal nerves and blood
vessels
35-37
(Figure 8 and Figure 9). Ultimately, the NDA aids
in eliminating inflammation of the joint capsule, which pre-
viously was caused by occlusal and parafunctional trauma.
At night a separate orthotic was used, which was a night-
time deprogrammer with a palatal ramp. This appliance, an
anterior discluder, keeps the condyles, mandible, and mus-
cles in a posture that is consistent with the occlusal trajectory
established with the day appliance. In addition, the posteri-
or teeth do not touch, significantly eliminating night clench-
ing.
38-40
Finally, by holding the jaw in position at night and
combining this with patient functioning in the NDA or-
thotic in the daytime, the musculature will reprogram to this
position and the TMJ capsules will adapt to the condyles
new posture. These two orthotics, worn over a period of 3 to
4 months, set the foundation for the subsequent Phase 2 and
Phase 3 treatments.
In addition to wearing the appliances, the patient had sub-
sequent trigger point, ligament insertion, and prolotherapy
injections. She also had the chiropractor do some cervical
adjustments. After 8 weeks of therapy, the patient reached
maximum medical improvement (MMI). All of her pain is-
sues were gone. The final Phase 1 records were taken, includ-
ing new tomograms, cephalograms, bitewing and perioapical
radiographs, JVA, EMGs, and jaw-tracking records. The
records showed objectively that she had reached MMI.
Phase 2
The orthopedic position established in Phase 1 was main-
tained in Phase 2 by constructing anterior composite incisal
ramps/blocks for the lower anterior incisor occlusion. In the
posterior, occlusal blocks were built on the occlusal surface of
the second molars. This tripod (Figure 10) maintained the
jaw and bite trajectory, which was established in Phase 1
through the NDA and the nighttime deprogrammer with
palatal ramp. With this functional tripod established, the
Phase 2 goals of orthopedic expansion could be accom-
plished as well as the orthodontic goals of rotating, leveling,
and alignment. The upper-arch orthopedic development
was accomplished through a fixed Hyrax expansion appli-
ance (Figure 11 and Figure 12). The lower arch development
was accomplished along with the upper arch and through
use of straight wire techniques (Figure 13 and Figure 14).
Final coupling of the dentition was accomplished through
verticalization with eruption of the teeth through elastics.
Continuing Education 2
14 CompendiumVolume 29 (Special Issue 1)
Figure 17 Completed case, right-side view.
Figure 18 Completed case, left-side view.
Figure 19 Completed case. The patient was pleased with
her final smile.
Phase 2 took 13 months. The patient then was placed in
retention for an additional 6 months (Figure 15).
Phase 3
With the completion of Phase 2, the patient was ready to
start Phase 3, full-mouth reconstruction to optimal dental
physiology. This process started by constructing the upper
and lower arch bite-registration stent out of Sil-tech (Ivoclar
Vivadent Inc, Amherst, NY). This bite registration stent
was constructed from the upper and lower models mounted
on the articulator. The mounting was from the current
complete orthopedic/orthodontic relationship established
in Phase 2. The bite-registration stent allowed the author to
prepare the teeth and then put a wash in the stent for the
upper and lower prepped teeth, which maintained the rela-
tionship established in Phase 1 and Phase 2. After con-
struction of the bite-registration stent, the upper and lower
models were prepped and both dental arches were waxed
up in an ideal relationship (Figure 16).
From this waxup, a triple-tray temporary stent was con-
structed. The design of the temporary stent enabled the
preparation of both arches in a single visit. The temporiza-
tion of the occlusion maintained the relationship estab-
lished in Phase 1 and Phase 2. The patient had both arches
prepped and temporized. After 3.5 weeks, the permanent
restorations were placed. The following day, the final res-
torations were fine-tuned with computerized occlusal analy-
sis. The laboratory constructed a new nighttime depro-
grammer with a palatal ramp for the patient to wear every
night. This appliance would protect against nighttime para-
function and maintain a healthy airway.
