House of Gnathology part II

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On September 25th. 2016 I had the opportunity and  the great pleasure to attend the First Congress of the House of Gnathology in Turin, Italy.The Congress was the  successful result of two years preparation in gathering the different concepts of five different Italian societies regarding the approach in diagnostics and treatment of temporomandibular disorders.The initiative,taken some years ago, by Dr. Eugenio Tanteri involved the Associazone Italiana Gnatologia, the Accademia Italiana di Kinesiografia ed Elettromiografia Cranio Mandibolare, the Associazione Italiana Pedro Planas, the Società Italiana Disfunzioni ed Algie temporomandibolari and the Società Italiana Odontostomatologia dello Sport.

Each society was given ample time to present its ideas which ot course differed but were aiming towards general improvement in the daily work of the clinicians.It was even discussed to try to design a common  clinical examination protocol which could be promoted by any society in assisting the clinician in often difficult decisions.It is evident from listening to the colleagues that utmost few clinically useful examination criteria exist. Despite decades of attempts in  focusing on research diagnostic criteria for temporomandibular disorders their use in the clinical situation has not given any overwhelming impact on the daily work by the clinician.

I am looking forward to more cooperation between the researchers and the clinicians in the future and congratulate the House of Gnatholoy for this its first attempt in improving the care of thousands of suffering patients.

 

 

Splint (Oral Orthosis) Adjustment, A Necessity?

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Absolutely not! In my opinion it is the initial sign of a pure failure in the first phase of the reversible treatment i.e. when the registration of the mandibular position, in which the device is going to be made, is taken.At the presence of a temporomandibular joint condylar asymmetry the higher condyle must be the guide in the registration. If this is not applied the splint will not provide bilateral oral stability and disturbing contacts will be the result.The never-ending trips to the dentist is being started.
A correctly made splint does not need any adjustments. It is a matter of how and when to wear the splint that will give the expected success.
There is one thing I cannot avoid to comment due to its absurdness. It was told in a discussion by a specialist in the field of facial pain that every splint needs to be adjusted regardless its fitness to the opposing jaw. Splint adjustment should show the patient the engagement and the involvment by the dentist. In other words, How stupid is that?

Too many adjustments on the dental work?

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Take a new panoramic X-ray or reevaluate the most recently taken one! Compare the vertical dimensions of the two temporomandibular joint condyles on the Ramus tangent. If they are not of equal height, start all over again and choose the higher condyle as the guide for your registration of the mandibular position to be used in the rehabilitation. In my opinion there is no other way to get the problem solved.
Merry Christmas and hopefully much less frustration and less adjustments in the Happy New Year!

Prefabricated occlusal devices,mouth guards or splints

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should in my opinion not be recommended or not even be considered. If there is a need for the above mentioned appliances there is always to be a diagnosis that can support their therapeutic aims. The dentist is the person who is qualified for the decision to be made before any intervention into the oral cavity. It is also of great importance that the oral device is made or fabricated in the correct mandibular position or in the correct relationship between the two jaws.

Most often the indication for an occlusal device is that the patient ( person in pain) is lacking an oral stability, which is being described by the patient as he/she does not know “how to bite”. This is mostly the reason why the patient is searching for a stable occlusion and this seems too often to  be the reason for the bruxing, used in advertisement as the indication for testing the prefabricated oral device.

When a prefabricated oral device is being applied or tried out by the patient him/herself the following is most likely to occur. The patient is biting into a mandibular position recognised and commonly  used as the bruxoposition. In other words, the patient does not get a new symmetrically balanced occlusion on the device. The search for stability will therefore go on. Another disadvantage with the kit for a prefabricated occlusal device is the softness of the material to be used.A soft material between the upper and lower jaws in a bruxer seems to function more as a resilient chewing gum instead of creating an oral stability. Thereby  the bruxing will continue and sometimes even increase. In conclusion, the promised relief in using the prefabricated splint will never occur.

A functioning splint definitely needs to be designed, checked, delivered and monitored by the dentist.

 

 

 

 

Splint adjustments

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do not seem to be too efficient as once the first one has been performed the next one mostly come very soon thereafter often requested by the patient. Too many dentists fall into the trap and after three to four visits the splint does not look the way it originally was supposed to look and/or function.

In my opinion, when the splint is fabricated in the correct mandibular position, it does not need any adjustments. It only needs to be worn during that time the patient is bruxing. Some patients need to wear the splint during the day. Others need to use the splint during sleep. If the patient belongs in the category arthrogenous origin of pain the splint has to be worn full time except for chewing.

One reason for the initially not comfortable or not efficient occlusal device is most probably that it is made in the wrong mandibular position. One major cause is that an existing temporomandibular joint condylar vertical asymmetry ,when present, has not been taken into account at the design of the splint.

It is my experience and sincere advice that no single occlusal device or splint should be made unless the temporomandibular joint condylar (a)symmetry. has been analysed and determined.

Oral Orthosis (splint) Failure

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is a fact when the patient does not get any relief despite a faithful wearing of the splint. Numerous adjustments made by the dentistIt are reported by many patients and yet no positive result. It is my clinical experience and it is therefore my opinion that the failure is mostly due to an unsuccessful registration of the mandibular position in which the orthosis is supposed to be made as most orthoses seem to arrive from the dental laboratory in perfect condition. This unfortunate dilemma seems to happen very often when the intercuspal position has been chosen in the registration at the presence of a vertical temporomandibular joint condylar asymmetry.

