Tinnitus and TMJ condylar asymmetry

Tags

condylar asymmetry recognition, Occlusal splint, Oral rehabilitation, Oral Stability, Retruded Position of the Mandible, Tinnitus

It seems, as if patients with tinnitus show a large lateral deviation of the mandible between the retruded position of the mandible and the intercuspal position, there might be a chance to influence the bothersome sound. A panoramic X-ray easily confirms or rejects the presence of a vertical temporomandibular joint condylar asymmetry. At an asymmety the lateral deviation of the mandible mostly occurs in the direction towards the “shorter” condyle side with that side condyle being forced upwards and backwards in the intercuspal position.
A stabilization splint fabricated in the correct mandibular position i.e. when the position is guided by the “higher” condyle and thereby making the splint thicker on the “shorter” condyle side and thus compensating for what is missing in vertical condylar dimension might be one solution to try. The splint is to be worn as much as possible. An immediate response is also most often not to be expected.
Thinking back of many patients my experience has been that many patients do not immediately feel a difference regarding their tinnitus. However , faithfully wearing the splint for a couple of weeks to months many patients have reported definitive relief. If so, the permanent solution of their problem may be to establish an oral stability via additional dentistry.

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.

Tinnitus and TMD

Tags

Asymmetry, condylar asymmetry recognition, Dentistry, Occlusal device, Occlusal splint, Oral Stability, Temporomandibular joint disorder, Tinnitus, TMJ rehabilitation, Treatment planning

Tinnitus in itself is not an indication for dental intervention. However,if tinnitus is mentioned at an examination of facial pain of either myogeneous or arthrogeneous origin there may be a chance to influence its existence. After reviewing some records of patients some years ago and present experience it is my opinion that it is about one third of the patients suffering tinnitus and TMD who will notice a reduction or even a total elimination of their tinnitus from oral stability initially from a stabilization splint compensating for a temporomandibular joint vertical condylar asymmetry, when present.

As it was just one third who reported a benefit regarding their tinnitus it must be up to the patient to decide if it is worth while to invest in an oral device fighting tinnitus. Objective information regarding a dubious result should precede the decision. It is also  important to tell the patient that very often the relief from tinnitus does not come immediately after the insertion of the device. It is reported by several patients that it could take a couple of months before they noticed a difference in their tinnitus. In conclusion: When a stabilization splint is being delivered  in trying to influence a tinnitus the patient might have to wear the splint several months before a change occurs  and before one actually knows if it was beneficial or not. 

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.

Sleep Apnea Oral Devices

Tags

Arthrogeneous origin of TMJ pain, Asymmetry, condylar asymmetry recognition, Dentistry, Myogeneous origin of TMJ pain, Occlusal device, Sleep Apnea, Sleep Apnea Device, Temporomandibular joint, Temporomandibular joint diagnostics, Temporomandibular joint dysfunction, Temporomandibular joint pain, Treatment planning

Nowadays MAD, the mandibular advancement device, seems to be delivered from almost every dental office in an effort to assist the medical profession fighting sleep apnea, a major problem for many of our patients. The device is supposed to direct the mandible forward and inferiorly in order to increase the air flow through the mouth. However, a standardized method in making the device seems lacking and many patients suffer discomfort or pain after wearing the device after various lengths of time. Dentists regularly also register changes of occlusion, most often posterior open bites.

As the device shall position the mandible forwards the most often clinically achieved index accompanying the impressions to the laboratory must be taken in a protruded mandibular position. But how much protrusion seems to be left at random. There are studies concluding that it does not matter whether the protrusion is 75% of maximum protrusion or only 25%. Nevertheless it seems accepted to allow a rather large amount of protrusion as additional protrusion as adjustment of the device  often is recommended in the cases where the originally designed device has not given the expected relief.

At a vertical temporomandibular joint condylar asymmetry an excessive and prolonged protrusion definitely puts the comfort of the patient and a  harm free function of the stomatognathic system at risk. At a vertical condylar asymmetry most likely the clinically taken index does not register the mandible in a symmetrically protruded mandibular position. Most likely the mandible is deviating towards the ” shorter ” condyle side. To then have this position maintained during six to eight hours of sleep with thus an awkward  and asymmetrical muscle function and temporomandibular joint condylar positions may be one reason for discomfort or facial pain at awakening.

One way to avoid the problem is to use the Maaxloc ( following the analysis of the vertical condylar heights in the panoramic x-ray ) in constructing the index which is to be used in the mounting of the models in the articulator. It is then easy to bilaterally just set the amount of individually determined protrusion to be applied in the fabrication of the device. A symmetrical protrusion is thereby achieved resulting in a more comfortable device.

A good friend of mine, Dr Staffan Lindholm, Stockholm, Sweden, is probably one of the most experienced dentists in Scandinavia when it concerns oral devices  in fighting sleep apnea. His expertise and unusual self criticism already several years ago  motivated him to compare the outcome of 59 conventionally and from just clinically taken indices  oral devices with another  59 devices constructed from articulator set protrusion of the models mounted with the Maaxloc registration. Six patients of the first group suffered pain and discomfort from  their devices while only 1 patient of the second group showed a minor dissatisfaction, but tolerated the splint. The 6 not successful devices in the first group of  patients were later adjusted according to a Maaxloc registration resulting in patient satisfaction.

In many discussions with fellow dentists and dental technicians Dr. Lindholm  proclaims the superiority of the Maaxloc instrument in constructing a more comfortable  and successful oral device. He is happy to generally tell about his continuing success with a 80-90% reduction of the risk to develop discomfort or pain in the patients who are forced to wear an oral device fighting sleep apnea by using the Maaxloc registration in mounting the models before its fabrication in the laboratory . In conclusion, please do consider a correct index in protrusion for the construction of any anti sleep apnea device at your choice and thereby enjoy a major increase of clinical success!