The patient returned 1 month later for computerized oc-
clusal analysis. The analysis objectively confirmed that the
occlusion was balanced and right and left cuspid disclusion
as well as protrusion were immediate and measurable to less
than 0.2 seconds. The patient was reevaluated at 6 months,
1 year, and 3 years posttreatment. Her symptoms have not
returned. Follow-up examinations using biometric instru-
mentation objectively show normal healthy muscle function,
normal jaw function, normal swallowing, and a normal air-
way. The patient is ecstatic with her final result (Figure 17
through Figure 19).
CONCLUSION
This case study illustrates the intimate relationship between
how teeth interdigitate and the impact interdigitation has
on the whole body. The patient presented with chief com-
plaints of jaw clicking and popping, jaw joint pain, head-
aches, bad bite, and dislike of the appearance of her teeth.
The patient went through three phases of treatment over a
period of approximately 2.5 years. The phases dealt with her
physiologic chief complaints, enhanced her orthopedic arch
form, straightened her teeth and, finally, prosthetically re-
stored her entire mouth.
The entire treatment plan was established by using ex-
tensive record gathering through radiographic and comput-
erized electrodiagnostic modalities. In this patient, many
different sources of record gathering were used to diagnose
the cause of the patients chief complaints before treatment
and ultimately to direct the course of treatment. The occlu-
sion was examined by mounting models on an orthopedic
articulator. This mounting showed the relationship of the
occlusal plane of the teeth to the maxilla, mandible, and jaw
joints. The function of the joints was assessed objectively by
JVA. The function of the muscles was assessed objectively
by EMG. These assessments illustrated pathologic muscle
resting and functional activity.
The functional activities assessed were clenching, chew-
ing, and swallowing. The degenerative and pathologic bony
orthopedics were diagnosed from various craniomandibular
radiographs. These radiographs illustrated improper neck
curvature in the cervical vertebra, bony apposition associat-
ed with clenching, and displaced TMJ posture bilaterally.
All of the observed diagnostic modalities directly influenced
the course of treatment selected for this patient. The com-
pleted treatment was subjectively and objectively very suc-
cessful, with the patient doing well 3 years after treatment.
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Continuing Education 2
16 CompendiumVolume 29 (Special Issue 1)
CompendiumVolume 29 (Special Issue 1) 17
1. A panoramic radiograph can reveal:
a. antegonial notching.
b. posterior displacement.
c. cervical degeneration in C5
through C7.
d. joint translation.
2. Right and left tomograms can reveal:
a. antegonial notching.
b. superior displacement.
c. spacing between the C1
and C2 vertebrae.
d. condylar neck fracture.
3. A cephalogram can show:
a. lordotic curvature.
b. cervical degeneration in C5
through C7.
c. joint translation.
d. all of the above
4. A lateral skull radiograph is excellent
for diagnosing:
a. failing restorations.
b. periapical lesions.
c. cervical degeneration in C5
through C7.
d. spacing between the C1
and C2 vertebrae.
5. What can be used as a diagnostic aid to
objectively detect pathology in the jaw
joints during function?
a. stethoscope
b. palpation of the jaw joint
c. patient interview, during which joint
popping and clicking can be heard
d. joint vibration analysis
6. What can be used to diagnose how well the muscles
of the stomatognathic system relax at rest?
a. palpation of the jaw joint
b. electromyograms
c. sonograms
d. right and left tomograms
7. The jaw tracking range of motion test can reveal:
a. maximum opening.
b. left lateral excursion.
c. right lateral excursion.
d. all of the above
8. In Phase 1, what was used to limit anterior/posterior
movement of the mandible and achieve significant
improvement in the airway?
a. neuromuscular demand appliance
b. separate nighttime deprogrammer
c. phonetic bite technique
d. prolotherapy injection
9. The orthopedic position established in Phase 1
was maintained in Phase 2 by:
a. constructing anterior composite incisal
ramps/blocks.
b. wearing a new nighttime deprogrammer.
c. orthopedic expansion with the straight wire
technique.
d. vericalization with eruption of the teeth
through elastics.
10. In Phase 3, what was used to maintain the
relationship established in Phase 1 and Phase 2?
a. a wash in the bite-registration stent
b. temporization of the occlusion
c. a new nighttime deprogrammer with a
palatal ramp
d. all of the above
Continuing Education 2 Quiz 2
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