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This article details a case report of a subject chosen from among patients treated in the author's clinic in the Posturology and Gnathology Section of the University Milano-Bicocca. It shows how the indispensable clinical analysis of the stomatognathic system and the connections between posture can be supported by instrumental analysis, such as the computerized occlusal analysis system and the force platform, to diagnose and treat dysfunctional patients.
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A. Baldini
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Annali di stomatologia
occlusal splint
Clinical and instrumental treatment of a patient with dysfunction of the stomatognathic system: a case report
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Case Report
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A. Baldini
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occlusal splint
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Clinical and instrumental treatment of a patient with dysfunction of the stomatognathic system: a case report
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0373 2 Clinical_Baldini:-      30-11-2010       18:55     Pagina 2




               Clinical and instrumental treatment of a patient
               with dysfunction of the stomatognathic system:
               a case report




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               Alberto Baldini, DDS                                             analysis (3), this may improve the clinical symptomatology
                                                                                of some patients.
               University of Milan-Bicocca                                      Following the most modern gnathologic approaches, the
               Dental Clinic (M. Baldoni)                                       stomatognathic system, which forms part of the postural
               Posturology and Gnathology Section (A. Baldini)                  system, is treated holistically (4, 5, 6, 7).




                                                                                                           zi
                                                                                Occlusion, however, is considered the pivot of both diag-
               Corresponding author:                                            nostic and therapeutic dentistry and the most recent sci-
               Dott. Alberto Baldini                                            entific research, which connects the craniocervical system




                                                                                            a
               “Centro Medico Polispecialistico Baldini”                        with the rest of the organism, requires a much more de-
               Via S. Orsola, 5                                                 tailed analysis of cranio-mandibular occlusal relationships




                                                                                         rn
               24100 Bergamo (Italy)                                            (8, 9, 10).
               Tel +39 035/691247                                               This case report shows the clinical-instrumental ap-
               Fax: +39 035/694280                                              proach carried out at the Posturology and Gnathology Sec-
               E-mail: alberto.baldini@unimib.it                                tion of the Dental Clinic of the University Milan-Bicocca,




                                                                                te
                                                                                following the clinical and instrumental protocols which have
                                                                                also been suggested by other authors (11, 12).
                                                                                In this case, in particular, the T-Scan and the force plat-
                                                                                form were used to treat a dysfunctional patient, who need-
               Summary
                                                                      In        ed to stabilize or balance occlusion using a splint. The ef-
               Clinical and instrumental treatment of a patient with            fectiveness of the treatment was verified using clinical and
               dysfunction of the stomatognathic system: a case re-             instrumental methods to document and confirm the im-
               port.                                                            provement of the clinical case following the protocols for
                                                                                the instruments used which were suggested by interna-
                                                         ni
               This article details a case report of a subject chosen           tional literature (13, 14, 15, 16, 17, 18).
               from among patients treated in the author's clinic in the
                                                                                The instrumental analyses do however have limits (19, 20,
               Posturology and Gnathology Section of the University
                                                                                21, 22, 23) and cannot replace, but merely be integrated
                                               io

               Milano-Bicocca.
                                                                                with the fundamental clinical analysis which must be car-
               It shows how the indispensable clinical analysis of the
                                                                                ried out according to the standards dictated in international
               stomatognathic system and the connections between
               posture can be supported by instrumental analysis,               literature (24).
                                      iz



               such as the computerized occlusal analysis system and
               the force platform, to diagnose and treat dysfunctional
               patients.                                                        Clinical case
                      Ed




               Key words: computerized occlusal analysis, posture,               A 55 years old female patient suffering from a regular
               force platform, occlusion, occlusal splint.                      (every day), spontaneous pain due to mastication in the
                                                                                right region of the masseter, with muscular tension inducing
                                                                                cephalea in the right frontal region 2 or 3 times a week,
                                                                                was referred to our department. This pain started 4 years
               Introduction                                                     ago, when a prosthetic rehabilitation on implants was in-
         IC




                                                                                serted in the right upper arch (Fig.1). The patient also suf-
               During the “Consensus Conference ”, held in Milan in 1997        fered from frequent cervicalgia.
               (1), it was reported that there was no scientific evidence       We started with the gnathological postural check-up, which
               to support a connection between occlusion and posture.           includes: static postural analysis via scoliometer (Fig.2) and
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               Thus, using occlusal treatment to prevent postural prob-         podoscope, evaluation of the skeletal and dental relations
               lems would not be justifiable . Other scientific articles have   (Fig. 3), showing the occlusal parameters with the pres-
               also reached this conclusion (2). During another “Con-           ence of crosses and dental inversion. We then made 3D
               sensus Conference” in 2008, was stated that the most re-         and 2D (Fig. 4) occlusion images with the T-Scan (T-Scan
©




