Splint (Oral Orthosis) Adjustment, A Necessity?

Tags

Centric relation, condylar asymmetry recognition, Dentistry, Occlusal device, Occlusal splint, Retruded Position of the Mandible, Reversible treatment, TMJ rehabilitation

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?

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Prefabricated occlusal devices,mouth guards or splints

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Bruxism, Dentistry, Occlusal device, Occlusal splint, Retruded Position of the Mandible

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.

 

 

 

 

Oral Orthosis (splint) Failure

Tags

Asymmetry, Bruxism, condylar asymmetry recognition, Dentistry, Occlusal device, Occlusal splint, Oral Stability, Retruded Position of the Mandible, TMJ rehabilitation

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.

TMJ Condylar Asymmetry

Tags

Arthrogeneous origin of TMJ pain, Asymmetry, Asymmetry Index, Centric relation, condylar asymmetry recognition, Dentistry, Oral rehabilitation, Oral Stability, Orthodontics, Retruded Position of the Mandible, Temporomandibular joint diagnostics, Temporomandibular joint disorder, TMJ rehabilitation, Treatment planning

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?

Tags

Arthrogeneous origin of TMJ pain, Asymmetry, Asymmetry Index, Bruxism, condylar asymmetry recognition, Dentistry, Occlusal device, Retruded Position of the Mandible, Temporomandibular joint diagnostics, Temporomandibular joint disorder, Temporomandibular joint pain, TMJ rehabilitation, Treatment planning

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!?

Migraine or ?

Tags

Bruxism, Dentistry, Facial pain, Myogeneous origin of TMJ pain, Occlusal device, Occlusal splint, Retruded Position of the Mandible, Reversible treatment, Tension headache

Although the specific diagnosis of migraine is defined as a chronic neurological disorder characterized by recurrent moderate to severe headaches often in association with a number of autonomic nervous system symptoms it is often by our dental patients used as the general term for facial pain with often also no response to the prescribed medication. This experience I share with many colleagues and yet I have to tell you about the 36 years old man, who was referred for chronic left side facial pain he had suffered for 18 years, half of his life. He had visited many doctors and he had also been taking a lot of medication during the years.

The pain occurred almost every day and was described by the patient as migraine on the left side of his face covering the left side temple and cheek area. Mandibular movements were normal. A panoramic X-ray did not reveal any pathology and showed a temporomandibular joint condylar symmetry.Static pain could be provoked for closing of his mouth. During our conversation it became obvious that a left side latero-protrusion was an often used position for bruxism, which also could be confirmed by marked facets of his left side front teeth.

After information about the possibility to initially wear a stabilization splint part time ( during day time working hours )  in order to avoid his unilateral abuse of the left side mm temporalis and the deep portion of masseter he decided to try. The stabilization splint was designed around the retruded position of his mandible, inserted without any adjustments and checked after another 6 weeks. At that time the young man announced that he had been completely free from any facial pain since the day after the insertion of the splint. It had been worn during the day except for chewing. He also showed an oral stability without the splint in his mouth.

In conclusion: When the dental patient is telling about his or her migraine that is not responding to the, by the medical doctor, prescribed medication DO PERFORM A FUNCTIONAL EXAMINATION OF THE STOMATOGNATHIC SYSTEM. There might be a chance to help the patient and not only his or her teeth.

 

 

 

 

Indices for jaw registrations

Tags

Bruxism, Centric relation, condylar asymmetry recognition, Dentistry, Mounting casts, Occlusal device, Occlusal splint, Occlusion, Retruded Position of the Mandible, TMJ rehabilitation

Sometimes it can be difficult to get a relaxed mandible in the process of jaw registration in the retruded position of the mandible in as well the diagnostic phase as in the steps of treatment. It happens mostly when the patient is a heavy bruxer or when the patient seems to defend him/herself against the pressure from the hands of the dentist in the clinical situation. A condylar asymmetry may add to the clinical difficulty in getting the registration right.
With the measurements of the vertical dimensions of the temporomandibular joint condyles and the Maaxloc device at hands the above mentioned problems can definitely be reduced.It is my opinion, which to a great extent I have achieved from the dental technicians, that the registrations made in the Maaxloc system get into a more retruded position of the mandible in comparison with the manually taken clinical indices which often are protruded.This conclusion is based upon several years of cooperation with Ines Selimanovic T.I.C. laboratory, Malmoe ,Sweden, an experienced dental technician, with whom I have made comparisons of by me taken clinical indices and by her made registrations in the Maaxloc device.
In conc;usion: To avoid unnecessary and time consuming adjustments despite quality of the dental work in the ” difficult mouth “it might be worth while to become critical to the manually taken clinical registration and consider the advantage of the Maaxloc device.

