night guards: a bad idea or an idea badly done?€¦ · these tmd patients have all these night...

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Night Guards: A bad idea or an idea badly done?

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by William F. Halligan, DDS

www.HalliganTMJ.com

******

Published by: William F. Halligan

4320 Genesee Avenue, Suite 207 San Diego, California 92117

USA

© 2013 by William F. Halligan. All rights reserved. No part of this book may be reproduced in any form or by any means

without prior written permission of the Publisher.

Information herein does not replace formal training in occlusal issues and every practitioner needs to use careful professional

judgment for each patient’s particular situation.

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Table of Contents

Introduction 4

Night guards: A bad idea? 9

Sleep Apnea 12

Night guards: An idea badly done 18

The canted frontal occlusal plane 23

The plain vanilla flat planed night guard with a twist 30

The Anterior Deprogammer 32

Variations on the anterior deprogrammer 33

About the Author 42

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IntroductionAn online article started it all. When I posted the article, Night Guards: a Bad Idea or an Idea Badly Done to my web site, I had no idea that it would be so popular. It was opened more than 200 times a day for weeks on end. Now, more than 9 months after it first appeared, it is still averaging well over 100 hits per day. This little article has now been opened many thousands of times, by dentists and patients alike all around the world.

Why so much interest? Because night guards fail to fulfill their intended result more often than they succeed.

Are night guards a bad idea? Yes; sometimes a night guard is the wrong thing to do. One of my objectives here is to help you decide when a simple night appliance is appropriate and when it is not.

Are night guards badly done? Yes! Almost every time. Doctor, you are probably making your share of night guards, and I’m sorry to tell you that you are probably making some key mistakes. After reading this you should be able to produce night guards that require far less adjustment and are much more comfortable for your patients.

Here, for the small number of folks who haven’t already seen it, is the original online article. It will provide an excellent starting point.

The phone call this morning was typical. A local dentist wanted to talk about a patient he is referring to me. Several different dentists have done crowns for her and none of those crowns are in good occlusion. She has also had several night guards and all have been painful to wear for a time—until one after another they all broke. “So, I’m sending her to you. I hope you can figure out what’s wrong. She’s just miserable. And she can’t wear a night guard.”

And only a week ago I was giving a presentation to a prosthodontic study group and one of the dentists asked me about night guards. When do I recommend them? What to do when they don’t work? What do I think about them?

My answer was unpopular to say the least. “In general, I think night guards are a bad idea.” You would have thought I said I was in favor of repealing the Bill of Rights.

“Wait a minute, Doctor. How about protecting teeth from wear?”

“If your goal is protecting teeth from wear, then night guards may be fine. Or, use a night guard to protect your new veneers. But for TMJ pain or masticatory muscle

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pain, I generally see poor results with night guards.”

Boy, that ruffled some feathers. But let me explain.

Why did I say what I did? In part it was because of my experience with TMD patients over the last 10 years. My answer was also the result of reading and research both online and in various textbooks on TMD.

When I meet a new patient, one of the questions I ask during the intake interview is, “Has anyone tried a night guard or splint of some kind for your problem?” The answer is usually yes, and at that point the patient digs one or several night guards out of a purse or pocket. There is almost always at least one night guard in the patient’s past; often there are several. It’s not unusual for a new patient to show me a clear plastic bag containing as many as 5 night guards. The record so far is 13.

The patient explains it like this: “You see my first night guard didn’t help; in fact I think I clenched even harder on it. But the dentist insisted I keep wearing it anyway. So I left that dentist and when the next dentist also recommended a night guard, I said I already had one. But he said he would make a better one. The first one was on the upper teeth and he said if he made it on the lower teeth it would be much better. But it sure wasn’t any better, so I left that dentist too…” And so it goes.

Based on hearing that litany literally hundreds of times, my logical brain says, all these TMD patients have all these night guards and they have not relieved the patient’s pain. Sometimes the night guard even made the problem worse. So, a night guard must not have been the right approach.

If the patient brings a night guard to the exam appointment, I do a T-scan occlusal analysis with the night guard in place. The situation then starts to come into focus: a design and occlusion that are simply wrong.

Of course, I’m not seeing every patient who has a night guard. Maybe some people out there are getting relief from night guard wear. I just don’t see those people.

Online research hasn’t helped much. There certainly isn’t much definitive. The best one researcher can say is, sometimes a night guard helps with TMJ pain and sometimes it makes it worse. And which it will be is not predictable.

Next, I turned to books already on my shelf. Jeff Okeson’s text did not deliver an opinion. However, Dr. Peter Dawson, in Functional Occlusion from TMJ to Smile Design had quite a lot to say.

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First, he says that routine use of a night time appliance should not be necessary if upon closing the patient’s teeth contact in verified centric relation and if lateral and protrusive movements cause disclusion of the posterior teeth.

But there are times, Dr. Dawson goes on to say, that a compromise is necessary. For example if there has been severe anterior attrition, then anterior guidance will not be ideal. In such cases anterior guidance may not be well established even with restorative dentistry. In that situation, a nighttime appliance will be appropriate for the clenching or bruxing patient.

