CATEGORY 86 AUSTRALASIAN DENTIST LINICAL from disc displacement. Constant checking for the habit (step 2 ‘instant awareness’) can be made by the patient placing their index finger on the upper front teeth to detect that the lower incisors/canines have not been positioned forward of the upper incisors/ canines. Instilling a new habit (step 3 ‘new habit’) involves protruding the lower jaw only to edge to edge protrusive or lateral excursion and verifying this position with the index finger. The finger can now be moved in a vertical direction from the top to the bottom gumlines of these teeth several times. During the process of instilling this new habit, the patient should say or think and repeat that ‘moving and crossing the lower jaw forward past this point (called cross-over) can be harmful and it needs to stop’. Recorded habits Following history taking and oral examination the patient can be escorted to a consultation room for further counselling of their recorded, but not previously discussed, habits and their treatment plan. For example, a common habit noted in a consultation room involves the patient chin cupping with their hand or tilting their head into the palm of the hand while the dentist talks. This habit will protrude the mandible resulting in the condyle leaving the TMJ fossa and with manual lateral force contribute to TMJ ligament stretching (De Coster, Van den Berghe; et al. 2005,Shore 1970) and muscular fatigue. In such a case, the patient would be told (step 1 ‘habit awareness’) to stop touching their face and the reasons. Their family and friends are encouraged to instantly inform (step 2 ‘instant awareness’) the patient of this habit. Instilling a new habit (step 3 ‘new habit’) often addresses other habits and issues, such as general body posture. A new habit for the chin cupping patient can be to instruct the patient ‘to sit up straight by tightening their lower abdominal muscles’. The reason given would be that sitting straight on the chair with their shoulders back and even results in good neck, face, and lower jaw posture. To help them not touch their face, knowledge of the correct position to rest their face and lower jaw requires instruction. The instruction might include the following comment ‘lips together with the teeth apart, between 1 to 15 mm wide, but the lower jaw should not be forward or to the side but in the hinging arc of opening’. The initial appointment should address the most destructive observed habits and the other recorded habits can be addressed during occlusal splint therapy. At the next appointment, feedback following the retraining of the above-mentioned habits should be addressed along with previously recorded habits. Instructions during fitting a splint The fitting of a ‘Fully Protective Occlusal Splint’ should be integrated with ‘Full Counselling’ during fitting and during a minimum of four splint adjustment appointments over a minimum threemonth period. The stages and timing of ‘Formal Occlusal Splint Therapy’ have been outlined (Darveniza 2022). Full counselling instructions for patients and dentists during fitting of a fully protective occlusal splint have been outlined (Table 1). Full counselling of oro-facial and occlusomandibular habits and adjunctive therapies during therapy have been outlined (Table 2). The process used to counsel patients using these tabulated instructions involves giving a written handout to the patient and explaining each point by the dental assistant and dentist in a team approach. During the one-hour appointment, Fig. 22 An extreme mouth opening habit, illustrates a 68 mm interincisal opening, which shows the result of TMJ ligament stretching. The plastic vernier calliper has been ideal for measuring mouth opening and the average mouth opening should be in the vicinity of 43 mm (Poveda-Roda et al. 2012). This TMD patient was instructed to ‘limit mouth opening to three folded fingers until all symptoms have subsided, to prevent further disc displacement’. Fig. 21 The left and right views illustrate an extreme right lateral protrusive cross-over habit with wedging of teeth. The right view identifies a lingually tilted 33 tooth which contacts against the 22 tooth while the 11 and 21 teeth wedge firmly against the 32 and 31 teeth. This mandibular protrusion resulted in the condyles leaving the fossae and the discs becoming displaced resulting in left clicking and TMJ pain. The patient was instructed that ‘edge-to-edge protrusion was not the default position’ and extending the jaw to this position is called crossover. Habit re-training involved asking the patient ‘to run their index finger from the lower gum of the front teeth to the upper gum while the teeth are at edge-to-edge protrusion, and to repeat the process’. This new habit emphasized that cross-over was unacceptable and that the ‘lower jaw default position was in the hinging arc of closure with the lips together and the teeth apart’. Fig. 23 This view illustrates a TMD patient during a sleep posture analysis, performed in 1992. The left-hand 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 moved the mandible and left disc medially 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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