TMJ Clicking Sound

Tags

Arthrogeneous origin of TMJ pain, Asymmetry, Centric relation, condylar asymmetry recognition, Dentistry, Myogeneous origin of TMJ pain, Retruded Position of the Mandible, Temporomandibular joint, Temporomandibular Joint Clicking, Temporomandibular joint diagnostics, Temporomandibular Joint Disk Displacement, Temporomandibular joint pain, Temporomandibular Joint Sounds

TMJ clicking sound has been reported, discussed, investigated and even visualized in thousands of articles during the past thirty and more years with a peak of interest in 1980-s. Common knowledge is that the sound is either due to deviations in form of the articulating surfaces of the condyle and / or the temporal component ( increase of cartilage in specifically overloaded areas of the articulating surface ) or to a displacement of the disk. Disk displacement often comes and goes and it is therefore not a surprise that it is more common among patients with a mainly myogeneous origin of pain. Since the result of comprehensive epidemiological  studies in the 1970-s it is also common knowledge that  the phenomena occurs in about 40% of the adult population.

Hopefully in not contributing to the too often clinically existing confusion of how to handle the sound I would rather suggest the following: Check the panoramic x-ray i.e. check specifically the temporomandibular joint condylar heights before you take any further steps in your attempt to help your patient!

Most probably you will find a shorter condyle of the joint with the registered clicking sound. Try to guide a mandibular rotation movement around the higher condyle and most likely the clicking sound disappears or at least gets a reduced  magnitude, when it is due to a latent disk displacement. If there is no discomfort or pain to be registered there is no real indication for intervention. However, if discomfort or a mainly myogeneous origin of pain is reported by the patient there is a need for an initially reversible treatment in form of a stabilization splint that compensates for the difference in vertical dimensions between the two condyles. The splint is to be worn part time . The patient is supposed to find a seemingly fast relief.  When the clicking sound is found in combination with a mainly arthrogeneous origin of pain the splint needs to be worn as much as possible for at least 6 months before additional permanent treatment is considered.

In addition , even if the clicking sound is due to a deviation in form ( of the condyle and / or of the temporal component )  the clicking sound may over time get reduced as a smoothening out of the articulating surfaces can be expected at a consequent long term  wearing of the correctly designed splint. Therefore I once again would suggest the use of the Maaxloc instrument in producing the index  which will be used in mounting the models into the articulator before the construction of the stabilization splint. The splint absolutely must compensate for the registered difference in vertical condylar height between the two joints in providing a symmetrical oral stability in order to eliminate the  painful and bothersome  tmj clicking.

Uneven Front Teeth Wear

Tags

Asymmetry, Bruxism, Centric relation, condylar asymmetry recognition, Dentistry, Occlusal device, Occlusal splint, Occlusion, Orthodontics, Preprosthetic occlusal adjustment, Retruded Position of the Mandible, Reversible treatment, Temporomandibular joint, Temporomandibular joint disorder, Temporomandibular joint pain, Treatment planning

may very well denote a temporomandibular joint condylar asymmetry and may therefore indicate the necessity of a panoramic x-ray in order to avoid negative consequences of a dental treatment. It is my experience that very often the front teeth ( the central and the lateral incisors ) of the quadrant of the ” higher condyle ” side are more worn than the equivalent teeth of the contra lateral side. The ” higher condyle ” side seems with a far more higher prevalence be used as the laterotrusive side ( working side ). The contra lateral side of the face then also looks bigger or thicker, most probably due to the unilateral hyperactivity of the superficial masseter muscle of that side. When this kind of an observation is made there is an absolute indication to proceed with a clinical examination in order to rule out whether pain or discomfort are involved.

