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Occlusion defects and their treatment are the most difficult issues in dentistry.
To a large extent, because there is still no consensus among experts about what is most important in this problem - the condition of the maxillary joint, the relationship of the chewing teeth with each other, or the condition of the muscles and ligaments of the dentofacial apparatus.
General overview
Dr. Kois offers his perspective and approach to solving occlusion problems.
He developed a device called a deprogrammer, which, according to the developer, makes it possible to eliminate occlusion dysfunction relatively quickly and easily.
But before talking about this device, it is necessary to say a few words about one of the main parameters of the dentofacial apparatus - the central ratio (CR) of the TMJ.
The CS is the position of the MF in which the condyle is relative to the glenoid cavity with optimal occlusion.
A feature of the temporal mandibular joint is that the articular head can be in different positions. This provides the lower jaw with the ability to move in different directions - open, move back and forth and left and right.
The main question: what position should be taken as the initial one, ensuring correct occlusion when closing the jaws? For a long time, experts disagreed about what the position of the condyle should be during CS. Today it is believed that the optimal position of the head of the joint is the anterosuperior position.
The Kois device is a removable orthodontic device designed to automatically install the movable jaw in the center position. Or, in other words, a device that facilitates the registration of a CA.
Structurally, the device is a plastic base with a vestibular arch embedded in it, running outside the dentition and serving as a retainer. The base is made of acrylic, the vestibular arch is made of thin but durable wire.
The device is placed on the upper jaw. The plastic base has a platform (stop) that serves for contact with the incisors of the lower jaw. It is this platform, in contact with the “units” of the lower jaw, that ensures the installation of the dentofacial apparatus in the CS.
When wearing the deprogrammer for a long time, the masticatory muscles are programmed in such a way that installation in the centric relation, and, consequently, correct occlusion occurs automatically.
In essence, the device performs the same function as occlusal splints (splints).
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The primary task in prosthetics and treatment of the dental system is:
Determination of the physiologically correct position of the lower jaw, the relationship of the teeth of the upper and lower jaw. These relationships of the teeth depend on the position of the lower jaw in a state of physiological rest and during its movement. And the position of the lower jaw directly depends on the condition of the teeth, the integrity of the dentition, and the condition of the muscles of the maxillofacial and cervical region. If the patient has extracted teeth or experiences muscle spasms (pain, “grinding” in sleep), then the position of the jaw will not be physiological. This may not be noticeable to the patient in the initial stage, but in the future it necessarily leads to facial, headache and muscle pain, as well as back pain, disruption of sleep and normal lifestyle.
Indications and contraindications
The device is indicated in the following cases:
- The need to reprogram the masticatory muscles to ensure correct occlusion.
- For diagnostic purposes, when it is necessary to establish the dental system in centric relation.
- With increased tooth abrasion. The device allows you to determine the type and cause of the pathology - occlusal dysfunction, bruxism or other parafunction.
- To control the height of the bite.
- If necessary, avoid premature contact of teeth.
Contraindications to using the device are:
- periodontitis of the lower incisors, manifested by their mobility (before using the device, mobility must be eliminated);
- gag reflex (to relieve it, you can try to reduce the area of contact of the acrylic base with the palate);
- the presence of inflammation in the TMJ (arthritis, arthrosis, etc.).
Important. Bruxism can be caused by neurological disorders. In these cases the device is useless. Patients with neurological deficits are advised to wear a mouth guard to prevent tooth wear.
Preparatory activities
Preparatory operations performed during treatment with a deprogrammer are largely determined by the individuality of the patient.
However, all the main parameters on which the patient’s occlusal status depends must be determined.
Risk assessment
Dr. Kois argues that for the successful treatment of dental anomalies, a correct approach to diagnosis is necessary, which consists of assessing the risks in all 4 areas that determine the functioning of the dentofacial apparatus - the biomechanical system, dentofacial, functional or periodontal.
The greatest difficulty is the assessment of functional (occlusal) parameters, since changes in the vertical position of the lower jaw cause its horizontal displacement.
Important parameters
The human dentofacial apparatus consists of 3 main components:
- joints (VNSJ);
- teeth;
- muscles and ligaments that move the LF.
