CATEGORY 78 AUSTRALASIAN DENTIST CLINICAL mandibular orientated explanation of how that particular unprotected mandibular movement was associated with this pain/strain. The explanation was reinforced by temporarily biodesigning canine guidance/restriction and/or sagittal bilateral guidance in protrusion with a wide thin metal cement mixing spatula or Lecron (Figs. 5, 6 and 7) (Darveniza 2023, Darveniza 2022). 7. patients were then informed of any parafunctional occluso-mandibular habits as reported by Darveniza (Darveniza 2023, Darveniza 2023) and believed responsible for the perpetuation of TMD symptoms via the repetition of these destructive mandibular vectors (Figs. 1, 2, 3 and 4), 8. patients were then given counselling including behavioural modification, often in the form of a new habit to prevent further repetition of their damaging habit according to Zeldow 1976 (Zeldow 1976) and Darveniza (Darveniza 2023, Darveniza 2023) (Fig. 8), 9. patients were given a sleep posture analysis, where indicated, usually during a splint adjustment appointment to prevent damaging habits to the TMJs and musculature as elaborated by Darveniza (Darveniza 2023) (Fig. 9), and 10. in the consultation room, with the aid of diagrams drawn or supplied to the patient, a commentary was given on the anatomy of the TMJ and the role a splint plays in improving the position of a displaced disc as described by Darveniza (Figs. 10, 11 and 12) (Darveniza 2023, Darveniza 2022, Katzberg et al. 1980, Nitzan 1994, Sanders 1986). Patient selection and treatment plan Two hundred dentate patients were selected and treated by the author in his private practice. Patients selected had a TMD with signs and symptoms of clinical disc displacement but not solely a muscle diagnosis. Patients with radiological signs of severe osteoarthritis, rheumatoid arthritis, arthralgia, or arthrosis were excluded. The TMD patients were selected with two or more of the following to qualify for this preliminary investigation: TMJ pain other than arthralgia (Dworkin and LeResche 1992), joint noises other than solely coarse crepitus (arthrosis) (Dworkin and LeResche 1992), chronic restricted mouth opening or closing other than myofascial spasm, noticeable deviation (2-3mm or more) of the mandible during opening but not associated with an asymmetrical mandible or acute muscular spasm, history of locking but not transient trismus. Six of the 200 Fig. 5 This view illustrates the lower midline located about 5-6 mm lateral to the upper midline region during left latero-protrusion. This resulted in a horizonto-lateral mandibular vector and destructive wedging of 32 between 22 and 23 forming an unprotected left lateral path with concomitant left TMJ and masseter pain. This patient suffered with chronic severe TMJ locking and associated restricted mouth opening. Fig. 6 This view illustrates a wide cement spatula angled vertically and laterally to simulate a median palatal ridge of an upper canine tooth. This spatula created a ‘temporary protective bite’ in left lateral occlusion with a restrictive and guided protective long canine rise path. This ‘temporary protective bite’ resulted in the pain disappearing during left jaw movement when moving along the spatula with this bio-designed protective left lateral path. When the spatula was removed and the patient moved left to final path the pain returned and this could be attributed to a disto-horizontal mandibular vector pushing the condyle towards the left TMJ disc. A bio-designed crown was recommended for the 33 tooth to create a left protective bite, with a similar vector to the direction of the spatula. Fig. 7 This view illustrates a completed biodesigned crown on 33 that created a left protective lateral occlusion with a vertico-lateral mandibular vector to complete ‘full occlusal therapy’. Bio-designing started with: proximal reduction of 32 and 34 during crown 33 preparation, a polycarbonate crown form to create a canine cusp, arylic resin lining, adjusting the 22 and 23 teeth to develop a protective lateral occlusion, taking an alginate impression of the temporary for a ceramist to doublescan for milling a duplicate zircona/ porcelain crown. Note that the canine cusp has been angled lingually to increase the length of the canine rise path. The patient no longer has TMJ pain and locking. Fig. 8 Extreme habit of tensing the platysma involves mandibular retrusion and the resultant retrusive vector pushes the condyles unnaturally towards the TMJ discs, with associated symptoms including digastric and sub-lingual muscle pains, TMJ pains and clicking discs. The patient was instructed to desist from doing this habit and habit re-training involved creating a new habit of ‘lips together teeth apart’. Fig. 9 This view illustrates a TMD patient during a sleep posture analysis, performed in 1992. The lefthand rests on the pillow with the second knuckle of the thumb penetrating into the left TMJ fossa. The patient slept with the full weight of the skull on this knuckle and others which helped create TMJ pain and medial movement of the mandible and left disc to the right side. This movement allowed the condylar head to move out of the fossa and the left disc to be antero-medially displaced without reduction, other factors also contributed. The recommend posture for sleeping on the left side mandates that the contralateral hand, the right hand, be placed flat under the pillow to support the mandible and TMJ’s and point of the shoulder.
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