Bruxism, Botox, and Dental Implants May 01 2017
Bruxism, Botox, and Dental Implants
Louis Malcmacher DDS, MAGD
Timothy Kosinski, DDS, MAGD
Patients presenting with functional and esthetic concerns can be restored a number of ways. Conventional treatment includes crown and bridgework, root canal therapy, core buildups and removable partial dentures. With the advancement in implant dentistry, and the access to dental education for our patients through the internet, dental implants have become an excellent alternative to our conventional procedures.
We all want the dentistry that we deliver to have an excellent long term prognosis especially with costly treatment plans. If a patient is investing thousands of dollars for an esthetic and functional smile, neither patient nor dentist is pleased when things go wrong in a short period of time. This usually means that you will be “married” to this patient for a long time re-doing complicated dentistry resulting in an unhappy patient and an even unhappier dentist. Before embarking on the dental implant journey with patients, it is important for every dental clinician to accomplish proper examinations and diagnostics to insure the highest rate of treatment success for a good long term prognosis.
One of the most important areas where clinicians fail to do a proper evaluation is in the area of bruxism. With 1 out of 3 patients having some level of bruxism, it is vitally important to get this under control with proper recognition and bruxism treatment before placing any dental implants or for that matter any dentistry.
There are two ways to evaluate a patient for destructive bruxism. One way is the physical examination of the patient. Most dentists are well trained to detect teeth wear which is a symptom of bruxism. What I would like to focus on is what the American Academy of Facial Esthetics (AAFE) refers to as “reading faces” for bruxism and occlusal disease. You are probably wondering what a patient’s face has to do with bruxism in the mouth. In the experience of thousands of AAFE members who are dental professionals, we would all tell you that “reading faces” is much more important than seeing what is happening in the mouth.
Let’s look at some faces together and it will be clear as to what I am talking about. Figure 1 shows a patient at rest. What do you see? If you learn to read her face, you will see very big masseter muscles with her left masseter being significantly larger than her right masseter. At rest, these muscles are unusually large which means they are getting quite the workout to achieve that size. Indeed, they are the same as any other muscle in the body, the more you work it, the larger it gets. Would it surprise you that this patient has significant destructive bruxism? I don’t even have to look in her mouth to know it. She didn’t even have to tell me about the 8 bruxism appliances she has had over the last few years which she chewed through and didn’t help her at all. Most certainly, before we perform any restorative dentistry in her mouth, we will need to address these masseter muscles which provide all the power to her bruxism. This is what we refer to as “reading faces”.
If we want to confirm objectively how much bruxism this patient has, we can have her take an overnight bruxism/sleep monitor test (STATDDS). We in fact did administer this test and found that her bruxism episodes index (BEI) was 6.2 which now gives us a baseline of the destructive bruxism that she has (a BEI over 5 is clinically destructive bruxism). It is foolish to attempt any restorative dentistry, especially implant dentistry, without addressing her bruxism issues concretely. It is for this reason that Dr. Gordon Christensen has said, “Bruxism monitoring is one of the most important concepts in dentistry today”.
Botulinum toxin (Botox, Allergan or Xeomin, STATDDS) is an excellent treatment for bruxism. What botulinum toxin will accomplish is reduce the intensity of contraction of the muscle through its mechanism of action of interrupting the neurotransmission of acetylcholine to the muscle. With proper training in the anatomy, physiology, pharmacology, and botulinum toxin delivery, a simple injection in each masseter will eliminate her bruxism and give her face a more esthetic appearance. This is confirmed by a post test with the STATDDS bruxism/sleep monitor which now shows her BEI to be 0.6, effectively eliminating her bruxism. Even more so, by reading her face in the post operative photo (figure 2), you can see for yourself that her bruxism is eliminated even without testing.
The advantages of using botulinum toxin for bruxism over any kind of appliance are no compliance issues to deal with and it is safe and effective. In this patient’s case, none of the bruxism appliances she had made were successful (she reported how each successive dentist told her the previous appliance wasn’t going to work but the one the new dentist made would definitely work). Her bruxism and 12 year history of orofacial pain was completely resolved with a treatment plan consisting of botulinum toxin injections and trigger point therapy. It is important to let patients know that it takes botulinum toxin 2-10 days to begin to work after treatment and will last for 3 months at which time the patient will need re-treatment.
Once a patient’s bruxism is under control, now it is time to go inside the mouth and implant treatment can begin with the clinician can feel confident of the long-term prognosis. Another way to deal with the results of bruxism is to use high strength restorative materials which can withstand the impact of excessive bruxism.
