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60 year old, no previous ortho. Takes medication for high blood pressure. States that she lost contact of her front teeth when biting and chewing 7 years ago after implants were placed. In October of '16, a new crown was done and after this she felt like "my whole bite is off, I have to do gymnastics to chew things." She stated that she bites her cheek on the left side and her left masseter is sore at night. She sleeps on her left side and has always had occasional headaches. " It hurts to chew gum. My jaw pops all the time when opening wide and it has done this for years." She complains of difficulty chewing and pain in her joints. She is aware of both grinding and clenching. A snoring appliance gives some relief of pain. She wakes up with pain ("real sore").

initial exam findings (October '16)

late opening click left side

ligament laxity-negative

muscle palpation: right and left masseters level 2, all others negative

range of motion normal

level 2 pain when provocation test of lateral pterygoid done

soft end feel

normal opening and closing paths

new exam items (January 17):

centric loading test-negative (I"m not sure if I was doing this right).

static excursions from centric (support chin and have patient attempt to move left and right while maintaining interocclusal position)-negative

Radiology Report: Both condyles are reduced in the vertical dimension and exhibit flattening, subchondral sclerosis and an anterior osteophyte formation on the superior aspect. Bilaterally, the posterior slope of the articular eminence is also flattened and sclerosed and forms a shallow incline congruent with the opposing condylar surface. Both condyles are superior to the center of their respective glenoid fossa nd there is resultant narrowing of the anterosuperior joint space on the right and the superior joint space on the left. Findings are consistent with degenerative joint disease that is radiographically stable on both sides.

In February the patient said that her bite had improved substantially and her symptoms had eased considerably.

Diagnosis: internal derangement with condylar displacement leading to a change in the occlusion. Placement of implants also may have contributed to a change in occlusion by initiating a change from a habitual occlusion where the condyles were out of the fossae to a position where the condyles had become more centered in the fossae (loss of anterior tooth contact reported by the patient). Associated muscular involvement.

patients chief complaint was to fix her bite. She is afraid of having any more dentistry done.

Prior to taking a wax bite for the mounted models I had her on a Lucia jig for 10 or 15 minutes and at the time I felt like her mandible was relaxed.

Treatment: flat plane splint therapy

Goals: obtain an accurate diagnostic mounting with condyles in a seated position in order to determine what type of dentistry can be done to "fix her bite".

Treatment progress: The splint was a "flat plane splint" without anterior disclusion. There was even contacts throughout. After two weeks patients symptoms had come back. She wore the splint full time. There was a lack of anterior contact on the splint. At that time her masseters were very sore (level 8). There were no joint symptoms. I am now thinking that my diagnosis should be that it is mainly a muscle problem, I converted the splint to an anterior bite plane. So I am going to see her next week and see how she is doing.

Any input on my exam and diagnosis would be appreciated. Further, what should I do if she comes in next week and her symptoms have not improved?

THank you,

Robert L. Nisson, DDS MSD