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Todays dental practice can increase patient satisfaction, as well liability; therefore, undergirding selection with accurate informa-
as profitability, through the use of emerging technologies in the tion is critical for proper use and quality of care. The aim of this
realm of dental appliances. Appliances can aid in an array of article is to serve as a quick reference for the practitioner in his
pathologies; however, many dentists struggle in their prescription selection of the appropriate dental device.
of appliances due to a lack of scientific literature on the devices Received: September 21, 2011
themselves. Blindly choosing an appliance can create a legal Accepted: February 6, 2012
A
fter graduating from dental rely on the one appliance covered in treat a stranger in pain by using irre-
school, dentists typically have dental school (the soft nightguard), versible therapies.1 This statement
gaps in their knowledge of the due to a lack of time or money for applies not only to understanding
extensive list of dental services a gen- further exploration of the options the service, anatomy, physiology,
eral practice can provide, especially available. Or they rely on the one and the latest research and science,
in the area of appliances. At best, guru-driven appliance stumbled but also understanding the patient.
the four-year curriculum provides upon in early CE courses and tend Until the purpose of each appliance
limited teaching regarding services to use it indiscriminately for all and the science of the pathology
that a caring, quality practice can patients in all situations. being treated are understood, much
provide. However, in the real world To provide the best service, a of the appliance therapy should be
of dentistry, there is a need to pro- doctor must know both the patient referred to a specialist. Each appli-
vide an expanded number of services and their pathology. As Dr. Mahan ance has a specific purpose and it is
to establish a quality practice. In wrote in 1991, one must never important to know them well.
this regard, an inordinate amount of
time and money are spent educating
doctors on expanded services not
covered in dental school.
Dental appliances have become
a multimillion dollar industry,
including such devices as:
Nociceptive Trigeminal Inhibi-
tion (NTI) devices (Therapeutic
Solutions International, Inc.), soft
nightguards, soft/hard appliances,
splints, deprogrammers, orthotic
and suckdown appliances, retainer-
type appliances, neuromuscular
appliances, and store-bought mouth
guards. These appliances are avail-
able for treating parafunction,
muscle pain, partial disc displace-
ments, complete disc displacements,
and osteoarthritis. However,
knowing which appliance to use in
a given situation can be challenging
(Fig.1). Many postgraduate dentists Fig. 1. A wide variety of dental appliances.
Orthotic appliances
The orthotic appliance is a passive,
hard appliance with a flat plane in
the posterior, evenly supported pos- in most orthotic didactic courses or Lundh et al indicated that there was
terior contacts, and shallow anterior participation courses. An orofacial no significant benefit of patients
guidance (slope). The orthotic was pain resident spends 2-3 years in treated with an orthotic (a flat
developed as part of orthopedic training for the appliance use in occlusal splint) over control subjects
therapy to treat significant pain and osteoarthritis cases. with no orthotic treatment.9 If
dysfunction of partial displaced disc Popular literature promotes the perceived fatigue, pain, sleep dys-
cases, complete displaced disc cases, misconception that the orthotic function, and anxiety are primary
and osteoarthritis (Fig. 2). Orthotics is the magic plastic appliance. targets for muscle-based pain, then
can also be used for simpler chewing Simply stated, the orthotic was one management of these factors would
system damage cases (such as chew- of the first appliances created to be the primary interventions.10
ing muscle pain and nocturnal brux- protect the joints and muscles from None of these factors are actually
ers/clenchers), on destructive bruxers parafunctional damage at night. related to the performance of the
for protection, to protect temporary One of the problems in analyzing appliance; this suggests the orthotic
crowns and bridges, reduce pain in the effectiveness of orthotics is may not cure all the aspects of pain
jaw joint damage, help achieve an determining their main functions associated with articular disc disor-
accurate bite, and help with many or benefits. Is the goal pain relief, ders. However, in a 1978 study by
chewing system pathologies. reducing parafunction, or fixing the Carraro & Caffesse, the use of only
An example of orthotic use is dysfunction? Does it stop clench- an orthotic (full-coverage occlusal
with patients who have dystonia of ing? Does it have a positive effect splint) improved both pain and
the jaw. Dystonia is a movement on occlusal relationships, tooth dysfunction symptomology.11
