Download TMD protocol to distribute, October 2015

A Protocol for the
Treatment of
Temporomandibular
Disorder
James E Metz, DDS, Diplomate ABDSM
Mickey C Harrison, DDS
The Metz Center for Sleep Apnea
1271 East Broad Street
Columbus, Ohio 43205
©2015, The Metz Center; Unauthorized reproduction or distribution will be
prosecuted. Requests for reproduction should be directed to Dr. James Metz at
[email protected].
1
Primary Site Stimulation (Stress Test)
The answer to differentiating temporomandibular dysfunction (TMD) from other head pain, even with
the complexities of cranial nerve V, may be a simple technique utilized by medical practitioners. Primary
Site Stimulation is a pressure technique that can be useful in the diagnosis of TM issues1 2. If the
clinician puts pressure on a specific structure and it creates the chief complaint, then one has usually
found the problem. The complexities and anatomic deviations of the system are not an issue here; the
goal is to find and reproduce the pain.
A simple example is that of a patient with “arm pain.” If they cannot tell the origin of the pain, the
practitioner must test. If the arm is examined by the use of primary site stimulation, then pressure is
applied by the clinician to various structures located in the arm. If the patient’s chief complaint is
“stimulated” while applying pressure to a specific structure, the diagnosis is complete, and whatever
was stimulated to hurt is the source of the pain. Realize that this test cannot predictably be
accomplished with palpation3 or jaw manipulation to diagnosis a TMD problem. The inaccessibility of
some muscles to palpation and the complexity of the system create the need for a different type of
testing.
The protocol is similar to the medical standard of care for distinguishing between local, projected,
referred and central pain and tenderness1. The stress test should become the standard of care for
dentistry, as it is in medicine. The test should always be a part of the complete TMD examination.
Two methods can be employed:
1. Anterior Deprogrammer (Figures 6, 7, 8)
2. Anterior Appliance (Figure 9)
Fig. 6 Anterior Deprogrammer, Retruded position
Fig. 7 Anterior Deprogrammer, Protruding mandible
Fig. 8 Ant. Deprogrammer, Checking posterior contact
Fig. 9 Anterior Appliance, Note: Excellent esthetics
2
The reliability of the stress test by either method has a high degree of confidence. Each of the tests will
give a yes or no to the diagnosis of TMD, but with a different urgency. Stress testing by either means will
minimize inconvenience, pain, misery or cost to the patient. However, if the practitioner wants a true
understanding of this TMD protocol with all of its ramifications, a complete knowledge of the anterior
deprogrammer must be gained prior to the use of the anterior appliance as a stress test method. At
least twenty-five patients should be diagnosed with the anterior deprogrammer stress test before the
anterior appliance is substituted.
It must be realized that sometimes there is no substitute for the expediency of the anterior
deprogrammer. This is especially true with a doubtful patient, or if a yes/no answer is urgently required.
The anterior deprogrammer stress test shows, vividly, the character and distribution of the pain related
to TMD4.
Once the anterior deprogrammer is understood, the anterior appliance is the most reliable diagnostic
tool available. However, the cost to the patient is greater. The anterior deprogrammer gives a quicker
diagnosis but does not separate TM joint patients from muscle patients as accurately as does the
anterior appliance. Testing with the anterior deprogrammer is completed during one office visit. If the
anterior appliance is used, a period of two weeks will be required for diagnosis.
The patient is asked to keep a record of their symptoms until they are pain free and the diary is
reviewed at each check appointment. The joint will sometimes remain somewhat painful (antiinflammatory medications can be utilized as needed) for a period of one week with the anterior
appliance. Approximately 60% of the time this pain will disappear during the first week. However, TMJ
pain should never be allowed to continue beyond the two week check. If the joint is still painful after the
initial two weeks, a pivotal appliance is indicated, and will be discussed in subsequent sections.
The stress testing with the anterior deprogrammer causes, among other things, an eccentric
(lengthening) contraction of the lateral pterygoid muscle5 6; an isometric contraction of the masseter,
medial pterygoid, and temporalis muscles; and pressure on the temporomandibular joint. Centric
relation occlusion and habitual occlusion will not normally be coincidental7. The doctor will usually be
able to demonstrate a “slide in occlusion” very conclusively after the test.
There are variations on the anterior deprogrammer.
 Huffman numbered leaf gauge (originally proposed by Hart Long8): mylar film 10 mm wide and
.1 mm in thickness attached together in book form, total thickness with all “leaves” 5.5 mm.
(Huffman Leaf Gauges, 853 Sylvan Shores Drive, South Vienna, OH, 45369-9517, phone
937.624.6101)9.
 Woelfel sliding guide: made from hard plastic, which is calibrated, and varies in thickness from .5
mm to 16 mm. The Woelfel sliding guide is the simplest to use and most sterilizable of the
anterior deprogrammers. (Girrbach Dental GmbH, Durrenweg 40, D-75177 Pforzheim, Germany,
phone 0049.723.1957000; see website at www.girrbach.de)10 11.
 Lucia jig: custom molded plastic which can be modified with an acrylic bur to any thickness
desired. The jig is generally molded over maxillary centrals for retention and has point contact
on a mandibular central10 12.
 NTI-tss (NTI-TSS Inc.) appliance: A modified Lucia jig, which can be used for a short time as an
appliance. The deficiency is the small number of teeth contacted in the lower arch. The
increased pressure on such few teeth is problematic, especially as compared to the anterior
appliance described in this paper13.
3
The claims of NTI-tss for the treatment of migraine are based on a 19 person study conducted in 1996 by
Lamey, Steele, and Aitchison at Queen’s University of Belfast and reported in the British Dental
Journal14. The Lamey study was conducted with full centric relation splints and not the NTI. The FDA
granted the acceptance for migraine because of the similarity of the NTI to the centric relation splint,
and the CR splints decreased migraine by 40%. Therefore, by this logic the NTI would also have this
effect. As stated previously, there is great confusion as to the diagnosis of migraine or TMD. Splints are
for TMD and may benefit some true migraine patients because TMD can be a secondary symptom.
Controlling a secondary symptom may decrease the frequency of the migraine, but true migraine will
not be controlled with an anterior splint. This leaves the claims of others subject to judgment.
The test with the anterior deprogrammer begins by:









Placing it between the patient’s maxillary and mandibular central incisors.
The patient must first protrude and then retrude the mandible to its most posterior position.
They then bite with “substantial” pressure on the deprogrammer.
The doctor or auxiliary must sit with the patient, making sure that they stay retruded and
continue to bite with substantial pressure. It is necessary that the test be conducted for at
least 7 minutes; muscles sometimes take that long to spasm. Many times the patient will feel
nothing prior to the onset of the painful spasm.
No posterior teeth can touch (see figure 8).
It is also important that the patient be comforted if the test produces a painful result, and
duplication of the symptoms is successful. The patient is never asked to continue beyond their
endurance. Place warm moist towels on affected area for comfort.
The Key: Once the patient reproduces the chief complaint, the test does not need to continue.
The diagnosis of TMD has been made, and an appliance (anterior or pivotal) is appropriate. The
following steps are physical therapy (refer to page 19 for more information). If the pain is minor
or the patient does not desire an appliance the following technique may be used to control
symptoms.
Once the pain begins, the patient should alternately bite for six seconds and relax for six
seconds.
Test continues for 7 but no longer than 10 minutes, measured from the beginning of testing.
The test is stopped prior to the 10 minutes if pain subsides. This is referred to as cycling the
muscle, which is a stretching of the muscle until the myospasm subsides.
A true joint patient will be in pain from the onset of the test, and seven minutes is long enough
for them to tolerate the discomfort.
The Key: If stressing a structure reproduces the chief complaint, then the source of the pain has
been diagnosed with the stress test.
A phenomenon occurs when a patient first complains of joint symptoms at the onset of the test. The
joint pain will sometimes go away after 2 to 3 minutes and is then replaced by the typical muscle spasm
related to TMD. It is hypothesized that a muscle spasm of the lateral pterygoid repositions the disc
(through the stretched TMJ capsule) in a more forward position than normal; once the disc is in this
forward position, it is sensitive to the initial testing15 (see figure 10). However, it will then reposition to a
more normal posture when the muscle starts to release. If the test is stopped prior to the 7 minutes the
clinician may incorrectly conclude that the patient has a joint problem, which is a more involved
treatment than that for a muscle spasm.
4
Figure 10: Left side, disc out of
position; Right side, normal
disc position.
The test is simple, but very telling because of the neurologic principle of primary site stimulation1 16.
Primary site simulation, as previously discussed, is the premise that if one presses on a structure that is
truly causing the pain, the pain will change. If the practitioner presses on a structure that is aching
because of referred pain, the pain will not change. If the stress test causes or changes the chief
complaint, the diagnosis of TMD is appropriate. It is important that the clinician asks the patient, “Is this
the same pain as your headache or just part of the headache?” The question can also be asked, “Is this
the pain for which you are seeking treatment?”
Patients can be both a TMD and headache sufferer. One of the conditions will be more significant. If
they are mainly a headache patient with a lesser amount of TMD, treating the TMD successfully will not
get rid of the headache. However, if the dentist is able to eliminate the TMD component, the headache
may decrease in either intensity and/or frequency17. Remember, the trigeminal nerve is the major
sensory nerve of the head and neck. Beware of referred pain18.
Advanced Understanding:
Another condition that may be associated with TMD deals with patients having otologic complaints,
such as otalgia, tinnitus, vertigo, and hearing loss. These individuals have a higher incidence of otologic
complaint than do control subjects without TMD signs or symptoms19. The overlap of symptoms is most
likely due to convergence. It is probable that other muscles can also be affected by the phenomenon.
Possibly, the tensor tympani, which dampens and stabilizes the inner ear to vibration, could also be
affected. Taking one more step, the tensor veli palatine may also be affected by convergence. Loughner
hypothesizes that the closing of the Eustachian tube, the responsibility of this muscle, creates a
sensation similar to a sea shell over the ear20. The sensation created may be the otologic symptom for
which the patient has a complaint.
5
TMD SPLINTS – WHEN, WHY, AND HOW21
Potential Sources of Headache and Orofacial Pain:
Vascular, Myofascial, Neurologic, and Intracapsular / Joint Pain
Stress Test by Loading, Resulting in Primary Site Stimulation
(“A Basic Orthopedic Principle for Diagnosis”)
Technique:
Time:
Muscle Activity:
TMJ Impact:
Anterior Deprogramming Device
.5-7 minutes
Temporalis contracts (Bilaterally)
Superior head of lateral pterygoid contracts (Bilaterally)
Inferior head of lateral pterygoid stretched to relaxed length (Bilaterally)
Compression/Loading of the condyle disc assembly and joint structures
NO PAIN – NOT TMD
PAIN – TMD
STARTS WITHIN .5 – 7 MINUTES
STOP BITING
STOP BITING
PAIN SUBSIDES (MUSCLE)
Educate the patient and cycle the muscle
(Home Care Instructions)
PAIN LINGERS OVER JOINT COMPARTMENT (TMJ)
(Capsulitis, Synovitis, Arthritides, or Nonreduceable