In accordance with this, Dr. Kois suggests considering 3 positions when diagnosing occlusion dysfunction - P1, P2 and P3.
P1 determines the position of the joint, namely the condyle. Since its location is not strictly defined due to the structural features of the TMJ, there are difficulties in establishing the CS.
This may be MIP, myocentric or habitual occlusion if functionality is not impaired.
P2 affects the occlusion of teeth, P3 affects muscles and ligaments.
Questions for the patient
To determine the degree of occlusal risk a patient is exposed to, it is necessary to test them by asking 5 questions.
Depending on his answers, a conclusion is made about the presence or absence of occlusion dysfunction:
- Do you have trouble chewing gum? A positive answer (“yes”) may indicate limited chewing amplitude.
- Do you have difficulty chewing dry foods (such as bagels) that require a lot of chewing? The answer “yes” indicates occlusal dysfunction.
- Have you noticed any changes in the functioning of your dentition over the last 5 years? Increased wear of teeth, their mobility, formation of teeth, and weakness of the masticatory apparatus should be considered as changes.
It should be borne in mind that normal wear of enamel is 11 microns per year. That is, normally, 100 years should pass before a 1 mm thick layer of enamel wears out.
- Do you need to bite into your food more than once? An affirmative answer means dysfunction of the dentofacial apparatus.
- Do you have trouble sleeping? This refers to throwing off the blanket at night, movement disorders or restless legs. If the answer is positive, the presence of parafunction or neurological deficit can be assumed.
A positive answer to any of the questions indicates a certain degree of dysfunction. When conducting the test, it is important that the answers are made based on the normal state of the dentofacial apparatus, without taking into account the patient’s adaptation to a negative situation regarding teeth.
If he has adapted to pathological changes in the functioning of his dental apparatus (for example, he began to eat only soft foods) and answered “no” to the first 2 questions, this does not at all indicate the absence of pathology.
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Preparation
Before installing the device, the doctor carefully examines each patient, taking accurate measurements. The accuracy of occlusion correction depends on the individual approach to determining the central point.
The doctor assesses all the risks and only after that installs the Kois deprogrammer. Based on individual data from biochemical, periodontal, and dentofacial examinations and the study of functional parameters, he selects an individual tactic for occlusion correction using a deprogrammer.
The lowest level of risk occurs when there is a slight occlusion and acceptable functionality of the masticatory apparatus. For patients at greatest risk due to neurological disorders, doctors choose integrative treatment approaches.
Manufacturing stages
Manufacturing a Kois deprogrammer includes the following operations:
- Obtaining alginate impressions from both jaws.
- Casting from plaster model impressions.
- Installation of models into the articulator with complete coincidence of fissures and tubercles.
- Making a vestibular arch from wire and installing it in a model of the upper jaw.
- Pouring the acrylic base. In this case, the vestibular arch is imprinted into the base.
- Trimming the base to form a platform (stop) for the mandibular incisors. Its width should be 3 mm, and its height should provide a bite gap in the range of 1-1.5 mm.
- The final stage is polishing the deprogrammer.
Principle of use
Before using the device, be sure to check the width of the platform. If it exceeds 3 mm, it must be corrected by abrasive treatment.
The device is placed on the upper jaw, and if everything is done correctly, it should be securely fixed on it, thanks to the shape of the base and the tight-fitting vestibular arch.
The patient is asked to take a comfortable position in the chair and press the articulation paper with his teeth, moving the jaw left and right, back and forth.
It is necessary to check the bite separation, which should be up to 1.5 mm. The contact of the platform with the mandibular incisors should be along their midline. If these conditions are not met, the device is corrected by removing excess material .
If necessary, occlusion correction is carried out by creating correct fissure-tubercle contacts of the chewing teeth, holding the LF in centric relation.
In the video, a specialist talks about the design and use of the Kois deprogrammer.
Wearing dates and confirmation
The device must be worn until the muscle structures are optimally deprogrammed. This takes from 2 to 4 weeks.
In some cases, specialists prescribe constant wearing (the device can only be removed for eating). This will help achieve muscle cell restructuring and create new muscle memory.
The initial point of contact when closing the mouth is indicated using articulation paper. If the patient closes his mouth and contact is confirmed, then deprogramming has occurred. The key distinguishing feature is repeatability.
