CATEGORY AUSTRALASIAN DENTIST 101 LINICAL 3). Formal fully protective occlusal splint therapy is the first stage of ‘Full Occlusal Therapy’ and results in a reproducible hinging arc of the lower jaw within the TMJ’s. This generally coincides with a marked improvement in the TMDand these two factors create a dental environment to safely and predicably move to the second stage called ‘occlusal equilibration’ (OE) (Figs. 3 and 4). Occlusal equilibration involves determining which teeth contact first in hinge occlusion or hinge bite and spot grinding with a medium speed handpiece and diamond burs (drills) until a second pair of teeth contact. This is performed with the aid of carbon type registration paper to register biting marks initially in hinge bite between the teeth and locating cusp tips and corresponding flat regions called centric platforms or centric stops (Fig. 4). Spot grinding is repeated numerous times until more teeth contact and become balanced between the left and right sides, which results in a protective hinge bite or occlusion. The other bites, namely left, right and forward bites may similarly be adjusted to create a protective occlusion in these excursive lower jawmovements (Darveniza 2001). This is precision work conservatively performed at the micrometre level usually by a highly skilled occlusal motivated prosthodontist. The aim is to have teeth simultaneously bite or contact in unison as the TMJ’s hinge and provide occlusal protection in excursive movements when the TMJ’s translate (Darveniza 2001). The third stage of ‘Full Occlusal Therapy’ is called anterior guidance (AG) for most patients and, for rare dolichofacial patients, molar guidance (MG) (Figs. 3 and 5). That is, protective guidance of the lower jaw is required by the opposing teeth contacting as the jaw moves sideways and forward. After occlusal equilibration a protective hinge bite can occur which is followed by bio-designing anterior/molar guidance. Each of the three excursive jaw movements (left, right and forward) are evaluated for the degree of protection or presence of unprotected occlusal schemes (Darveniza 2001). Orthodontic therapy is always considered first to improve anterior guidance. Following orthodontic therapy immediate occlusal equilibration is recommended and a new fully protective upper occlusal splint fabricated as a retainer as well as for TMD management. If orthodontics is not required, biodesigning anterior guidance using crowns or temporary composite resin overlays or porcelain veneers can be performed on any short lower canines and upper canines with inadequate canine restrictive ridges or upper centrals without bilateral protrusive ramps (Fig. 5) (Darveniza 2001). This paper on ‘Full Counselling’ describes how to instruct patients, dental assistants, and dentists for themanagement of TMD’s. Methods Counselling patients with TMD symptoms has been refined by the author since 1981 with an emphasis on recommendations by Zeldow on habit change (Zeldow 1976). Conservative management of TMDs in this process starts with counselling followed by fitting ‘Fully Protective Occlusal Splints’ and four splint adjustments over a minimum three-month period (Darveniza 2022,Darveniza 2022,Darveniza 2022 ). ‘Full Counselling’ encompasses during these stages concurrent targeting of occlusomandibular habits followed up with habit modification techniques and addressing improving body posture and sleep posture analysis when required. Habit modification The author’s patients with damaging habits underwent habit re-training as outlined by Zeldow 1976. This involves three steps, namely: (1) habit awareness, (2) control old habit with instant awareness and (3) instil a new habit (Zeldow 1976). The replacement of a bad habit with a good one involves time, effort, patience, and reinforcement. The investigation by the author into what oro-facial habits a TMD patient has starts immediately the patient sits down in the dental chair. Habits will be discernible during the first appointment at the following stages of history taking and oral examination in the dental chair and counselling in a consultation room. History taking for a TMD patient begins by listening to and asking a patient what problems do they have with their jaw joints, jaw, face, bite, or teeth? During these questions, the dentist must observe all unusual or excessive motions of the head, neck (Fig. 6), shoulders, eyes, lips, eyebrows, nose, cheeks, forehead, scalp, temple, tongue (Fig. 7), lower jaw and teeth, hands, and body posture. Any observed unusual or excessive habits should be recorded while Fig. 10 The left view in centric occlusion (CO) with a lower midline 1.5 mm to the right of the upper midline and with a hobby of playing the viola on the left side. The right view illustrates the patient pointing to the right TMJ which becomes painful when performing an occluso-mandibular habit of left latero-protrusive clenching on a wedging contact. The wedging contact involved the labial surface of 22 wedging against the lingual surface of the 32 tooth resulting in right TMJ pain. Fig. 8 This workplace habit of handto-jaw posture resulted in the palm of the right hand pushing the chin to the left and the first knuckle of the index finger protruding into the right TMJ fossa while the neck tilted to the right side with pain. The patient was instructed to desist from touching the face with the hand and habit retraining involved creating a new habit of addressing good body posture by ‘sitting up straight, tensing the lower abdominal muscles, and keeping the shoulders level’. Fig. 9 Extreme pencil clenching habit performed during clerical work resulted the condyles being pushed posterior (disto-horizontal vector) and superiorly into the TMJ discs with instant TMJ tenderness and then pain. The relevant patient instruction was to desist from doing this habit and habit re-training involved creating a new habit of ‘lips together teeth apart’.
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