OK, so first off, my apologies for poor documentation on this case - this is a patient of the previous owner that was sqeezed in to see me yesterday. 59yo woman complaining of pain, particularly on the L side for several weeks. She notes that she gets mild-moderate pain "on occasion" that has been there for years. Usually she will do "exercises where she puts her tongue on the roof of her mouth and opens and closes without touching her teeth" for a few minutes, several times a day, eats soft diet, and the pain will usually subside in a matter of days. This time, however the pain does not seem to have subsided. She also notes very loud popping of the left joint which "you could hear on the other side of the room". She states that her joints have always made clicking sounds, but not this loud. When I saw her, she was not in acute pain, though she said that when she opens moderately wide, she notices the pain. So, eating crusty breads, apples, etc., seems to bother her. She also states that it seems to be worse at night. Interestingly, when I palpated the muscles, there really wasn't anything that was tender. Used a leaf guage to do a load test and no issues at all. So no clinical photos (didn't have time) but I did take some alginates, which was no easy task as she has a tiny mouth and her oral opening is quite small - could barely fit a plastic anterior Coe tray......So here's what we got.....

[image:DSC_0161.jpg][image:DSC_0163.jpg][image:DSC_0159.jpg][image:DSC_0160.jpg][image:DSC_0162.jpg]

As you can see - deep overbite, minimal overjet of the incisal edges, pathway wear, some edge to edge wear. I started to put some block out resin in some areas in preparation for making an appliance - there are actual undercuts of the palatal aspect of the incisal edges because of how retroclined they are.

I discussed options with her. Usually, my first course is what she's been doing - soft diet, plenty of water, NSAIDS, massaging any sore muscles, etc. She said she'd been doing those things and it hasn't helped. So my next step is usually to make an appliance - anterior deprogrammer of some sort - usually an upper with a flat incisal guide plate to allow complete posterior disclusion in all excursions. However, as you can see from the photos, that's not going to be an easy task without opening her up significantly. Lastly, I told her that I thought that the source of her pain is from her muscles, but that her front teeth are so restrictive that it's not allowing her jaw to go where it wants to go - basically the teeth are getting in the way and that an ortho consult might be necessary.

So my first questions would be how to manage in the short term. Any other suggestions? Any suggestions on how to fabricate an appropriate appliance in a case like this? Again, I just don't see how to give her a shallow guidance or anterior flat plane contact without opening her up substantially. Could this considerable opening of the vertical lead to more muscle symptoms? Any thoughts or suggestions are appreciated.

Brett