If pain is present the stomatognathic system needs to get normalized. This is easily accomplished with the insertion of a correctly designed stabilization splint. The splint preferably already at the dental laboratory is  fabricated in the correct relation between the models i.e. the models have been mounted in an articulator according to the index ( registration ) made in the Maaxloc and thereby based upon the difference between the two condylar heights. Within a couple of weeks, not to say surprisingly often within a couple of days, the patient returns with markedly reduced pain or completely without pain. Also without any difficulties the patient normally finds his / her natural way in getting his / her teeth together. However,on the ” shorter condyle ” side tooth contacts are missing. This most often results in a slide between the mandibular reference position, RPM, and the intercuspal position and therefore often indicates a need for extended dental treatment or at least a change of direction of your earlier planned treatment.  The empty space between the teeth of the ” shorter condyle ” therefore needs to be filled in or the teeth of the ” shorter condyle ” side need to be built up. After four to six months and with a reversible approach in form of a partial and casted metal splint cemented on the not occluding teeth of the ” shorter condyle ” side oral stability is achieved. Personally I always have that splint casted in gold and made for the lower premolars / molars. The earlier worn stabilization splint is being adjusted to the new and reversible occlusion and is used part time, during sleep for an individually determined length of time. Finally permanent treatment can be considered at the choice of you and your patient.

Uneven front teeth wear occurs and is also sometimes observed in young patients.In these individuals it may be even more important to analyze the vertical dimensions of the two temporomandibular joint condyles. At a condylar asymmetry an index via Maaxloc may serve as an adequate guide to relate the upper and lower models of the teeth, indicating the correct vertical dimensions of the jaws after completed treatment and thereby contribute to the best outcome of the orthodontic treatment. In not addressing the condylar asymmetry, when present, in the initial phase of treatment planning there is always the risk to deliver a yet perfect occlusion but in a not perfect occlusal plane, i. e. a perfect smile what concerns the teeth but less perfect what concerns the smiling mouth of the whole face.

 

Reversible Oral Stability, One Splint and that’s it

Tags

Asymmetry, Bruxism, Centric relation, condylar asymmetry recognition, Condyle (anatomy), Dentistry, Occlusal device, Occlusal splint, Radiography, Retruded Position of the Mandible, Temporomandibular joint, Temporomandibular joint disorder, Temporomandibular joint pain

Through the insertion of a stabilization splint fabricated in the correct mandibular position i.e. in RPM(=),RPM(R) or RPM(L) it is easy ,not to say the only way, to confirm or justify the preliminary diagnosis of the complaint of facial pain.Needless to say , I take for granted that the mandibular position is determined from the analysis of the vertical dimensions of the two temporomandibular joint condyles visible in the panoramic x-ray. The values conclude with the difference in mm provided the technician with the impressions of the upper and lower jaws. Via Maaxloc you or your technician produce the index with which the models are mounted into the articulator of your choice. The splint is fabricated in hot curing acrylic and at a condylar asymmetry it will be somewhat thicker at the ” shorter condyle ” side ,as it is compensating what is missing in the vertical dimension of that condylar height. The splint does not need to be adjusted if your measurements and impressions/models are correct. It fits directly into the mouth of your patient. There are many hard and good working technicians who perfectly provide excellent splints. My opinion is that if the dentist needs to adjust a splint the error most likely must have happened in the clinical situation as the technician is working with the models of non changeable materials and correctly mounted in the articulator.

The patient is then to wear the splint depending upon the preliminary diagnosis. Full time use, 24 hours a day, except at eating at arthrogeneous origin of pain as the anatomical joint structures need support. Part time use of the splint, day OR night, at myogeneous origin of pain as the masticatory muscles needs to be interrupted in their hyperfunction  i.e. given the possibility to rest. I do think that the reason why even  perfectly fit splints do not give the patient any relief is that the splint is worn at the wrong time of the 24 hours. To wear a splint during sleep when bruxing occurs during the day does not make any sense to me. Just a change in the way the patient is wearing the splint may result in complete relief.

Personally I never prescribe soft splints. In my opinion they function as chewing gum due to their resilience and should be avoided in any bruxing situation. In conclusion, there is only one splint that also can be looked upon as universal . That is the conventionally made stabilization splint  ( the old Michigan splint ) fabricated around the correct mandibular position in RPM. No problem All continents !