Good, you may be thinking. Night guards are okay then. But consider Dr. Dawson’s description of a night appliance. First, whether it is an upper or lower appliance, when the patient closes on it, all teeth should contact the guard at the same time AND the mandibular condyles should be in verified centric relation. And furthermore, when the person shifts into right or left excursion, the posterior portion of the night guard should disclude immediately.

And also bear in mind that Dr. Dawson was writing about protecting teeth from wear as a result of bruxing and muscle pain due to clenching. Actual TMJ pathology with anterior disc displacement, requires full time repositioning of the condyles, not just a night time guard.

I am in total agreement with Dr. Dawson’s description of a proper night appliance. Unfortunately, not even one percent of the hundreds of night guards I have seen come close to meeting the criteria. In fact, whatever improper occlusal scheme is present in the dentition is usually carried out without change in the night guard.

Dr. Dawson goes on to say that an anterior deprogrammer is a useful appliance for clenching and that actual EMG studies show a decrease of anterior temporalis and masseter contraction by 80% when an anterior deprogrammer is used.

In my practice patients are treated in both day and night time appliances. And my night time appliance is either a deprogrammer or a special appliance that has cuspid rise ensuring no posterior contact during excursions.

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Kois Deprogrammer

Back to the question, what do I think of night guards? If we can agree that by “night guard” we are now talking about Dr. Dawson’s kind of night appliance with verified C.R. and with posterior disclusion upon lateral excursion, I will modify my answer and say they are fine for protecting the dentition including your recently placed porcelain veneers. That kind of night guard will also be useful to decrease muscle pain from parafunctional habits.

But if you are using a night guard to correct TMJ pathology, the appliance alone will not solve the problem of internal derangement.

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A good question to always ask yourself before any treatment is What is the diagnosis, Doctor?

If the diagnosis is clenching or bruxing in the certain absence of TMJ pathology, a night appliance could be appropriate. But how will you make the night guard? Will you do upper and lower casts and a facebow mounting (or do a proper mounting on an Accu-liner articulator), and will you do a bite registration in verified C.R. (by now you know that for me, verified C.R. means verified radiographically)? And will you meticulously adjust that night guard and also be sure that there is posterior disclusion on lateral excursion?

Be honest. I think that for most, the answer is NO. And I don’t blame you. I don’t think you can charge the normal fee for a “night guard” and do all those things. The articulator mounting alone would require far too much time and expense. Therefore you are not likely to do it Dr. Dawson’s way. Or mine. And yet, that is exactly how the night guard should be done.

And then I’m back to the original question and the original answer: In general, I think night guards as they are most commonly made are a bad idea.

How are people finding my article? I don’t advertise, after all. Because there are programs that let me follow the digital bread crumbs, I can see the inquiries folks entered on their browsers. I see that there are dentists searching for a better way. I see internet searches that are obviously from dental patients: “My night guard made my TMJ worse.” “My night guard doesn’t work.” “Night guard hurts.” “How is a night guard supposed to work? Mine doesn’t!” And so on with literally thousands of such internet searches.

Are some of these Google searches from your patients? Well, let’s hope not. But here’s the truth: The majority of night guards made are either badly done or were not appropriate for a given patient in the first place.

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Night guards: A bad idea?“A night guard is a thoughtless appliance.” Dr. Steven Olmos

Why consider a night guard? Well, our patients complain of grinding or clenching. Or perhaps, you see clear signs: Tooth wear, gingival recession, lingual tori and so on. But do take a little time to think about it. Why is the patient grinding? There can be several reasons. Pain elsewhere in the body can lead to clenching of the teeth. Poor occlusion as well as emotional stress and nighttime breathing issues—snoring and sleep apnea can also cause nighttime bruxing habits.

Neck pain and back pain will often lead to clenching and grinding habits. Certainly, go ahead and fabricate the night appliance, but be sure to encourage chiropractic, physical therapy, massage therapy, yoga, etc. Reducing the cause of the parafunctional oral habit can lessen the necessity for the night appliance and add considerable longevity to the one you make. A lot of these pain patients can destroy a night guard pretty quickly.

Poor occlusion, faulty dentistry, lateral interferences, lack of anterior guidance and canine guidance.

Laura, a 20 year old college student who had orthodontics as a teen, came into my office last week looking for a second opinion. She had been diagnosed with “TMJ” five months previously and was wearing an occlusal guard. She had very tender masseter and temporalis muscles on the right side, as well as right side neck and shoulder pain. She told me that the night guard actually made her pain worse.

Tomograms of Laura’s temporomandibular (TM) joints were normal. She had normal range of motion. She also had very heavy occlusal contact on the posterior teeth on the left and little or no contact on the right side. T-scan actually showed that more than 80% of her occlusal force was on the left side posterior teeth when she closed in centric occlusion or maximum intercuspal position (C.O. or MIP). She also had no canine guidance on the right side with heavy posterior interferences. Occlusion with the night guard was also heavy on one side only.

