Systematic Treatment Using a Direct Deprogrammer to Resolve Long-Standing Problems in a Phobic Patient

A 65-year-old female college professor presented with masticatory muscle discomfort, joint sounds, and the lack of a repeatable bite, symptoms she had been suffering from for many years. She reported that her bite problems had seemed to worsen after previous dental work was done. She now believed her teeth were “disintegrating, wearing down, and chipping” (Figure 1). The last restoration, a lower right crown, was uncomfortable, and she could not find a comfortable bite. She was apprehensive about treatment due to these negative experiences and clearly stated that she did not want any “cosmetic dentistry” despite being aware that her teeth were unattractive (Figure 2). She shared that her primary goal at this stage in life was comfort as opposed to esthetics, saying she wished not to have to endure further dental work “when I am 80.”

The patient had a history of high blood pressure, which was being controlled, and was taking a statin. Her long-term history of gastroesophageal reflux disease (GERD) had been treated previously with pantoprazole (Protonix®, Pfizer) and she felt it was under control at this time. She was ASA 2 due to her age and was, therefore, a moderate risk.

This patient was dental phobic, as determined by a self-reported score of 8/10 on her dental history form. She reported negative past dental experiences, because each time she saw a dentist she felt her bite worsened and she developed muscle pain. She did not like the pontic on the lower right bridge. She felt her teeth were worn and getting worse, and she lacked a stable bite and blamed her past dentists for poor restorations that caught food. Moreover, she did not sleep well and snored.

Periodontal: The examination revealed light bleeding upon probing, generalized 3-mm probing depths with a few 4-mm depths in the posterior, and no radiographic bone loss greater than 2 mm. The patient was diagnosed as AAP type II.

Risk: Low
Prognosis: Good

Biomechanical: Upon clinical examination, advanced wear on teeth and dated crowns with fractured porcelain were noted. Food was being lodged in open contacts between teeth, causing decay and halitosis. All posterior teeth showed signs of root decay and erosion typical of an acidic environment (Figure 3 and Figure 4).

Risk: High
Prognosis: Overall poor, although hopeless for the carious teeth if untreated

Functional: The patient was keenly aware of active wear and a changing bite. Clinically, her front teeth were worn, and she could not find a “home” position for her jaw (Figure 5). The initial diagnosis was occlusal dysfunction.¹ Based on her medical history, she was at risk for sleep apnea and was open to a sleep study.

Risk: Moderate
Prognosis: Poor if untreated

Dentofacial: In the full-smile position, all anterior teeth were fully exposed, placing her at high risk. She was adamant about not wanting any dentistry for cosmetic reasons; she was only interested in functional work that would help her keep her remaining teeth for her lifetime. For this reason, there was no discussion of the dentofacial benefits during the case presentation or restorative work.

Risk: High
Prognosis: Poor if untreated

This patient desired to keep her teeth for her lifetime with minimal dentistry in the future. She wanted the work done once and done correctly. The treatment plan was recommended to accomplish the following:

• Remove decay, preventing further destruction of tooth structure.
• Cover eroded portions of tooth structure to protect them from further breakdown.
• Replace form and function of cracked porcelain restorations.
• Open the bite to create room to restore lost tooth structure.
• Flatten occlusal planes and align them with the patient’s face.
• Restore occlusion in a repeatable centric relation position.
• Lengthen the front teeth to replace lost tooth structure.
• Replace the pontic of the bridge with an implant.
• Treat a possible sleep disorder.

The treatment plan involved fabrication of an immediate direct Kois deprogrammer, along with study models, a bite registration, photographs, and a diagnostic wax-up. The plan called for restoring lost tooth structure, caries, and defective restorations using indirect porcelain restorations for teeth Nos. 2 through 15, 18, 19, 28, 30, and 31, and direct composite for teeth Nos. 20, 21, and 27. An implant/abutment/crown restoration was planned for tooth No. 29, and extraction was planned for tooth No. 32. Additionally, a sleep study would be done.

Because the patient had felt let down by previous dental work that did not meet her expectations, the initial interview was critical to the success of this case. The interview was done outside of the operatory both to remove barriers to communication and provide an environment where the patient and clinician could sit face to face while she explained her physical and emotional discomfort. It became clear that she needed to feel heard (emotionally healthy) and get pain relief (physically healthy) in order to build enough trust to proceed with any clinical procedures.

The patient returned 1 week later and was seated in the operatory. Load (joint) and immobility (muscle) tests were performed.² These tests were negative, indicating that her temporomandibular joints could accept loading and a deprogramming appliance would be an appropriate strategy for her.³ An immediate direct deprogrammer was fabricated (see sidebar, p.424) to give her immediate relief from her long-term bite problems (Figure 6). Within 2 days she reported “more comfort than I have had in years.” She agreed to wear her appliance for 2 more weeks, then return for a comprehensive examination, models, a bite registration, and photographs.

Clinical assessment and the photograph of the lips in repose were used to determine the ideal incisal edge position (Figure 7), and a wax-up was made on the mounted models. A silicone jig was made of the wax-up of teeth Nos. 6 through 11 before the posteriors were waxed. A second silicone jig was made after the posterior teeth were waxed (excluding the second molars). This provided stable anterior and posterior stops for provisionalization.

