From: "Arturo R. García D.M.D."
To: "ROOTS"
Sent: Thursday, February 10, 2011 12:23 AM
Subject: [roots] Recent case 2-5-11

This was one of my happiest professional moments.  Helping this pt and
seeing his case finished.  It was my pleasure to know this pt.  What a
nice guy.  What a good attitude and sense of humor.  A hard working guy he
never gets down.

He lost the lower jaw from #30 up to the bottom of the neck of the condyle
because of oral cancer from a heavy duty smoking habit. That condyle just
hangs there and does nothing.  He also had a radical dissection of all of
the muscles from the angle of the right side of mandible down the neck
right down to the clavicle.

This case had a little bit of everything including 2 intentional endos on
24 and 25 with post/core to create better retention for the subsequent
porcelain crowns.  Both teeth were vital.  I used Ghassan's F2
reciprocating technique, instrumented with EDTA and NaOCL using an Endo
vac.  Obturated with Resilon/Epiphany all squirt technique using an Obtura
2.  Posts were #1 Ti flexi posts with composite cores.

When he first presented his maximum vertical opening was about 13 mm.
Withe help of some NM dentistry including TENS and a K7 bite workup we
were able to open him up to about 25mm- between the thickness of the new,
normal sized teeth.  Not ideal, but he will never be either.  I also had
the invaluable help of a Rocabado trained PT who helped me mobilize him
quickly and helped keep him stable.

There are 3 sets of pictures- pre op, temps and post op.  Apologies for
the poor quality of the before pics.  Because of the high doses of
radiation he had during his Ca tx over 10 years ago we could not place
implants in the lower jaw.  Otherwise he would have ideally had a lower
implant supported full arch hybrid as well.

An interesting note was that without first molar occlusion on the lower he
would easily destabilize and loose his range of motion (ROM) and not be
able to open beyond 15 mm and have muscle pain and soreness on the right
side.  When we delivered a lower acrylic partial that gave him first molar
occlusion he quickly stabilized and we were able to keep him stable. This
even further reinforces the idea that you should ALWAYS shoot for first
molar occlusion in rehabs to help with immediate and long term occlusal
stabilization.

When he destabilized he would back to grinding his food in the way he did
before we started which led to the destruction of his front teeth.  Once
stable he was able to chew in a more normal fashion and grind his food in
the back as he should.

Obviously this case is a dramatic demonstration of the first molar adage
because of the lack of a right condyle and musculature.  Think of what
happens to people that have both condyles and all of the associated
muscles working.  Over time, without first molar occlusion, they
destabilize too.

All implants were placed by our own Dr. Rick Kline.  They are Implant
Direct replant.  Upper hybrid by Root lab.  Wax ups, occlusal scheme,
lower eMax porcelain and partial by Bob Clark and Williams Dental lab.
This case was ~7 months from a to z. Of course, we forgot to get his post
op CT after completing the case.  We'll get it at his 1 month follow up as
well as some recontouring of the incisal edges of the lower anteriors.

Arturo



This is a worthy publication as a case report
- it's what I've been asking for forever - Kendo

Showoff.  I'm getting tired of this case. :) - gary

It wore me out too :-) - Arturo

Wow, great case. How did you decide where to start with  the occlusion?
It's hard enough with 2 condyles :-). The patient must have been made up.

Kind regards, - James

Hi James, Thank you for your kind words.

You're right- even with 2 condyles it's sometimes tough to get a
usable/comfortable bite.  I use a neuromuscular approach for all bite
change cases.  I look at muscle EMG's (electromyograms), ROM (range of
motion) and CT scans of the TMJ's.

I DO NOT treat to a joint position.  I treat to a comfortable muscle
position, one that allows as normal a ROM as possible. As well as room for
normal sized teeth :-).  The muscles are king and the teeth and bones are
merely at their beck and call.  The bones and teeth (especially the
condyles- as in a bent or beaked condyle) are either supportive of a
comfortable muscle postilion or in the way of one.

Regards,- Arturo