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T-scan of Laura’s occlusion showing heavy biting force on the left posterior teeth and no anterior contact. Her night guard simply duplicated this badly unbalanced occlusion.

“You don’t appear to have a TMJ problem at all,” I told her. “The pain is largely due to your bite. Your jaw muscles really aren’t enjoying the extreme imbalance of biting

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force. You should be seeing a chiropractor for your neck, but I’m going to recommend that your dentist do some composite bonding to the right side teeth to see if an even bite will solve the jaw pain. Long term, I think you’re looking at having braces again. You have nice, straight teeth and an attractive smile, but unfortunately your bite is really off. I don’t believe you should have the left side teeth adjusted down. The right side just needs to function better. And do not wear that night guard. You already know it’s not helping. When your bite is corrected you may discover that you don’t need any night guard at all.”

I see these occlusal issues more often than you’d expect and after they are addressed the muscle pain associated with bruxism usually goes away.

One interesting case I saw last year is mentioned in my blog, Doctors, do you leave crowns just out of occlusion? The patient was a 30-something young man who had TMJ pain and pain when chewing.

He said his dentist recommended a night guard.

“Well, how do you feel in the morning when you wake up? “ I asked him. “Do you have any jaw pain? Any tiredness as if you’ve been clenching or grinding all night?”

“No. That’s the funny thing. I don’t have a problem in the morning at all. At least, not until I eat breakfast. Then it starts to hurt and gets worse all day.”

So, what do you think a night guard will do for this guy? Correct. It wouldn’t do a thing. The problem was an unbalanced occlusion, with lack of contact on his right side posterior teeth and heavy biting force on the left side teeth. While a lot of people will develop a nighttime bruxing habit with that kind of poor occlusion, he did not. A night guard would have done nothing for him, except possibly make him worse.

There is an interesting article on the subject of occlusal interferences in the October 2012 issue of The Journal of Cranio Mandibular Practice (Cranio: volume 30, number 4) by Dr. Robert Kerstein. Using T-scan along with EMG recording, he demonstrates that tension in masseters and temporalis muscles can be released almost instantly by relieving posterior interferences to lateral movement. It’s worth reading the full article, but I think the take home lesson is clear: If your patient has painful muscles of mastication, look first to the occlusion, especially check for proper canine guidance. If it’s lacking, either do coronoplasty to get rid of interferences or restore the canines to proper function. The result? Better overall function and probably no need for a night guard.

The article is available on PubMed.gov.

http://www.ncbi.nlm.nih.gov/pubmed/23156965

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Sleep ApneaAirway problems that lead to snoring and sleep apnea can also cause clenching and grinding. Ask your patients a simple question, “Do you snore? Have you been told that you snore? Is it frequent?” This will start the discussion.

Here is a list of common signs and symptoms of sleep apnea. Some of these depend on observations by a bed partner and some will be noticed by the patient himself.

• Loud snoring that disturbs others

• Sounds of gasping or choking

• Breathing pauses—from 10 to 90 seconds

• Frequent awakening

• Waking up in the morning with the feeling that you didn’t get enough sleep

• Morning headache

• Daytime sleepiness

• Fatigue, tiredness throughout the day

• Mood swings

• Trouble concentrating

One simple screening tool is the Epworth Sleepiness Scale. This only takes a few minutes for a patient to fill out and can give you a very good indication of the degree of daytime sleepiness.

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Most pulmonologists state that if a person scores 10 or above on the Epworth scale, referral to a sleep lab is indicated—a score that high generally means the person suffers from sleep apnea.

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In my office, I use a pharyngometer as a screening device, and if the result shows a compromised airway, I refer to a sleep lab for an overnight sleep study. If you want to pursue sleep appliances as a part of your practice, you should consider purchasing the Eccovision technology. But even without it, pay attention to the list above. If you suspect sleep apnea, refer for a sleep study. This can literally be lifesaving.

Sleep apnea is a serious medical problem leading to a number of complications from cardiovascular disease to an increased risk of auto accidents—falling asleep at the wheel is all too common with these folks.

In any case, doing a standard night guard for a sleep apnea patient is not going to help. Special sleep apnea appliances may be appropriate depending on the situation. Oral appliances for sleep apnea can be effective but the design and fabrication of these devices is beyond the scope of this book. Constructing oral appliances for sleep apnea can be a valuable addition to your practice and if you are interested I’d certainly recommend you take some courses. I do not recommend that you blindly or arbitrarily make some mandibular advancement device for a person with sleep apnea and hope it works. These sleep appliances can be simple to make, but you have to know what you’re dealing with and you need to be able to adjust and titrate these devices properly.

I first attended a course on sleep apnea, and the dentist’s role in recognizing and treating it, more than 12 years ago. The course was taught by Dr. Barry Glassman. He is an excellent and entertaining lecturer.

