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?

Prefabricated occlusal devices,mouth guards or splints

Tags

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.

 

 

 

 

Splint adjustments

Tags

Asymmetry, Centric relation, Dentistry, Myogeneous origin of TMJ pain, Occlusal device, Occlusal splint, Oral Stability, Retruded Position of the Mandible

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

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.

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.

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. 

Mounting casts

Tags

Asymmetry, Asymmetry Index, Centric relation, condylar asymmetry recognition, Dental laboratory work, Dentistry, Mounting casts, Occlusal adjustment, Occlusal device, Occlusal splint, Occlusion, Oral rehabilitation, Oral Stability, TMJ rehabilitation, Treatment planning

The other day I had to check the mounting of the casts of the upper and lower jaws of a patient with a condylar asymmetry of about 6%. The reason for my visit to the dental laboratory was that the right side lower four units bridge had been redone and several times before that adjusted. And yet the patient found it too low i.e. her teeth of her right side did not contact in occlusion unless she  forced her mandible to the right.

During the visit at the laboratory it became once again obvious to me from the discussions with two well experienced dental technicians that very often the indices to be used in mounting the casts cannot be used. The indices are perforated and mostly show slides in the material used indicating that the mandible of the patient has not been stable at the time of index registration.  Therefore the technicians try to analyze different facets of the occlusal surfaces of the casts. They try to fake the movements of the patients mouth that have created them and thereafter, still manually, they fix the casts in the position which seems to  be the starting point for the suspected movement.This position usually is looked upon as the intercuspal position and will be used for the subsequent mounting of the casts.

At a condylar asymmetry it is therefore easy to understand that with the above described mounting of the casts the crowns or bridges of the ” shorter condyle ” side will be too low. Clinically oral stability will be lacking despite the insertion of the prosthodontic work. Very often tooth contacts of the ” higher condyle  ” side will be looked upon as occlusal interferences and removed in an ” adjustment “.This actually results in a decrease of the vertical dimension and a not one hundred percentage satisfied patient.

The problem and frustration can easily be avoided if the vertical condylar asymmetry is transferred into the Maaxloc instrument. A registration at the clinic or at the laboratory is made  and used in mounting the casts with the result that mostly the prosthodontic work can be inserted  without any adjustment at its delivery.

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!