disorder that causes the muscles to position (retention), tooth wear, jaw If a patient has jaw pain and is
contract and spasm involuntarily. joint loading, and so forth? a significant grinder or clencher at
In these cases, an orthotic can Many scientific studies on dental night, the orthotic appliance will
be used to protect the teeth. The appliances, especially the early provide some pain reduction. A
orthotic is essential in osteoarthritis ones, are unclear in terms of the 2011 study by Badel et al found
cases to decrease the muscular definition or design of the appliance that orthotics reduced pain in 83%
loading of the joint; however, the used, type of treatment utilized, of the cases examined, which echoes
accuracy required in the placement sample size, or the studys definition the 1998 study by Ekberg et al that
of the appliance goes beyond the of success. In a 1992 study of disc reported a reduction in pain due to
standard training and skills taught displacements without reduction, orthotic use.12,13
In restricted opening cases, the pain), jaw dysfunction, dystonia, joint related cases. The studies
orthotic has been purposed by some destructive bruxism, and even of occlusion, sleep, and EMG in
to recapture the disc.14 In actuality, restorative cases with difficult bite.16 appliances with proper anterior
the orthotic may assist with relax- A wide variety of pathologies can guidance of the orthotic produced
ing the superior lateral pterygoid affect a specific joint. To achieve the least muscle recruitment.42
muscle, but as stand-alone therapy, usable results, the definition of the Other studies have reported that an
it is not likely to provide enough pathology must be clear. orthotic reduces EMG activity in
muscle relaxation to recapture the The widespread effectiveness of bruxing patients.43-47 Elsewhere, it
disc. It would have to shorten the orthotics for relieving myofascial pain has been reported that an occlusal
lateral ligament to the disc and (that is, pain in the chewing muscles) orthotic tends to reduce the level of
repair the retro-discal elastin tissue is indicated in two separate reviews of EMG activity in masseter muscles
to affect such an outcome, which literature by Clark and by Major & during maximum clenching.28,44,48,49
is unlikely to work as a stand-alone Nebbe.17,18 These reviews show that Different parameters, such as
appliance or therapy. In a 1991 many studies report the effectiveness the length of time of a particular
study, Kirk observed the orthotic of orthotics in relieving symptoms of study, can affect a studys results.
did reduce inflammation in the joint pain and dysfunction.17-37 Kovaleski & De Boever reported
and joint loading, and did improve A 1998 study by Canay et al that orthotics reduced muscle activ-
movement (disc condyle transla- reported an orthotic produced no ity, but it took days or even weeks
tion), but concluded that, the con- change in electromyography (EMG) before the reduction in symptoms
cept of disc capture is a clinical term from maximum biting but did were apparent.50 To properly evalu-
only, and does not indicate that an reduce complaints of pain signifi- ate the success of any one particular
actual change in intra-articular ana- cantly. In this study, the defining study, the pathology must be clearly
tomic relations has occurred.14 success via lower pain perception defined. A 2003 study by Ekberg
The challenge in determining reports was a problem in analyzing et al reported that an orthotic was
the effectiveness of an orthotic the effectiveness of orthotics.38 In more effective in myogenous cases
appliance comes from the fact that a 2010 meta-analysis, Fricton et al than in disc displacement cases.34
articular disc disorders, myofascial examined 44 random controlled In a critical evaluation, Clark
pain dysfunction (MPD), bruxism, trials (RCTs) and found that the reported that orthotics offered
and osteoarthritis are different orthotic improved jaw joint/muscle 70%-90% effectiveness in treating
multi-factorial pathologies. For pain compared to no treatment joint muscle damage cases.17 More
example, a 1984 literature review at all or treatment using non- recently, Kuttila et al reported a
reported a 90% success rate when occluding appliances.39 Conversely, reduction in clinical signs when an
using orthotics and occlusal therapy Okeson reported that EMG activity occlusal splint was used by individ-
to treat temporomandibular joint decreased for most patients wearing uals with osteoarthritis (secondary
disorder (TMJ); however, a mixture orthotics.40 Dahlstrom et al found otalgia was reduced as well).51
of treatments were utilized and the that patients who either used an The non-directive, passive,
specific role of the appliance in treat- orthotic or underwent biofeedback reversible, flat-planed, and shal-
ment was indistinct.15 Even when demonstrated equal reductions in low anterior guidance orthotic is
the focus is on a single variable, the terms of EMG activity.41 used to protect muscle and joints
actual effectiveness may be hard to The orthotic reduces the power at night, but it can protect other
