Insight to Patient's Comments
Sore Jaw / TMJ
"I'm still having headaches"
Teeth feel "fat" / itchy
Can't seal lips / drooling
"My teeth have moved"
"My jaw is sore/tired after eating"
"I cant' bite with my front teeth"
Goals of the NTI Therapy
1. Minimize the muscle contraction intensity. Method: Allow for incisor contact only, in any excursive/protrusion position.
2. Minimize the joint strain/load during masticatory parafunction. Method: Minimize condylar rotation during occluding events by minimizing the VDO and posterior freeway space.
During initial consultation, review #8. Prior to dismissing patient following initial delivery or follow-up adjustment, confirm that they can’t remove the device without using their hands and cannot “make it hurt” while clenching in all excursions (if they can do either, you’re not done).
PROBLEMS AND SOLUTIONS
The problem is most likely excessive vertical dimension. Intensely clenching on the device should not illicit joint pain. If so, reduce the height of the Discluding Element and check in all excursions (by having them clench), especially in protrusive. (The patient may have never had protrusive movements included in their parafunctional movements, but now with the NTI device they may developed new activities…so don’t believe them if they claim, “I don’t do that”). The slope of the Discluding Element may need to change dramatically in order to prevent excessive VDO in protrusive.
If employing opposing sliders, confirm that they are not comprised of two flat surfaces. Sculpt the distal ends so that the upper slider looks like a smile, and the lower slider looks like a frown, creating a tangent point contact between the two.
Check for occluding contacts in excursive movements.
The patient may be complaining that they “still have a headache” (when they may not realize that their intensity and or frequency has decreased). Assuming all listed remedies have been accounted for, remind the patient that intense clenching is a lot like speeding on the freeway. We have taken our foot off the gas, while not employing the brakes, so the reduction in speed is gradual.
Assure the patient that this is not uncommon and is due to the reestablishment of normal PDL health. Prior to using the NTI, the patient had been compacting their teeth within their sockets on a regular basis. Explain to the patient that it is similar to the tingly sensation one gets after ones “foot falls asleep” from sitting on it wrong. As the PDL regains its normal state, it can be hypersensitive, creating the sensation of fatness“. The sensation will resolve within two or three days.
Can’t seal lips / drooling
Reduce the facial walls as much as possible. Reduce the facial bulk of the DE. A primary-clenching patient should be reminded that their assumption that lip seal is necessary is really their parafunctional muscular condition trying to fool them into thinking that it’s so. Many of these patients’ clenching habits include tight lip seal and creating a vacuum within their mouth. When they no longer can do that, they feel that something is wrong, when in fact, what they have been doing is part of their parafunctional disorder. Also, with a new foreign object in their mouth it is normal for excess saliva production for a period of time. Suggest placing a towel on their pillow for a few nights. Sculpting the device to make it as natural as possible will help.
“My teeth have moved”
The first assumption a patient usually makes when becoming aware of a change in mandibular position is that is that individual teeth must have moved. They are somewhat convinced of this based on their identification of just one tooth that is contacting prematurely. They should be reassured that as their musculature normalizes, the horizontal flexibility of their mandible and seating of their condyles (which can happen unilaterally), will present as a lone posterior molar hitting prematurely.
“My jaw is sore/tired after eating”.
As posterior interferences are revealed as the musculature normalizes, the patient’s jaw gets tired, as the lateral pterygoids are charged with the responsibility of “putting on the brakes” during masticatory elevation, so as to prevent traumatic occluding. Look for new interferences and reduce them (with patient consent).
“I can’t bite with my front teeth”
INSIGHT: When initially consulting with the patient, note the degree of incisal overlap on those patients with minimal to no incisal overlap, discus the circumstance of muscular normalization (as symptoms improved) where the condyles may be allowed to superiorly seat to their most braced, protected position and note it in their chart. The mandibular shift may fulcrum on the most posterior molars (making it appear as if the upper molar(s) have extruded), thereby preventing the incisors from meeting (for patients with normal to considerable incisal overlap, this is typically a non-issue). This may go completely unnoticed by the patient.
So as to prevent any claim that “the patient’s teeth have moved”, some practitioners will provide dual “full coverage” NTI devices, where one arch includes a Discluding Element. Glidewell Lab and any National Dentex affiliates can fabricate these)
Because the patient is wearing an NTI at night, there is no functional purpose for the occluding scheme to provide “immediate posterior disclusion via canine rise with transition to incisal guidance”, as the NTI provides instant incisal guidance. What the patient simply needs is the ability to acquire incisor edge-to-edge contact. Instruct the patient to protrude and close as if they were trying to incise on a piece of paper. In that position, mark the contacting posterior cusps, and reduce them (typically the palatal cusps). Continue the process until incisor’s edges can touch in protrusion (when the patient retrudes, they will most likely still appear to have an AOB, as there may be little to no anterior coupling). The patient will now be able to functionally to be able to incise and chew food.