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?

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.

 

 

 

 

Asymmetry Index ( AI ) for temporomandibular joint Condylar Asymmetry

Tags

Arthrogeneous origin of TMJ pain, Asymmetry, Asymmetry Index, Centric relation, condylar asymmetry recognition, Dentistry, Myogeneous origin of TMJ pain, Occlusal adjustment, Oral rehabilitation, Oral Stability, Retruded Position of the Mandible, Reversible treatment, Temporomandibular joint, Temporomandibular joint diagnostics, Tension headache, TMJ rehabilitation

For more than twenty years I have been working on a regular basis with Dr Ugo Gambardella, Medical Space in Seriate, Italy. In 1993 we founded the T.A.C. Seriate clinic, ( Team Approach to Craniomandibular disorders ) in order to optimize the diagnostics and treatment of patients suffering facial pain due to dysfunction of the stomatognathic system. Dr Gambardella was already then experienced in prosthodontics as well as in implantology.
Already at the start it became obvious to us that a large portion of the mostly referred patients showed a condylar asymmetry and a lack of oral stability. Initially our treatment aimed at a normalization of the stomatognathic system via a stabilization splint in its design compensating for the condylar asymmetry, when present, and providing at least a temporary oral stability. After 6 – 12 months several patients wanted to have permanent oral stability, which then was achieved through mostly prosthodontics , sometimes in combination with preprosthetic orthodontics.
Some years ago and then more than 5 years after completed treatment the patients were invited to have their situation evaluated and to tell how they felt and how they were functioning after treatment. The equivalent clinical examination of their stomatognathic system was executed by an Italian speaking colleague, who did not know what kind of treatment the patients had got or been exposed to. The teeth depicted in the panoramic overview X-rays were covered i.e. made not visible to the examiner while the two temporomandibular joints were shown.
The condylar asymmetry was analyzed and for each patient an Asymmetry Index ( AI ) was calculated according to the following formula: ( R – L : R + L ) x 100 i.e. the right side condylar height minus the left side condylar height divided by the sum of the right and left side condylar heights multiplied by 100. Thus an asymmetry index was expressed in percentage for each patient.
The results of the subsequent analysis showed that after more than five years with permanent oral stability no patient any longer was found with a mainly arthrogeneous origin of pain. Myogeneous origin of pain was also frequently eliminated or markedly reduced. All patients showed an increase of maximum mouth opening.
The patients were grouped and analyzed according to the asymmetry index ( AI ) . It can be concluded from the results that patients with an AI > 3 % in general benefit from reversible treatment. Patients with an AI in the range between 3 % and 10 % may do well with just a temporary oral stability in form of a stabilization splint i.e. the splint can be worn part time, which for most patients means during sleep. As the participating patients with an AI > 10 % definitely benefitted the most and also felt subjectively completely different, mostly totally pain free after the treatment it is our opinion, that when you find a condylar asymmetry > 10 % in a patient with a diagnosed facial pain, you can comfortably suggest permanent occlusal treatment after the initially reversible period in the correct mandibular position guided by the higher temporomandibular joint condyle. The permanent treatment then executed in the same mandibular position will provide oral stability.

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.