CATEGORY AUSTRALASIAN DENTIST79 CLINICAL selected patients had an arthrogram or MRI and of these five were diagnosed with non-reducing discs and the other reducing discs. Patients were advised that the treatment plan for their TMD was ‘full occlusal therapy’ (Table 1) performed sequentially (as needed) and slowly along with specified adjunctive therapies elaborated by Darveniza (Darveniza 2023). The 200 patients were offered three sequential occlusal therapies, with time guidelines (Table 1), but could stop at any stage. In Stage 1, all patients started with ‘Formal Fully Protective Occlusal splint therapy’ (Darveniza 2022, Darveniza 2022, Darveniza 2022) (Table 1) (Fig. 13). In Stage 2, many patients who underwent splint therapy decided to continue onto occlusal equilibration. In Stage 3, the remaining patients who had completed Stage 2 chose to continue onto molar guidance (Darveniza 2024) or anterior guidance (Darveniza 2001). Treatment included the ‘Full Counselling’ protocol at the examination appointment and all other Fig. 10 Schematic vertico-oblique view of the TMJ’s, teeth and surrounding structures of a 14-year-old with a premature contact 17/47, often due to erupting wisdom teeth, and a normal condyle/disc/ fossa assembly and centred disc. Fig. 11 Schematic vertico-oblique view of a physiologically adapted mandibular position from the previous figure, but now with an adaptive centric occlusion and physiologically adapted disc. The TMJ disc shows anterior displacement with reduction and a stretched posterior ligament. The physiological adaptation process involves posturing the mandible forward and laterally to circumnavigate away from the prematurity to achieve maximum interdigitation. An aetiological hypothesis could be that with hyperfunction of this off-centred mandible that the thickest portion of the disc was used to shim the fossa/condyle to stabilise the mandible during mastication which resulted in disc displacement. Fig. 12 Schematic vertico-oblique view of the TMJ discs during ‘Full Occlusal Therapy’ illustrating a ‘Fully Protective Occlusal Splint’ with four splint adjustments, occlusal equilibration, and molar/anterior guidance in a time sequence. An aetiological hypothesis of a displaced disc re-centring during full occlusal therapy has been diagrammatically presented by: (1) decreasing parafunction, such as clenching, abolishes negative pressure (Nitzan 1994) on the superior portion of the disc (short pointed red arrows) which releases the crushed disc from the fossa by relieving the suction-cup effect (Sanders 1986); (2) relaxing the muscles of mastication, including the superior head of the lateral pterygoid muscle (long pointed red arrows), allows the elastic posterior ligament to gradually retract between splint adjustments or ‘rubber band recoil’ (Katzberg, Dolwick; et al. 1980) (rounded red arrows) the disc; and (3) when adhesions break (green broken springs) the disc can recentre aided by the elastic ligament. SEQUENCE OF TREATMENT USUAL TIMING 1. Formal Fully Protective Occlusal Splint Therapy involves 4 splint adjustments (SA) 1.1 Splint adjustment 1: 1 – 2*+ weeks after fit 1.2 Splint adjustment 2: 2 – 3† weeks after SA 1 1.3 Splint adjustment 3: 3 – 4 weeks after SA 2 1.4 Splint adjustment 4: 4 weeks after SA 3 *= 1 – 3 days after fitting if an acute TMD condition † = can be longer if a chronic TMD condition Recommend removing wisdom teeth, if necessary, after SA 4 if jaw comfortable or ideally after first fine tune bite adjustment 2. Occlusal Equilibration involving 3 occlusal adjustments (OA) 2.1 Major Occlusal Adjustment At months 4 – 5 2.2 First fine-tune OA: 1 – 2 months after major OA At months 5 – 6 2.3 Wisdom teeth removed (if necessary) At months 7 – 8 2.4 Second fine-tune OA: 4 months after first fine-tune OA At months 9 – 10 3. Bio-design Molar Guidance/Anterior Guidance by using various modalities starting with: 3.1 Orthodontics, thereafter occlusal equilibration and possibly composite resin overlays, porcelain veneers and crowns if molar or anterior guidance is still unprotected 3.2 If no orthodontics, bio-design a sagittal bilateral protective After month 10 path with composite resin or crowns for protrusive ramps on central incisors and crowns on the molars for dolichofacial patients 3.3 Including bio-designing a vertico-lateral mandibular After month 10 movement with a fully protective lateral guidance/restrictive path with composite resin or crowns for canine rise and crowns for molar rise for dolichofacial patients 4. Reline or new fully protective occlusal splint Continue nocturnal wearing Over a minimum 3 month period along with concurrent ‘Full Counselling’ of oro-facial habits and occluso-mandibular habits during full occlusal therapy Table 1. Stages and timing of ‘Full Occlusal Therapy’ appointments (Darveniza 2023, Darveniza 2023). Recording percentage improvement of symptoms Patients were grouped depending on what stage they completed. Group A patients only wanted ‘formal occlusal splint therapy’, Group B patients followed splint therapy with occlusal equilibration and Group C patients continued from splint therapy and occlusal equilibration to have a bio-designed molar or anterior guidance. Clinical notes of selected TMD patients from Groups A, B and C are illustrated (Table 2). Following each occlusal therapy, the patient was asked what level of improvement, in percentage terms, had been achieved from the initial examination to the end of each stage. Most patients replied giving a single percentage figure which was recorded but many gave a range, and for these patients the mean was recorded. The final improvement in percentage terms was recorded following
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