Disc)
Muscle
Joint
Splint of choice:
Anterior Appliance
Splint of choice:
Pivotal Appliance (Always Bilateral)
Wear time: Only at night
Wear time: 24/7 for one month but Never while
eating. After first month gradually reduce daytime
wear until symptoms abate (6 months to 1 year).
Splint will require an adjustment each month.
Stress test by loading the TMJs to
confirm healing (10 Minutes).
Mechanics: Physical therapy for the lateral
pterygoids. Ensures Anterior Disclusion!
Mechanics: Unloads and decompresses TMJ.
6
Anterior Deprogrammer Stress Test Technique22 23
1. Place the anterior deprogrammer at midline between the maxillary and mandibular central
incisors22 23 24.
2. The patient first protrudes, then retrudes the mandible to its most posterior position. The
patient bites with constant, substantial pressure on the anterior deprogrammer.
3. During the entire test, no posterior tooth can touch. An excessive number of leaves should not
be added to accomplish the separation of the posterior teeth. If 5 to 10 additional leaves
(beyond first contact) are used, that should be sufficient.
4. Most TMD patients exhibit symptoms from the damaged tissue within .5 to 7 minutes24.
5. During the test, ask the patient, “Is this a familiar pain?” It must be similar to their “headache,”
for which they are seeking treatment, to qualify as a familiar pain. The intensity of the headache
may not be the same but the character will be familiar.
6. The familiar pain must be the patient’s chief complaint.
7. The stress test changes to alternately biting for 6 seconds and resting for 6 seconds after pain
develops.
8. The pattern continues for several minutes or until the pain subsides. Generally, the pain will
subside within the ten minutes.
9. If pain starts in the joint and remains in that area after seven minutes the pain will only get
worse. Stop the test. The pain will not subside.
10. Never ask a patient to continue beyond their endurance. Place warm, moist towels on affected
area for comfort.
The Key: Once the patient reproduces the chief complaint, the test does not need to be continued. The
diagnosis of TMD has been made, and an appliance is appropriate.
Advanced Understanding:
Steps 7-10 are physical therapy. If the TMD complaint is minor muscle pain or if the patient does not
desire an anterior appliance, the stress test technique may be used at home by the patient two times
each day to control symptoms (early AM and late PM). The therapy technique will only make the TM
joint patients more uncomfortable, therefore it is only recommended for muscle patients.
7
ANTERIOR APPLIANCE
STRESS TEST TECHNIQUE
The Anterior Appliance is both a diagnostic and therapeutic modality. The appliance must be adjusted
properly for the test to be valid. The chief advantage of the Anterior Appliance over the Anterior
Deprogrammer is that the patient does not have to be subjected to the “creation of the headache,” but
the practitioner must first understand the anterior deprogrammer concept. The appliance stretches the
lateral pterygoid (both superior and inferior heads) over a longer period; and, normally, the patient does
not experience the pain of cramping.
Three outcomes are possible with the Anterior Appliance, worn for diagnostic purposes, after two weeks
of wear:
a. The patient feels no difference – TMD is not the patient’s source of pain.
b. The patient experiences pain in or around the ear, which does not go away after two weeks –
switch to Pivotal Appliance.
c. The patient feels significantly better after a two-week period of wearing the Anterior
Appliance – great!
Mechanics of the Anterior Deprogramming Device and Appliance:
Utilizing the muscles of mastication and guide planes one can take advantage of force vectors to stretch
the lateral pterygoid (superior and inferior head) and seat the condyle. These actions can be done with
either the anterior deprogrammer or anterior appliance. If either is placed between the central incisors
with no posterior tooth contact and the patient bites -- an anterior superior movement of the condyle
must occur25 26. The anterior deprogrammer does this quite easily but the anterior appliance must be
adjusted properly to achieve this goal. Refer to anterior appliance adjustment.
Please note the force vectors, if the
anterior teeth are brought into
contact without posterior tooth
contact.
Superior head of lateral pterygoid
is stretched.
Inferior head of lateral pterygoid
is stretched.
The condoyle is forced to assume
a more superior, anterior position.
The disc is compressed.
The anterior appliance decreases the mechanical stress on the masticatory system. However, if the TMJ
is the source of the pain, the anterior appliance will increase the pain in or around the ear. If the joint is
the problem, the use of the anterior appliance should be discontinued. The use of the pivotal appliance
is indicated.
8
A Review of the Flow Chart
Refer patient or find a cause other
than TMD.
NO PAIN – NOT TMD
The patient will only feel tired and no duplication of pain will happen. No pain is a sure indication that
TMD is most likely not the problem.
Exception – If the test is negative, ask the patient if he/she is in a headache cycle now? If not, the test
should be attempted again during a headache cycle. The variable nature of the bruxism can cause
muscle pain to come and go.
PAIN – TMD
TMD is the diagnosis
STARTS WITHIN .5 – 7 MINUTES
Pain (chief complaint) is duplicated within 3 to 7 minutes, and stops if the patient releases.
Most TMD patients fall into this category27 28.
Treatment: Anterior Appliance