gauge, since some factors (such as of the bite by opening the vertical. structures of the stomatognathic
clenching) vary from day-to-night, Maximal clenching on an occlusal system as well, particularly the
from night-to-night, and even from splint is significantly lower than teeth and tooth bone. One of the
person-to-person. Clenching can the maximum bite in tooth contact great benefits of the orthotic is that
occur both day and night. As a result, position.28 The maximum power the units are reversible and conser-
an appliance worn only at night may occurs when teeth make maximum vative. The ADA presently recom-
not address the complete problem. contact; opening the bite with a mends using reversible therapy for
Since the 1980s, science has tried piece of plastic will reduce the joint muscle pathologies. Many
to document the effectiveness of the power, which is why different authors using reversible therapy
orthotic for treating disc displace- appliance designs may provide place the effectiveness of the
ments, osteoarthritis, MPD (jaw some or slight benefits in muscle/ orthotic at higher than 70%.34,52-54
Functional Occlusion.68 When the jaw joint, and result in pain. The
Table 2. Benefits of orthotic jaw joint is pulled downward/for- teeth are hotwired to the brain
appliances. ward to fit the tooth-protected bite, to control the chewing muscles
the muscles have to splint the con- and therefore the brain can use its
Relieve muscle and joint pain dyle on the slick incline. It is analo- memory in engrams to control the
Reduce power gous to holding a bowling ball on a tooth-protected bite. The orthotic
slanting board with oil on it. When binds the teeth together, intercedes
Reduce muscle recruitment
the jaw muscles are recruited to hold between contacting teeth, and alters
Reduce IAP
any position for a period of time, the ability of the teeth to control
Stop lubricant destruction the chewing muscles will eventually the muscles. The use of the orthotic
Reduce clenching and grinding fatigue, lactic acid builds up, and improves the jaw joints ability to
Splint teeth together with reduced loading pain results. The value of measuring direct the muscles to the bone-
CR against CO seems to be related braced position (that is, CR), which
to the size of the difference and the anatomically refers to the most pos-
amount of clenching (parafunction) terior superior position of the jaw
receive equilibration, orthodontics, in CO (Fig. 1 and 2). A small dif- joint. The anatomical description
or reconstruction: If the orthotic ference (0.01 mm) is not significant does not adequately define CR.
cannot reduce the pain, the dental enough to cause much muscle The CR position is where the
effort is unlikely to resolve it either. splinting, but a large CR=/=CO least muscle activity occurs and the
Making this discovery at an early difference (3 mm) will produce a ideal position for the jaw joint to
stage stops the dentist from promis- significant amount of muscle splint- reduce muscle recruitment at night.
ing relief from alteration of tooth ing. In other words, muscle activity The fifth nerve is much larger than
structure that may not be attainable. increases as the difference between the other cranial nerves because
The orthotic reduces the damage the ideal jaw joint position and the it contains the bundles of fibers
resulting from the prolonged repeti- tooth protected bite (CR and CO) from the plexus of nerves around
tive loads of parafunctional activity increases. An ARS or neuromuscular all 28 teeth and combines with the
on teeth; such activity can lead to appliance would increase the CR other important head structures it
traumatic damage and pain.65 and CO difference, thus making the innervates. The teeth have power
The overall interpretation of the problem worse; therefore, a moder- over muscles to control the tooth-
scientific literature suggests that the ate to large CR and CO difference protected bite because the teeth are
orthotic is an appropriate appliance is definitely a contraindication so important to survival. Therefore,
for reducing damage to the joint for a neuromuscular appliance or a persons teeth being hotwired to
muscle complex due to nighttime ARS.16 The multifactorial nature of the brain may be viewed as an evo-
parafunctional activity.65-67 The muscle and disc displacement cases lutionary advantage. The orthotic
orthotic, along with an NTI (depro- means that a dentist must consider can redirect or deprogram the
grammer), appear helpful in achiev- more than jaw joint position and muscles or dissipate muscle activity
ing centric relation (CR) (jaw joint the tooth protected position when by allowing the jaw joint to go to
bite) in a few rare cases where the determining what aggravates the the position where there is the least
jaw joint instability disallows proper chewing system. Again, one factor muscle activity and allows those
centric occlusal (CO) position. alone, such as the measurement muscles to be controlled more by
Most dentists who challenge of CR against CO, usually needs the jaw joint.
