53 comments (Add your own)

1. Scott Poling wrote:

I have a 14 year old female patient that has a definite click on the left TMJ. The disc is disclocating but reducing on closure. The patient has no signs of bruxing and dose not complain of soreness in the mornings. I was thinking of doing a anterior deprogrammer to assess CR and her occlusion. I noticed a contraindication for joint derangements. Would the deprogrammer be appropriate in this situation?

March 26, 2007 @ 9:15 AM

2. Scott Poling, DDS wrote:

Addendum to the previous. The 14 y/o also has locked open.

March 26, 2007 @ 3:24 PM

3. Shannon Johnson, DMD wrote:

First lets address the splint question as if the patient will be wearing the appliance for an extended period of time...Anterior deprogrammers are best used in cases Piper Class 1, 2, and 5. For patients with displaced lateral or medial pole disks (Piper 3 and 4), the potential risk is that you may worsen the disk displacement as the condyle seats into the socket. In essence you may promote the condyle to slip further off the disk. Rather than an anterior deprogrammer, I would use a centric relation splint that is full coverage with even intestity centric contacts and a shallow anterior guidance.

Now lets address this concern as I believe you are asking...you want to use an anterior deprogrammer (lucia jig) to help take your bite record. Please let me know if this is a correct assumption. In this case, where the patient may be using a jig for only a few minutes, you can try it. Have the patient remove the jig immediately if she feels any discomfort in the joint area. Load test and verify centric as you would normally if she is comfortable.

This discussion can also lead into joint diagnosis. You want a clear and definitive joint diagnosis so that you can determine long term stability of her case. There is a significant difference in long term stability for Piper 3's versus Piper 4's. Have you diagnosed the joints?

April 4, 2007 @ 11:51 AM

4. Dr. Barry Glassman wrote:

I use anterior midpoint stop appliances (B splints and NTI's) DAILY and successfully with patients with internal derangements, including patients with disk displacements with reduction anteriorally, anteriomedially, and medially. The force vectors of the musculature are not posterior, and the decreased forces in the system created by the anterior contact often result in decreased pain and increased function. Us of JVA and jaw tracking evaluating joint vibrations and ROM has substanciated the subjective success in many cases.

June 20, 2007 @ 8:36 AM

5. Steven D Bender DDS wrote:

There is a growing body of evidence that would indicate the above assumptions to no longer be accurate. Many investigators have demonstrated a decrease in elevator activity utilizing the anterior midpoint stop appliance while full arch appliances with posterior tooth contact tend to allow for an increase in elevator activity during clenching. Allowing for condylar seating under limited loads is an ideal therapeutic outcome. A well constructed, full arch splint will also allow for condylar seating but according to reports, allow for increased load of the articulating surfaces in comparison to anterior stop appliances.
exquisite attention to fabrication, fit and adjustment is crucial for success with any appliance. This would also be true for the anterior stop style. Many failures or exacerbation of symptoms seen in our office are the result of poorly fabricated and/or adjusted appliance.
Hope this helps,

June 20, 2007 @ 12:16 PM

6. Jim McKee wrote:

This question is a great question because the situation is so common. The key to predictable treatment planning begins with diagnosing the condition of the TM joint. The TM joint will either be structurally intact, strucuturally altered at the lateral pole or structurally altered at the lateral pole and medial pole.

In patients who have structural alterations at both the lateral and medial pole, MRI imaging is the only diagnostic tool that will allow the dentist to predictably design on occlusal scheme on an occlusal appliance. In patients who present with discs that are in the 11:00 position in the medial pople, anterior mid point appliances have the potential to seat the condyle superiorly and cause additional forces on the already weakened attachment. Also, patients who present with large disks that are displaced medial (confirmed with MRI) are at an elevated risk for pain and skeletal distortions due to the potential for compromised blook flow to the joint. The patients I have seen who present with these cases have not fared well with the anterior midpoint appliances.

My personal experience is to use a full arch appliance is patients who have structural alterations at both the medial and lateral pole. In order to be effective, the appliance must be carefully relined to insure that there is no movement under occlusal pressure in any area of the appliance. Additionally, the appliance requires precise adjustment for even contacts in adapted centric posture/treatment position along with a very flat anterior guidance. While this design has worked extremely well for many dentists and patients over the years, there are some cases that this design will not help...most likely the two cases outlined above. Without an MRI, it is not possible to explain this to the patient before treatment begins.

MRI in conjunction with cone beam 3D imaging will give the necessary infromation to explain condyle size, condyle position, disc dise, disc position, the condition of the condylar marrow space. In today's world of comprehensive dentistry with treatment plans involving implants, esthetics, orthodontics, occlusal therapy, etc., TM joint imaging is a necessary diagnostic tool for the physician of the masticatory system.

Hope this helps

Jim

June 26, 2007 @ 12:18 AM

7. eric wrote:

Would a NTI or bite splint be good for me?
I was diagnosed with TMJ and i know its from grinding/stress. However i noticed that one side of my lower jaw is higher than the other whats wrong there. Is that realted to stress as well.

email me marinerseric@gmail.com

July 3, 2007 @ 6:31 PM

8. Jim McKee wrote:

Eric,

The best way to determine what occlujal appliance would be best for you is to diagnose the condition of the joints. If one side of your lower jaw is higher than the other side, then something had to cause the canted occlusal place. Possible causes would be genetics, altered eruption patterns, condylar breakdown, etc. Find a dentist who has been trained in diagnosing TMD from a lateral pole/medial pole perspective and go through the examination process. It will not only help you but also how you explain the problem to your patients.
Good luck

Jim

July 8, 2007 @ 12:25 AM

9. Steven D Bender DDS wrote:

How can an MRI help the dentist design an occlusal scheme on an appliance when the effect of the appliance has been shown to be independant of occlusal scheme (ie. equivicol results of a permissive or stabilization appliance compared to palatal only)? All that is known is that the elevator muscle activity will increase with more occlusal contacts, especialy in the posterior aspect.

