A protocol for the Treatment of Temporomandibular Disorder James e metz, dds, Diplomate abdsm mickey c harrison, dds the Metz Center for Sleep Apnea



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Stress Test by Loading, Resulting in Primary Site Stimulation

(“A Basic Orthopedic Principle for Diagnosis”)

Technique: Anterior Deprogramming Device

Time: .5-7 minutes

Muscle Activity: Temporalis contracts (Bilaterally)

Superior head of lateral pterygoid contracts (Bilaterally)

Inferior head of lateral pterygoid stretched to relaxed length (Bilaterally) TMJ Impact: Compression/Loading of the condyle disc assembly and joint structures




NO PAIN – NOT TMD






PAIN – TMD

Starts WITHIN .5 – 7 Minutes



Stop biting

Pain Lingers Over Joint Compartment (TMJ) (Capsulitis, Synovitis, Arthritides, or Nonreduceable Disc)

Stop biting

Pain Subsides (Muscle) Educate the patient and cycle the muscle (Home Care Instructions)



Muscle
Splint of choice:

Anterior Appliance


Wear time: Only at night
Mechanics: Physical therapy for the lateral pterygoids. Ensures Anterior Disclusion!

Joint
Splint of choice:

Pivotal Appliance (Always Bilateral)
Wear time: 24/7 for one month but Never while eating. After first month gradually reduce daytime wear until symptoms abate (6 months to 1 year).

Splint will require an adjustment each month.

Stress test by loading the TMJs to

confirm healing (10 Minutes).
Mechanics: Unloads and decompresses TMJ.




Anterior Deprogrammer Stress Test Technique22 23


  1. Place the anterior deprogrammer at midline between the maxillary and mandibular central incisors22 23 24.

  2. The patient first protrudes, then retrudes the mandible to its most posterior position. The patient bites with constant, substantial pressure on the anterior deprogrammer.

  3. During the entire test, no posterior tooth can touch. An excessive number of leaves should not be added to accomplish the separation of the posterior teeth. If 5 to 10 additional leaves (beyond first contact) are used, that should be sufficient.

  4. Most TMD patients exhibit symptoms from the damaged tissue within .5 to 7 minutes24.

  5. During the test, ask the patient, “Is this a familiar pain?” It must be similar to their “headache,” for which they are seeking treatment, to qualify as a familiar pain. The intensity of the headache may not be the same but the character will be familiar.

  6. The familiar pain must be the patient’s chief complaint.

  7. The stress test changes to alternately biting for 6 seconds and resting for 6 seconds after pain develops.

  8. The pattern continues for several minutes or until the pain subsides. Generally, the pain will subside within the ten minutes.

  9. If pain starts in the joint and remains in that area after seven minutes the pain will only get worse. Stop the test. The pain will not subside.

  10. Never ask a patient to continue beyond their endurance. Place warm, moist towels on affected area for comfort.

The Key: Once the patient reproduces the chief complaint, the test does not need to be continued. The diagnosis of TMD has been made, and an appliance is appropriate.


Advanced Understanding:
Steps 7-10 are physical therapy. If the TMD complaint is minor muscle pain or if the patient does not desire an anterior appliance, the stress test technique may be used at home by the patient two times each day to control symptoms (early AM and late PM). The therapy technique will only make the TM joint patients more uncomfortable, therefore it is only recommended for muscle patients.

ANTERIOR APPLIANCE

STRESS TEST TECHNIQUE

The Anterior Appliance is both a diagnostic and therapeutic modality. The appliance must be adjusted properly for the test to be valid. The chief advantage of the Anterior Appliance over the Anterior Deprogrammer is that the patient does not have to be subjected to the “creation of the headache,” but the practitioner must first understand the anterior deprogrammer concept. The appliance stretches the lateral pterygoid (both superior and inferior heads) over a longer period; and, normally, the patient does not experience the pain of cramping. dsc00184


Three outcomes are possible with the Anterior Appliance, worn for diagnostic purposes, after two weeks of wear:

    1. The patient feels no difference – TMD is not the patient’s source of pain.

    2. The patient experiences pain in or around the ear, which does not go away after two weeks – switch to Pivotal Appliance.