CO (that is, tooth bite) by restor- to be combined with other muscle The majority of patients have a
ing many cases are familiar with recruiting activities in order to fully difference between CR and CO that
measuring CR against CO in a small breach the adaptive capacity of is small enough not to worry about,
percentage of cases, yet the subject the chewing system. If the patient but in a few patients, the difference
of CO is not covered in most dental experiences tension in chewing is large enough for the case to fail
schools. A great deal of literature muscles, clenches, cervical hyper- in terms of patient comfort. If a
on CR=/=CO is found in the post- contraction, muscle splinting, or crown and bridge case succumbs
dental school education of Spears, bite inefficiencies, measuring CR to jaw pain, it must be managed
Pankey, and Dawson, especially the against CO may overstimulate appropriately with an orthotic and
latest edition of Dawsons book, the chewing muscles, overload the orthopedic therapy.
Orthotics can be used for other Emergency appliances can be pro- deprogrammers primarily involves
purposes, such as: allowing dentists duced quickly and inexpensively for case reports such as the 2010 report
to test patient comfort following treating sudden onset muscle pains, concerning a 61-year-old whose
an increased vertical dimension; simple partial disc displacements, short-term jaw pain was relieved by
removing occlusion from a cracked or minor traumas. The primary using the deprogrammer.71
tooth (thus relieving pain); deter- purpose of emergency appliances In cases involving osteoarthritis
mining if parafunctional activity is to decrease muscle activity or or completely displaced discs, emer-
has injured a tooth (thus ruling deprogram muscles. gency appliances will increase joint
out occlusal trauma and avoiding loading on the condyle. This loading
the need for root canal surgery); Deprogrammers presses on the innervated retrodiscal
assessing the patients psychological The word deprogrammer refers to an tissue, thus increasing jaw pain.72
stability during the adjustment appliance used to reduce the use or According to McKee, one can test
stage; protecting porcelain crowns, recruitment of muscles, leading to a deprogrammer on a completely
bridges, or implants from bruxism/ reduced muscle inflammation and displaced disc by load testing the
clenching damage at night; resisting pain. The insertion of an NTI in jaw joint to confirm that the con-
tooth movements or retaining teeth clenching patients leads to significant dyles are not pressing on retrodiscal
after braces (especially in cases reduction in EMG activity of the tissue.72 One dilemma is that load
where bruxism/clenching exists or jaw-closing muscles.69 The depro- testing a jaw joint is not part of the
in jaw damage cases); managing grammer is an anterior segmental formal training in dental school. To
tension headaches; tracking condy- appliance or piece of plastic placed in avoid failure with a deprogrammer,
lar bone loss in osteoarthritis cases; the front of the mouth to keep back practitioners should initially inform
and protecting teeth in dystonia. teeth apart (Fig. 4). Deprogram- the patient it is a diagnostic device
Table 2 summarizes the benefits mers have been used for years in to differentiate the partial displaced
provided by an orthotic. orofacial therapy for emergency cases disc from the complete displaced
involving muscle pain. In orofacial disc. A deprogrammer will fulfill its
Emergency appliances pain therapy, the use of the depro- purpose if it increases the pain in
Some appliances may serve as an grammer in emergency pain cases the joint pain case, helping diagnose
emergency tool for acute jaw pain is preferred to the orthotic for long- a completely displaced disc.
(that is, joint or muscle patholo- term care (Fig. 5). In a study by Van The deprogrammer can also help
gies). Like medications, these Eijden et al, clenching on the incisor define the proper bite to manufacture
emergency appliances have specific teeth resulted in significant decline in and deliver the large bridge in mod-
purposes (primarily to deprogram EMG activity as compared to clench- erate difficult bite cases. For instance,
muscles and decrease muscle ing in maximum contact of teeth.70 if the lateral pterygoid is not relaxed
activity) along with side effects. Published research concerning enough to give the proper bite for
Fig. 7. An example of a suckdown appliance. One benefit of the suckdown is separate the posterior teeth, cushion
the ease of making the appliance the bite, and reposition the jaw to
and the ease of insertion to the produce a more adaptive bite. The
patient. Another benefit is the lower appliance was designed to achieve
cost. Patients also readily accept it even pressure on both sides of the
changing the terminal hinge posi- due to its thin nature and its similar arch. For muscle cases, this helps
tion.88 Even though cases in which contours to teeth. to reduce uneven muscle activity
CR and CO do not match are rare, Suckdown appliances are good due to even posterior contacts; the
they occur often enough to need as tooth protectors and retainers. even pressure from side-to-side and
deprogrammers to assist at bite deter- By molding an appliance to the tooth-to-tooth helps to reduce the
mination in the evolving world of position where the teeth should be irregular muscle activity. Like the
reconstruction (crowns and bridges). positioned, the suckdown device will soft splint, the Aqualizer still has
In reconstructive dentistry, a few help to keep the teeth in place. The posterior lateral interference that
patients are assumed to have a dis- reduction in power due to opening increases chewing muscle activity.