One of my first in-depth courses in sleep disordered breathing was with Dr. Ed Spiegel. Ed was a leader in the field of TMJ therapy and dental appliance therapy for sleep apnea. Ed passed away in early 2013. He will be sorely missed by the dental community.

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Oral appliance therapy for sleep apnea is a very rapidly developing subject in dentistry and there are many good courses available. You may want to check courses offered through the American Academy of Dental Sleep Medicine. In any case, I recommend that you pursue some education in this area before attempting to treat the sleep apnea patient. It’s not as easy as it looks.

The Somnomed sleep apea appliance—my current favorite among many FDA approved apnea

devices.

Internal derangements of the TMJ

And then we have to consider actual TMJ pathology. Although flat planed night guards have been advocated for the patient with various stages of disc displacement and even disc perforation, these patients require much more careful treatment and usually 24 hour a day stabilization. While it’s true that I make night appliances for my TMD patients, they are almost never a simple “guard” and they are done in addition to a daytime appliance that provides for function, i.e. chewing and speaking, in addition to proper positioning of the condyles within the glenoid fossae.

Again, the treatment of actual internal derangements of the TM joints goes well beyond the scope of this book. If you wish to dig deeper into this subject there are a number of good courses available. You can even obtain your master’s degree in oral facial pain. Tuft’s University School of Dentistry in Boston, MA has an outstanding program. My first recommendation though would be the mini-residency offered by the American Academy of Craniofacial Pain.

But if treating these conditions is not what you care to do, you should at least be able to spot them. Take the time for a few screening steps. I believe there are five things to look for and if they are present, I’d recommend referral.

First, check the frontal occlusal plane. Simply place a tongue depressor left to right just

http://www.aadsm.org/

http://www.google.com/imgres?imgurl=http://www.merrellclinic.com/graphics/somnomed.jpg&imgrefurl=http://www.merrellclinic.com/oral-appliance-therapy.html&h=189&w=250&sz=4&tbnid=6V-ioR9aE6RGAM:&tbnh=98&tbnw=130&prev=/search?q=somnomed+picture&tbm=isch&tbo=u&zoom=1&q=somnomed+picture&usg=__bsiaUTOsGV4IBCBO2lIATsGv3zM=&docid=TMsfW2_abXZQPM&sa=X&ei=z3bgUcOpCOaiywHRmoBQ&ved=0CFkQ9QEwDg&dur=3424

http://www.aacfp.org/

http://www.aacfp.org/

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behind the anterior teeth and have your patient close. Look for the tongue depressor to be essentially level. Research over the past 10 or more years says that if there is an obvious cant, then there is about a 75% chance of an internal derangement of one or both TM joints.

Canted frontal occlusal plane

Headaches are often caused by TMJ problems. Ear congestion and ear pain are also nearly universal when there is internal derangement of the TMJ.

Additional things to look for are limited opening, say 35 mm or less, painful TM joints on palpation, deviation or deflection on opening, and obvious clicking upon opening and closing. You should think of these observations as screening tools as I wouldn’t call any one of these signs diagnostic. And yet if two or three of these signs is present, be suspicious; a night guard alone could be a bad idea. Either refer for a TMJ evaluation or obtain good joint images for these patients and be sure that a qualified person reads them. Or, you may wish to take a course in conebeam CT interpretation yourself.

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Above, a tomogram of a normal temporomandibular (TM) joint.

And here, posterior displacement of the condyle.

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Night guards: An idea badly done.Most of the patients I see for TMJ evaluation already wear a night guard; most of these patients have had several. The night guards have not helped relieve the patients’ symptoms. Sometimes this falls under the Night guards: a bad idea category and sometimes they belong in Night guards: an idea badly done. And sometimes both descriptions fit: The situation didn’t call for a night guard in the first place, and the one that was made wasn’t made properly.

First problem in the badly done area? Fit. You must have a decent impression and it needs to be properly poured. I know you probably heard this as freshmen in dental school, but it bears repeating. You do not have to use the most expensive impression material; a good alginate should work for most of these appliances. But you do need to capture as much detail as possible. (I must admit that I’m often taking impressions on a person with very limited range of motion and I don’t capture every detail myself—just ask my lab technician.)

Good detail—including hamular notches—in a maxillary alginate impression

Most of us already know how to do excellent impressions. It comes down to paying close attention to details. Most lab technicians can do an excellent job pouring impressions, but

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if it’s done by auxillaries in your office make sure they are well trained.

A few years ago I noticed that when one of my assistants poured impressions, her stone models always had some rather impressive bubbles. I reminded her to use very small increments of stone when pouring , but the problem persisted. So one day I called her into the lab and asked her to watch while I poured a new impression.

First I sprayed the impression with debubblizer – I use Almore brand, but I’m sure any commercial product would be fine – then started pouring stone very slowly with no more than a ¼ tsp. at a time, until the inner surface of the impression was coated.

“Oh!” she said. “So that’s what you mean by small increments. I was pouring in maybe a tablespoon or so to start. I thought that was a small amount.”