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Our patient is a 43 year old female who presents to our practice with a chief complaint of missing maxillary right and mandibular left dentition, broken down bicuspid teeth and unesthetic, worn down maxillary anterior teeth (Figures 3-5). She is treated for Crohn’s disease with Asacol and was diagnosed with micoadenoma pituitary gland.
When patients present with missing posterior occlusal stops, function then rests on the anterior teeth. This may result in excessive wear and un-esthetic flattening of incisal edges as a result of her occlusion and her bruxism.
Here our patient had several concerns including pain in the upper right quadrant, fractured teeth and loss of occlusion due to the missing maxillary right teeth and mandibular left teeth. It was determined that her mandibular teeth were in good repair and maintained esthetic contours.
She presented with a fractured maxillary right first bicuspid and a painful second bicuspid (Figure 6). She is unhappy with her smile. We discussed the possibility of retaining teeth #4 and 5 and consulted with an endondontist who found tooth #4 unrestorable. A conventional post and core and crown was completed on tooth #5.
The decision was made to restore the maxillary arch with dental implants and strong esthetic crowns. This would increase the vertical dimension of occlusion, improve the length of the teeth to a younger appearance and provide stability to the occlusion due to restoration of the posterior regions.
For this case, the Hahn Tapered dental Implant system (Glidewell Direct, Irvine , CA) was used due to it’s innovative design and initial stability following surgical placement. The system allows for the practitioner to angle and position the implant into available bone due to the pronounced threads that bore firmly to maximize bone adaptation. There is a buttress thread pattern that allows this stability and reduces bone resorption at the crest, which is often seen with other implant systems. Corornal microthreads help to preserve the crestal bone. The Hahn implant is processed with a resorbable blast media which promotes osseointegration. (1,2) There is also an intentional machined collar on the implant which helps with soft tissue health. The internal design of the implant is a conical hex connection. This connection insures a firm and proper prosthetic seal. Note that the prosthetic design is one of platform switching, with all abutment connection on the inside of the body of the implant.
The surgical protocol for the Hahn implant system is precise. First a 2.2mm diameter pilot drill is used to create the initial osteotomy. This establishes proper depth around any vital anatomy and the mesial-distal angulation of the implant. I prefer to parallel multiple implants to the natural tooth roots. Proper depth is determined radiographically. Next 3.5mm and 4.3mm diameter osteotomy burs of established depth are used to create the final osteotomy. The Hahn implant is threaded into the prepared site and torque is established. Here 40Ncm of torque was achieved upon initial placement. Cover screws are inserted into the implants. The beveled surface of the implant is positioned slightly subcrestal in the immediate extraction socket, but at the crestal ridge of the edentulous molar site.
Using CAD/CAM designed and milled custom abutments allow for proper emergence profile and smile design. The margins are created at or just slightly subgingival to maintain tissue health and eliminate the possibility of cement staying in the gingival sulcus. Screw retained crowns are used when the vertical occlusal space is compromised or where milled abutments would be too short to maintain a cement on crown. Here Bruxzir anterior esthetic crowns were used. These are of a monolithic zirconia material formulated to maximize esthetics and strength in the esthetic zone of the anterior regions of the mouth. This all ceramic material is designed for long term strength and durability and some natural translucency. The implant retained crowns are virtually designed and milled using the most innovative CAD/CAM technology.
The plan was for dental implants to be strategically placed in the maxillary right second bicuspid and first molar area, following atraumatic extraction of the non restorable bicuspid tooth. The maxillary right first bicuspid was treated with a post and core assembly and a new functional crown.
Tooth #4 was atraumatically removed and the site grafted with Cerasorb Tri-Calcium Phosphate 250-1000 microns (Curasan Corp.) and a 4.3mm X 13 mm Hahn dental implant immediately inserted and torqued to 40Ncm (Glidewell Dental). A second 4.3mm X 8 mm Hahn implant was also placed in the edentulous maxillary right first molar site using a flapless technique. The implant engaged bone anterior to the maxillary sinus (Figure 7). The implant placement was prepared and then verified for proper orientation and position with CBCT images (Vatech) in figures 8 and 9. Note that the immediate implant placement is about 1mm subcrestal allowing for proper physiologic reorganization of the bone.
The implants were allowed to integrate for approximately 4 months prior to impression techniques and fabrication of a custom abutment and implant retained cement on Bruxzir crown on the #4 implant and a screw retained implant crown in the #3 implant (figures 10 and 11).