crepancy between CR and CO that bite is minimal since the appliance is Like a soft appliance, it increases
a deprogrammer may reveal during very thin. The suckdown appliance joint loading and produces some
the course of managing TMD/MPD can be converted into an orthotic increase in muscle activity.
or large reconstruction cases. by adapting acrylic precisely to the Practitioners and patients should
For cases of emergency muscle appliance, but the cost of conversion be aware that the Aqualizer will
pain, emergency appliances such is not cost effective. The suckdown increase pain in complete disc dis-
as suckdown (Fig. 7), Aqualizer appliance may be ineffective as par- placement. In addition, it can rupture
(Fig. 8), and other prefabricated tial disc displacement therapy due in cases of destructive bruxism. Its
emergency appliances may be to its duplicaton of lateral guidance use is limited due to its ability to help
acceptable. The suckdown appliance interference, its duplication of poor only in muscle cases and also due to
is made on a model of the patient anterior guidance patterns, and its the difficulty of patient retention,
with all the cusp and fossa relation- continuation of clenching; thus, the particularly in cases where the patient
ships and interferences reproduced muscle recruitment deprogramming has an anxious or nervous tongue.
in the appliance. The primary has not been accomplished.56
purpose for the suckdown is tooth Athletic guards
protection in parafunctional situa- Aqualizer Some medical doctors and young
tions, but many orthodontists use Aqualizer is a self-contained, dental graduates with a limited
these for retainers. The side effect, disposable splint filled with fluid knowledge of jaw problems may
due to reproducing interferences that can shunt from one side to recommend that a patient purchase
(walls of fossa), is increased muscle the other for equalization. It is a a soft over-the-counter (OTC) ath-
activity in clenching. If the bite ready-to-use, prepackaged appliance letic guard for joint muscle patholo-
inefficiencies are a small factor for for treating MPD/TMD patholo- gies; however, they were created
excessive muscle use, the suckdown gies and for emergency situations primarily for tooth protection. The
will not be effective in reducing involving mostly muscular jaw pain athletic guard is also bulky, which
muscle activity. (Fig. 8). A layer of fluid is used to can irritate gums, the tongue, and
Fig. 9. En example of an OTC sports guard. Fig. 10. An example of an anterior repositioning splint.
cheeks. Besides the production ensuring less dependence on pain appliance is not stepped back fast
errors found in any OTC product, medicines, and the convenience enough or is left in the anterior posi-
an athletic guard may be difficult of a fast approach. Emergency tion too long, causing overgrowth of
to keep in place or may not fit appliances are quick (used on the retrodiscal tissue (permanent poste-
the patients bite properly. One of same day), effective (on muscle- rior open bite) making it impossible
the primary benefits of an OTC based pain), acute (usually used to return to CR.
athletic guard is its low cost. One for only brief periods of time), Many patients with acute pain
of its potential negative side effects and cheap (as compared to full in their jaw joints will go to an
is relying on patient-directed care, coverage appliances). emergency room for relief of the
using a tool that may not target pain. However, most ER doctors do
the real problem due to incomplete Acute trauma appliance not fully understand acute trauma
diagnosis. The soft and compress- The emergency appliance used for to jaw joints and may fail to refer
ible athletic guards introduce significant acute trauma to the the patient to a specialist in a timely
interferences that increase muscle jaw joint is a short-term anterior manner, setting the stage for limited
activity and loading of joints repositioning appliance. Its primary use of emergency appliances. A
(Fig. 9). Whether due to mass pro- purpose is to manage pain associated trauma to the jaw causes acute fluid
duction manufacturing errors, the with pressure on retrodiscal tissue retention in retrodiscal tissue that
increase in clenching, or the patient in part due to swelling (significant pushes the disc and condyle down-
acting as doctor with self-directed inflammation) in the temporo- ward and forward, so an indication
treatment, the soft athletic guard mandibular joint, similar to the of jaw trauma requires the need for
has a high failure rate as a jaw joint treatment of a swollen ankle. The not only timely referrals but also the
pain appliance. The waste of money purpose of an acute trauma appli- use of an acute trauma appliance.
