CATEGORY 80 AUSTRALASIAN DENTIST CLINICAL three or more years from fitting the splint. The years of follow up since fitting the splint (with a minimum of three years) and those patients still wearing a splint were recorded. A splint wearer was deemed as a patient who wore a splint on average of six nights or more a week over the follow up period. Missed nights were accepted if a patient had a respiratory condition (flu, sinus infection or other affliction) that obstructed their airway or another debilitating condition that interfered with splint wearing. All data was recorded by the author either in the surgery on recall or by telephone call, as many of the follow-ups were years after treatment (Table 2). Occlusal equilibration A patient was considered ready for occlusal equilibration when the splint showed near reproducible centric stops (mostly after four or more splint adjustments) and mouth opening was sufficient to fit a red band medium speed handpiece. If mouth opening was insufficient the patient was advised to consider the following: physiotherapy and muscle relaxation medication and lastly arthrocentesis and simultaneously Botox (masseter and temporalis muscles but not in the TMJ) before occlusal equilibration. None of the patients in this study had arthrocentesis or Botox during the treatment regime including the follow-up period. Occlusal equilibration was performed according to the following principles and techniques as espoused by Ramfjord and Ash (Ramfjord and Ash 1966,Ramfjord and Ash 1971,Ramfjord and Ash 1983) and Arnold and Frumker (Arnold and Frumker 1976). Occlusal registration was performed largely with Accufilm (Parkell, Farmingdale, New York, USA) using two layers of red/ black registration paper together in articulating forceps for larger centric stop area of registration as illustrated (Fig. 14). This resulted in two colour choices of paper, namely two layers with red showing referred to as ‘double red’, or two layers of black named ‘double black’ for registration on different restorative surfaces (Kelleher Group A – 48 patients completed Stage 1, Group B – 96 patients completed Stages 1 and 2, Group C – 56 patients completed Stages 1, 2 and 3. Patient Sex Age Patient notes Self-reported improvement (%) Years Splint wearing No. follow-up at follow up Stage 1 Stage 2 Stage 3 Final (OST) (OST + OE) (OST + OE + MG/AG) Group A patients – OST 135 F 18 TMJ pain R, clicking R & L, temporal headaches, 0 NPBR NPBR 0 10 No deviation 2mm R, noisy clicking at breakfast table, 80% improvement after 6 months, patient gradually stopped wearing splint and symptoms returned. 172 M 66 TMJ pain L, clicking L, clunking L, locking, earache L 85 NPBR NPBR 85 3 Yes ‘for 20 years’, masseter pain L, deviation 2mm R. 179 M 36 Masseter pain R & L, clicking R & L, locking – had to 100 NPBR NPBR 100 6 Yes be forced open after eating big chocolate. Group B patients – OST+ OE 72 F 27 TMJ pain R & L, deviation 3mm R, MRI TMJ L, anteriorly 20 20 NPBR 20 3 Yes displaced disc without reduction, masseter pain R & L, temporal pain L, ear pain L, frontal pain L, eye pain L. 130 F 42 TMJ pain R, clicking R, ‘almighty’ cracking R, temporal 5 88 NPBR 88 3 Yes headaches, masseter pain R, deviation 4mm R, restricted opening 26mm, severe TMJ pain, ‘no painkillers help’. 17 F 44 TMJ pain L, restricted opening 30mm, deviation 5 100 NPBR 100 10 Yes 3-4mm L, masseter & temporal pain L. Group C patients – OST + OE + MG/AG 7 F 17 TMJ pain R & L, masseter pain R, digastric pain R, 30 30 30 30 3 No locking jaw, ear pain R, deviation 2-3mm L, restricted opening 35mm, clunking R & L, composite resin overlays 13 and 23, poor sleeper and inconsistent splint wearer. 177 F 40 TMJ pain L & R, clicking L & R, deviation 3mm R, 5 10 90 90 5 Yes canine look-alike crown 42 for right protective bite. 6 F 39 TMJ pain R & L, restricted opening 23mm, temporal 10 20 100† 100 17 Yes & masseter pain, migraines, MRI antero-medial non-reducing discs R & L, molar rise crowns 17 27 37 47 for occlusal reconstruction. (OST = Occlusal Splint Therapy, OE = Occlusal Equilibration, MG = Molar Guidance, AG = Anterior Guidance) † Molar guidance performed rather than anterior guidance. NPBR = not performed but required Table 2. Three selected patients from Groups A, B and C
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