As I clearly stated in my column, I am aware that there are many different philosophies of how to approach occlusion, all of which have clinical success a significant portion of the time.
As an educator, I face two critical concerns regarding the possible misuse of what I teach. First, if I teach only one method of doing anything and instill in my students that all other approaches are bad, I have created a situation in which anytime a patient presents with that specific problem, the clinician will try to apply the methodology I taught. That may be completely appropriate, but it also may be that other approaches would be equally successful, and more conservative, for a given situation.
An example would be maxillary central incisors that were traumatically lost, leaving a large ridge defect. If I taught students that bridges were bad and implants were good, the student might believe that the treatment plan should include implants, even if it meant multiple surgeries were necessary for bone grafting, soft-tissue grafting and implant placement, while still achieving only a mediocre result because of the severity of the presenting defect. In the same situation, a fixed bridge with pink porcelain might be perfectly successful, much simpler and less expensive and might achieve an even better esthetic result. The point is, the clinician needs to know that both approaches may be successful, and also when and how to use each one.
The second problem I face as an educator is the misuse of what I teach, for the purpose of increased production at the expense of the patient. Every teaching institution, regardless of philosophy, faces this issue. The educator cannot control the ethics of how his or her teachings are applied. A clinician may make the personal decision to present a more complex or expensive treatment plan, using certain principles he or she has been taught to justify the treatment, even when another less complex or costly plan might be equally successful.
I chose the example of measuring from the cementoenamel junctions, or CEJs, of the maxillary central incisors to the CEJs of the mandibular central incisors, because it is discussed by several different occlusal philosophies, not just the one Dr. Bryson mentions. This measurement usually is compared with an average measurement of 18 to 20 millimeters most commonly found in Class I unworn dentitions. If this measurement varies from the average, the challenge becomes interpreting how to apply the information clinically. For example, if the measurement is 14 mm, there could be multiple etiologies.
An example would be a young patient with unrestored and unworn posterior teeth, but worn anterior teeth. The CEJ-to-CEJ measurement may be diminished owing to secondary eruption of the anterior teeth with no alteration of the patient’s vertical dimension of occlusion. Because the anterior teeth need to be restored, two possible approaches to treatment are
- – orthodontic intrusion of the anterior teeth to correct gingival levels, followed by restoration of only the anterior teeth to correct the esthetics and occlusion, leaving the patient at his or her existing vertical dimension;
- – clinical crown lengthening to position gingiva and bone at the correct level, followed by restoration of only the anterior teeth to correct the esthetics and occlusion, preserving the patient’s existing vertical dimension and unrestored posterior teeth.
For a patient with unworn, unrestored posterior teeth, a practitioner may decide that the diminished CEJ-to-CEJ distance from the worn and over-erupted anterior teeth is evidence that the patient has lost vertical dimension. The danger for this patient is that the practitioner now may use that criterion to justify telling the patient that he or she needs his or her bite opened and the posterior teeth restored.
I am not saying that any teaching institution or occlusal philosophy teaches students to do this. I use the CEJ-to-CEJ issue as one example, not as an indictment of any institution or philosophy that teaches it as part of an occlusal evaluation. However, to pretend that clinicians aren’t using their occlusal beliefs to justify certain treatment plans ignores what practitioners see being done around the country—and published on a regular basis.
Every occlusal philosophy faces these challenges with elements of what is taught, which is why it is important for clinicians to hear that multiple approaches often can be successful. The treatment approach chosen always has to put the best interests of the patient first.
