Treatment requirements for pain resolution

The treatment for  a malaligned jaw is both simplistic and often difficult.  The proper treatment is nearly always anterior repositioning of the lower jaw through the use of one or more diagnostic orthosis (what many call a splint).  The difficulty arises in achieving the precision necessary to create a stable and effective therapeutic repositioning.  In many cases, long term jaw malalignment has caused the person to become systemically hypersensitive, hence they get worse with an orthosis unless it is done very precisely.  The degree of precision required in many cases is much more than most dentists have been trained to provide.  I have developed a number of techniques that allow for more precise jaw stabilization.

Further failures in splint therapy often come because dentistry has not yet agreed on what should be the treatment goals.  That is, there is no agreement on what is the best treatment for cranio-mandibular dysfunction (see ICCMO position paper).  My 30 years of experience has led me to believe that the ideal treatment is not based on occlusion (which most dentist strive to achieve), but is based on ideal jaw function (see article on Bio-mechanical Principles of Occlusion ).

Treatment begins with a thorough medical history.  Often the patient has experienced multiple symptoms in their past that are likely due to the life long neurological disturbance induced by the jaw malalignment.  Knowledge of the patient’s past is very helpful on planning the appropriate appliances and supportive therapies. Sleep habits, medications, airway adequacy, dietary limitations, psychosocial stress level, allergies, and behavioral considerations are but a few of the concerns when taking a medical history.

Diagnostics performed before treatment typically include jaw motion analysis, study models, postural evaluation, photographic pictures, and TMJ x-rays.  Occasionally other records are required.

Treatment is typically divided into three phases: Phase I- to find the therapeutic position of the lower jaw; Phase II- stabilize the jaw in the therapeutic position; and Phase III-long term maintenance.

In Phase I (diagnostic repositioning of lower jaw) typically takes 3 to 6 months  The types of appliances that I use to reposition the jaw are less bulky than those used by most dentists.  The appliance I use most often is a “twin block crozat”.  This is a hybrid appliance that combines the smallness of a crozat framework with the effective repositioning mechanics of twin block pads.  This appliance I have been using for over 20 years with a tremendous degree of success.  It provides a wide

advantage over other types of orthosis in that it can be used for both pain resolution and orthodontic/orthopedic resolution. It can correct asymmetrical dental malalignments; it doesn’t interfere with cranial motion; it doesn’t interfere with speech, its hygienic, it can be modified (i.e. versatile), and it can be used in conjunction with other appliances as needed.

Phase II in initiated when it becomes evident that there is a therapeutic position that needs to be maintained for the long term.  This is done in one of three ways or a combination of two or more.  Most cases are finished orthodontically- the primary tooth movement being the passive eruption of posterior molars to support the lower jaw in a more forward and downward position.  In some cases the teeth do not erupt fast enough so crowns are cemented over the top of existing molars.  In some instances a permanent partial is fabricated out of durable materials that the patient wears over their existing teeth to maintain the proper jaw position.

Phase III is the retention phase.  Most patients wear an appliance

at night for the rest of their life.  This is necessary because the jaw displaces when they are unconscious, causing the jaws joints and muscles to get traumatized.  The appliance is like a security blanket, and most patients become highly attached to their night appliance because they sleep better and awake more rested and relaxed.

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