Occlusal Splint Therapy: An Option for Unsuccessful Dental Implant Treatment?

THE 5Ps always apply. Obviously the overall functionality of the dentition was overlooked initially and subsequently. Proper CR and CO are important in all cases. In this case, targeted Botox® treatment should have been used/needs to be used to be able to determine proper CR and CO, and lessen hard and soft tissue imbalances. A full gnathologic work-up should have been performed/ needs to be performed to determine para-functional from functional generated pathways. Comprehensive Orthordontic/Prosthetic treatment will most likely be required. Splint therapy is in and by itself a one way street to nowhere. Splint therapy in conjunction with Botox® with a definitive oral rehabilitation plan is plausible.

In English- the way your teeth meet is not in harmony with the way your jaws want to close. Many people have this problem, some before and some after treatment. Botox use in occlusal problems is not a common method and this may be something the previous dentist has had good results with, but most do not use this and suggesting this to your dentist may suprise him/her. If the problems have only been since the implant crowns then they are interfering with the jaw movement and positioning. You need to have a good record taken of how the jaws 'like to close' before the teeth get in the way ( this is CR- centric relation ) so that the implant crowns dont prevent the other teeth interlocking ( this is CO-centric occlusion). If you have a clicking jaw or had a click which has now disappeared you may have a displaced disc. That is the part that sits between the bones and lets them slide over each other. Splint therapy would be the normal treatment course for this.

It may be worth your time, money & effort to look for a neuromuscular-trained dentist. They are trained & equipped to analyze the difference, as Dr. Aneiros says, between where your teeth want to meet and where your jaw (muscles) what to close. And, I would add, where those muscles want to relax. The Botox is sometimes used to help locate the relaxed position, but is complicated to use as a diagnostic-it lasts for months.

The Dr. that mentioned the benefits of occlusal therapy is absolutely correct. Once her musculature is supple and stabilized, then the teeth can be brought into their proper occlusion, without the muscles working against them. This is the basic premise of Peter Dawson's seminars. It is relatively easy to obtain from any doctor proficient in his teachings. She can be predictably treated as long as she has no other permanent TM joint dysfunction that is also contributing to the occlusal instability. This just may be a slam dunk!!

Find a dentist who knows how to use a leaf guage.

John, is that like the leaf guage I use to measure my car engine clearances? I REALLY don't need more materials & equipment to research....

On rereading the initial question, I mostly wonder what is happening with Sara's TM joint. It sounds as if one side may be collapsing (since the expansion is unlikely) thus leaving her with an open bite somewhere.

Mike sorry I didn't get back earlier re the leaf guage. In appearance yes the leaf guage is very much like a feeler guage except the leafs are a little shorter in length and are made of plastic. In essence use of the leaf guage allows you to take a bite record of the patients jaw in true CR. It is an amazingly cheap ($20) tool that I find fantastic for TMJ problems, complex rehabilitation cases and general day to day use where you want to take a bite in true CR. You will be amazed once you have used this gadget and wonder why they never taught you this at dental school. Do spend the time to learn about it. The Guru in the USA is Dr William McHorris - check out his website for further info.

John, I went to Dr McHorris website and found no information on how to use the leaf guage. All I found was advetisements to his courses. Could you give a brief description on how to use these guages? I have a set and am not sure how to proceed. Thank you.

Larry, what you are asking is very difficult within the constraints of this website due to the time it would take for me to type up all I know. What I will do is give you a few basics and then urge you to go back to Dr McHorris's website and contact him to buy his book "A compilation of Papers" - which has all of what you need (in particular his article 'The condyle-Disc Dilemma from the the Journal of Gnathology Vol. 3, No.1, 1984. You may also look at attending one or more of Bill's workshops - his knowledge is amazing. Anyway, you start by placing enough leafs between the patient's incisors until they no longer have posterior contact whilst biting in the retruded position. By doing so the only muscles contracting are the superior head of the lateral pterygoid (which is attached to the disc) and the anterior and middle fibers of temporalis. Without posterior proprioception, the remaining closure muscles masseter and internal pterygoid do not contract. What happens now is that the patient's habitual bite is being deprogrammed and the condyle will slowly move up towards the eminence. Very shortly the patient will let you know that they can feel their back teeth touching and at this time you remove the leaf guage add a few more leaves and continue as before ('forward and now back') - it is important to advise the patient that they are not to close their mouth at any time unless the leaf guage is in between the front teeth!!!!!. Continue with the therapy adding leafs as necessary until the patients bite appears to have stabilised and no further leafs are required to maintain an open space between the posterior teeth - Do not take a bite until the guage has been in the patients mouth for at least 5 min. It's worth spending a few secs explaining what has just happened. Pretty much all adult patients have a poor occlusion in which prematurities abound which results in the patient occluding in MIP 'out of CR' - that is the condyles are not fully seated with their disc assemblies against the eminence. So, when we use the leaf guage, the condyle and disc are in a way, forcibly seated against the eminence through the actions of temporalis and the s.head. of the lat ptery. As the seating progresses posterior contacts between the prematurities start to come into play but are then removed through the addition of more leafs. Eventually, the condyles find their way home the posterior contact remains open and a bite with beauty wax can be taken -WITH THE LEAF GUAGE STILL IN PLACE ( I use my DA to remove and replace the leaf guage at the bite stage. Only cusp tip indexing is required and so for some patients who had only minimal interferences, only a small space may exist between the posterior segments once the condyle is in CR, and so it may be necessary to add a few more leafs until you have the correct gap so that only cusp tip impressions are obtained. I should warn you that the leaf guage is also used in TMJ pain diagnosis and management and during the course of the therapy it it is quite common to cause transitory pain to the TMJs (managed with warm towels) with patients who unknowingly are bruxers and have a superior head of the lat pterygoid that is in a state of tetany (the isolation of the temporalis and the lat pterygoid will initially load the fatigued muscle and then allow it to relax - this is when the patient suddenly feels 'relie'). Mounting of the patients casts on the articulator with a face bow record will require approx 3-4mm of opening when mounting to accommodate the thickness of wax. Larry, I have tried to give you a snapshot of how it works but I have left out a lot of detail. I urge you to contact Bill, get the compilation of papers and find out who is the closest member of the International Gnathology Academy and watch how its done. Gnathology members are incredibly knowledgable people who really enjoy spreading the message and mentoring others. It's amazing that such a piddly little device can so empower you in the operatory. Hope this all helps. Regards John

One other thing Larry, the wax is required not only for mounting of the casts but because its presence is felt by the posterior proprioceptors which allow for the firing of masseter, which is required for complete seating of the condyle and disc assembly against the eminence!

John, thank you so much for the time you spent explaining this. I am continually amazed and gratified to see how many of our fellow dentists are willing to help each other. Larry

John, thank you for the Leaf Guage Primer. This could be a great addition to our armantarium.

I would agree with the prosthodontist in that occlusal splint therapy to stabilize the jaw muscle with a hard acrylic appliance.