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The chief complaint starts in 3 to 7 minutes, and if biting pressure is released – the pain will go
away. It can radiate into the joint, temples, back of the neck, sinus area, top of head, or just
about anywhere else in the head and neck region
The chief complaint will be duplicated (not intensity
STOP BITING
but character)
PAIN SUBSIDES (MUSCLE)
Patient comfort is always of the utmost importance
Educate the patient and cycle (refer to page
Fabricate the anterior appliance
21) the muscle
Give patient home care instructions
 Have patient keep pain diary
 Recall in two weeks
A supportive nature is very helpful during the procedure.
The stress test can really hurt. An excellent idea is for the
practitioner to experience the test, before administering it to
patients. The physical therapy technique of applying warm,
moist heat to the painful area makes the contraction more
bearable. The painful muscles are probably the lateral
pterygoid complex and/or the temporalis29 30.
The deep masseter may also play a role.
9
(Home Care Instructions)
Muscle
Splint of choice:
Anterior Appliance
Wear time: Only at night
Mechanics: Physical therapy for the
lateral pterygoids. Ensures Anterior
Disclusion!
BENEFITS OF THE ANTERIOR APPLIANCE:
1. The anterior appliance with shallow anterior guidance is the least invasive definitive therapy.
2. Anterior appliance is much easier to adjust than the typical centric relation splint.
3. The number of adjustment appointments is considerably less than with full occlusal splints. The
design allows for more healing between appointments and retains its adjustment longer, because
the posterior occlusion is not involved.
4. The breakage problem is significantly reduced (without posterior tooth contact the masseter and
the medial pterygoid do not contract nearly as forcefully30).
5. Patient compliance is higher. Because of the design, saliva makes the appliance almost disappear.
TWO CONCERNS WITH THE ANTERIOR APPLIANCE EXPRESSED BY MANY PRACTITIONERS:
Many practitioners have asked if this lack of posterior contact causes a problem. The answer is clear -- it
does not cause teeth to shift, when the appliance is used as described.
o
o
The appliance should not be used for eating or during the day after the first two weeks.
No change in the occlusion has been evident from the pretreatment casts. It is
important, however, to include the two “C” clasps, which are retentive, on the first
premolars. Otherwise movement may possibly occur between the maxillary first
premolar and maxillary canine.
Since the appliance is small – will the patient swallow it and is the appliance stable? If made correctly,
stability will not be a problem. After fabrication, place the appliance and ask the patient to try and
“knock it loose” without using their hands. If the retention is not sufficient, reline or use Biostar
(pressure forming unit) from Great Lakes Orthodontics for fabrication.
Advanced understanding:
Not all patients who have TMD symptoms are aggressive bruxers. The anterior appliance is very
successful for muscle patients – except for one group. The group that will not have success is made up
of the patients who do not aggressively brux. They will come to the office for their two week check, and
not one mark on the anterior appliance can be found. The management of this group must include
home care instructions, the utilization of the anterior deprogrammer for exercise, and the anterior
appliance. The anterior deprogrammer stress test (all steps) is used prior to sleep and when the patient
wakes in the morning. It is recommended to leave the anterior appliance in place during the exercise.
The anterior appliance along with the exercise utilizing the anterior deprogrammer will generally control
the muscle symptoms. It has been observed that this group is structurally the smallest of the female
patients31; they are the group that holds their mandible forward in protrusion instead of bruxing.
It is important to note that the design of the appliance may impact how the patient sleeps and breathes
at night. It has been shown by Gagnon and also Nikolopoulou that in subjects with sleep apnea, an
occlusal splint may cause an elevation in AHI32 33 34. The advantage of the anterior appliance is the
minimal thickness of acrylic. It is designed to allow for as much tongue space as possible. If an occlusal
guard is too bulky, it will crowd the tongue and force it to the posterior, which aggravates the person’s
airway while they are attempting to breathe during sleep, potentially contributing to an increase in
respiratory disturbances, hypopneas or apneas.
10
The test for occlusal change is quite simple:
 An accurate pretreatment impression is taken, poured immediately in die stone, and filed for future reference.
It is imperative that the cast be accurate and meticulously cleaned of inaccuracies.
 Another impression is taken and poured six months to a year later with equal care. The patient cannot wear the
anterior appliance to this appointment!
 The pretreatment cast is pressed into soft red compound to leave cusp tip impressions and excess compound is
removed.
 The second cast is then tried into the compound impression – there should be no discrepancy.
Advanced Understanding:
