Talking about reversibility of splint therapy.

Someone asked for my advice

Talking about reversibility of splint therapy.
Someone asked for my advice. Instead, I would like to ask a few related questions here. A patient had a few minor (muscular) TMJ symptoms but no history of clicking and had good mouth opening. After wearing a splint for several months, the patient developed clicking and the mouth opening limited to one finger width. The splint was adjusted several times within 2 years but these symptoms did not improve. The patient was advised to remove the splint and let the situation go back (within a few months). It turned out that without the splint, the posterior teeth no longer met properly (and comfortably) as they used to do before the splint. The front teeth no longer touched except for one (as I remember) while they used to touch before the splint.
Clicking is present on one side at wide opening and occasionally on the other side too. Mouth opening remains at one finger width. Besides the “usual” neck pains, tinnutus has developed. The bite did not go back to where it used to be. I think it’s about a year now. During the treatment (when clicking was present) the MRI showed normal joints.
My questions are: If clicking means displaced discs how could the MRI be normal? Or was it due to a non-qualified radiologist reading it? Or maybe the discs were recapturing and somehow the MRI never caught them when they were out?
IMO, if a few months of time did not make the jaw go back where it used to be, this is not going to happen on its own. Is this correct?
As I am suggesting to the patient, doing nothing will likely make the discs become displaced without reduction. Is this correct?
What would be a good approach now to help this patient?
I’d appreciate your suggestions.

Discussion

Paula Circa
Following (only one tooth contact after using splints when before that I had an occlusion)

Paula Circa
Tatiana Gelfand why do you say “doing nothing will likely make the discs become displaced without reduction. Is this correct? “

Tatiana Gelfand
I have an impression from dental literature that if the bite is not stabilized, i.e. the jaw is not stabilized, then TMD (i.e. disc displacement) will get worse with time. I would like to hear what dentists will say.

Paula Circa
Ok I get what you mean, from not having contact on posterior teeth , bite is not stabilized then disc could get displaced, sounds logical , it is tricky though I would say my discs got more displaced from some splints I used (although they were supposed to be stabilizing splints and all contacts were adjusted and drilled to have a supposedly stabilized bite) if this patient has no cranial distortions and discs seem ok, maybe they won´t get displaced , and it is a good opportunity to escape from splints (I would do that if I were in this person´s shoes)

Tatiana Gelfand
IMO, splints which displace discs are repositioning splints. Moreover, they reposition the jaw (usually forward– this is the current dental fashion) in a way so to block access to CR. Or to block the freedom of the jaw to move where it wants.

Paula Circa
Why do you think moving the jaw forward blocks access to CR?

Paula Circa
Adam Matthew yeah I was thinking the same, but I get lost sometimes, I become sure of one thing and then read sth and start doubting again! What a nightmare!

Tatiana Gelfand
Adam Matthew , probably it is. But this case is the result of repositioning the jaw. This is why I am asking what would dentists suggest to do now? When the problem with the discs was caused.

Tatiana Gelfand
Paula Circa , because this is what they want to do– to make you bite more forward, i.e. to make it your “new home”.

Julie Vandervelde-Moll
An MRI is only as good as the radiologist reading it assuming the quality of the scan is good. I have had several misreads at excellent facilities including one that said my implant was seated and the screws well seated and attached but in reality my implant was loose in the fossa and all 4 screws were not even in the implant. I found development cuts showing the screws in the surrounding muscle and brought it to my surgeons attention.
I have worn many different types of splints and when removing them my bite has returned to normal eventually but it does take time. However I did not develop new symptoms just a worsening of the current symptoms when wearing the orthotic/ splint. I would worry this person had a new event occur while wearing the device and the bite will not return to normal until the disc issue is taken care of.

Tom Busch
It’s been something like nine months for me, and my bite has not returned to normal.

Julie Vandervelde-Moll
Tom Busch it took over a year for my bite to close after the NTI disaster. I would talk to a qualified dentist to get re-evaluated and see if there is something more that can or should be done to help.

Tatiana Gelfand
Over a year? Wow!

Julie Vandervelde-Moll
Tatiana Gelfand I am trying to remember exactly how long it was in the 16-18 month time frame. My bite was really open and I hit only very slightly on one bicuspid at first. When I say return to normal I mean completely back to where I started not just my teeth meeting just to clarify.

Tatiana Gelfand
So the position of the jaw changed back to normal, right? Or the teeth extruded to close it?
Sounds a bit strange to me that it was so gradual. My jaw responds at most within a few days, usually immediately.

