This video is an excerpt from the June 2015 Dawson Faculty Office Hours with Drs. Jeff Scott and Steve Hoard. Moderating is Dr. Pio Modi (PM). To watch the full office hours and to sign up for future office hours, visit the Videos and Webinars page.
The following is a transcription of this video excerpt.
Question: What do you do with a pain patient who has more pain after wearing a B-Splint?
JS: The first thing is: take it out. You knew that already. The point is - the pain got worse. Now I don't know exactly what pain that person had to start with (because that information wasn't provided with this question) - was it joint pain or muscle pain?
If you're wearing a B-Splint, typically that's an anterior deprogrammer, that appliance is designed to help with muscle incordination and clenching. Now we can't get rid of clenching completely. We just decrease the amount of muscle contractive force by 70% by putting an anterior deprogrammer in. So you say, well it's not going to 0, but a person that's had a lot of headaches and pain from clenching will get a lot better by wearing a B-Splint.
If it gets worse, it makes me think it's not a muscle problem. It very well could be a joint problem.
If it's a joint problem, a B-Splint or any other type of anterior deprogrammer is likely to make it worse. The theory on that is, that causes an increase in the seating of the joint and whatever intracapsular disorder it is going on; it's just pressing on retrodiskal tissue or the inflammation in the joint.
The other reason would be that the B-Splint is not adjusted correctly.
It could be if you made a full coverage lower like a Biostar blank and made your own deprogrammer on it (or had a lab make it) and you're still getting posterior contact. When they touch maybe in the front there is no posterior contact, but if they have a deeper curve of spee their posterior teeth can interfere as they protrude onto that ramp. They're bumping into the back and they find that spot and work on it, causing them to increase their muscle activity. Or if they're going laterally they pick up a cuspid.
We always adjust occlusal splints so if they slide forward-back-forward-back they never fall off the ramp. If they go left-right in any direction, they cannot catch the cuspid on either side. Sometimes you have to carve away the lateral side of the ramp to make sure the cuspid has a free path. If they can find a cuspid for any reason, they'll move their jaw over there and camp out and crush that cuspid, causing more pain. That's another possibility as to why that could be worse.
SH: When pain is mentioned - is it joint or is it muscle. Jeff has done a great job of explaining adjustments.
I have had some patients that when we place them in an anterior deporgrammer, whether it be a B-Splint or some sort of lucia jig, that try to hold their mouth forward and hold it in or are big clenchers.
In that case I give instructions on how to relax their muscles and jaw. I get them to open and close several times, move their jaw forward and back over the splint or the anterior deprogrammer, and get them to actually relax their muscles.
JS: One other thing I was thinking in relation to what you said, if they are moving forward and sliding all over trying to hold it in, but if they are moving their jaw in a protusive way and have a deeper curve of spee, it's like well, what do you do? If you start adjusting on that back molar, it's almost perferating it. It's totally fine to just cut off the back molar. All the base does is help hold it stable. It's totally fine to just cut off the second molar completely, round it, smooth it. Your retention will still be good and it should give you enough room for a deeper curve of spee.
PM: Any instructions, Jeff, if you do cut off the second molar as far as length of wear. Are there any limitations if you're not in a full coverage splint?
JS: Are you concerned about supereruption? So here's the answer to that. It's not a problem. The reason it's not a problem is because they aren't wearing this 24 hours a day. They wear it at night only. In the day time we tell them as best they can to keep their lips together and teeth apart, but they've got to eat. They can't typically do their job with that B-Splint in place. We use it primarily as a nightime only appliance and therefore even the little bit of contact during the day from chewing and swallowing is enough to keep the posterior teeth from supererupting. So it's not a problem to cut off the back end because they aren't wearing it 24/7.
Photo Credit: Greatk Lakes Orthodontics