To avoid unnecessary disappointments and frustrations for both parties (patient and the dentist) I therefore would like to emphasise the importance to recognise the vertical dimensions of the two temporomandibular joint condyles.The analysis of a panoramic X-ray is an easy tool to use. At a vertical dimensional difference between the two temporomandibular joint condyles the difference can easily be transferred into the Maaxloc by Dentatus. That instrument visualises the vertical difference in the intermaxillary relation between the the two sides of the mounted casts at the occlusal level and thereby may assist in finding the clinically correct mandibular position for the fabrication of the oral orthosis. In this way the thickness of the orthosis may be different between the two sides of occlusion. What is missing in vertical dimension on the shorter condylar side must be compensated for at the level of the teeth.Much less adjustments of the orthosis may be the result not to say adjustments of the orthosis will not be necessary at all.

Common Core in Dentistry?

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Most likely it is the tooth. However, in 2015 that is neither good nor professional  enough. It is my opinion that it should be expanded to at least encompass the function of the whole masticatory system and to realise the importance of maintaining its bilateral uniqueness. In doing so the dentist, in the diagnostic phase as well as in the therapeutic phase, may enter into the dilemma of how to handle the treatment when the two temporomandibular joint condyles are not identical regarding their vertical dimensions.

In order to restore the occlusion and provide an oral stability with an optimal masticatory function the correct mandibular reference position needs to be found. At a temporomandibular joint condylar vertical asymmetry it may clinically be difficult to manually manage. The Maaxloc instrument by Dentatus should therefore be recommended. It assists the clinician in finding the mandibular position to be used in the rehabilitation, in guiding and directing the mandibular function around the higher and mostly normally developed temporomandibular joint condyle. Not considering a temporomandibular joint condylar vertical asymmetry, when present, is devastating  for the patient and the dentist.

Occlusal Adjustment at a TMJ Condylar Asymmetry?

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Be careful! The tooth contacts which seem to be occlusal interferences at the first sight when the conventional retruded contact position of the mandible is being executed may not be disturbing tooth contacts at all. If they are located on the higher condyle side they may denote the vertical dimension of the inter maxillary relationship and should in my opinion not be removed. Only precontacts on the shorter condyle side are to be looked upon as true interferences and can be removed to such an extent that tooth contacts are established on the higher condyle side.

With the risk of repeating myself I  do want to advise the clinician to build up the occlusion on the shorter condyle side instead of adjusting the teeth through occlusal adjustment on the higher condyle side.In this way we will secure a correct vertical dimension between the two jaws in occlusion and thereby rescue the patient from a too low vertical dimension of the occlusion after completed dental work often jeopardising the function the temporomandibular joints.

TMJ Condylar Asymmetry

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when present,is a must to consider, in any dental rehabilitation. I dare to have this opinion after more than three decades of experience in treating ” asymmetrical ” patients shared with several successful colleagues. Although I repeat my opinion   it seems relevant as we on a regular basis are exposed to excellent crowns, bridges,supra constructions on implants and even completed orthodontics and yet a not satisfied patient.The chosen mandibular position for the rehabilitation in the majority of these patients has not been correct.

Results of recent research performed in different countries indicate that the mechanics of the temporomandibular joint is essential in order to maintain a pain free and functioning stomatognathic system (Quintessence International Symposium, Scottsdale,Arizona February 6-7, 2015). Overloading of the joint seems  not only to jeopardize the intraarticular structures of the joint resulting in anything from internal derangement to osteoarthritis but also to be the trigger for masticatory muscle pain.

At a vertical temporomandibular joint condylar asymmetry the loading of the two joints is in danger as the vertical dimensions of the two condyles are not equal. Therefor the vertical dimensions of the two temporomandibular joint condyles need to be analyzed before any treatment is initiated. It is of utmost importance to determine the highest condyle as at an asymmetry  this condyle has to be the guide for the mandibular movement of  rotation(the Retruded Position of the Mandible)in which the rehabilitation is going to be executed.

Additionally,in patients with functional facial pain it sometimes might be difficult to clinically manipulate the mandible into the correct position for rehabilitation. At such occasions the result of the vertical condylar analysis in the panoramic X-ray easily can be transferred into the Maaxloc device by Dentatus, in which the index for the mandibular position of the planned rehabilitation is made.

TMD 2015, Condylar Asymmetry?

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Reflecting back on the interesting information given by eighteen well known international speakers at the Quintessence International Symposium on TMD & FACIAL PAIN and HEADACHE, Bridging the Gap Between Current Research and Clinical Practice in Scottsdale Arizona ( February 6-7,2015, Co-Chaired by Drs Daniel M.Laskin and Charles S.Greene ) I once again would like to stress the importance to recognize a temporomandibular joint condylar asymmetry when present. Several speakers stressed the overloaded temporomandibular joint as the cause of TMD and advised to pay less attention  to the masticatory muscles initially at  the examination of TMD pain. Lack of synovial liquid and mini ruptures or even nano ruptures of the joint tissues are to be looked upon as causes for cartilage degeneration with osteoarthritis / osteoarthrosis as the end result.

It is my opinion that in combination with bruxism a temporomandibular joint condylar asymmetry needs to be acknowledged and addressed. The shorter condyle side joint is in its morphology unstable and easily develops internal derangement of its articulating parts.  The well known phenomenon of disk displacement is thereby a fact and the first step in joint break down with the diagnosis Arthritis microtraumatica art.temp.mand. In this perspective occlusion becomes extremely important . The shorter condyle side joint needs to be supported with the correct vertical dimension of occlusion. What is missing in vertical dimension inside that joint needs to be compensated for at the level of the teeth of the ipsilateral side. In my mind this is the only possibility to create a stable occlusion with the maintenance of improved joint function after the initially reversible approach with an orthotic device.

Finally a statement/question that might need some thoughts: How much longer are we as a profession going to talk about occlusion without considering the vertical dimension of the two temporomandibular joints!?