First equilibration

 Did what I would call my first equilibration recently. Technically in the purest sense of equilibrations I have done a few by building patients up who have lost vertical in a balanced position but this was the first reductive equilibration where the patient had a significant improvement very quickly.

 The situation was the boss had done a small restoration on the distal surface of the 28 and the patient said things hadn't felt right after that so I was immediately thinking it was an interference in centric relation bite. I quizzed her more and she explained there was a strange feeling, not a pain but a discomfort that didn't feel right when she chewed sometimes but not all the time. Anytime patients describe this difficult to describe phenomenon, I think of an occlusal imbalance until proven otherwise. She also complained of halitosis that started after the filling which I chalked down to food packing (which I discounted) and mild periodontal disease or sinusitis as a cause.  

I took a leaf gauge and started to open her up, at 1.0mm she reported no contacts so I kept closing her down and there was nothing happening. What I learned is that it is important that they are biting posteriorly and in the action of retrusion so I got her to protrude on the leaf gauge then retrude then clench. Magically she had left hand side contact at 1.0mm, nothing at 2.0mm then I closed her down to first contact at 1.6mm. I took out the articulating paper and got her to retrude on it at 1.6mm but there was nothing at the 28. Confused, I moved the the 25 and there was a strong contact on the mesial incline of the palatal cusp corresponding with a massive wear facet. It turns out the patient kept localising the 28 as the source of her problems because it was apparent to her that her issues started after placement of the restoration whereas they were probably present for many years on and off. She is a chronic day and night bruxer, intensely brachyfacial with massive masseters and often wakes in the middle of the night with a sore jaw and a headache.

With the patient's permission, I took a polishing bur and dusted the surface of the wear facet with immediate improvement. The patient was very surprised that everything felt more even and things pretty much felt normal after 1 second of work. I used the leaf gauge again and was surprised to find that she was now contacting at 0.4mm at the mesial aspect of the same wear facet where I had missed with the bur. I adjusted this and she went to even contact at 0.1mm which was pretty much even. 

As this interference is on a non axial incline, the patient is shifting her jaw to the side (left) from centric relation to maximal intercuspal position. therefore, small adjustments in the interference will result in very large changes to the vertical position. If the interference is on an axial position e.g cusp tip or fossa, you will need to remove almost the same amount of vertical tooth structure to have the same change in vertical position. 

Simple procedures like this, efficiently diagnosed and implemented can raise the patient's confidence in you significantly and it was vital in this case that I listened to the patient to get my diagnosis before I checked the teeth but also harboured some skepticism and check other teeth than what the patient was indicating.