               cent scientific literature provided weak evidence supporting     III,Tec-Scan, Boston Usa, Dl Medica, Milan, Italy). These
               the connection between posture, occlusion and the neu-           showed the occlusal loads to be distributed somewhat
               rophysiological integration of the body’s mechanism (3).         asymmetrically (60% on the right and 40% on the left) with
               Both orthodontists and physiatrists participated in the Con-     particular overloading at the right posterior section, as
               sensus which advised treating dysfunctional patients             shown also on the force/time diagram (Fig. 5). The dy-
               with a reversible (and, thus, not irreversible) gnathologi-      namical evaluation of the occlusal load distribution demon-
               cal postural treatment. After a correct, specific diagnosis      strated significant premature occlusal contact at the lev-
               has been made, which is supported by careful clinical            el of 14 in a temporal sequence, with an occlusal time of

               2                                                                                         Annali di Stomatologia 2010; I (2): 2-5
0373 2 Clinical_Baldini:-       30-11-2010         18:55      Pagina 3




               Clinical and instrumental treatment of a patient with dysfunction of the stomatognathic system: a case report




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               Figure 1 - Orthopantomography with the implant for prosthetic
               rehabilitation at the level of 15 and 16 visualized.




                                                                                                  a                zi
                                                                                     Figure 4 - 2D display of the asymmetry of the occlusal loads on
                                                                                     T-Scan III, right section with 60% of the load on the right and 40%




                                                                                               rn
                                                                                     on the left.




                                                                                     te
                                                                            In
                                                                                     Figure 5 - Asymmetry of occlusal loads.
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                                                  io
                                        iz
                       Ed




               Figure 2 - Static, postural evaluations on scoliometer, with slight
         IC




               postural asymmetry.                                                   Figure 6 - Posturometry on force platform with accentuation of
                                                                                     the projection of the loads towards the back and torsion in cen-
                                                                                     tric occlusion.
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                                                                                     0.876 seconds more than the physiological average. The
                                                                                     computerized occlusal analysis was carried out detecting
                                                                                     the centric contact points and the contact between the pa-
©




                                                                                     tient’s dental arches was checked 3 or 4 times in order
                                                                                     to check the repeatability of the test (16, 17, 29).
                                                                                     Using the Force Platform Correkta (Dl Medica, Milan Italy)
                                                                                     in the physiologic rest position, we observed that the loads
                                                                                     projected slightly towards the back with torsion. This was
                                                                                     emphasized in centric position (Fig. 6) as if occlusion wors-
                                                                                     ened postural balance. Inserting cotton rolls in the oral cav-
               Figure 3 - Intra-oral picture, right section with cross of 23/33.     ity seemed to improve the postural position (Fig. 7).

               Annali di Stomatologia 2010; I (2): 2-5                                                                                                3
0373 2 Clinical_Baldini:-       30-11-2010         18:55       Pagina 4




               A. Baldini




                                                                                                                          i
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                                                                                       Figure 9 - On the force-time diagram the red and green lines co-
                                                                                       incide, as a result of arranging the loads symmetrically between
                                                                                       the two hemiarches after the insertion of the splint.




                                                                                                                      on
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               Figure 7 - Posturometry on force platform with improvement of
               the postural position inserting cotton rolls in the oral cavity.




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                                                                                       Figure 10 - Improving the postural balance measured on force
                                                                             In        platform Correction with the splint inserted in the oral cavity.



                                                                                       After 4 months of wearing the splint, the masseter pain had
                                                              ni
                                                                                       significantly lessened , the cervical pain had stopped and
                                                                                       the frequency of the bouts of cephalea had reduced.
                                                                                       The same clinical and instrumental improvements were ob-
                                                                                       served stable at 6, 9, and 12 months.
                                                   io


               Figure 8 - Best positioning of the occlusal centre of force (COF,       Discussion and conclusions
                                        iz


               little red and white dot) with the splint inserted in the oral cavity
               and a better distribution of the occlusal loads between the right
               and left hemiarches.                                                    Our experience in treating dysfunctional patients shows
                                                                                       that a clinical and instrumental approach is best suited to
                       Ed




                                                                                       diagnose and treat patients who often present postural and
                                                                                       occlusal problems. These instruments are able to quan-
               As according to force platform protocol, the postural sta-              tify and measure the obtained gnathological postural bal-
               bilometric analysis was carried out with eyes opened and                ance. However the instrumental analysis cannot replace,
               closed, in rest position, in centric occlusion and with cot-            but merely supports the essential clinical analysis carried
               ton rolls ensuring subjects are in orthostatic state, with the          out according to international standards (RDC/TMD) in di-
               patient’s arms by her sides in a relaxed fashion, with feet
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                                                                                       agnostic literature (18, 24, 28, 29).
               slightly apart forming a 30° angle and heels 2 cm apart.
               (18)
               The patient was advised to have a Michigan stabilization
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               Annali di Stomatologia 2010; I (2): 2-5                                                                                                         5