    3. The patient feels significantly better after a two-week period of wearing the Anterior Appliance – great!


Mechanics of the Anterior Deprogramming Device and Appliance:

Utilizing the muscles of mastication and guide planes one can take advantage of force vectors to stretch the lateral pterygoid (superior and inferior head) and seat the condyle. These actions can be done with either the anterior deprogrammer or anterior appliance. If either is placed between the central incisors with no posterior tooth contact and the patient bites -- an anterior superior movement of the condyle must occur25 26. The anterior deprogrammer does this quite easily but the anterior appliance must be adjusted properly to achieve this goal. Refer to anterior appliance adjustment.



picture1c:\cyc\leafgauge.bmp

Please note the force vectors, if the anterior teeth are brought into contact without posterior tooth contact.

Superior head of lateral pterygoid is stretched.

Inferior head of lateral pterygoid is stretched.

The condoyle is forced to assume a more superior, anterior position.

The disc is compressed.

The anterior appliance decreases the mechanical stress on the masticatory system. However, if the TMJ is the source of the pain, the anterior appliance will increase the pain in or around the ear. If the joint is the problem, the use of the anterior appliance should be discontinued. The use of the pivotal appliance is indicated.


A Review of the Flow Chart

NO PAIN – NOT TMD


Refer patient or find a cause other than TMD.
The patient will only feel tired and no duplication of pain will happen. No pain is a sure indication that TMD is most likely not the problem.
Exception – If the test is negative, ask the patient if he/she is in a headache cycle now? If not, the test should be attempted again during a headache cycle. The variable nature of the bruxism can cause muscle pain to come and go.


PAIN – TMD

Starts WITHIN .5 – 7 Minutes

TMD is the diagnosis



Pain (chief complaint) is duplicated within 3 to 7 minutes, and stops if the patient releases. Most TMD patients fall into this category27 28.

Treatment: Anterior Appliance


Stop biting

Pain Subsides (Muscle)

Educate the patient and cycle (refer to page 21) the muscle

(Home Care Instructions)





Muscle
Splint of choice:

Anterior Appliance


Wear time: Only at night
Mechanics: Physical therapy for the lateral pterygoids. Ensures Anterior Disclusion!

The chief complaint starts in 3 to 7 minutes, and if biting pressure is released – the pain will go away. It can radiate into the joint, temples, back of the neck, sinus area, top of head, or just about anywhere else in the head and neck region

  • The chief complaint will be duplicated (not intensity but character)

  • Patient comfort is always of the utmost importance

  • Fabricate the anterior appliance

  • Give patient home care instructions

  • Have patient keep pain diary

  • Recall in two weeks

A supportive nature is very helpful during the procedure. The stress test can really hurt. An excellent idea is for the practitioner to experience the test, before administering it to patients. The physical therapy technique of applying warm, moist heat to the painful area makes the contraction more bearable. The painful muscles are probably the lateral pterygoid complex and/or the temporalis29 30.

The deep masseter may also play a role.


BENEFITS OF THE ANTERIOR APPLIANCE:


  1. The anterior appliance with shallow anterior guidance is the least invasive definitive therapy.

  2. Anterior appliance is much easier to adjust than the typical centric relation splint.

  3. The number of adjustment appointments is considerably less than with full occlusal splints. The design allows for more healing between appointments and retains its adjustment longer, because the posterior occlusion is not involved.

  4. The breakage problem is significantly reduced (without posterior tooth contact the masseter and the medial pterygoid do not contract nearly as forcefully30).

  5. Patient compliance is higher. Because of the design, saliva makes the appliance almost disappear.

TWO CONCERNS WITH THE ANTERIOR APPLIANCE EXPRESSED BY MANY PRACTITIONERS:

Many practitioners have asked if this lack of posterior contact causes a problem. The answer is clear -- it does not cause teeth to shift, when the appliance is used as described.





    • The appliance should not be used for eating or during the day after the first two weeks.

    • No change in the occlusion has been evident from the pretreatment casts. It is important, however, to include the two “C” clasps, which are retentive, on the first premolars. Otherwise movement may possibly occur between the maxillary first premolar and maxillary canine.

Since the appliance is small – will the patient swallow it and is the appliance stable? If made correctly, stability will not be a problem. After fabrication, place the appliance and ask the patient to try and “knock it loose” without using their hands. If the retention is not sufficient, reline or use Biostar (pressure forming unit) from Great Lakes Orthodontics for fabrication.