There is no evidence that an anterior appliance will cause a progression of disc displacements. There is also NO evidence to support that an anterior disc displacement will compromise blood flow. Osteonecrosis of the condylar head is more likely to be a result of oxidative stresses from pathologic loading (Nitzan, Milam).

July 16, 2007 @ 12:21 PM

10. Jim Boyd, DDS wrote:

Jim mentioned: "The patients I have seen who present with these cases have not fared well with the anterior midpoint appliances"

The Gold Standard for the full-coverage splints described above is to provide for IMMEDIATE posterior disclusion upon excursion from CR. Why? Because that leaves *only* the incisor edges to be in contact with the splint, with the ideal contact being at the anterior midpoint, thereby minimizing the muscle contraction intensity that strains the joint and pathologically loads the disc.

The risk of appliance therapy is not the provision of incisal-only contact while in CR, but of the practitioner's poorly designed device. For example, it is not uncommon for a practitioner to mistakenly provide an anterior-midpoint appliance with a Discluding Element that provides excessive Vertical Dimension of Occluding. Doing so will create excessive condylar rotation during the occuding events, which can further complicate the condition. With NTIs, for example, the DE must *always* be adjusted and customized for the patient. I have seen many cases fail to respond when the practitioner simply removes the NTI from the box and "puts it in". Rather that abandon the concept, modifying the design to adhere to therapeutic protocol rectifies the matter.

Obviously, occlusal appliances themselves have no ability to seat the condyle superiorly and cause additional forces on the already weakened attachment. Vector forces generated by combined muscle groups do that, which only occurs during occluding events. The force vectors are then a function of the scheme of the occluding teeth and position of the condyle during the event.

With properly provided incisal edge contact, there is no ability to seat the condyle more superiorly and cause additional forces.

July 17, 2007 @ 10:29 AM

11. Lisa D. wrote:

I've noticed that with the past 6 months I have noticed jaw pain and slight headaches when I awake. I mentioned to my dentist and they noticed my teeth were starting to wear down on the bottom. I'm trying to get my insurance to cover a bite splint. They say it will not prevent me from clenching. My question is will the bite splint if worn at night help to relieve the headaches and muscle pain in my jaw. I'm trying to appeal my case to prevent further damage to my teeth. Thank you

August 11, 2007 @ 11:37 PM

12. Jim McKee wrote:

Steve,

From a techical perspective, elevator muscle activity may increase but the area of force distribution also increases. An anterior deprogrammer is approximately 10 square mm where a full arch appliance is approximately 100mm. Assuming the amount of muscle force generated will seat the condyles with either appliance, then the force will be distributed between the condyles and the appliance.

AVN was a controversial subject in the early 90s as those of us who have attended AES meetings can attest to with first hand experience. While Nitzan and Milam's excellent work show the effects of pathologic loading, it is extremely unlikely that this excesive loading would occur if the disc was intact at the medial pole. Today, marrow space disorders are a commonly accepted entity when talking to dentists/radiologists/etc who have not been influenced by the politics of the early 90s.

From a non-technical perspective, TM joint imaging is absolutely necessary to be able to inform the patient of the level of breakdown as well as the prognosis for treatment. MRI and cone-beam imaging offer the best imaging options at this time for suspected advanced joint problems.

Jim

August 14, 2007 @ 1:49 PM

13. Jim McKee wrote:

Lisa,

An appliance may help the pain that you are experiencing. The best way to determine if an applaince will help is to have an examination that will determine the condition of the TM joints and evaluate the way your teeth contact. After the exam, it will be more clear if an appliance will help as well as what type of applaince should be used.

Jim

August 14, 2007 @ 1:52 PM

14. Rache Smith wrote:

Short of picking up the phone book and calling every doctor in the country, is there a database of MDs trained in the Dawson method? How can I go about finding one near me?

September 10, 2007 @ 1:37 PM

15. Steven D Bender DDS wrote:

Jim,
As much respect as I have for you I have to point out that your statements lack evidentiary support. Numerous studies have shown that anterior only contact significantly reduces elevator muscle activity and therefore according to logistic modeling, reduces condylar loading (Baad-Hansen et al, Becker, Tarrantola et al,May et al). Full arch orthotics have shown an increase in elevator activity (Chandu, et al, Nishigawa, et al). Nitzan's work with articular pressures demonstrated a net increase in intra-capsular pressure while clenching on a full arch, posterior contact appliance (81.2% decrease from maximum voluntary = a net of 18.8% increase). Witter has shown over longitudinal prospective studies that a loss of posterior dentition is not a risk factor for TM joint disorders.
The key point to remember is that the density of periodontal mechanoreceptive fibers increases the more anterior in the arch making the central incisors the most innervated and therefore sensitive teeth to noxious stimuli. So, the location of force is pertinent as far as anterior-posterior but not surface area.

As to pathological loading of the disc; this is what CAUSES laxity of the tethering ligaments leading to discal location. The free radical production resultant from oxidative stresses causes breakdown of the synovial tissues resulting in a loss of integrity of the discal and other ligaments. The pathological loading is from nocturnal parafunctional activity where intensity, frequency and duration become the determining factors; not occlusal determinants. Osteonecrosis is not in doubt here; it is the etiology of such that seems to be debatable. With the abundance of collateral circulation to the condylar head, muscle impingement theories are somewhat naive.

