Centric Relation

What is your full diagnosis, aetiology assessment and proposed treatment plan?

what is the level of dentition full or partial?

what is the status of posterior molar support?

Are you planning fixed or removable prostheses?

Is the erosive tooth loss controlled or uncontrolled?

Does the hyper kyphosis you describe not cause a “forward head posture” per se?

Please elaborate as this is an undefined question, you have only presented partial information

Rather than committing yourself to one position or another why don't you record the position that the patient is at right now and then make them an occlusal guard at that position. I can only be at the horizontal position the vertical position is something you're going to have to confirm. If the patient does well in the horizontal and vertical position if they are not causing wear on the occlusal guard after a couple months then you probably could build the patient into that position. If they are having soreness joint area and chewing is no better you have, at the very least prevented yourself from doing extensive reconstruction position would not have worked.

Assuming that things have worked up to this point, I may well restore the posterior teeth in a composite material and go for another three or six months. The composite will allow me to establish vertical and horizontal positions.

So the next question should be what happens if the patient doesn't become comfortable in that position. The first thing that I would do then would be to try to establish a vertical position that they are comfortable in, assuming that it would still be the same horizontal position. If I cannot find a vertical or horizontal position that the patient is comfortable in I tell the patient that I'm not skilled enough to handle their problem And I let them walk away.

@steven eckert ! Wow! Thanks a lot for an ellaborate answer! Usually patients are very impatient and do not comply with splints.i did giv him a splint..but later on gave him composites..he is comfortable with the appearance but unhappy with the mastication..

It's a tough situation. The patient that you have described is one who has a physical disability that compounds their condition So you can really feel for this person. But we have to make sure that we listen to them with empathy while at the same time thinking about offering solutions that are physical rather than emotional. When you say that patient is impatient and does not comply with splints I would agree that this is probably true but to a great extent if they don't comply with the splint therapy they may well never achieve successful treatment.

Sadly, we can't treat everyone. Some people are refractory to treatment. For some patients, if they can't identify the problem we will never know if there is a solution for it.

A good friend of mine, when speaking to patients will tell the patient that they understand that the patient has a problem but the patient needs to understand that it is their problem and it doesn't get any better by making it the clinicians problem. It becomes an ownership of the problem situation. I can never own the patient's problem, the best I can do is try to help them treat it. So, once again, coming back to the statement that the patient grows impatient with splint therapy this makes sense to me but I can only help to solve a problem that has been developing for years and years (was this patient in their 70s) but any solution that I offer the patient is not going to have the immediacy that they would so desire. This patient will frequently become a dental shopper rather than becoming a dental patient.

When rehabilitating a patient one must keep in mind that the wear and tear and settling in of contacts Anteroposteriorly brings into effect other changes in the surrounding musculature. Reversing this must be done carefully and incrementally.

I normally make my patients lie down at a 45 degree angle as this makeshift it easier for them to avoid thrusting their mandible forward. I now repair the most worn out teeth ( usually the first molars) with glass ionizer cement . After patching up the lower molars I use the renewed thickness as a template to patch up any worn areas in the remaining dentition.

I thin use Baush’s BK01 articulating paper to fine tune the dynamics of occluion at this level. The patient uses these interim GIC restorations for a week with intermittent adjustments if called for and then using the final level as the baseline restorations are planned.

Unlike composite which can also be a bit tedious to place for an elderly patient, GIC has a certain degree of give as it auto levels itself to a contour most suitable for the patient’s style of chewing & this provides a valuable insight into planning the final occlusal scheme.

Put simply the aim is to rehabilitate an elderly patient to a point 3 or 5 years in the past making the restoration more realistic and comfortable

Thankyou for sharing your experience Dr Prakash. It would be of great help if you share any clinical case. the questions that come to my mind are; which GIC you use? light cure or chemical cure? bcz GIC usually doesnt give sufficient time. secondly, do you think these GIC increments would provide stable occlusal stops? what i have understood is that you are able to get a workable OVD by using these GIC stops, but the centric relation position and the functional occlusion cannot be achieved by this method.

Chemical cure GIC is preferred. You’ll be performing the patchwork in steps and increments from the most worn out to the least.

After the first two stops have been placed and contoured by the patient gently closing on the GIC and also performing recursive/chewing movements, the remaining teeth are selectively restored within the confines of this OVD increase (usually 2-3 mm). Even this slight increase causes quite a bit of initial discomfort over the first 24 hours and in spite of post placement immediate adjustments a subsequent sitting after 24 hours is mandatory. If for example the wear and tear of a lower molar has an added dimension of maxillary molar tipping the offending cusp can be identified and selectively adjusted.

After original cuspal prominences and restoration contours have been adjusted the patient uses this ‘mock up’ for 3 to 4 days during which the GIC tends to get further leveled and contoured in accordance to the patient’s chewing habits and comfort instead of a dentist or lab imposed perfect occlusal scheme that may lend for visually spectacular restorations but an unhappy patient.

The end point at one week is used as a guideline and this scenario would very naturally have an occlusal scheme mimicking what would naturally be seen in a 70 year old with a degree of wear and tear that would permit a degree of freedom or laxity in movements.

The chief objective in most of my patients has usually been that the restoration of height allows for better interproximal contacts ( no food getting in), less hypersensitivity(preservation of vitality) & a gentle shift of the chewing from the edges of worn teeth towards restored ‘shallow’ cusps (minimizes cheek & tongue bite)

The initial process is almost reversible in case the elderly patient is unsure or unhappy and the interaction over the first 2 to 3 sittings goes a long way in establishing a degree of trust and allows for a better understanding of the patient’s actual needs much before actual preparations are performed allowing for true consent from the patient