Hey Spear community,

One issue / question we all deal with often is the right appliance therapy for clenchers, grinders, and clenchers and grinders. Obviously there are a million theories, strategies and appliances out there... Being a University of Michigan guy, of course I was trained in a "Michigan bitesplint" - full maxillary coverage with even contacts with cuspid rise. I've seen that appliance taught by numerous TMD courses, but to me, it feels this appliance would be most useful for a "grinder" and not as much for a clencher.

I'm guessing the data and "studies" out there are also all over the map, so I just wanted to put out to the community to find out what you guys are finding are "best practices". I have been hearing more from people to ditch the cuspid rise, and just do a flat plane. Especially in some cases where sleep apnea might be involved (let's even just table that part of the discussion! I don't want to open a complete can of worms!).

More specifically I am wondering about clenchers. The classic discussion/argument would go like this: A big camp of dentistry would say make some type of anterior discluding device (NTI, deprogrammer, or some variant). This seems to make sense in that it unloads the muscles and loads the joint (assuming patient has no joint issues). This seems to be an undenyable fact (correct me if I'm wrong). You load those anterior teeth you get muscle relaxation. This would relieve muscle pain, prevent clenching and get the outcome we're looking for. Of course you have to adequately monitor and manage the potential outcomes of loading the joint.

The flip side of this (which I've heard from CE seminars and many dentists apart from formal teaching) is that these appliances can cause posterior eruption - Even when wearing for only 6-8 hours at night. I've heard plenty of peers over the years say "you never get posterior eruption" and plenty say "I've seen so many anterior open bites caused by these appliances... good way to get sued". I have seen a few spot cases (cases I inherited) where I HAVE seen anterior open bites from these types of appliances (even with just night time wear) but they are probably few and far between. But they are very challenging cases then to manage - especially one case I inherited where a patient had a massive anterior open bite.

I guess herein lies my true question... are you guys using these anterior discluding appliances (in non-joint pain patients) for your clenching patients... and if so, what appliance design are you having the best outcomes with? If not, do you just use a flat plane appliance or a cuspid rise "Michigan" appliance?

I'm sure the answers are going to vary greatly, but wanted to hear the discussion.

Of course you have your NTI style appliances, but I've heard of some comfort and compliance issues (patients take them out... they fall out). Then I've heard of a retainer like device with an anterior discluding element. This seems to make sense too, but again the idea of posterior eruption seems concerning.

I guess one of my thoughts is what about a full upper flat retainer with a discluding element. Reason being, many times if we take out #31, we'll see #2 hyper erupt, but if we take out #2, it seems far less common for #31 to hyper erupt. This is purely anecdotal (is there any evidence based research out there on this?) but I see plenty of lower molars drift mesially when the anterior tooth is out, but hyper-eruption seems far less common. It happens, but many times it doesn't. Whereas the upper molars seem to hyper-erupt quite regularly (and mesiallly shift if the anterior tooth is out).

So, if you made a full coverage upper appliance with an anterior discluding element wouldn't that solve the upper hyper-eruption, but also allow the anterior contact to prevent the clenching? the risk would seem ONLY to be lower hyper-eruption? If you saw hyper-eruption, you'd stop the appliance wear and hopefully only need to do minor enamelplasty (if you catch it early enough?)

Sorry for that mouthful, but I don't know that I've seen good comprehensive answers to these questions and especially if there is research and evidence out there supporting these concepts/concerns.

Thanks so much!

Steve