Maxillary model with hamular notches and incisive papilla marked

While good fit is imperative, the biggest problem I see with night guards is occlusion. I typically see night guards with heavy posterior occlusion and little or no anterior contact. That’s a sure recipe for even harder nighttime grinding and worse pain in the masseters and temporal muscles. In addition I almost never see a night guard that is well balanced

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left to right. Put an appliance with 70, 80 or even 90% of the occlusal force on just one side, and your patient won’t be too happy. The smart ones will stick the appliance in dresser drawer and forget about it. Some will suffer in silence. Some will change dentists.

So, what can you do to ensure good occlusion? Good upper and lower models of the dentition and a bite registration taken at the desired vertical dimension.

That is a key step that is almost never done—I know because I’ve talked with your labs. And skipping that step is actually not your fault. It’s your dental school’s fault. I know that doesn’t seem possible, but it’s true.

You may have been told back in your school days that half of what you learned would be wrong, but they didn’t know which half. It was said in a somewhat tongue-in-cheek fashion and yet there was some truth to it.

Well, here’s something they were wrong about (and as far as I can tell, academic dentistry still gets it wrong). “The first 25 mm of opening is pure hinge movement,” they told you, and they were absolutely wrong.

If you believe the myth of pure hinge movement, you’ll never understand why your appliances as well as full dentures—implant supported of course—and possibly even partial dentures come out so screwed up.

After all, if the first bit of opening is pure hinge movement, all the technician has to do is mount the models in C.O. and then drop the pin on the articulator to open vertical and the mounted models should perfectly duplicate what happens in the mouth.

I know some of you cuss your lab technician when you see that your carefully designed night appliance comes back from the lab contacting only on 2nd molars. How the heck is that possible?

Well, it is because there is no pure hinge movement with normal opening. The condyles begin to translate down and forward immediately.

Want proof? Place your index fingers lightly against the sides of your face just anterior to the tragus of the ears. Now, open a little bit—I mean just a little. Three or four mm. What happened? I think you just felt the tips of your fingers dropping into the space left by the condyles as they translated down and forward.

Is that a big deal? It’s a huge deal if you want to make a decent appliance.

The articulator opens with pure hinge movement. Your patient does not. If you want

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accuracy you must do the bite registration in the desired vertical of the finished appliance.

Bite registration? And in the desired vertical? Absolutely. When I talk with technicians from California to Indiana, they tell me that’s a missing step. Those technicians say that at least they are getting both upper and lower models now. A few years ago they were just getting one model—upper or lower—with a prescription for a vacuum formed night guard. As you probably know, that just duplicates the patients’ existing occlusion at an increased vertical. That’s a recipe for trouble. So, sending both models is a step in the right direction. But without a proper bite record your lab tech is still lost in space.

Lab techs around the country tell me that they generally don’t receive bite registrations at all, and even when they do get a bite record it is one taken in centric occlusion. “The dentists just don’t understand how useless that is,” one technician told me just this week.

Just repeat to yourself, “There is no pure hinge; there is no pure hinge…” Except on the articulator and that does not count.

Now, a brief aside just to be fair. Is there ever pure hinge movement in our patient’s TM joints? Yes. That can occur under two circumstances. First, if you are doing bi-manual manipulation with the fingers of both hands applying upward pressure on the angles of the mandible and your thumbs on the chin, you can force the mandible into pure hinge movement. I’d be careful about taking a bite registration with bi-manual manipulation. The articulator may be able to duplicate that bite, but your patient will not.

Another situation where pure hinge movement occurs is the closed lock of the TMJ with total disc displacement—although that’s usually one joint not both. And in this case you don’t want to do a night guard anyway.

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After deprogramming the muscles, in this case with an Aqualizer, and with the person slightly open, I injected a PVS bite registration material between the anterior teeth. After determining that this is a relaxed and comfortable position for the patient, I add PVS bite registration material (Memoreg 2 by Heraeus).

http://www.google.com/url?sa=i&source=images&cd=&cad=rja&docid=GmOgT3VS8iM8XM&tbnid=rjnPozY7E_1FXM:&ved=0CAgQjRwwAA&url=http%3A%2F%2Fwww.tmj-munich.com%2Fen_index.html&ei=H5HtUeDvE8fSyAH1xYGwCg&psig=AFQjCNHYaRSNwXTUxhHglz5K-8jYwL_pmA&ust=1374610079372010

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The canted frontal occlusal plane

When a person has this kind of skeletal asymmetry, there is almost always an uneven occlusion left to right—generally the low side hits first and hardest. It’s not just helpful for your lab technician to be able to duplicate that canted occlusal plane when mounting your patient’s models, it’s close to imperative. How to communicate this slant to the frontal plane to your lab? Either a good facebow mounting or the Accu-liner articulator.