Julie Vandervelde-Moll
Tatiana Gelfand my jaw returned to my normal position but I had a normal bite to start with. I am assuming the change took so long because I even to this day have issues with my bite changing if I have swelling in the joints like with weather change or when I am sick with lots of sinus pressure. I will try and swing by my dentist office for the scans showing the progression of return. I think I have one every 3-4 months as it was returning.

Julie Vandervelde-Moll
Right now my bite is only hitting on two back teeth on the left but my right side is pretty swollen. It’s enough swelling it’s compressing the trigeminal nerve v2&3 because my lips and tongue tip are numb. It’s been this way about 10 days I am guessing another week or so and it will return to normal

Jill Mitchell
Perfect example of someone being damaged by an improperly designed splint. IMO splint treatment isn’t reversible.
This person needs to find a qualified dentist to take over their case and start from scratch.

Tom Busch
I agree, splint treatment is not reversible. At least not for me it wasn’t.

Jill Mitchell
Dentists are bending truth when they say it’s reversible. The only people I know that this worked fir were extremely simple easy cases

Tatiana Gelfand
For extremely easy cases everything will work unless the dentist is a complete … completely incompetent. 🙂

Tom Busch
Tatiana Gelfand I’m sure they’re out there. 😃

Tatiana Gelfand
George Dawson, Jill Banks made a good comment above about the splint reversibility. Yes, the dentist asked to remove the splint and let the jaw go back where it was. But the teeth no longer met properly. Clicking and limited mouth opening were already present after a few months in the splint. So they remained the same. But worse than before the splint because these were not present.

Tatiana Gelfand
It was a forward repositioning splint, as I mentioned. I’d rather not provide more details.

Jill Mitchell
George Dawson yea for most part but I don’t agree

Tom Busch
I wore my splint for about 4.5 months, and it’s the same for me as your friend in regards to the posterior teeth no longer meeting properly or comfortably as they used to do before the splint.

Kristin Weithas Furth
my daughter wore splint for a few months and in the time developed an anterior open bite. It did NOT reverse and we have a mess now.

Paula Circa
I had a really interesting conversation with an orofacial myologist today that reccomended to chew gum and hard food for an open bite ( I showed her my pictures) and she advised this, and I would add a myomunchee, I would tell this patient to try this before any splint and if that has no effect then reconsider splints IMHO

Amy Marie
Following

Rodney Baier
Do we know the patients condition prior to getting the splint? Any premature contacts? Slides? Interferences in lateral movement? Envelope of function? Any muscle tenderness to palpation? Posterior joint inflammation? Pain on loading?

Rhianon Jean
Following

Tatiana Gelfand
Rodney Baier, the patient says that all teeth touched perfectly. I think there was nothing from a dentist to answer your questions about the bite (if I find out, I’ll add this later). Since eating was not a problem, I guess that there was no pain on loading. From the TMJ related symptoms there were: headaches, tightness in cheeks, feeling of something stuck in the throat, head pressure, ear pressure, jaw joint pain.
IMO, this indicates some over compression, i.e. possibly low VDO or possibly not adequate guidance. I do not see reasons for repositioning the jaw.
The question is how can the jaw be helped to go back where it belongs?
Clicking on one side indicates to me that the jaw was also shifted uni-laterally with the splint. Hopefully, the disc displacement is not medial.

Samer Elketebi
That sounds exactly like my story and condition

Rodney Baier
Tatiana it would be important to determine what was causing the headaches, pressure, pain….
Its not uncommon for people to adapt to unstable situations(especially developed slowly over time). Then when something interferes with the adapted situation the system breaks down(final straw).
This is why it is very important to do a thorough evaluation to formulate differential diagnosis prior to any intervention.
Patients come in all the time saying everything is fine. Upon thorough evaluation often numerous issues are uncovered.

Tatiana Gelfand
Rodney Baier, I have more details. A wisdom tooth was extracted and during the procedure with the mouth open, the joints started hurting and never stopped. As I guessed, the dentist who examined the patient (in regards to these pains) prior to making a splint, did not provide any info about his findings. He did a 3D scan and said that the joints are too far back. After the clicking and limited mouth opening were caused by the splint, he tried to restore the bite, as I said for 2 years but with no success. On the other hand, the MRI showed normal joints at the beginning of symptoms with the splint.
I understand well what you are saying about being used to a non-perfect bite which feels great. However, we are now talking about the joints! How to bring them back in place (actually literally back in the joints, because the jaw was moved forward according to the current dental fashion). One finger mouth opening is really not a pleasant way to live, not to mention tinnitus and other symptoms.
Any thoughts how to help?
Do you think waiting longer (it’s been 1.5 years without the splint) might still be beneficial or inversely, it might be bad for the joints?