Imaging can not tell us anything about prognosis. Again, the literature would seem to imply that the incidence of progression is unknown. In his latest text, Jeff Okeson reports that according to most literature on the subject, patients tend to become stable on there own or with very conservative therapy.
Hope this makes sense and is helpful,
Steve

September 12, 2007 @ 6:02 PM

16. tracy dobson wrote:

dear sir,

would love to know if one should risk using a kois appliance if having had no jaw problems ie pain, or teeth problems until a bad crown placed has caused bite to change.

do have odd bite pattern but am very worried after all the things done in the past year to try and fix my problems that this appliance may destabalize me to a worse state when the need for braces is probably the real answer.

very afraid to risk it???
help please
thanks

tracy

September 16, 2007 @ 1:38 PM

17. tracy dobson wrote:

dear sir,

would love to know if one should risk using a kois appliance if having had no jaw problems ie pain, or teeth problems until a bad crown placed has caused bite to change.

do have odd bite pattern but am very worried after all the things done in the past year to try and fix my problems that this appliance may destabalize me to a worse state when the need for braces is probably the real answer.

very afraid to risk it???
help please
thanks

tracy

September 16, 2007 @ 1:38 PM

18. Marvin Flick wrote:

My wife was advised by her dentist that she needed an NTI because she was grinding her teeth.She did however have an over bite. She had a clicking jaw at the time with no pain. When she started wearing the Nti she started having headaches so the dentist prescribed pain pills. The headaches went away within a couple of weeks, so she continued to wear the NTI as instructed, 24-7. Four months later she observed in the mirror that her teeth now matched in the front and within hours she yawned and her jaw dislocated. The MRI showed that she had an anteriorly dislocated and distored disc on the left, with no evidence of recapture. No she can not chew, her mouth will only open 20 cm, she has severe pain in the left ear and most of the time from the top of her head to her shoulder on the left side. I took her to Cleveland Clinic, no help. She is now seeing a different dentist who made her and full splint which he has adjusted at least 30 times in the past 9 months. This seems to help the pain some for short periods of time. Please advise if you can recommend anyone that can help. It appears my wife is maimed for life.
She blames the NTI, is she correct?

October 12, 2007 @ 9:36 AM

19. Jim Boyd, DDS wrote:

Marvin said:
"When she started wearing the Nti she started having headaches so the dentist prescribed pain pills".

The proper response would have been to identify the method in which your wife was "defeating" the NTI device. Provided properly, an NTI will either reduce muscle contaction intensity and joint strain/load (thereby reducing symptoms), or it will do *nothing* (thereby ruling out nocturnal parafunction as a contributory activity to the presenting condition).

"The headaches went away within a couple of weeks, so she continued to wear the NTI as instructed, 24-7."

It is physically impossible to wear an NTI "24-7". It's design and intent is to control nocturnal parafunction. Based on her initial response, there was/is an oversight in the therapeutic protocol.

"Four months later she observed in the mirror that her teeth now matched in the front and within hours she yawned and her jaw dislocated. The MRI showed that she had an anteriorly dislocated and distored disc on the left, with no evidence of recapture."

And those findings may have been there long, long before the initiation of therapy.

"Now she can not chew, her mouth will only open 20 cm, she has severe pain in the left ear and most of the time from the top of her head to her shoulder on the left side. It appears my wife is maimed for life...She blames the NTI, is she correct?"

A piece of plastic residing on the incisors, just by itself, cannot cause the above description. But a piece of plastic, improperly provided without an insight as to the nature of the pathologic activity of the on-going nocturnal parafunction, can intensify and complicate signs and symptoms (that's a line from my lectures, BTW).

Is she maimed for life? No.
Does she require a re-evaluation and assessment of her parafunctional activity? Yes.

October 12, 2007 @ 2:03 PM

20. Jim McKee wrote:

Steve,

Sorry for the long delay in responding...I also have great respect for you and your work however, we both know that the literature in the field of TMD/occlusion is incomplete at best and misleading at worst. I don't disagree that anterior appliances decrease muscle activity and they can be very beneficial in many patients. However, the condition of the condyle has to have some pertince to the discussion. While imaging cannot predict the future, it can lead to an important discussion regarding the condition of the tissue that we are treating. If an orthopedic surgeon did not image the knee and treated by doing what other claim is effective, the treatment would be judged below the standard of care. It really should be no difference for the TM joint. While conservative therapy is the goal for all patients, some require a surgical intervention if conservative therapy has not been successful. The usual surgical patient has either pain that is not manageable or skeletal distorations.

In terms of progression, I think it is a new ball game today. We are seeing more TM joint damage with greater severity at earlier ages. Imaging confirms this beyond any doubt. Condyle/fossa ratios, ramus lengths, condylar surface areas as well as other factors can all be analyzed today and confirm that growth disorders do indeed occur. These young patients ( almost always young women) need intervention due to the skeletal distortion that has occurred. These cases certainly are not all AVN cases...although AVN of the mandibular condyle is a regularly accepted entity today. I'm assuming you meant disc impingement as opposed to muscle impingement but if enough MRIs are reviewed, there is no doubt that AVN will be present.

Finally, the question of what causes disc derangements is really at the heart of the matter. I must admit that I have changed my thinking on this matter over the years. I initially thought that occlusal forces (function/parafunction or any other occlusal forces) caued the majority of disc problems. Currently my thougts are that disc problems are caused by traumatic incidents...it may take one incident if it is severe enough or more likely a cumulative effect of several traumatic events. There are too many young patients who have not have enough time to parafunction to the extent necessary to tear the ligaments.

To be fair, the patient base that we see is probably different. I know that you see predominantly pain patients which is different type of patient than the patients I typically see. My practice is about 1/3 TMD/occlusal problems and 2/3 restortative/esthetic cases. The TMD patients I see are almost exclusively referred by dentists who suspect a joint problem. I don't see too many patients who present with more medically based problems. Enjoyng the discussion...looking forward to a longer talk together at the AES meeting in February.

Jim

October 16, 2007 @ 10:43 PM

21. Jim wrote:

Dear Marvin,

I'm sorry to hear about the problems your wife is having. A complete TM joint exam would help to gain a more clear understanding of the problem. Depending on the results of the exam, TM joint imaging may be indicated. If so, a MRI and cone beam imaging offers excellent information that can help to diagnose the condition and lead to treatment decisikons.

Good luck,

Jim

October 16, 2007 @ 10:47 PM

22. Jim McKee wrote:

Dear Tracy,

My advice would be the same advice as Marvin...have a complete TM/occlusal exam and you'll have more information to make a decision.