Many labs—though certainly not all—have Accu-liner articulators and these devices make this kind of mounting easy. Unfortunately, I understand that the Accu-liner articulator is no longer being manufactured. An alternative to the Accu-liner is now available from another company. I was able to inspect one at a recent meeting of the AACP. It looks solid and well-made. It should offer dentists the same ability to do an accurate mounting of models without the use of face-bow that the Accu-liner provided. For information click Acculator.net.

http://acculator.net/

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The Acculator Articulator replaces the Accu-liner.

In any case, the Accu-liner system is based on the HIP plane—a plane described by connecting the two hamular notches with the incisive papailla; this plane is near perfect representation of the orientation of the maxilla against the cranial base. If there is a cant to the occlusal plane, it will also be canted vis-à-vis the HIP plane. Voila! No face bow required. Just a perfect mounting position for the maxillary cast. All you need is a darned good impression that captures the hamular notches.

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An Accu-liner mounting based on the HIP plane.

The other alternative is to use a facebow and make sure it records the cant. How many are using facebows? My lab connections tell me maybe 1%, and even then ...well, see for yourself.

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Does any person have a maxilla that slants down at 45 degrees from the horizontal? Most instructions for using a facebow say to use the Frankfort Plane, illustrated here.

So, placement of the facebow should look like this.

In this modern facebow, the dentist or assistant is guided by a nasion bar that helps keep the recording device parallel with the Frankfort Plane.

http://www.google.com/imgres?imgurl=http://content.answcdn.com/main/content/img/oxford/Oxford_Sports/0199210896.Frankfort-plane.1.jpg&imgrefurl=http://www.answers.com/topic/frankfort-plane&h=568&w=424&sz=38&tbnid=mbnGaCJuzWWx2M:&tbnh=90&tbnw=67&prev=/search?q=frankfort+plane&tbm=isch&tbo=u&zoom=1&q=frankfort+plane&usg=___1X-kMF81RskP144xS44vJzF1RY=&docid=mluCJpfItBc6oM&sa=X&ei=Va3ZUdCuJsv2iQKDzoD4Ag&sqi=2&ved=0CDIQ9QEwAQ&dur=3513

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Some authorities suggest using the inferior border of the ala of the nose and the superior border of the tragus of the ear as landmarks. Researchers do not agree on this point though, and in any case the photo above looks like a much exaggerated position of the maxillary cast.

If you want to use a facebow, here are two good references. Both of these should prove useful: The Use of a Face Bow for Function and Esthetics

And: The Artex Facebow

http://www.dentalaegis.com/ida/2012/04/the-use-of-a-face-bow-for-function-and-esthetics

http://www.jensendental.com/artex/facebow/rotofix2.htm

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Proper articulator mounting with bite registration.

In my opinion you don’t need to use facebow routinely to receive a good night guard back from the lab unless you’re dealing with a canted frontal occlusal plane.

It is simple to check for this. Just have the patient close on a tongue depressor and look. Is there an obvious cant? If there is and you don’t communicate that to the lab, you’ll get back a night guard that is high on one side. Every time. Canted frontal occlusal plane? Use a facebow or work with a lab that uses the Accu-liner articulator.

William F. Halligan, Frank Madrigal, the owner of True Function Laboratory, and one of his

employees, Delia Tapiz, at the True Function floor display at the annual meeting of the American

Academy of Craniofacial Pain.

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By the way, I work with True Function Lab in La Mesa, CA almost exclusively and have had consistently good results for more than 10 years.

I have also worked with a number of others labs over the years including Space Maintainers Lab (various locations in North America, Australia and Asia), John’s Dental Lab in Indiana—especially for longer term appliances—and Strong Dental Lab with locations in Michigan and Ontario, Canada.

I happen to use the Accu-liner articulator in almost every case. For complex restorative dentistry it has its limitations, but for night guards and my TMD treatment appliances, I find this system valuable and very accurate.

There are many designs for night guards and in the following section I’ll show a few of my favorites—you’re bound to see something new here along with the reasons for various designs.

http://www.truefunction.com/

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The plain vanilla flat planed night guard with a twistA commonly used design for the flat planed night guard is one that allows for even occlusal contact all the way around and at the same time allowing various mandibular movements—left and right lateral, protrusive and retrusive all the while maintaining even contact. This would describe a full denture with perfectly balanced occlusion in all excursions—it would also be just as difficult to produce.

It is much more practical to make a night guard that hits evenly on both sides when the person closes but has anterior and canine guidance (posterior disclusion) on lateral movement. That is, canine guidance is a heck of a lot easier to achieve than perfect balance of all posterior and anterior teeth in all movements. Maybe that’s why God or Nature made most of us with canine protected occlusion; it made fabrication easier even for the Creator of the stars.

Left: A flat planed splint. Right: A flat planed appliance in place on the upper arch.

A flat planed night guard in place.

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This is likely your most frequently used design, (though it may not be after you’ve finished reading this) but pay close attention at delivery. I use T-scan for every appliance delivery (see my article, “The wonders of T-scan..” on my web site). But even without T-scan you should be able to adjust an appliance by carefully observing marks made with articulation paper. The patient’s proprioception can guide you as well.