Advanced understanding:

Not all patients who have TMD symptoms are aggressive bruxers. The anterior appliance is very successful for muscle patients – except for one group. The group that will not have success is made up of the patients who do not aggressively brux. They will come to the office for their two week check, and not one mark on the anterior appliance can be found. The management of this group must include home care instructions, the utilization of the anterior deprogrammer for exercise, and the anterior appliance. The anterior deprogrammer stress test (all steps) is used prior to sleep and when the patient wakes in the morning. It is recommended to leave the anterior appliance in place during the exercise. The anterior appliance along with the exercise utilizing the anterior deprogrammer will generally control the muscle symptoms. It has been observed that this group is structurally the smallest of the female patients31; they are the group that holds their mandible forward in protrusion instead of bruxing.


It is important to note that the design of the appliance may impact how the patient sleeps and breathes at night. It has been shown by Gagnon and also Nikolopoulou that in subjects with sleep apnea, an occlusal splint may cause an elevation in AHI32 33 34. The advantage of the anterior appliance is the minimal thickness of acrylic. It is designed to allow for as much tongue space as possible. If an occlusal guard is too bulky, it will crowd the tongue and force it to the posterior, which aggravates the person’s airway while they are attempting to breathe during sleep, potentially contributing to an increase in respiratory disturbances, hypopneas or apneas.



  • The test for occlusal change is quite simple:

    • An accurate pretreatment impression is taken, poured immediately in die stone, and filed for future reference. It is imperative that the cast be accurate and meticulously cleaned of inaccuracies.

    • Another impression is taken and poured six months to a year later with equal care. The patient cannot wear the anterior appliance to this appointment!

    • The pretreatment cast is pressed into soft red compound to leave cusp tip impressions and excess compound is removed.

    • The second cast is then tried into the compound impression – there should be no discrepancy.



anterior appliance casts

Advanced Understanding:
Q: What comes after the successful use of the Anterior Appliance?

A: For a true TMD patient with no airway issues, no further treatment is needed, unless the patient desires a more definitive answer.



Photo – Masseter, TMJ, and Other Structures
If the patient feels encumbered by the appliance or the amount of wear time, what should be done?

  • An excellent set of casts are mounted on an Arcon articulator to determine the person’s occlusal and skeletal relationships. Time is saved by making the maxillary posterior segments removable.

  • A careful and complete diagnostic work-up (including radiographs, consultations, testing, etc.) must be accomplished before any irreversible treatment is rendered.

  • The methods available to clinicians, as dentists, are limited. A well planned occlusal adjustment that satisfies the mechanics of the anterior appliance may be the best option. Care must be taken that the adjustment is not overly damaging to the system. All options need to be considered!

The Key: If the mechanics of the anterior appliance can be duplicated, then the success should be replicated. The correction, if completed and goals are met, gives a very similar situation to that of the centric relation splint. The reduction of painful symptoms with appliance therapy is very well documented35 36 37.

If the individual is a sleep patient with airway concerns and TMD symptoms, it is appropriate to screen them with a high resolution pulse oximeter once their TMD symptoms have been addressed. They can then be referred for a polysomnogram as needed and treated with a mandibular advancement device. This will be further discussed in subsequent sections.

The Anterior Splint Diagnostic Technique
Potential Sources of Headache and Orofacial Pain:

Vascular, Myofascial, Neurologic, and Intracapsular / Joint Pain


Stress Test by Progressive Loading

Technique: Anterior Appliance

Time: 2 weeks / 24 hour wear, except when eating

Muscle activity: Temporalis contracts (Bilaterally)

Superior head of lateral pterygoid contracts (Bilaterally)

Inferior head of lateral pterygoid stretched to relaxed length (Bilaterally)

TMJ Impact: Compression / Loading of the condyle disc assembly and joint structures



NO CHANGE – NOT TMD






After two weeks if ….