Q: What comes after the successful use of the Anterior Appliance?
A: For a true TMD patient with no airway issues, no further treatment is needed, unless the patient
desires a more definitive answer.
If the patient feels encumbered by the appliance or the amount of wear time, what should be done?
 An excellent set of casts are mounted on an Arcon articulator to determine the person’s occlusal
and skeletal relationships. Time is saved by making the maxillary posterior segments removable.
 A careful and complete diagnostic work-up (including radiographs, consultations, testing, etc.)
must be accomplished before any irreversible treatment is rendered.
 The methods available to clinicians, as dentists, are limited. A well planned occlusal adjustment
that satisfies the mechanics of the anterior appliance may be the best option. Care must be
taken that the adjustment is not overly damaging to the system. All options need to be
considered!
The Key: If the mechanics of the anterior appliance can be duplicated, then the success should be
replicated. The correction, if completed and goals are met, gives a very similar situation to that of the
centric relation splint. The reduction of painful symptoms with appliance therapy is very well
documented35 36 37.
If the individual is a sleep patient with airway concerns and TMD symptoms, it is appropriate to screen
them with a high resolution pulse oximeter once their TMD symptoms have been addressed. They can
then be referred for a polysomnogram as needed and treated with a mandibular advancement device.
This will be further discussed in subsequent sections.
11
THE ANTERIOR SPLINT DIAGNOSTIC TECHNIQUE
Potential Sources of Headache and Orofacial Pain:
Vascular, Myofascial, Neurologic, and Intracapsular / Joint Pain
Stress Test by Progressive Loading
Technique:
Time:
Muscle activity:
Anterior Appliance
2 weeks / 24 hour wear, except when eating
Temporalis contracts (Bilaterally)
Superior head of lateral pterygoid contracts (Bilaterally)
Inferior head of lateral pterygoid stretched to relaxed length (Bilaterally)
Compression / Loading of the condyle disc assembly and joint structures
TMJ Impact:
NO CHANGE – NOT TMD
AFTER TWO WEEKS IF ….
MUSCLE PAIN - RESOLVES / IMPROVING
OR
TMJ - PAIN PRESENT IN TMJ AREA
AFTER 2 WEEKS – PAIN PRESENT IN TMJ AREA
PAIN HAS INTENSIFIED OR STAYED THE SAME OVER JOINT
AFTER 2 WEEKS -- PATIENT IMPROVED
PAIN HAS DEFINITELY IMPROVED AND PATIENT FEELS THAT THEY ARE RECOVERING
(Muscle Pain, Capsulitis, or Synovitis)
COMPARTMENT
(Arthritides or Nonreduceable Disc)
Muscle
Joint
Splint of choice:
Anterior Appliance
Splint of choice:
Pivotal Appliance (Always Bilateral)
Wear time: Only at night
Wear time: 24/7 for one month but Never while
eating. After first month gradually reduce daytime
wear until symptoms abate (6 months to 1 year).
Splint will require an adjustment each month.
Stress test by loading the TMJs to confirm healing
(10 Minutes)
Mechanics: Physical therapy for the lateral pterygoids
Ensures Anterior Disclusion!
Mechanics: Unloads and decompresses TMJ
12
Requirements of Anterior Appliance
1. Appliance must be stable – Cover entire facial and lingual surfaces of teeth numbers 5 through
12 and cut off occlusals on 5 and 12. To reduce retention, prior to fabrication, the deep
undercuts on the cast should be blocked out. Less desirable solutions are to decrease the facial
coverage and/or cut through the appliance’s facial interproximals with a fine disc to separate
the teeth. Remember, the more esthetic the appliance – the greater the compliance. If the
retention is not sufficient, reline or use Biostar pressure forming unit from Great Lakes
Orthodontics for fabrication.
2. The appliance is adjusted until the mandibular six anterior teeth touch. A smooth arc of contact
is desired and if a mandibular anterior tooth is severely out of alignment – it should be ignored.
3. The anterior deprogrammer should be used to adjust the appliance
after two weeks of wear; this should never be done at the delivery
appointment. The technique is to add leaves until no tooth touches
and then take away one leaf at a time, while adjusting contact, until
no leaves remain. Even contact of all teeth with the TMJs seated is
the goal.
4. Anterior guidance must be very shallow and as flat as possible but
retain some angle in order to separate the posterior teeth.
5. At least 3mm of “slide area” required from centric point to edge of
splint.
6. Posterior teeth cannot touch – if they do, the appliance will not work!
The patient returns in approximately 2 weeks for check. They must
wear their appliance to the appointment. The check is to refine the
appliance. If a posterior tooth touches, one must add to the splint. Adjust contacts with the
anterior deprogrammer.
A Key: if the patient complains of joint symptoms after two weeks with this type of splint, one should
not continue. One must change to a pivotal appliance.
7. Patient instructions – wear appliance at night only and follow home care instructions (Page 19).
If for the first two weeks the patient is having significant problems, daytime wear is permissible.
After patient symptoms are relieved, the patient should use as needed.
8. Patients should always be prescribed Colgate Prevident Fluoride Gel (not Colgate Prevident 5000
