Over-Opened Vertical Cases

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[5/31/23 – An OC Study Club Forum Post RE: Over Open Vertical, Failing FM Rehabs, NM Dentist Lost Focus]

Greg, Steve and all,

I really like this point you made:

“…. but it seems that these patients have been restored to a pathological vertical.  Virtually none of my unrestored cases have an excessive vertical problem.  They almost universally have other issues including inadequate vertical.”

You are so right…these excessive vertical problems are all man made by dentists who have created and induced dysfunction in the name of NM physiologic health or desiring to improve cosmetics.  They unknowingly created more problems to the patient even though the intent was to be helpful in correcting the patient’s vertical occlusal deficiencies and smile profile.  Because of a flawed or incomplete NM understanding of dental occlusion and how best to find vertical they assumed the teachers advocating TENS to “relax muscles” or teachings that endorsed the low EMGs was the way to establish vertical or even using structural intra oral landmarks as the anterior gingival to gingival shimbashi values as guides they still missed the fundamental principles of really knowing how to establish “homeostasis” and neutrality between the upper and lower jaws which includes the supporting musculature and jaw joints – condyles and discs.  Of course “airway” and “tongue posture” are also misunderstood, skewed and even used to blame the unhappy clinical demise.

As NM dentists we lost our focus. We got easily distracted with gimmicky teachings, things, toys/ devices, some simple tricks that would seemingly make our dentistry easier, but failed when these paradigms were pushed to another level.  When these things didn’t establish homeostasis/stability to our patients some either gave up because the problem now was too difficult/challenging or too complex for their simplistic desire to cut more preps and bond more ceramics to the teeth with the hope of avoiding the real underlying issues of the unseen musculature – diagnosis?  The unrecognized narrow goal posted or narrow adaptive patient now just became the nightmare case who is now pressing the limits of one’s dental education and training, let alone one’s professional reputation. The beautiful full mouth esthetic case now becomes another NM nightmare problem or does the NM trained dentist just give up on their neuromuscular occlusal understanding, telling the world and profession that what they learned doesn’t really work?, etc.

What about the patient? They complain that they are having headaches (temporal) pains they didn’t have before the FM rehab. They report they are seeing PT, chiropractic’s, message, acupuncture, etc. to help resolving their tight shoulder muscles.  Occipital pains are typically not the concern of most NM dentists.  Palpable SCM tension and anterior scalene musculature, let alone the facial/masseter tensions on the facial….how can that be an occlusal problem?  Some even tell the paining patient that their newly acquired bites all look good.  Patient is even told the K7 says they are on trajectory!  But the patient says, I don’t care about what that K7 says…I don’t feel good….I am having pains and discomfort and bad headaches that are debilitating me…my quality of life is compromised where I no longer can work and the meds are not helping me.  So, now what?  Does the dentist just fold and give up?  Because the patient is now a whiner and complainer and taking up too much clinic time?  The time spent wasn’t taking up too much of the doctors time when they were willing to prep and seat the restorations…but now the case became a nuisance when the doctor didn’t feel he/she was getting paid for the extra time it took to try to deal with the problem…but what was the dentist to look for if something was wrong? To the typical NM dentist the case seem to occlude correctly. Marks all seem to show even contacts… but the patient says they are getting headaches, neck aches, shoulder pains and even numbness down their hands and fingers.  Let alone they are clenching and grinding constantly.

Who is to blame for something that now exists at this diminished quality of life?

What is the protocol and plan to remedy this situation?

Sure, gather more records and data. Document document document…but how is that going to fix the problem and pains the patient is actually feeling and experiencing 24/7?

Now everyone involved has an issue….

How are you going to remedy this problem if this type of case showed up to your office?  Do you avoid it? Does the dentist decline treating the case? Do you refer out…to whom…? Will that remedy the patient’s problem?  Consider if you or I did the FM rehab.  What would we do?

Let’s try to systematically list the things we would do first.

  1. What records would we need to take if this patient showed up to our practice for help?
  2. Would you consider this an occlusal restorative problem or an airway or orthodontic problem?
  3. Would you consider this a psychosomatic problem? [But when the case was initially diagnosed and examined, no one at that time thought the case was an emotional stressed problem].
  4. Is this a PT or adjunctive therapist or medical problem?
  5. What would you scan and digitally record if any?

What would you do?


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