Good luck

Jim

October 16, 2007 @ 10:49 PM

23. Steven D Bender DDS wrote:

Jim,
Your points are well taken. I would propose though, that children do in fact brux, reportedly more so than adults, to enough of an extent as to incur damage to the articular structures via oxidative stress injury. Due to the child's exaggerated time in stage 2 and REM sleep as compared to the adult, there is more opportunity for bruxism events. It has also been noted that children are much harder to arouse from the sleep stages as compared to adults. This could lead to a more vigorous bruxing event. One can simply not discount the beautiful work of Chuck Milam in this area.

I too enjoy the discussion, especialy with a man of such insight and integrety!
Steve

October 19, 2007 @ 5:13 PM

24. scott ma, dds wrote:

Dear Mr. Marvin Flick:
It appears that your wife'condition is long standing as limited mouth opening. The first thing you can do is to find a practioner who is skillful in manual reduction of displaced disk. For long time limited mouth opening, it usually goes along muscle spasm. Therefore, a cool spray of masseter muscle may facilitate downward distraction of mandible. Once the mandible is depressed downward, move the mandible to right side. If disc is successfully reduced, a loud pop sound can be heard and normal range of mouth opening can be restored. I have treated one patient who had 3mm mouth opening resuling from disc displcament. However, her contiotion was only 3 or 4 weeks. Your wife's contion appears much longer. If the disc can not be reduced manually, a well made cr occlusal appliance or sugical intervention is warrented. hope this helps
sincerely
scott ma,dds

November 11, 2007 @ 11:38 PM

25. Vanicha P wrote:

Dear Doctor,
I would like to share my experience and ask some questions regarding full coverage occlusal splint.
Some of my patients with DDR and intermittent locking got joint lock or more uncomfortable after wearing a stabilization splint. How this could happen? Could somebody explain the TMJ mechanics on this topic. Thank you.
P Vanicha

December 1, 2007 @ 7:00 AM

26. Karen Hicks wrote:

I am a lifetime clencher. I used an NTI in my early twenties. I have used a top mouth guard for the last several years. About 8-9 months ago I woke up with severe jaw pain and limited motion. I can open my jaw about 28 mm. I went to a neurologist to rule out any other issues. I went to a "TMJ" specialist and he said to get physical therapy and go back to wearing the NTI. I still had a great deal of pain with the NTI - so I went to get a second opinion from a maxofaccial(sp?) surgeon. He said that I have significant arthritic degeneration in both jaw joints and they are both dislocated. I did have an s-ray as well as an MRI. One side has already created its' own scar tissue - the other side has not. He said that he would not wear the NTI for even a day because it would create more of a problem because of the dislocation. I spoke to the original "TMJ" specialist and he said - "different doctor, different opinion" - although this NTI was made without the benefits of an MRI. Although the surgeon did recommend surgery for one side of the jaw - he did recommend getting a second opinion and seeking Physical Therapy and perhaps acupuncture. I have done both of these and have seen little improvement.I am 38 years old and this affects every moment of my life. Any opinions on whether the NTI should not be worn with a condition like mine?

January 3, 2008 @ 1:31 PM

27. Steven D Bender DDS wrote:

Karen,
To be therapeutic, any intra-oral appliance must be well thought out designed, fabricated, and adjusted precisely for your particular needs. If the NTI is causing your pain and symptoms to worsen, it likely does not meet the appropriate criteria to be therapeutic. if properly made and adjusted, the NTI can significantly reduce the pressures exerted on your jaw joints and muscles during night-time clenching.
I suggest finding a doctor who is experienced with NTI therapy and have them evaluate your current appliance. In most cases, fine tuning the appliance can make a huge difference in the results!
Good luck,
Steve

January 16, 2008 @ 12:56 PM

28. Maria Longo, DMD wrote:

Karen,
I agree with Dr. Bender. I find that 80% or more of occlusal or splint therapy offered in the USA is less than adequate. We are supposed to get as close to Centric Relation, or the place where the jaw are seated properly along with the joint (healthy or not) and the base of the skull. It sometimes requires numerous follow-up visits to "chase" the jaw and muscles to their proper place. This means we have to fine tune the appliance until there are no changes in the alignment and the joints, bones and muscles are all "happy".

January 17, 2008 @ 8:59 PM

29. wrote:

I have both TMJ discs displaced. The left without reduction and the right with. I had a full coverage splint adjusted many times with little improvement of symptoms. The ear pain is a horror. Recently it was suggested I try the NTI splint. I am confused by what I read (not to be used in patients with ineternal derangements). Will this help? I certainly don't want to make it worse.

Karen

January 29, 2008 @ 6:53 PM

30. Joe Patient wrote:

After reading many insightful posts here, I am downright disgusted with my dentist and am finding another one. My dentist recommended I wear one, had an assistant make it, and was handed a cheesy brochure and ushered out. The dentist did not participate in my treatment beyond suggesting the device and billing me.

I wore the device a few days before noticing my jaw was misaligning and I had trouble talking withing hitting my teeth together due to my lower jaw starting to move over to the left from where it used to be. It has since moved back. I threw out the NTI.

Now I just need to find a good dentist, it's my fault for not doing my homework on this until now, but I never needed to until now.

Joe

February 6, 2008 @ 4:48 AM

31. Lawrence Gottesman, DDS wrote:

Dear Dr. Shannon:

I am currently undergoing a rather extensive literary review concerning the function of mechanoreceptors in anterior and posterior teeth and their role in neuromuscular coordination.

It seems that there is a misinterpretation as to the effects of anterior tooth stimulation and the jaw opening reflex.

Firstly, the jaw opening reflex refers specifically to the transient reflex exchanges between muscle groups as influenced and modulated by tooth contact in the anterior region, the central incisors having a dominant role in only an inhibitory contribution over the elevator muscles. The information related to this reflex is mostly predicated on animal species with some recent human studies. The actual masticatory reflex is considered to be under the auspices of a central pattern generator (CPG) as a means of regulating or coordinating multiple tasks between several systems as an automatic phenomenon that can be modulated by various mechanoreceptive or cognitive stimuli.