Paste), and they should place a “pea size” amount of the Gel in the splint before bed (Colgate
Palmolive, www.colgate.com).
13
Joint Pain and the Pivotal
Appliance
Indications for the pivot appliance defined38:
STOP BITING
PAIN LINGERS OVER JOINT COMPARTMENT (TMJ)
(Capsulitis, Synovitis, Arthritides, or Nonreduceable
Disc)
Joint
1. Non-reducible dislocated articular disc,
confirmed by MRI.
2. Systemic disease entities that cause arthrogenous
pain in TMJ during the stress test (e.g., arthralgia,
osteoarthritis, osteoarthrosis).
3. Post-surgical involvement of the TMD.
4. Intracapsular pain -- determined to be the TMJ by
either stress test.
Utilizing the anterior deprogrammer to stress the system,
the patient will begin to exhibit symptoms within the first
minute. The pain will only intensify as the test continues.
Splint of choice:
Pivotal Appliance (Always Bilateral)
Wear time: 24/7 for one month but Never while
eating. After first month gradually reduce daytime
wear until symptoms abate (6 months to 1 year).
Splint will require an adjustment each month.
Stress test by loading the TMJs to
confirm healing (10 Minutes)
Mechanics: Unloads and decompresses TMJ
After the patient exhibits symptoms, the test changes to alternately biting for 6 seconds and resting for
6 seconds. The pain will only increase in intensity, and does not diminish. Stop test after 7 minutes. A
diagnosis is evident, and nothing will be gained by continuing. Joint derangements are highly probable39
40
. Many times the patient will relate that they cannot chew anything hard (bagel, pizza crust, chips,
tough meat, etc.) without causing a headache.
A Key: Experience has shown that approximately 60% of patients initially reporting pain in the joint
while chewing are not joint patients but are actually muscle patients41.
If there is ever a question of joint involvement with the anterior
deprogrammer test the practitioner has two choices:
1. Place cotton rolls on both the left and right sides between the first and
second premolars, then tell the patient to bite hard42. The placement
here is very important. Too far back on the molars and you will
unload the joint; and too far forward on the anterior teeth, the lateral
pterygoid, and temporalis are stimulated.
 Joint patients will have pain
 Muscle patients will not have pain
2. Fabricate an anterior appliance and prescribe an anti-inflammatory medication. Seat appliance
and wait two weeks. Sixty percent of the time, after 1 – 2 weeks the joint symptoms will
disappear. If they do not resolve – make a pivotal appliance.
14
Special Situation for Disc Displaced Less than Four Weeks:
1. Time is of the essence and all treatment must be completed in 4 weeks or the joint begins to
fibrose, which will prevent the disc from repositioning.
2. If the displacement is recent (less than 3 weeks), an anterior appliance is fabricated that day
for the patient. The patient is then placed on a Medrol (methylprednisone, Upjohn)
Dosepak six (6) day regimen (4 mg, 21 tablets), provided there are no contraindications.
3. Patient should be seen after 3 days on Medrol and questioned about range of motion and
symptoms.
4. If range of motion is back to normal and the symptoms are in remission, then wait another
three days and reexamine.
5. If all normal – congratulations – if not proceed to step 6.
6. If displacement has not reduced, consider having a capable specialist perform a TMJ
arthrocentesis, a nonarthroscopic lavage and lysis, which is highly efficient in this particular
type of TMJ problem.
7. After the injection procedure, treat the patient with an anterior appliance to stabilize the
disc.
8. Time is of the essence. The surgeon must perform this
procedure immediately, within the 4 week deadline.
9. The use of the anterior appliance for stabilization has been
very successful31. If joint symptoms
persist a pivotal appliance is necessary.
Treatment for a Painful Joint:
The pivotal appliance is generally effective for the displaced disc. It has the ability to alter the mechanics
of the jaw at the joint level to an unloaded, uncompressed treatment position43 44. The appliance is
perfectly flat, over the most distal tooth. Both left and right contact at the same time (refer to
requirements of pivotal appliance handout). The pivotal appliance transfers the fulcrum from the TMJ
to the teeth intentionally, until healing occurs.
The patient does not eat with the appliance in place, and the appliance is worn 24 hours each day.
Generally, after 6 weeks the appliance is only worn at night. Treatment time is variable, but is generally
at least 4 to as many as 18 months. Time must be given for healing to occur. Wear of the appliance
continues until the loaded position is comfortable. One may test, as previously described, to assure
healing of the TMJ has occurred. One of the true pleasures of dentistry is to see the positive change in
the TMJ patient; sometimes, the personality change is dramatic.
How to determine if the loaded position is comfortable
(Tests all previously described):
1. Anterior Deprogrammer
2. Cotton rolls in the premolar area
3. Anterior Appliance
15
Variation of the Cotton Roll Test One Can Perform
To Validate the Idea of A Pivot:
The concept of changing the mechanics at the joint level requires a careful analysis of the mechanics
