Correcting a Pathologic Joint Position using Mandibular Torque and a Fixed Orthosis (part 3)
You can really begin to second guess yourself and be self critical when things are not going as planned. When I placed my father in a neuromuscular removable orthotic there was little improvement. (Slide 1)In fact the pain might have been slightly worse in the left TMJ although he was now on Myo-trajectory. The Myo-centric bite had brought him down and forward, but his I-CAT scan revealed a disturbing fact. (Slide 2) The left condyle was riding against the articular eminence in the Myo-bite position. (Slide 3)We tensed and tensed and tensed in fact we tensed so much… once for about five hours while I was treating other patients in my office and completely forgot about him. Could we find a bite position that would relieve his pain within his joint? My father never really complained of muscular pain throughout this experience.
Repeated evaluations with the K-7 system showed that the orthotic was on Myo-trajectory. This created a dilemma; every Myo-bite taken left him in a bone to bone situation on the left side. We originally began with a removable orthotic to attempt to alleviate his condition. However his bite relationship without the orthotic did not leave him with a functional occlusion to eat with. We were not making much progress with the removable orthotic anyway. We made the decision to change to a fixed orthotic. We then used a new Myo-bite for Roy’s fixed orthotic. (Slide 4) As you can see there were extensive degenerative changes now in the left joint as time went on. (Slide 5, 6, 7) We can see the condyle directly against the eminence and the formation of joint mice or calcified bodies and bone fragments floating within the joint space. (Slide 8) His opening became even more limited.
It was getting very hard to believe that things were going to get better. Was surgery going to be the only option? Was my father going to have to live with pain and suffering after paying for my education? He was traveling from New York to Colorado once a month for treatment. (Slide 9) My father is a research mathematician. His scientific nature leads him to question everything in the minutest detail. He was well aware of my neuromuscular practice and successes with others. The problem had really hit home. The pressure was building. It was time to prove that neuromuscular dentistry was the way to go and was not quackery.
When we looked at his original radiograph things almost looked better before treatment. I had several thoughts about what to do. Should I remove the orthotic and see what happens. Well without the orthotic he was in constant pain with no bite. And he was in pain with the orthotic on Myo-centric trajectory but at least he could chew. (Slide 10)Could his issues be related to the orthogonal axis of his cervical neck? Repeated tens of spinal accessory nerve XI showed no improvement or change in the Myo-trajectory, it was always the same. My father had no history of pain or cervical neck symptoms. I began to think about his dental history, the chronic break down of the left posterior teeth and subsequent crowning one after the other over the years.
(Slide 11) The intra-oral signs were there long before his symptoms. There was a loss of vertical dimension, occlusal wear of anterior teeth and abfractions, tori, lingual version of lower bicuspids, fractured teeth and deep bite. My father explained that he had chewed ice for years. As a teenager when his wisdom teeth were removed he began chewing almost exclusively on the left side after pain on the right. He continued this habit throughout his life until restored in a neuromuscular bite. (Slide 12) The fact that we crowned almost the entire left side as these teeth fractured over the years was interesting. (Slide 13) After years of restoring the left side he began fracturing the right side as well. I began placing crowns on the right side, one tooth after another. In August 2006 my father began complaining of pain in tooth number 31. There was a distal fracture extending through the pupil floor to the mesial. I placed a crown on number 31 and sent him home to NY. Shortly after the pain worsened and an endodontist determined the tooth was fractured through the root system. He removed the tooth and placed a bone graft. (Slide 14)We placed an implant in the extraction site in August 2007. Now my father had lost his posterior stop on the right side, setting him up for catastrophic failure. One month after the implant was placed with a healing abutment at tissue height my father ate his infamous ham sandwich. The years of gradual loss of posterior vertical dimension first on one side then the other had finally taken their toll. As medical professionals we are told to “do no harm”. Well a whole lot of harm was done here over the years… one crown at a time.
Perhaps the years of pathologic muscle function combined with the degeneration within his joints was preventing me from finding the ideal functional position. The atrophy of the system was not allowing TENS to correct the X/Y plane. If the torque created by the occlusal breakdown had led to this problem then maybe torquing the occlusion the opposite way might correct him.
I was lucky to have some great people to fall back on. I made a phone call to Dr. Norman Thomas at LVI. He screamed into the phone’ torque him, as he was running to deliver a lecture. Torque Him… hmmm. Well that’s easier said than done. What side do we torque on? How much? What can we expect to happen? Well I thought lets give it a try. The destruction of his teeth on one side of his mouth and then the other had created torque in his mandible. Could we correct the years of degenerative torque in his occlusion by torquing his bite back? He was tensing at home with a BNS-40; so I called him and had him TENS with 2 Popsicle sticks or tongue depressors taped together and held between his teeth. First placed on one side and then the other to see if there was any difference. He also adjusted the balance of the TENS to one side or the other to see if it would release the condyle on the left side. He noticed no difference.
On his next trip I decided to alter his orthotic. It seemed to make sense that we needed to torque the left side to rotate the condyle away from the bone. If I torqued the right side it would seem to jam the condyle back into the eminence. On his next trip we began with one hour of TENS. Then I began adding to the left side. I first re-measured my anterior and posterior vertical dimensions, because they had to be exact. I confirmed the measurements three times before starting. I added a small amount of composite resin to tooth number 19 since it would give me the most secure stop. I lightly pulsed him once with the TENS unit, into the material and cured it. I checked my measurements and I had indeed increased the vertical on the left side by one millimeter. I then added resin to the second molar and the bicuspids. I increased the gain and pulsed him hard into the material and then light cured it. He was now hitting right on the tips of all cusps on the left posterior with a one millimeter increase. There was now no contact on the right side. I cranked the tens unit up until he was hitting hard and then altered the balance so the right side was only pulsing. I tensed him for another hour or so in a Zero Gravity chair. I then sat him up balanced the pulse of the Myomonitor and checked his bite. (Slide 15) He was now hitting on both sides … Harder on the left but some on the right. I decided to leave him like that and let his own muscle function do the work. That night he noticed no difference in the pain he was experiencing while eating. I was lucky I could monitor the patient this way. I was able to watch every bite. He seemed like he was opening a little wider while eating. My father grabbed a raw carrot and crunched through it without complaining. I was afraid he was going to fracture the orthotic. The next day we tensed for one hour and began checking the bite. He was now hitting on both sides. With a slight adjustment to the right side and adding a little resin to the cusp tips of his right first bicuspid, he was now hitting evenly again.