Rodney Baier
Tatiana Gelfand sounds like the splint/appliance never achieved its goal. I would guess its either not done ideally or a proper diagnosis hasnt been made.
Always good news(and usually much easier to manage) if the joint isnt damaged(based on mri findings)
My advice would be to try to get a diagnosis of what exactly the current condition is then formulate a plan based on that

Tatiana Gelfand
Thank you! What do you think should be included in this diagnostics? Another mri, 3d-scan or just the tap-tap, slide, move the jaw forward, etc. ?

Supriya Jadhav
I stopped using spint cold turkey.. it was very uncomfortable initially.. but jaw and teeth went back to initial position in 2 months time. You really have to take your attention out of your mouth and into other activities and put your splint somewhere where it’s difficult to reach.. that’s the only way to reverse it..

Supriya Jadhav
I was just talking about me.. and I am fine..

Andrea Stevens
I have a question as a dentist on this forum. I see many people talking about “splint therapy” (which as I read seems to refer to a variety of types of oral appliances) and after discontinuing treatment can’t get their teeth together….yet most people saying this also say they had a “normal bite” before splint therapy. I’m confused…with a “normal bite״…why the need for splint therapy?

Jill Mitchell
Normal bite to us means we are touching evenly or so it seems in all teeth. We may have horrible symptoms but after splint we only touch on for example front teeth…. or just a few teeth.

Tom Busch
What Jill said.

Rodney Baier
Tom and Jill. Its a bit more complicated then this but the simplistic explanation is that the body will tend to adapt the position of the lower jaw in order to have the most teeth touch evenly(its most efficient for function). The adaptation is typically muscles bracing/posturing the lower jaw into the position of maximum tooth contacts even if its unstable to where the joints should be. Some call this a CR(centric relation)-MI(maximum intercuspation) discrepancy. The muscles are often programmed to MI(much like a limp while walking). Once it goes beyond the bodies adaptive capacity things can start to break down. This can be seen in worn teeth, fractured teeth, recession or TMD related issues.
Sometimes any intervention(splint or a restoration) can “un-program” the muscles and the jaw will reposition itself. Some people may be able to “refind” their MI while others will not(for various reasons).
Thats why the goal of appliance/splint therapy is to find maximum tooth contact with a stable joint position(optimized bite). There is some debate on the exact position of joint but almost no debate on where the tooth contacts should be.
Add in all the other factors such as airway, posture, joint damage, nutrition…… and the intervention(splint) is the drop of water that tipped the bucket over. Sometimes its hard to get water back into a tipped over bucket

Tom Busch
That makes sense to me Rodney Baier. Hey, can I ask where you learned about treating TMD? You often seem to have an informed perspective.

Rodney Baier
Tom Busch lots of different places Ive trained. Have a few excellent mentors that are invaluable.
Theres often much debate(and sometimes contention) between different philosophies but at the end of the day most all of us want the same thing to help get our patients healthy. Even with differing techniques we all want to get the bite and joints to work in harmony while trying to manage all the other components involved. There are some wonderful people on this site that dedicate their lives to trying to find the answers. Unfortunately we dont have all the answers and worse yet the vast majority in the profession have very little knowledge.

Tatiana Gelfand
Andrea Stevens, “I’m confused…with a “normal bite״…why the need for splint therapy?” Me too!

Tatiana Gelfand
Where did you post it, Joseph Schmidtchen?

Rodney Baier
Joseph Schmidtchen most people agree on tooth contacts. The debate is where should the Md be during these contacts.
I remember learning a saying years ago:
All posterior teeth touch simultaneously and even, with anterior teeth lightly touching. When you squeeze, neither a tooth or the Mandible moves laterally. When you move in excursive, no back tooth hits before, harder than, or after a front tooth.
There can always be individual circumstances that are different but Id argue this is what most all of us are trying to accomplish to obtain what Clayton terms”optimized bite”

Tatiana Gelfand
Rodney Baier , exactly! The main problem is to find where to create this bite.

Rodney Baier
Tatiana Gelfand thats the challenge. There is no definitive science supporting any of the philosophies. IMHO if you are treating meticulously with intent and follow solid protocol any of the philosophies can have a high success. Using any of the methods or philosophies half assed with typically produce poor outcomes.
I like to think of it like diet and exercise. There are various paths to success but the fundamentals are all similar and if done with intention results can be better

Rodney Baier
Mandible

Lenka Dubsky Prescott
Mine has not been “normal” for years thanks to orthodontic treatment.