and the frustration for the patient is ance is to reduce pain without using
definitely one of the athletic guards opioids (Fig. 10). This anterior repo- Soft appliances
most negative attributes. Occasion- sitioning appliance pulls the condyle Another group of appliances are soft
ally in an acute muscle pain case, down and away from inflamed ret- full-coverage appliances (Fig. 11).
the soft athletic guard interferes rodiscal tissues. When incorporating The majority of dentists use the word
with the trauma to teeth enough steroids, muscle relaxants, and physi- nightguard to refer to these profes-
for the patient to perceive a reduc- cal therapy, the emergency anterior sionally made appliances; however,
tion in discomfort. repositioning device can effectively the term has been overused to refer
The favorite reasons for using reduce acute trauma pain in the jaw. to OTC or Internet-ordered soft
emergency appliances are in The biggest side effect of the anterior appliances. True nightguards are
helping reduce urgent care pain, repositioning device occurs when the full-coverage appliances made with
Fig. 13. Long-term wear of ARS produces posterior open bite that must have the occlusion corrected
post-ARS. In this case, they have used a partial to restore the occlusion that was changed with ARS.
Fig. 12. An example of a segmental appliance. Left: A patient with a posterior open bite wearing an ARS. Right: The same patient without the appliance.
be remade because it cannot be the micro-movements of the teeth soft/hard appliances can be used for
relined. Skilled impressions and and the appliance still fits. The hard parafunctional cases, muscle-based
proficient lab work reduce the material on the outside means a cases, and even some simple early
chances of this happening, but at longer life for the appliance due to partial displaced discs.
times it does occur. its resistance to the grinding forces
A fourth problem that occurs is of the chewing system. In addition, Segmental appliances
when the patient bites in maxi- this appliance is less compressible Segmental appliances only cover a
mum intercuspation when the goal than a soft nightguard, increasing its partial aspect of the occlusal table
is to deliver the appliance in cen- ability to be more accurate on the (Fig. 12). The segmental appliance
tric relations (jaw joint bite). If the occlusion, which could help in some can be divided into anterior and
opposite arch occlusion is too far muscle cases. Another benefit of posterior segmental devices. The
off, the thin hard surface and the soft/hard appliances over soft appli- anterior segmental devices are also
need for major additions are too ances is their improved adaptability known as deprogrammers.
difficult to overcome. In this case, for changes to the anterior guidance, The posterior segmental appliances
the appliance has to be remade. which occur in a small percentage cover both sides of the arch, but
The management of fit and of cases that have CO and CR only posterior teeth. The posterior
occlusion on a completely hard discrepancies large enough to increase segmental creates the bite-reducing
splint is an accomplished skill that chewing muscle activity. In these power with an increase in vertical
requires major training in order cases, there is a need to add acrylic from the acrylic. These appliances
for the appliance to achieve all to the front aspect of the appliance. allow for posterior interferences due
its purposes, but on an appliance The main drawback to soft/ to the lack of anterior guidance while
with some compressibility it can be hard appliances is that, like soft increasing muscle recruitment in lat-
nearly impossible. It is believed the appliances, they aid in some muscle eral and protrusive movements. The
degree of accuracy needed on the cases but are not very effective in combination of reducing power and
appliance goes up as the instabil- joint damage cases. The posterior increasing muscle activity may equal
ity in the jaw joint goes up. This disclusion on movement would not small improvement in patients with
might indicate that the soft/hard be adequate enough in all cases for muscle pathologies. The posterior
appliance is not well-suited for the significant jaw joint instabilities segmental appliance increases joint
complete displaced disc or osteoar- such as osteoarthritis or complete loading, making it inappropriate for
thritis. No studies are available to disc displacements. Unless the exact compromised joint tissue pathologies
confirm this proposition. status of the disc position is known, (that is, completely displaced discs
The beauty of the soft/hard the concern for the soft/hard appli- or osteoarthritis). They could be
appliance is that in patients with ance would be using it on a joint used as posterior retainers, provided
irregular wear of the appliance, the muscle case that is more complex the anterior teeth are stable and
adaptable inner surface allows for than it appears at first. However, the the posterior teeth are not involved
Fig. 14. Upper ARS device inserted into mouth. Note the ramp used to reposition
the mandible forward. Fig. 15. ARS end-to-end bite.