Secondly, this reflex is signaled by activation of high threshold, rapidly adapting mechanoreceptors responding to directional tensive stimuli. They respond more to high phasic forces in order to rapidly unload the teeth as a protective mechanism.

Therefore, horizontal forces trigger the receptors located closer to the fulcrum area of the PDL. The low threshold, slowly adapting receptors are far more abundant and located in the apical region of anterior teeth. They respond to both phasic and sustained stimuli, however, their stimulation is excitatory in influencing muscle closure activation.

Thirdly, these excitatory and inhibitory reflexes occur in milliseconds with respect to the activation of the jaw closure inhibitory reflex. Subsequent to the inhibitory phase, there is a reinstitution of the excitatory mechanism.

Fourthly, molars have mostly excitatory jaw closure mechanoreceptor initiative and have a large predominance of low threshold mechanoreceptors responding mostly to axial compressive stimuli.

The abundance of tooth receptors descend from centrals to molars.

In light of this information, the NTI appliance or any appliance with a mini-anterior platform, which tends to axialize forces over the over lower centrals (also involved in the same reflex response as upper central incisors)may actually initiate some excitatory activitity of the elevator group, but without co-activation of the molar mechanoreceptors because they are out of occlusion. Aditionally, to my knowledge, there have been no studies on anterior deprogrammers, like the NTI, which isolate localization over the 2-4 anterior teeth and their opposing counterparts and the sustained effect load has on anterior mechanoreceptor activation. I think this makes the B splint a better choice because it does not load the anterior teeth selectively.

The NTI may actually work becauase it initiates an excitatory effect over closure muscles, like the Kois appliance, and allows the condyles to seat without interference from molars or their mechanoreceptors. In addition, the Kois appliance has an added benefit (in my opinion) of activating palatal soft tissue (which also contains mechanoreceptors) as a stimuli for decreasing muscle closure excitation.

I would also like to comment on appliances and intraarticular derangements. If there has been loss of normal integrity of the condyle disk assembly, whether congenital or traumatic, this is an internal derangement! It seems we save the use of this term for painful intraarticular sequelae. I think what we need is a classification of derangements to include the painful and nonpainful joints along with the other obvious parameters.

With respect to treating a painful intraarticular problem, if an anterior minimal incisal table appliance won't help, don't expect a splint with universal contacts to provide a greater benefit because it coactivates molar mechanoreceptors.

Finally, with respect to sleep bruxism, I have found that less damage occurs with an appliance similar to the B splint and the Kois as a hybrid between the two. Cuspid protection does not apply to sleep bruxism. Bruxism is not under the control of a conscious state. Most sleep bruxers continue to brux even in the appliance.

Thanks for the opportunity to share my knowledge with the Dawson folks...say HI to Pete and the rest of the gang for me.

Sincerely,

Larry Gottesman, DDS

March 3, 2008 @ 6:01 PM

32. Steven D Bender DDS wrote:

Larry,

Thank you for you very insightful comments. As to the periodontal mechanoreceptors: I'm sure you have seen the papers that indicate the postulate of there only being a single type of receptor (low threshold) that react with varying rates depending on the stimulus and angulation of such stimulus.

Another fact to remember is that there is a significant void in studies concerning the mechanoreceptive mechanism and it's affect on masticatory muscle activity during sleep. We can currently only hypothesize based on animal studies and awake human studies.

One other point worth mentioning is that recently, Timothy Miles has indicated a lack of a "jaw opening reflex" in humans. His contention is that the "reflex" is more consistent with an abrupt quiescence of the elevator activity in response to a noxious stimulus.

Translating the current relevant research into the sleeping human model should become a goal for future research endeavors. Only then will we be able to develop standards in which we can initiate the most appropriate treatment protocols for our sleep bruxism patients.

March 7, 2008 @ 9:40 AM

33. Larry Gottesman, DDS wrote:

Dear Steve:

I am familiar with the papers, however there are many questions to be asked and hopefully answered.
Currently, the trend in dentistry is to place a wishful and inferential logic to justify what we do and why we do it. I think that most of our questions can never be answered well enough for a few of us, like you and me. Little emphasis has been placed on intrapulpal mechanoreceptors and the relationship of various neurotransmitters, cytokines and proinflammatory agents within the pulpal tissues and how they impact the sensory organ of the tooth/pdl complex. Furthermore, little importance has been placed upon the integrative aspects of the oral sensory system as it relates to coordinated function on a molecular level. Even more complex would relate the relationships of these entities in disease or predisease states.

You sound like a well versed, well read and interested doctor. I would love to have an academic relationship with other dentists like yourself. This is hardly the tip of the iceberg!

My email: lgottesmandds@aol.com if you're interested.

Thanks,

Larry Gottesman

March 12, 2008 @ 6:27 PM

34. Just_John wrote:

I've clenched ever since I overstretched my jaw about 7 years ago. I wore an NTI for 5 years with no improvement in masseter tension/pain.

I tried a full coverage splint for 1 year. It didn't make me better or worse. Then I got a headache that never leaves. Worse upon waking.

I went back to the NTI for 6 months. The headache is slightly better, but not much. What seems to help more is the 4mg Zanaflex at bedtime that a neurologist prescribed.

I sought a 2nd opinion from a colleague of the dentist who made the full coverage, but who also fabricates NTI's. He did a bite test that showed I'm only biting on my molars and that I have a small degree of open bite.

When I wear the NTI my mandible closes and pulls back very far on the discluding element. The 2nd opinion dentist agrees with the full coverage dentist that when using the NTI, the joints take the load. He says that my condyles have resorbed from using the NTI.

The 2nd opinion dentist asked me what I would rather do, preserve my condyles or get minor headache relief. (for someone listed on the NTI website, he wasn't very positive on the device, but at least he was honest.)