involved. A skull helps in the understanding of the pivot mechanics. Here is a test which may be
performed in one’s own office, when the clinician has diagnosed a probable TMJ problem:
1. Place cotton rolls bilaterally in the first and second premolar area.
2. Instruct the patient to bite hard – the joint will be painful (The placement is critical to ensure
stimulation of the proper muscles; pressure on anterior teeth can cause contraction of the lateral
pterygoid and temporalis muscles, which confuses the test due to referred pain).
3. Move back over the most posterior molar and bite hard – the joint will not hurt. What changed?
The mechanics changed!
Lateral
Posterior
Extended disc
Superior head of
Lateral Pterygoid
Anterior
Deep Temporal
Nerve
Photo of disc is taken from the middle cranial fossa, the floor of
which has been removed45. It should be noted that the disc has
been displaced but the retrodiscal tissue has “extended the
disc.” Collagen makes up much of the retrodiscal tissue and can
be remodeled into disc tissue.
Conditions must be such that healing can happen. It is the goal
that the pivotal appliance will create these conditions. If the
patient’s pain is relieved, it is extremely likely that this healing
has occurred.
Medial
TWO CONCERNS WITH THE PIVOTAL APPLIANCE EXPRESSED BY MANY PRACTITIONERS:
1. Many practitioners have asked if this lack of anterior contact causes a problem. The answer is clear
– it does not cause teeth to shift, when the appliance is used as described. The patient must
understand they cannot eat with this or any appliance. Tooth movement can occur if this appliance
is used for longer periods than described46.
2. Since the appliance is two unilateral, unconnected appliances, will the patient swallow them and are
they stable? If made correctly, stability will not be a problem. After fabrication, place the two
appliances and ask the patient to try and “knock them loose” without using their hands. If the
retention is not sufficient, reline or use the Biostar (pressure forming unit) from Great Lakes
Orthodontics for fabrication.
Perfectly Flat
In this area
Second Molar
First Molar
Second Molar
First Molar
Second Premolar
Second
Premolar
16
Requirements of Pivotal Appliance
1. Appliance must be stable – Cover entire buccal and lingual surfaces of mandibular molars and
second premolar. The appliance is two separate pieces. If the retention is not sufficient,
reline or use the Biostar pressure forming unit from Great Lakes Orthodontics for fabrication.
2. Add orthodontic acrylic to central fossa area of last mandibular molar, which has an opposing
maxillary molar; make this addition as thin as possible and flat (If no molars exist, the dentist must supply
them; this can be done with a removable partial denture or implants. If more retention is needed, grooves can be cut in the RPD
for stabilization). At least 2mm of “slide area” is required from the centric point where the mesial
lingual cusp of the last maxillary molar makes contact to edge of splint.
3. Adjust the splints so they both touch at the same time when the patient closes with the
tongue pressed against the roof of their mouth. No attempt is made to achieve centric
relation.
4. Teeth anterior to the last molar cannot touch – if they do, the appliance will not work! The
patient must wear the appliance at all times, except when they eat, and return in
approximately 2 weeks for a check. Examine, to be sure no teeth anterior to the contact point
touch, and that the area where the posterior maxillary molar touches is perfectly flat. A
relatively small depression in this area will prevent the appliance from functioning correctly.
5. If appliance is adjusted properly the joint symptoms will be nearly nonexistent or much
improved after 3 to 5 days. (A temporal headache indicates the pivotal appliance is too thick.
High Angle Class ll patients have this problem, due to lack of freeway space. A solution is to
make the appliance thinner or move the pivot to the first molar area.)
6. Patient instructions – wear appliance except when eating and follow home care instructions
(Page 19). After 6 weeks switch to nighttime wear only. Treatment time varies with age and
magnitude of the problem. The normal length of time is from 6 to 18 months. The health of
the joint can be determined by running a stress test with an anterior deprogramming device,
anterior appliance or cotton rolls (described previously).
7. After the loaded position is no longer painful, discontinue use of the pivot and treat as a
muscle problem only. If the anterior appliance is not painful, treatment is successful.
8. Patients should always be prescribed Colgate Prevident Fluoride Gel (not Colgate Prevident
5000 Paste), and they should place a “pea size” amount of the Gel in the splint before bed.
Anterior Appliance
17
The Pivotal Appliance
Perfectly Flat
In this area
Second Molar
First Molar
Second Premolar
Premolar
Advanced Understanding
Mechanics of the Pivotal Appliance
Possible Axis:
Condyle—Condyle
Condyle-Fulcrum
18
Home Care Disciplines for Muscle and Joint Soreness
James E. Metz, DDS, 1271 East Broad Street, Columbus, Ohio, 43205
614-252-4444, [email protected]
The time it will take to gain comfort will depend, in part, upon you following these instructions.
1.
MOST IMPORTANT DISCIPLINE – Preferred position of sleep

