Creative Dental Treatment Planning
Posted by: Dr. DeWitt Wilkerson
One thing that becomes quickly apparent, when seeing many patients with unusual and difficult histories, is how often we must make decisions, based on scientifically based logic, when textbook answers are not available for each and every situation.
I had an interesting case in point a couple of weeks ago. A patient I restored last year, due to severe anterior wear, called asking us to see her 19 year old daughter. She was experiencing sore muscles, left side TMJoint clicking, and facial pain each morning upon waking. She was also suffering from headaches 2-3 times a week.
The New Patient Examination
Upon examination, she reported palpation tenderness of the Superficial and Deep Masseters, Medial Pterygoids, and Temporalis Muscles. She expressed some discomfort in the left joint area, which felt sore to the touch. The left joint demonstrated an early opening (3mm) reciprocal click , which through load testing, doppler auscultation, and CBCT Scan was determined to be an early Piper Stage IVa. The right joint was a Piper Stage I. Her mandibular range of movement was within normal limits, but wide opening produced tenderness in the area of the Deep Masseters… classic for clenchers. Occlusally, her seated joints and seated bite were simultaneous. She demonstrated acceptable anterior guidance and posterior disclusion. She showed no signs of wear on her teeth indicative of bruxing patterns.
As a differential diagnosis, we placed warm Delar wax between all the teeth with the joints seated, chilled the wax in ice water to a brittle hard state, placed it back between the teeth, and had her clench. This produced a slight soreness in the left joint, which could be due to a combination of muscle and joint inflammation, and moderate derangement.
We then reheated the underside of the wax bite, had her move her mandible forward 4-5 millimeters until her left joint clicked (recapturing the disc displacement), and asked her to close into the softened wax so all teeth touched. We chilled the wax and had her bite firmly into the hard wax record. She felt no discomfort in the left joint when the condyle was repositioned forward. She was asked to open and close her mouth several times, each time biting forward into the wax record. She could do so with no clicking in the left joint (recaptured disc). This brought a smile to her tired face!
Based on our analysis, we diagnosed the problem as one relating to parafunction, primarily in the form of clenching, and an internal derangement with inflammation, of the left joint.
Dental Treatment Planning
Now for the fun… beside NSAIDs, what can we do to help her? We decided not to place a traditional “C.R. Splint.” We tested that option with the first wax record, and it made her left joint feel more sore. We don’t want to risk making her more uncomfortable with our treatment.
We considered placing an “Anterior Repositioning Splint” (ARS) since that’s what the forward positioned bite record mimics. We didn't want to have all her teeth touch the ARS. This could allow her to still clench on her back teeth all night and make her muscles sore, even if her joints felt better. We believe clenching is a primary cause of her problems.
B Splints/NTIs/ anterior deprogrammers all work well for reducing elevator muscle forces by separating the back teeth, but are contraindicated for unstable joints.
So here was our thought, make her an ARS that only touches on the incisor teeth, to wear at bedtime. This should protect her from compressing her sore joints and retrodiscal tissues, keep her fully under the disc, and also reduce parafunctional clenching forces by as much as 70-80% all night. This idea seemed to have scientific merit to help the problems we were recognizing. So we tried out our idea (see photos).
She wore it the first night and reported--- no clicking in the morning, with no sore muscles or headaches either. Her Dad called me and said it was nothing short of miraculous. He immediately scheduled himself for a new patient exam!
I’m glad to say she has continued to be comfortable, so far, and we will see her again during her Spring break to reevaluate her condition.
One case study may seem anecdotal at best, but we have seen dozens of examples through the years, where we have used the logic of previous scientific evidence to try new ideas which may become future standards of care.
Meanwhile, it sure is fun to creatively work outside the box from time to time!