MUSCLE PAIN - RESOLVES / IMPROVING

OR

TMJ - PAIN PRESENT IN TMJ AREA


AFTER 2 WEEKS -- PATIENT IMPROVED

Pain has definitely improved and patient feels that they are recovering

(Muscle Pain, Capsulitis, or Synovitis)



AFTER 2 WEEKS – PAIN PRESENT IN TMJ AREA

Pain has intensified or stayed the same over joint compartment

(Arthritides or Nonreduceable Disc)




Joint
Splint of choice:

Pivotal Appliance (Always Bilateral)
Wear time: 24/7 for one month but Never while eating. After first month gradually reduce daytime wear until symptoms abate (6 months to 1 year).

Splint will require an adjustment each month.

Stress test by loading the TMJs to confirm healing (10 Minutes)
Mechanics: Unloads and decompresses TMJ


Muscle
Splint of choice:

Anterior Appliance


Wear time: Only at night
Mechanics: Physical therapy for the lateral pterygoids Ensures Anterior Disclusion!



Requirements of Anterior Appliance

  1. Appliance must be stable – Cover entire facial and lingual surfaces of teeth numbers 5 through 12 and cut off occlusals on 5 and 12. To reduce retention, prior to fabrication, the deep undercuts on the cast should be blocked out. Less desirable solutions are to decrease the facial coverage and/or cut through the appliance’s facial interproximals with a fine disc to separate the teeth. Remember, the more esthetic the appliance – the greater the compliance. If the retention is not sufficient, reline or use Biostar pressure forming unit from Great Lakes Orthodontics for fabrication.




  1. The appliance is adjusted until the mandibular six anterior teeth touch. A smooth arc of contact is desired and if a mandibular anterior tooth is severely out of alignment – it should be ignored.

anterior%20appliance%20apart%202


  1. The anterior deprogrammer should be used to adjust the appliance after two weeks of wear; this should never be done at the delivery appointment. The technique is to add leaves until no tooth touches and then take away one leaf at a time, while adjusting contact, until no leaves remain. Even contact of all teeth with the TMJs seated is the goal.




  1. Anterior guidance must be very shallow and as flat as possible but retain some angle in order to separate the posterior teeth.




  1. At least 3mm of “slide area” required from centric point to edge of splint.




  1. Posterior teeth cannot touch – if they do, the appliance will not work! The patient returns in approximately 2 weeks for check. They must wear their appliance to the appointment. The check is to refine the appliance. If a posterior tooth touches, one must add to the splint. Adjust contacts with the anterior deprogrammer.

A Key: if the patient complains of joint symptoms after two weeks with this type of splint, one should not continue. One must change to a pivotal appliance.


  1. Patient instructions – wear appliance at night only and follow home care instructions (Page 19). If for the first two weeks the patient is having significant problems, daytime wear is permissible. After patient symptoms are relieved, the patient should use as needed.




  1. Patients should always be prescribed Colgate Prevident Fluoride Gel (not Colgate Prevident 5000 Paste), and they should place a “pea size” amount of the Gel in the splint before bed (Colgate Palmolive, www.colgate.com).

Joint Pain and the Pivotal Appliance



Indications for the pivot appliance defined38:

1. Non-reducible dislocated articular disc, confirmed by MRI.

2. Systemic disease entities that cause arthrogenous pain in TMJ during the stress test (e.g., arthralgia, osteoarthritis, osteoarthrosis).

3. Post-surgical involvement of the TMD.

4. Intracapsular pain -- determined to be the TMJ by either stress test.


Stop biting

Pain Lingers Over Joint Compartment (TMJ)

(Capsulitis, Synovitis, Arthritides, or Nonreduceable Disc)






Joint
Splint of choice:

Pivotal Appliance (Always Bilateral)
Wear time: 24/7 for one month but Never while eating. After first month gradually reduce daytime wear until symptoms abate (6 months to 1 year).

Splint will require an adjustment each month.

Stress test by loading the TMJs to

confirm healing (10 Minutes)
Mechanics: Unloads and decompresses TMJ

Utilizing the anterior deprogrammer to stress the system, the patient will begin to exhibit symptoms within the first minute. The pain will only intensify as the test continues.
After the patient exhibits symptoms, the test changes to alternately biting for 6 seconds and resting for 6 seconds. The pain will only increase in intensity, and does not diminish. Stop test after 7 minutes. A diagnosis is evident, and nothing will be gained by continuing. Joint derangements are highly probable39 40. Many times the patient will relate that they cannot chew anything hard (bagel, pizza crust, chips, tough meat, etc.) without causing a headache.
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