CATEGORY AUSTRALASIAN DENTIST 73 CLINICAL was vertico-lateral mandibular movement (Darveniza 2023, Darveniza 2022). The patient was shown their inherent unprotected occlusal scheme and the perceived effect on TMJ and muscle pain, and joint noises. Following this the patient was asked to pinpoint muscle or joint strain/pain during an unprotected mandibular movement. Occluso-mandibular counselling Occluso-mandibular counselling of TMD patients involves explaining the relationship between tooth contacts (occlusion) and their influence on directing mandibular movements that maybe harmful to the TMJs and associated musculature. This can be illustrated by providing a biodesigned temporary protective bite using a correctly angled thin metal instrument, a cement mixing spatula or Lecron, followed by an occluso-mandibular orientated explanation (Darveniza 2023, Darveniza 2022). This counselling should include how the temporary bite now with a protective mandibular vector, re-directs the mandible during an excursive movement and generally relieves/modifies TMJ pain and/ or muscle strain/pain, and momentarily ceases/softens joint noises. The procedure starts with the patient being shown their inherent unprotected occlusal scheme and the perceived effect on TMJ and muscle pain, and joint noises. The patient was asked to pinpoint muscle or joint strain/pain during an unprotected mandibular movement. This was followed by an occluso-mandibular orientated explanation of how their jaw movements were damaging to the TMJ’s and musculature. The patient was informed that changing the shape of teeth can result in a bio-designed protective bite for their jaw movements (Darveniza 2001). The patient was informed that a temporary protective bite was going to be bio-designed in their mouth with the aid of a thin metal instrument (Darveniza 2023). Correctly aligning a thin metal mixing spatula or Lecron between the molars created a simulated lateral restrictive ridge. The patient was directed to move laterally on the instrument placed over the upper molar and arbitrarily angled about 3040 degrees vertically and 10-20 degrees anteriorly depending on the size and shape of the lower tooth. Similarly, a spatula was placed between the central incisors to create a simulated protrusive ramp to direct the mandible in protrusion. These temporary protective movements mostly resulted in a diminution of TMJ or muscle strain/pain. Patients were informed that initially a splint with a similar protective bite would be made and, in the future, molar guidance would be biodesigned with crowns for specific teeth to create a long-term protective bite. Patients were further advised to refrain from parafunctioning on their now identified unprotected occlusal schemes. Case selection and Full Occlusal Therapy Two hundred dentate patients were selected and treated by the author in his private practice. Patients selected had a TMD but not solely a muscle diagnosis. Patients with severe osteoarthritis, rheumatoid arthritis, arthralgia, or arthrosis were excluded. Patients had two, or more, of the following to qualify for the study: 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 mm or more) of the mandible during opening but not associated with an asymmetrical mandible or muscular spasm, history of locking but not transient trismus and reducing or nonreducing disc displacement. In accordance with the sequential nature of ‘full occlusal therapy’, each patient following ‘formal fully protective occlusal splint therapy’ then proceeded, if they wished, to occlusal equilibration. Following the necessary occlusal adjustment appointments and achieving a stable reproducible hinge occlusion, the patient could then proceed to be fitted with a crown to bio-design molar guidance. Fully Protective Occlusal splint for a Dolichofacial patient The parameters for bio-designing a maxillary Fully Protective Occlusal Splint were followed according to the study performed on 200 patients by Darveniza and reported in 2022 (Darveniza 2022, Darveniza 2022, Darveniza 2022). Designing molar guidance in a splint for a dolichofacial patient can successfully be used (Graham 1986, Graham 1988, Rugh 1989). A molar rise designed splint appropriately addresses lateral guidance/restriction but to accurately design a sagittal directed bilateral protective protrusive path simultaneously on left and right molars has challenges (Darveniza 2022). Hence, the author prefers anterior guidance as protrusive ramps anteriorly can easily and accurately be developed even though a large anterior open bite creates a challenge for lip comfort. In the 2022 reported study the mean thickness of 100 splints was measured as 4.3 mm at the first molar with standard deviation of 0.61 mm (Darveniza 2022). To replicate this in a dolichofacial patient results in the height of the anterior guidance protuberance of about 20 mm on the labial surface at the midline depending on the size of the open bite. This protuberance affects lip comfort, and the technician needs to be instructed to design a 4 mm overjet into the anterior of the splint and angle this protuberance posteriorly (Fig. 1). When assessing the labial prominence of the splint, the lower lip should be lifted upwards and outwards with the thumbs and index fingers and laid back on the labial surface of the splint to check for prominent bulging of the splint that may distort the lower lip which could result in discomfort (Fig. 2). In many instances this anterior guidance protuberance needs to be ground-in to allow the lower lip to move uninterrupted across the curved labial surface of the splint (Fig. 2). Design elements of molar guidance This preliminary investigation of 200 TMD patients revealed only three had a dolichofacial skeletal pattern with concomitant anterior, premolar and open bites. All three patients required molar Fig. 1 This dolichofacial patient with a large open bite illustrates a ‘Fully Protective Occlusal Splint’ with an anterior guidance protuberance that has been contoured prior to polishing. This splint has an overjet of 4mm to allow for the development of medium steep and long canine and protrusive rise protective paths. This overjet results in a decrease in the volume of the anterior guidance protuberance caused by angling the lump posteriorly, which in turn minimises lower lip impingement. Fig. 2 The result of a 4 mm overjet and posterior angled anterior guidance protuberance allowed the splint to fit comfortably on the inside of the lower lip. Note this protuberance had a continuous arcuate shape to fit neatly against the lower lip.
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