Sleep on your side with the pillow high on your head, and with no pressure on the jaw. Speak with Dr. Metz if you have a
question, especially if you are abnormally tired during the day with a sufficient amount of sleep.

Use a rolled up towel or pillow against the back to keep from changing to flat on the back. It is very hard to change sleep
habits, so do not give up! As long as 6 months is sometimes needed to change sleeping positions.
2.
Avoid caffeine and sugar as much as possible, both are stimulants to the nervous system.

Intake of coffee, Mountain Dew, cola, diet cola, tea, chocolate, etc. should be very carefully monitored and curtailed.

The caffeine contained in one cup of coffee is the maximum amount a person should consume per day.

Caffeine can get rid of a headache and can cause headache.

Reducing your intake of caffeine “cold turkey” will bring on headaches in many people.

You may need to take ibuprofen (400 mg. four times a day, read the warnings on the packaging) to control a withdrawal
headache from caffeine.
3.
Eat a soft diet and avoid chewing as much as possible.

Absolutely no gum chewing.

Avoid clenching your teeth.

No bagels, hard carrots, tough meats, or anything that requires “hard chewing.”
4.
Avoid clenching your teeth during the day. Many people think they do not clench but most do at times.

A good technique for catching yourself clenching is to program your brain to think, “Am I clenching my teeth?” You can use
every day events to “jog” your memory. Think! Every time you look at your watch (before you even think of the time) or walk
through a door, try to catch yourself clenching. After practice, this technique is very effective in preventing TMD headache
during your waking hours.

Small “sticky dots” from a stationary store can remind you not to clench. Put one wherever it will be a good reminder. If you
see one, think “am I clenching my teeth?” (Technique from Dr. Gordon Douglass, San Francisco, CA)

If you catch yourself, place your tongue in the roof of your mouth and push hard while you move your jaw up and down.
5.
Avoid over opening and stretching your jaw. A two and one-half finger width of opening is maximum distance allowed, especially when
yawning; push up with a fist under your jaw when yawning to limit opening.
6.
Take your medications.

Medication helps to gain control of symptoms more rapidly by decreasing inflammation.

Call the office or emergency (911) if you feel an allergic reaction is occurring, and discontinue medication use immediately.
7.
Wear your appliance!

You can decrease the wear time of the anterior appliance as soon as you start to feel better.

The pivotal appliance needs a 6 to 18-month period to accomplish its goals and the wear time is variable. Never wear the
appliance after the initial 2 week period during the day.

After the pivotal appliance healing period, the anterior appliance will follow.

Never wear either appliance when eating.
8.
It is your responsibility to maintain contact with the office.

If you start to have pain, call the office.

A regular check appointment is essential, especially for the pivotal. Initially the appointment time is every two weeks. After
control is gained, every three to six months is essential.

Never wear the pivotal appliance singly because the appliance will cause harm.

Never wear a broken appliance.

Call if you have a problem or if your appliance is making the symptoms worse.

Call immediately if the pain starts to center in or around your ear.
19
1
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Loughner BA, personal communication 2003-2010
21 ©James E Metz, DDS, 1271 East Broad Street, Columbus, Ohio, 43205, 614-252-4444, www.ColumbusDentistry.com; Flowchart developed
with Dr. William McHorris, Memphis, Tennessee
22 McHorris WH, American Academy of Restorative Dentistry, 1995
23
McHorris WH, personal communication, 1982-2003
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31Metz JE, Clinical experience and observation, 2003-2015
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37 Manns A, Valdivia J, et al, The effect of different occlusal splints on the electromyographic activity of elevator muscles, J Gnathology, 7:61-73,
1988
38
“Indications for the pivot appliance” originally proposed by Dr. William H McHorris, Memphis, TN
39 Blackwood H, Arthritis of the mandibular joint, British Dental J, 115:317-376, 1963
40 Toller P, Osteoarthritis of the mandibular condyle, British Dental J, 134(6):223-31, 1973
41 Metz, JE, Clinical experience and observation, 1998-2013
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43 Okeson, J.P., Bell’s Orofacial Pains Fifth Edition, Chicago: Quintessence Publishing, 301, 1995
44Jiang T, Condyle and mandibular bending deformation due to bite force, Kokubyo Gakkai Zasshi, J Stomatological Society, Japan, 59(1):142-59,
1992
20
45
Dissection courtesy of Loughner BA, 1990-2000
Dahl BL, Krogstad O, The effect of partial bite raising splint on the occlusal face height, an x-ray cephalometric study in human adults, Acta
Odontologica Scandanavia, 40(1):17-24, 1982
46
21