The dental laboratory (Glidewell Lab) fabricated a custom abutment for the maxillary right first bicusipid implant. Note that the margins are prepared at or just slightly subgingival to insure that cement removal is simple and complete. The maxillary molar implant is restored with a screw retained Bruxzir crown. The access opening is easily concealed with a composite resin (figures 12 and 13).
The mandibular left posterior site was also restored with Hahn dental implants. The plane of occlusion was established using the mandibular arch, which was in better repair.
Due to the excessive wear and flattening of the maxillary anterior teeth due to bruxism, Bruxzir anterior esthetic crowns were planned for teeth #6-12. These would establish not only esthetics, but the increased incisal opening would improve function and facial esthetics (figure 14).
Advanced dental implant designs and surgical protocol enable the practitioner to routinely treat patients with missing teeth. The implant integrate in a relatively short amount of time, and are restored with high quality, functional and esthetic implant retained crowns. The innovative Bruxzir anterior restorations provide for great strength, durability, translucency and attractive smile design for all cases and especially for those that suffer with bruxism.
The dental clinician now has a number of different options to deal with bruxism which must be addressed before restorative dentistry. The days are gone where a dentist just gives a patient a bruxism appliance with the thought that the bruxism is under control before restorative and implant treatment. This article has presented the concepts and case presentations using bruxism monitoring, botulinum toxin (Botox) for bruxism, and high primary stability implants, and strong restorative materials. Every dentist needs to get trained in these areas which will help achieve best therapeutic patient outcomes possible. Both of the authors are heavily involved with training general dentists in these areas and every general dentist is capable of placing implants and using botulinum toxin treatment for bruxism. Get trained today!
Louis Malcmacher DDS MAGD is a practicing general dentist and an internationally known lecturer and author. Dr. Malcmacher is president of the American Academy of Facial Esthetics (AAFE). You can contact him at 800 952-0521 or email drlouis@FacialEsthetics.org. Go to www.FacialEsthetics.org where you can find information about live patient Botox and Dermal Filler Training, Frontline TMJ/Orofacial Pain Trigger Point Therapy, Dental Implant Training, Frontline Dental Sleep Medicine, Bruxism Therapy and Medical Insurance, download his resource list, and sign up for a free monthly e-newsletter.
Disclosure: Dr. Louis Malcmacher is a consultant for STATDDS.
Dr. Kosinski is an Affiliate Adjunct Clinical Professor at the University of Detroit Mercy School of Dentistry and is in private practice in Bingham Farms, MI. He is currently the Associate Editor of the AGD journals. He is a Diplomate of the American board of Oral Implanvology/Implant Dentistry and the ICOI, and is a Fellow of the AAID, the ACD and ICD and the ADI. He can be reached at firstname.lastname@example.org .
- Piattelli M, Scarano, A. Paolantonio, M et al. “Bone Response to Machined and Restorable Blast Material Titanium Implants.” An Experimental Study in Rabbits.” Orla Implantol. 2002: 28 (1): 2-8.
- Nishimoto SK, Nishimoto, M, Park SW et al. “The Effect of Titanium Surface Roughening on Protein Absorption, Cell Attachment, and Cell Spreading.” Int. J. Oral Maxillofac Implants. 2008 Jul-Aug: 23(4): 675-80
Figure 1. Reading this patient’s face tells you she has destructive bruxism and TMJ/orofacial pain.
Figure 2. Post treatment with Botox resolves her bruxism issues and allows restorative treatment to begin.
Figure 3. This patient is a bruxer who has worn down her maxillary teeth significantly and is missing some posterior teeth.
Figure 4. Digital periapical radiographs illustrate large broken restorations and caries present.
Figure 5. Radiograph shows more of the same including a significant loss of tooth structure on the cuspid due to bruxism.
Figure 6. Tooth #4 was deemed non-restorable and endodontic therapy treatment on #5.
Figure 7. Post operative radiograph of Hahn implants ideally placed.
Figure 8. Post operative CBCT images (Vatech America) of implant #3 in proper orientation
Figure 9. Post operative CBCT images (Vatech America) of implant #4 in proper orientation
Figure 10. After 4 months of integration, impression copings are placed into the internal design of the Hahn implants.
Figure 11. A radiograph is made to insure a complete seat of the impression copings.
Figure 12. A custom abutment is fabricated on #4 and a screw retained one piece Bruxzir crown and abutment is made for #3.
Figure 13. Occlusal view of the two implant crown in positon.
Figure 14. The final esthetic result is achieved by reducing excessive wear and using high strength restoratives.