Note that I've had lots of physical therapy and I'm disappointed that PT seems like more art than science.

I'm depressed that in 2008 there seems to be nothing that can be done to help me. Am I wrong?

Sorry for the rant.

Thanks,
John

March 26, 2008 @ 9:40 PM

35. Nik wrote:

Hi People,

We have Doctors/Dentists talking about Splint therapy for TMJ disorder.

In basic language which is understandable to us mere mortals - What is the job of the splint? and how can it re-align the teeth/jaw?

What are the pros and cons of Splint therapy?

Thank You.

Nik

March 28, 2008 @ 11:49 AM

36. Nik wrote:

It seems Oral/Maxillofacial surgeons, ENT surgeons and Dentists are all divided in opinion regarding splint therapy, there is so much literature which is for and against Splint Therapy and there is so much literature which tells us that splint therapy works in some people and it does not work in others and for some people splint therapy makes TMJ disorder symptoms much worse.

There is so much conflicting arguements!

Who are we mere mortals supposed to believe?

Thank You.

Nik

March 28, 2008 @ 11:54 AM

37. Hector Valladares wrote:

Dear friemds;
As a patient who suffer of the problems of TMD; I want to ask if these methods
are efficient:

1, The method of obtain the centric relation with the tongue;
2, The new method of use the plastic pad called "Aqualizer" for obtean the centric relation with it.

What opinions have you about these methods.

March 29, 2008 @ 7:22 PM

38. wrote:

I will try to answer these questions as best as I can. The literature is indeed divided on whether or not oral appliances work or do not work as therapy for temporomandibular disorders. What the science lacks is standardization in protocols for fabricating and adjusting the appliance. As a dentist who only treats these facial pain patients, I encounter many splints that are brought in by patients who report that they do not work. Many times, adjustments to the splint can turn a non-therapeutic appliance into one that is quite useful. It's not the appliance that is bad but how it has been delivered and adjusted.

The NTI appliance will not cause condylar resobrtion or breakdown. there is, in fact scientific evidence that supports the opposite view. Those who indicate that the pressure at the joints increases are simply wrong. when open bites in the front develope after wearing an NTI, it is a result of the jaw going into a more orthepedicaly stable position in the socket. So, if the condyle goes up into the socket of the skull, the front teeth will open slightly. This is considered a therapeutic outcome and can be managed if desired.

Finding the proper bite using the tongue position is a way that some dentist utilize. It is not the most accurate position as unhealthy muscles can cause the jaw to go to positions that may be orthopedicaly unsound. The aqualizer type splint is, in my opinion, not a therapeutic device. By placing the load on the back teeth, a person is able to clench much harder than they can on their front teeth. An ideal appliance will serve to limit the amount of force we can produce by providing a feedback mechanism when we clench. When an appliance only allows front tooth contact, we are not able to produce near as much force as when the back teeth are in contact.

The key to recieving the most appropriate therapy is to seek the care of a dentist specialy trained and commited to treating patients with these disorders. One avenue would be to go to www.aaop.org to find a doctor in your area. Hope that helps,
Steve

April 7, 2008 @ 5:51 PM

39. Steven D Bender DDS wrote:

Sorry, forgot to insert my name in the post

April 7, 2008 @ 5:53 PM

40. Hector Valladares wrote:

Thanks Steven for your response;
I am from Peru;
Are there some dentist from peru what has taken some course in the center?
Best regards

April 10, 2008 @ 6:30 PM

41. Chad wrote:

Hi,

I have been diagnosed with MPD and Internal derrangement (dd w/o reduction) by a very knowleadgable specialist...however I am now wondering if that diagnosis is correct. Any input would be MUCH appreciated. I am extremely desperite have tried both NTI and centric relation splints with no reduction in pain...

panoramic x-ray indicates one condyle is slightly larger than the other...no missing teeth...all wisdom teeth removed. no prior clicking or other jaw issues before this incident.

Initally I had an acute flare up with limited opening (18mm) and sharp pain which lasted a few weeks...probably from a nocternal habit. After a month, the sharp pains resided but a tightness and dull pain remained.

Went to physical therapy and after only 2 1/2 weeks, opening went from 29mm to 48mm. Pain reduced somewhat, but still remains. Tightness and pain begins at 11 and stops around 8:30pm every day for the past 8 months...mornings i feel fine...and I don't grind during the day. Pain is typically left deep face/cheek(Lateral pterygoid?) and on the opposite side that had the initial flare-up. I often feel best when eating believe it or not.

Pain can temporarily be relieved(for a minute or so) by either streching (opening wide as possible) or by "seating" the condyles(wiggling the mandible up and back as far as it will go and holding it there.)

questions

1. Based on my symptoms, what would be my recommended treatment/splint therapy? I assume since the pain resides when my jaw is moved posteriorly that an anterior repositioning appliance wouldn't be a good choice, right?

2. Do you think my original diagnosis (dd w/o reduction) is still accurate considering I went to physical therapy and gained almost 20mm in 2 weeks? Seems like more of a spasm or muscle-splinting restriction to me.

any insight would greatly be appreciated.

~Chad

April 14, 2008 @ 3:36 PM

42. Linda Carrington wrote:

Hello,
I am a patient, a woman of 47 years, who was given an NTI that covered four front teeth to replace my old full upper bite splint. After wearing the NTI at night only for about a year and a half, my bite changed, and there is a space between my upper and lower front teeth that was never there before. I can no linger use my teeth to bite my fingernails (I know, not good anyway!) or other small things like thread when sewing and the like.

My dentist insisted that the NTI could not make my teeth move like that, but my orthodontist took a look and said it certainly could have.

I now have a full upper bite splint modified to allow free movement of my front teeth. The front teeth have dropped to some degree, but now are once again misaligned and I may need orthodontist work to once again align the teeth.

It is my contention that the NTI was the cause of the gap between my upper and lower teeth, especially since the new bite splint with the open front has helped the teeth lower.

