Occlusion Time Reduction(OTR) therapy in treatment of TMD; …a Pilar-Type Orthotic Technique

                                                                   Edited for patient to understand

PHASE ONE TREATMENT

OTR is best described as that period of time it takes to reduce faulty contact of upper and lower posterior(back) teeth. Occlusion Time Reduction (OTR) is a procedure created to  balance the way the teeth should work during which period of time muscle physiology is changed. OTR is completed during inception of Phase 2 treatment of Temporal Mandibular Disorder(TMD). The Phase 2 treatment is initiated after muscle integrity has been restored due to successful Phase 1 treatment. Phase 1 treatment is that period of time where all upper and lower posterior(back) teeth are taken out of physical contact with each other during periods of the day when not eating. and taken out of contact while sleeping. A Pilar-Type Maxillary(upper) Deprogramming Orthotic is created. The orthotic can be worn up to 20 hours of the day maximum. This in essence is active OTR therapy.  During this Phase 1 period of time while wearing the deprogramming orthotic, and taking all upper and lower posterior teeth out of contact, elevator muscles of the head are once again in control of Jaw movements; like when you were maybe 10 years old when teeth and muscles were in harmony with the jaw joint complex. Muscle tension and stress is removed and teeth are resigned to not touching, creating an environment where muscles are in control of jaw joint function without teeth interference. Temporal (Temple) muscle activity is reduced 70% and masseter(cheek) muscle activity reduced 50%;…Trigeminal nerve activity is markedly reduced. Many aggravating symptoms disappear such as sleep disruption, migraines, tension headaches, tinnitus, dizziness, sinus and throat issues, eye muscle disturbance, etc.… All because of elimination of uneven bite contact and night-time posterior tooth clenching between upper and lower back teeth.(canine teeth to back)  whether there is jaw movement or not.

REASONS FOR PHASE ONE

Prior to inception of phase 1 treatment teeth are in control of jaw movements where jaw movements are predicated based upon where teeth wish to contact and slide; and where there is no true muscle control. Attempts to relax muscles via Botox, Tens or E-Stim, etc. at this stage do not give  true muscle control a chance to function, you are only treating the symptoms, while ignoring the source. Gross prematurity of upper and lower tooth contact that is so visibly obvious can be dealt with on initiation of phase 1 treatment by shaving tooth surface enamel off visibly high tooth contact.  However, we do not make critical tooth imbalance adjustments during phase 1 treatment; as muscles are not in condition to give us good readings on upper and lower bite occlusion. There is no quick fix other than time and muscle healing. It may take six months or more for true muscle and connective tissue healing before critical tooth imbalance adjustments can be accomplished. This is where proper orthotic maintenance comes into play throughout Phase 1 treatment.

TYPE OF ORTHOTIC

To put the patient back into muscle control during Phase 1 treatment we must fabricate a custom made deprogramming orthotic that will enable this process. This deprogramming Pilar-Type Orthotic fabricated on the top front 4 teeth (a maxillary orthotic). A maxillary(upper) orthotic gives greater stability over a mandibular(lower) orthotic due to greater surface contact area of appliance to tooth then if it was made to go over the bottom 4 Front teeth. Second, the maxillary orthotic concept is more comfortable and gives greater vocal control over speech. All this is true only if the appliance is correctly made chairside taking at least two hours of time to fabricate…there is no short cut. The maxillary(upper) orthotic is much more difficult to fabricate.

WHAT MAKES THIS ORTHOTIC DIFFERENT

Much effort must go into anatomical design and thickness of Pilar-Type Maxillary(upper) Orthotic. The orthotic must be fabricated chair-side with patient jaw movements guiding orthotics shape. Laboratory processing does not give us accuracy on proper angle of the sliding ramp (plane of occlusion) or front, back and lateral maximum extended movements of the jaw. These features of the critical design must be dealt with; built into the shape of the orthotic to begin; with this not being something that can be dealt with after it has been created by an outside laboratory and you try to fix it in the patients mouth after it comes back from the lab. Fabrication of this deprogramming orthotic must be accomplished by the dentist hands-on at the dental chair for maximum accuracy and eventual success.

MORE COMPELLING REASONS FOR THIS ORTHOTIC

There are other attributes of the Pilar-Type Maxillary(upper) Orthotic’s sliding ramp which can always be adjusted to meet certain needs and  at a certain vertical height can possibly capture an articulate disc into proper alignment with the mandibular condyle and have action as a “pull -forward” Splint Insertion in addition to NTI type attributes. If the articular disc does not audibly pop into place (over mandibular condyle) during the manipulation procedure ,you have at least decompressed the tissues of the joint by moving the condyle inferiorly (forward) and restoring superior joint space and potentially eliminate negative bone on bone contact. Restoring superior joint space will allow the joint’s articular disc to move into its proper position at some future time during treatment.

READY TO START PHASE TWO

When Initial stage of phase 2 treatment where muscle control is apparent and jaw movement Is in harmony with jaw joint; that is the time when critical tooth imbalance adjustments are initiated. This is the moment when muscles have healed and will produce accurate movement without tooth influence or anticipated movements via faulty muscle memory. Again, we are not attempting bite adjustments during a period of time where there is muscle disharmony.

INITIAL PHASE TWO TREATMENT WITH ORTHOTIC

At first visit of Phase 2 treatment, with Pilar-Type Maxillary(upper) Orthotic inserted in the mouth maintaining muscle control of jaw movement, the orthotic covering these  four front teeth only is gradually reduced in vertical size in the mouth until there is an upper and lower posterior(back) tooth contact created…. That initial posterior upper and lower tooth contact as a result of reducing the Orthotic’s vertical height is the first premature tooth contact that must be removed. This created upper and lower premature tooth contact is reduced by shaving down successively the height of premature tooth contacts, again and again as the Maxillary Orthotic continually made smaller and smaller until …right and left side multiple contacts between upper and lower back teeth occur at same time… all done under muscle control (always with orthotic in mouth).

WHATS NEXT

After this initial phase 2 treatment of muscle controlled tooth imbalance adjustments, only then can additional treatment if needed be implemented, such as functional orthodontia, bridgework, onlays, etc. Deprogramming orthotic should be maintained for control of tension and stress especially with females. Females account for 85% of TMD and Migraine.  Remember, TMD is a dysfunction with many symptoms; Migraine being one of them. TMD is not a disease, it can be controlled but not eliminated.I recommend Orthotic wear every night along with day-time wear when there is periods of stress and tension; in the gym,jogging, driving a car more than an hour, etc.