The third appointment was the case presentation, where the patient was shown the waxed models and the treatment sequence was presented. The new incisal-edge position was discussed, and the patient was relieved to hear that she could visualize the result in her mouth before any irreversible treatment would be performed. A financial arrangement was agreed upon.

With the patient under sedation, tooth No. 32 was extracted, and an implant was placed in the area of tooth No. 29. Two weeks later, she returned for the initial restorative appointment. The silicone jig made from the anterior wax-up was filled with an automix bisacryl material (Kerr Temphase™, Kerr Dental, www.kerrdental.com), then placed in the mouth to allow direct visualization of the proposed changes (Figure 8). After patient approval, teeth Nos. 6 through 11 were prepared using the direct mock-up as a reduction jig. Provisionals were made with a lingual anterior stop to act as a deprogrammer. This stop was adjusted to the desired new vertical dimension. This was easily verified because the second molars were not prepared, making it possible to use a jig transferred from the mounted models to the mouth. Once the new vertical dimension was established on the anterior stop, the jig created from the wax-up of the entire maxilla was used to prepare and temporize teeth Nos. 3 through 5 and 12 through 14. The newly established vertical dimension was verified using a silicone index made between the unprepped second molars on the mounted models.

During the second restorative appointment, maxillary indirect e.max® (Ivoclar Vivadent, www.ivoclarvivadent.com) restorations were cemented with RelyX™ UniCem (3M, www.3MESPE.com) using standard protocols.

At the third restorative appointment, the lower right posteriors were prepared and provisionalized, and tooth No. 27 received a direct composite restoration (Filtek™ Z250, 3M ESPE). When the patient returned for the fourth restorative appointment, the right posterior e.max restorations were cemented, and the left posteriors were prepped, as treatment planned, with the lower left indirect restorations cemented at the next appointment.

After restorations were completed (Figure 9 through Figure 11), a sleep study was done and a mandibular advancement appliance was placed.

This patient was treated with a systematic approach taught by the Kois Center with preoperative diagnosis and risk assessment that ensures predicable results and educates the patient. Furthermore, the focus that was placed on rapidly relieving the patient’s discomfort allowed this phobic patient to gain trust in the clinician and complete the treatment, which enhanced both her physical and mental health.

The author wishes to thank the Kois Center (Seattle, WA) and its staff and volunteers for their support, as well as Payne Dental Lab, Inc. (San Clemente, CA).

Special thanks to James Polley, DDS for his suggestion to use Triad Gel in the fabrication of the Direct Deprogrammer procedure.

Marc J. Beshar, DMD
Private Practice
New York, New York

With the teeth in maximum intercuspal position (MIP), the amount of overbite and overjet is determined. If the overbite is deep, the anterior stop of the deprogrammer will be invisible and positioned lingually to the central incisors. With a normal overbite relationship, the stop will be even with the incisal edge. If there is a vertical anterior open bite, a small stop will be visible beyond the maxillary central incisor edge. When applicable, the patient should be informed that a small amount of clear material might show when wearing the appliance.

A piece of translucent custom tray material (Triad TruTray™, DENTSPLY, www.dentsply.com) is cut and rolled into a 4-inch x 1/4-inch worm shape (Figure 12). (For convenience, these can be made ahead of time and stored so they are quickly available for use.) With the patient seated in the supine position, a square of cotton gauze is used to dry the teeth. Beginning on one side, the tray material is placed at the palatal free gingival margin in the middle of the first molar (Figure 13). Depending on the room temperature and humidity, the operator’s gloved fingertips may need to be wiped with petroleum jelly to prevent the tray material from sticking to the gloves. The material is adapted around the arch, gently tapped into place while a minimum thickness of approximately 1.5 mm to 2.5 mm is maintained. The material elongates as it is adapted. Any excess material is pinched off when the TruTray has been adapted to the contralateral first molar (Figure 14).

The material is cured with an intraoral curing light for 60 seconds, keeping the light in motion until the material achieves an initial set (Figure 15), as tested with light finger pressure. To prevent the appliance from locking under the emergence profile of the teeth, once initial set is confirmed, the deprogrammer is gently teased loose but not removed (Figure 16). The key to easy successful removal is to loosen the deprogrammer while only initially set, but with enough set so it will not break when it is removed. The appliance is then reseated and completely cured (Figure 17). This material is slightly flexible even after complete curing, so it does not too easily lock in the mouth. However, if the appliance does lock in place, the operator can simply section it and attempt to remake it again. The risk of locking the appliance in position is increased where missing teeth or large gingival embrasures are present.

The excess material is trimmed with an acrylic bur, and the appliance is adjusted until there is a firm snap as it seats into position. The incisal platform is created by placing, then curing, a small amount of Triad® Gel Clear™ (DENTSPLY) to form the anterior stop at the midline (Figure 18). A small amount of TruTray may also be used, although the Gel Clear will provide a smoother platform. The height of the stop is adjusted until there is clearance of 1 mm to 1.5 mm between the molars. Once the clearance is confirmed with articulating paper, the appliance is removed and adjusted extraorally to create a small contact point on the platform, ideally on one of the lower central incisors (Figure 19). If the retention seems inadequate, the appliance can be relined with Gel Clear.

When all of the necessary adjustments are completed, the appliance is polished and then brushed with mint-flavored toothpaste to remove any residual unpleasant taste. The post-insertion instructions are the same as those that would be given for a laboratory-fabricated Kois deprogrammer.