ARS devices were designed to appropriately might help decrease system, which is approximately half
remove the click in cases with lateral the indiscriminate use of the ARS of the opening distance. If, in fact,
pole partially displaced discs. If the on all types of disc displacements the displaced part of the disc at
disc was only partially displaced in and osteoarthritis. The biggest the lateral portion or even middle
the anterior and medial direction, mistake in the use of the Gelb or disc area has turned into a blob
the ARS might recapture the lateral ARS appliance is the one-size-fits-all shape, the disc cannot be recaptured
pole portion of disc; using the ARS treatment without the ability to because the three convex surfaces
alone will not eliminate the problem determine the severity of displace- do not fit together (Fig. 14 and 15).
unless the factors that caused the ment. The amount or degree of Using MRI, Eberhard et al reported
lateral ligament tear in disc displace- displacement and the amount of that the ARS appliance could not
ment are eliminated also. The use of time the displacement was present recapture a non-reducing disc or a
this appliance alone seems doomed are critical factors in how Gelb or severely degenerated disc.115
to failure. However, in an ARS ARS therapy could be considered a
appliance study by Williamson & success (which most studies define Neuromuscular appliance
Sheffield, the patients in that study as removal of clicking). Despite its side effects, lack of
self-reported improvement of 90% A second problem exists regarding research (science), and potential
success in three years.117 the severity of displacement. If the for lawsuits, the ARS appliance is
In the complete displaced disc, degree of disc displacement is all still being used today as the neuro-
the longer the disc is displaced, the the way to the medial pole (disc is muscular appliance of choice. The
more likely it will lose its biconcave completely displaced), the distance neuromuscular dentist uses a trans-
shape (in other words, it turns to move the condyle forward to cutaneous electrical neural stimula-
into a blob). This change makes it recapture the disc by the ARS is too tion (TENS)-induced outside
difficult to recapture the disc, as great. In other words, if it is neces- chewing muscle-fatigued bite.52 The
the three convex surfaces do not fit sary to move the mandible forward TENS-induced bite moves the con-
together or have stability. The ARS so much that the lower incisors are dyle downward and forward so that
is not realistic for treating complete near or past end-to-end, all anterior the neuromuscular bite is forward to
displaced discs or osteoarthritis, but guidance (overjet and overbite) will the patients tooth bite (maximum
the science in Gelbs day did not be removed, which helps reduce intercuspation). In this way, the
allow for differentiation of partial muscle recruitment. If you move neuromuscular appliance becomes
versus complete displaced disc the condyle downward and forward, an anterior repositioning appliance.
cases. We presently have enhanced so that the condyle is at or past The high cost of neuromuscular
MRIs and are able to see the disc, the eminence, you remove all the therapy is due to the need to crown
position and shape, which if used translational ability of the chewing or orthodontically reposition
Appliance Tooth load Parafunction Joint load Periodontal Muscle Bite change
Orthotic Decrease Decrease Decrease Decrease Decrease No
Deprogrammer Decrease posterior Decrease Increase Decrease posterior Decrease Yes
NTI Decrease posterior Decrease Increase Decrease posterior Decrease Yes
Suckdown Decrease Increase Increase Decrease Increase No
Aqualizer Decrease Increase Increase Neither Increase No
Soft appliance Decrease Increase Increase Neither Increase No
Soft/hard Decrease Increase Increase Neither Increase No
Posterior segmental Decrease Slight increase Neither Decrease anterior Slight increase Yes
LVI Anterior teeth Decrease Increase Anterior teeth Decrease Yes
Gelb/ARS Anterior teeth Decrease Increase Anterior teeth Decrease Yes
the literature, the NTI is appropri- of science, common sense, and pain management: A practitioners handbook.
ate for cases involving short-term empathy. Prepare for the world of New York: Guilford Press; 1996:33.
6. Wedel A, Carlsson GE. Factors influencing the
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