Night guards that patients bring in from other offices are almost always uneven left to right—and sometimes the difference is rather gross. Also, even when the lab makes the guard with a small anterior ramp to produce anterior and canine guidance, there can still be heavy posterior contact in lateral excursions. If you’ve done your bite registration at the desired vertical, your lab tech at least has a clue to proper mounting. And if you’ve communicated canted occlusal plane to your laboratory, you should receive a night guard that doesn’t require much adjustment. But even so, use your articulating paper and look. Then, have the patient go through various excursions and look again.

Not doing these steps will lead to the night guard you just delivered lying forgotten in a drawer somewhere in your patient’s bedroom, never to be worn.

Having discussed flat planed night guards here, including some advice on how to do them better, I also should tell you that I almost never do a night appliance that has posterior contact.

Why not? For the clenching or bruxing patient, I believe the key is to get all the posterior teeth out of occlusion all night long (and sometimes most of the day as well). That will stop the masseter and temporalis contraction most of the time. For me, the horseshoe arrangement with posterior contact is contra-indicated for our headache and pain patients.

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The Anterior DeprogammerThe night appliance I use most frequently is the anterior deprogrammer. I suppose it doesn’t even fit the category of “night guard,” as it is totally different in design. Similar to the Kois deprogrammer-the difference is that it occludes with the 4 lower anterior teeth, while the Kois generally contacts only the lower centrals, or even just one lower central—the idea here is no contact on canines or posterior teeth in any excursion.

Anterior Deprogrammer

I make the anterior discluding element only thick enough to cause separation of the posterior teeth. And I aim to make that separation of upper and lower molars is very slight—no more than the thickness of a couple of sheets of paper. Minimal increase in vertical is key ingredient.

There are two additional factors. First, the anterior discluding element needs to be parallel with the plane of occlusion, both from and anterior-to-posterior perspective but also right to left. Especially be careful not to slant the deprogrammer up on the posterior (for an upper appliance). Doing so will cause the patient to slide the mandible posteriorly, displacing the condlyes to the posterior and that is bound to cause an increase in symptoms.

Second, you must make the discluding element wide enough anterior-posteriorly to prevent the patient from retruding the lower anterior teeth off the acrylic.

How do you make sure the appliance is parallel with the frontal plane of occlusion? Face bow mounting or use of the Accu-liner as discussed above. And at delivery, just look: How are the anterior teeth meeting the acrylic? If it appears correct, use articulating paper to be sure.

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Anterior deprogrammer in place.

While I prefer to do full coverage of the upper dentition, a patient with an exaggerated curve of Spee presents a problem: you may not be able to cause disclusion of the 2nd molars—and sometimes even 1st molars—without increasing vertical more than seems practical. In that case, I end the appliance at the 1st or 2nd bicuspid.

And this may bring up a question. What’s the difference between an anterior deprogrammer and an NTI? From a functional point of view, not much. If the NTI is made correctly. More on that later. (Hint: most NTIs are not so carefully made. The NTI is deceptively simple looking; but keep in mind that nothing is as easy as it looks).

Variations on the anterior deprogrammerAlthough I stated at the beginning that using a night guard in the presence of real TMJ pathology is not indicated, I do see one situation that I believe is an exception. That is the Piper stage two disc displacement (for a full discussion of all five stages in Mark Piper’s classification system go to TMJSurgery.com.

Dr. Piper defines stage one as a normal, healthy TMJ with no pain, no clicking and no disc displacement. Here is his definition of stage II:

The very earliest disease developed within the temporomandibular joint is laxity of the lateral collateral ligament. These patients are typically symptomatic from nighttime bruxism. Hence, they might develop nighttime headaches, daytime fatigue in the elevator muscles and clicking which could occur first thing in the morning. This clicking typically reduces with a few early morning opening movements of the mandible.

http://www.tmjsurgery.com/classifi.htm

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In my practice, any patient that may have internal derangement of the TMJ gets joint imaging and joint vibration analysis (JVA by Bioresearch). If the condyles are displaced on x-ray and there is significant clicking, this patient requires more than just a night appliance, in other words 24 hours per day stabilization.

But the person with stage II displacement, described above, may experience excellent results with a properly designed night appliance.

I first encountered this situation a few years ago.

An excellent local orthodontist phoned me and I could hear some concern in his voice. “I just finished ortho for a 17 year old boy,” he told me. “He’s wearing Hawley retainers and now he says he’s clicking every morning. He wakes up with TMJ pain and says there’s a hitch when he first goes to open. Like he’s locked. What do you think?”

I told him to send the young man in for an exam. Results? No pain on palpation. Normal x-rays and normal joint sounds. Well, this should be easy, right? How about I bond an anterior discluding ramp onto his upper Hawley? So I did that.

The next morning the patient called the office and said the problem was not solved. He woke up clicking; he had pain and a feeling of almost being locked closed.

He must be retruding the mandible and displacing the discs at night, I decided. So I had him come back to the office and added a vertical ramp to the discluding element so that the lower incisors would be blocked from posterior movement.