What do you think?

April 21, 2008 @ 3:03 PM

43. Dr. Michael Manhard wrote:

I am not sure that you have considered all of the reasons that potentially may casuse a change in bite as you have described, including the NTI. Only a trained dentist can do this for you.

If an NTI were to be worn 8 hrs per day only.... that would leave 16 hours without it. Considering 2/3 of the day without it, it is hard to believe that a permanent change could happen ....unless some other force is at work to reinforce this "open bite" during the day.

An example of a force that could do this might be your tongue getting between the front teeth while swallowing during those 16 hours without the NTI. Did you bring up the changes to your dentist at regular checkups?

Anyway the front teeth should "couple"(move together) if you simply leave out any appliance.

By the way, why did you need it in the first place?

A partial appliance leaving the front teeth free should be used with great caution. Research tells us that "back teeth only" touching triggers more grinding in some patients.

Hope this helps!
Dr Manhard

May 21, 2008 @ 4:59 PM

44. Elaine wrote:

I have an open bite and have been told that I have TMJ disorder. Only my back 8 teeth 2 on top/bottom each side touch. It has progressively gotten worse, in mm for the past 10 years. I have been told by 2 orthodontists that i need to have jaw surgery to fix the problem before the pressure on my back teeth causes more problems. I am 28 years old, is this really necessary? Will a splint or NTI device help in my case? I don't have much jaw pain, but I do clench and grind at night. I am also having issues with my insurance covering this type of surgery, stating that is is for asthetics only.
I appreciate anyones help and advice.
Elaine

June 24, 2008 @ 12:23 AM

45. Natasha wrote:

I am a musician (I play the oboe), and I have recently been experiencing migraines and jaw pain when I play. I haven't played for the last couple of weeks, but I still feel some tension in my jaw, especially at night. Is this possibly related to TMJ, and is there a splint or mouth guard that could help?

thanks

August 8, 2008 @ 7:59 PM

46. Ben wrote:

Could someone please help me because I don't know whether TMJ is my real problem. In February of 2007 I got aural fullness (left only) from noise exposure -- a very loud squeaky printer near me at work. The fullness soon became with me much of the time. It would definitely occur at concerts after about 45-60 minutes, even quieter acoustic concerts. The ENT gave me drops, order a CT scan -- ruled out ear problems. In retrospect I wonder whether it could have been activity of an inner ear muscle. A retired ENT cousin of mine told me TMJ problems can be irritated by noise exposure and to look into TMJ.

My dentist took no X-rays but did some manual tests and then after muscle relaxants failed fabricated an upper-tooth full-tooth mouthguard which I now see has a great deal of vertical dimension -- very thick. My symptoms worsened throughout the year until the ear fullness became constant ear pain -- still left side only except some very occasional touches of right side pain for a moment.

Then I asked my dentist about the NTI (as I did at the outset, when he dismissed it as "controversial") and he agreed to make me one though he said he did not think it would solve the problem. But he made me an anterior deprogrammer but it was not an NTI. It was fabricated in a lab (not Keller), allowed for plenty of canine contact, had no discluding elements, and had a ridge to put the lower mandible in a set position. I see the lab that made it did not indicate it for TMJ (just bruxism) and seems to no longer be making it (perhaps due to complaints?). In any case immediately upon using this appliance my symptoms worsened markedly -- severe pain in both ears and neck pain and jaw pain, which prior to then I'd only had touches of (and that was only after the start of split therapy). My dentists said it was just an adjustment period and encouraged me to keep wearing it.

I soon had full-blown severe hyperacusis and chronic severe otalgia. I got a proper NTI made and my jaw and neck symptoms resolved quickly. The ear pain and hypeacusis (and tinnitus, which developed two weeks later) continued. A neurologist found a trigger point in my sternocleidomastoid muscle (left) and injected it with lidocaine, which relieved the tinnitus temporarily and the hyperacusis was gone the next day (only to return later). So I am thinking I stretched my neck by biting over or under the device and maybe caused some ear problems. Also I understand the canines will go at the device all night intensely so grinding is worse in intensity and frequency. One canine hit directly; the other could with some lateral jaw movement. I had the dentist shave off the part of the ridge where the canines could hit but I on't think he did so completely (so they could still barely hit) and again no disclusing elements, and the ridge which I understand is not part of a proper NTI.

I next tried a MORA but developed left-side facial pain in two weeks and went back to the NTI.

Much later I went for another opinion and was diagnosed with articular disc displacement -- diagnosis from doppler blood flow (restrictedblood flow) not X-ray (though X-rays and tomogram were taken). A splint to move my jaw and get the discs back away from the arteries next to the ears was made. After a week of using it my right ear pain may be better, my left worse, and I now have new pain in my lower jaw area.

No ENT's will do anything, but I keep thinking my ear pain may be from ear muscle dysfunction not TMJ. Particularly since the pain started upon noise exposure from the printer and now becomes markedly worse upon exposure to any static noise or electronically created noise such as music and beeps. I have been told that noise can aggrivate TMJ pain, which is why I approached my dentist for a TMJ diagnosis in the first place. But can noise be this much related to a TMJ problem? And what of the articular disc displacement diagnosis from doppler blood flow?

Also I had two temporal tendon lidocaine injections which took ear pain away for two hours and have been diagnosed with temporal tendonitis though I have never had a problem eating or chewing. I definitely brux as I find myself waking up doing it. The NTI was great for taking away the pain caused by the prior device; could it have dislocated the discs though (I wore it about a year). The dentist diagnosing the articular disc displacement says the displacement was caused by accident not grinding.

Does any of the above mean anything to anyone? Apologies for typos.

February 11, 2009 @ 4:35 PM

47. Tia Tracey wrote:

Hi

I'm looking for advice. Some years ago my jaw started clicking - kind of a two-stage opening - and about 3 years ago the clicking got noticeably louder. When it finally seized up and stopped passing the clicking point, and I started experiencing considerable pain, I was referred to a Maxillofacial surgeon. He sent me for an MRI scan, diagnosed anterior displacement of the right TMJ and sent me for an MRI scan. After the scan he concluded the damage was a 3 and 4 on the Wilkie scale on the left and right sides respectively and recommended surgery.

I went to a second Maxfac surgeon for another opinion and he diagnosed the condition as reducing, tried me on a course of muscle relaxants for a few weeks to see if that would help (it didn't), told me to stop rock-climbing etc (anything that causes tension - I did for a while) and recommended a splint. After a few misplaced applications for the waiting list on the health service I eventually abandoned the splint-fitting as I wasn't really having so much pain any more - the jaw still doesn't open fully but I've kind of got used to it, and the pain was only sporadic. The fact that I never got back to that second level of opening always made me suspect non-reduction was the more accurate diagnosis, however it does open slightly further than it did when it first locked up.

Recently it started troubling me a bit again so I went to my new dentist to get a splint fitted. He fitted me with an NTI (fully moulded on the front four teeth), but the first couple of nights it seemed to put a lot of pressure on my front teeth, pushing forwards unless I was in full clamped-down bite position, and one in particular was in pain when I woke up. I was also concerned that my mandible was being pushed very far backwards, which I wasn;t sure was correct as it seemed to be causing tension in the joint and mild spasming as I tried to get to sleep. I went back to him to explain and he shaved a few spots off the shelf to try to get a more even bite distribution. Only now my jaw slips very slightly to the side and when I woke up this morning my jaw joint was in pain. In its previous position, despite the tooth being sore in the morning the jaw was actually very comfortable.

So, the question: do I get him to refit the NTI splint, do I try to get another type of splint, e.g. the Michigan splint, or do I just abandon it all??

Note that I think I'm more of a clencher than a grinder, but I have noticed my bite position get deeper over the years and there is definitey a torque to the right-hand side(30-something female - I know, typical TMD patient...)

Many thanks for any advice you can provide.
Tia

March 6, 2009 @ 5:16 AM

48. cc wrote:

Hector
i was having horrible face and neck pain and numbness on my left side and was recommended the aqualizer. it has been a lifesaver - after about 2 weeks my pain was gone! i didnt think it would do anything, but i was desperate to try anything that might work. i hate the thought of being so dependent on something, but i cant go 1 night without it. i did that once, thinking it wouldnt make a big difference, but i was back to the pain and numbness the next morning. it took about another week for the pain/numbness to go away, but it hasnt come back (been several months). so yes i think the aqualizer is worth it! if you have to wear a splint anyway, why not wear this less bulky appliance? the theory is that the h20 takes the force instead of your teeth/jaw... i dont understand it but it works for me and is much cheaper than all the other options ($25).

April 13, 2009 @ 6:48 PM

49. Tristram wrote:

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April 18, 2009 @ 11:15 AM

50. Althea wrote:

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April 18, 2009 @ 12:24 PM

52. wrote:

I'll try to make this as short as possible. I am a 50 years old female. I had braces as a teen and the ortho did a great job. I had good occlusion and nice straight teeth - never any problems that I knew of or anything a dentist ever noticed. A couple years ago I noticed a couple teeth were getting slightly crooked - and I mean ever-so-slightly. An ortho told me he could straighten them out with spring retainers in 5-6 mo. I had no clue any risk was involved. I got the retainers and wore them, as instructed, all the time except when eating. 10 months later my teeth were more crooked and, to make matters worse, I noticed my bite was out of whack. My teeth are touching in the back and I can't close them together like I used to and can't chew right. I took out the retainers when I noticed the bite change and left them out 6 months hoping they'd move back but they didn't. I've never had any TMJ issues and still don't that I know of. I need this fixed but don't know who to believe or what to do. I've had numerous "second" opinions and some want to fix it with braces and others tell me that is a big mistake. They want me to wear a splint and let the jaw get in a comfortable position and then braces/surgery or both. They say if I just go get braces I could make it worse. I'm petrified. I'm scared the splint will do more irreversible damage. I need my problem fixed because it is so disfunctional. I think what happened is when I had the retainers in (top and bottom) my top and bottom teeth couldn't touch each other. Instead they would clamp down on the retainer. This acted like a splint, mouthguard, etc. allowed my bite to change and since I wore it all the time I didn't have the down time that allows the bite to move back. When the original orthodontist made the retainers the molds were destroyed. I only have detailed "before" pictures to show my original teeth. Can someone please explain why trying just braces first would be such a bad idea? By the way, one of the "2nd opinions" said that, according to the molds he took, it looked like I had some slightly worn spots (that he determined to have been there before I wore the retainers)on some teeth (including some front teeth). This led him to believe, although I had no outward problems before I wore the retainers, I could have had some underlying issues. Any insight or direction would be greatly appreciated.

March 17, 2010 @ 10:55 PM

53. Concerned Patient wrote:

I'm a 45 year old female. I had invisalign and braces 6 years ago. Since then I have come to have two "wobbly" and sore pre-molars. My dentist wants to get me to CR by wearing a Kois deprogrammer for a few weeks, then he can evaluate whether he can file some teeth and equalize the load on the pre-molars, or get braces to achieve the same effect.

While I am waiting for the KD to be made, my two teeth are getting more sore by the day. So last night I put on my invisalign retainer and bit down into a half a tube of toothpaste.

This seemed to accomplish a few things - my jaw and lower teeth were unable to hit and "land" anywhere on my upper - well protected - teeth. This "pillow" was custom made and fit my mouth perfectly becasue it was squishy. My lower jaw was hard pressed to go back to it's usual spot and it felt as though it was starting to relax.

The tube of toothpaste was half full and biting down on it created a small comfortable gap between my jaw and upper mouth (maxillary??)

Is this a crazy idea? I will go see my dentist next week, but not before I try this custom "tooth pillow" for a few more nights.

May 7, 2010 @ 4:15 PM

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