An Anterior deprogrammer with a lingual ramp to prevent mandibular retrusive movement.

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The next morning I received the disappointing phone call again. No, the patient told me. That did not work either.

Next I asked some fairly basic questions that I hadn’t asked before. “Is your clicking and pain on one side or both sides?”

“I think just one side. The left side,” he told me.

“And do you sleep on your back or on your side?”

“I always sleep on my side. Let’s see. Yeah, on my side. On my right side and with my hands up under my chin.”

So then I could see what to do. I had to limit that forced lateral movement of the mandible. The only thing I could think of at that time was a Somnomed snoring/sleep apnea appliance. Not because the young man was snoring; he wasn’t. But because it seemed to me that a Somnomed should limit sideways movement.

So I did a bite registration in a slightly protruded position, sent models to Space Maintainers Lab, and received a nice Somnomed. Problem solved. No morning pain, no clicking and no feeling that he might lock closed.

I encountered a few more cases like that one over the next several months and my solution was always the Somnomed. And by the way, it was an okay solution. It did work.

However there were two problems. First, the Somnomed is a bit bulky, with two full coverage acrylic mouth pieces and those two shark fins. I love the appliance for snoring and sleep apnea but for a minor ligament laxity, I thought there must be a simpler, more elegant solution.

Second, the Somnomed is a rather pricey appliance. Fully worth it for solving the medical problem of sleep apnea, but for a little clicking and a temporary “stuck” feeling in the morning, maybe a less expensive alternative could be found.

And I did. By the way, I don’t claim to have invented this approach. Mine is just a variation on an appliance that has been used by others.

It is a one piece appliance with vertical flanges that lightly contact the upper posterior teeth.

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Both photos: A lower deprogrammer that also restricts lateral movement.

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A lower deprogrammer that also restricts lateral movement worn by a patient.

For my patients whose only complaint is morning clicking and locking and who have no symptoms during the rest of the day, this little device has been the answer. Notice that it is an anterior deprogrammer—there is only contact on the anterior incisors upon closure. But if the patient attempts lateral movement, and especially if the person is sleeping on her side and her hands or the pillow puts lateral pressure on the mandible, she is not going to cause a displacement.

I use this appliance frequently now. For a lot of these side sleepers who click or temporarily lock on one side in the morning, this is the design I use.

How about the NTI? The device sure gets mixed reviews; just go to an online NTI forum. Some folks on the forum express gratitude for the NTI and the relief the device has given them. Others complain that their pain is the same or worse; some say the NTI is too tight and hurts the teeth while others say it is too loose and they fear they could swallow or choke on the thing.

I spoke with Dr. Mike Pilar recently about his experience with the NTI as well as his observations regarding NTIs he sees from other offices. Dr. Pilar, whose practice is in Tappan, New York, says that he has probably done more NTIs than anyone else in the

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country and therefore has the experience to back up his opinions.

Dr. Pilar says the NTI is an excellent appliance when done right; and he takes a rather extraordinary amount of time to do them right. He is probably correct in saying that this is what it takes.

He told me that most NTIs are done with much too great an increase in vertical dimension, and I agree with him. I have certainly seen NTIs done with really exaggerated vertical.

In addition, he states that the discluding element must be precisely done so that there is no tendency to cause posterior displacement of the mandible.

He considers this step to be vitally important. And again, I agree with him. In examining patients who already have an NTI and are still in pain, I have often seen the NTI sloped or slanted in such a way that the mandible is forced posteriorly.

“The discluding element,” he told me, “should be parallel to the ala-tragus occlusal plane. I rarely see that part done right. I also see canine contact and that’s a no-no. And the reason patients complain about tightness is that the interproximal isn’t relieved enough and the gingival papilla can also be impinged.” (For a discussion of the ala-tragus line in prosthetics click here.)

In short, Dr. Pilar thinks that the NTI is an excellent device, but doing them right requires a lot of time and attention.

Regarding fit, Dr. Pilar says that dentists just have to get better at handling the acrylic (usually Snap brand). Too many of us are taking shortcuts during this important step.

Personally, I use the NTI occasionally, but not frequently. It seems there is an important place for the NTI if—and it’s a big if—it is fabricated and adjusted with great care.

I hope to learn more about Mike’s philosophy on the NTI. I think I will find that his approach is very similar to what I do with laboratory fabricated devices.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3056949/

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There is one more design I use occasionally. True Function Lab calls it the “Halligan night appliance”, though I’m not going to claim I invented it. My wife calls it the “bicuspid bumper.”

Whatever you call it, here it is:

It doesn’t even seem likely that this design would work. It breaks a lot of rules: it has canine contact, it has posterior (one bicuspid) contact, it requires adjusting for balanced occlusion in all excursions on four teeth. And yet, I have found it almost universally com-fortable whenever I’ve used it.

I use this design in two circumstances. First, for the person who has been wearing an NTI and is developing anterior open bite, I want to get rid of all occlusal force on the incisors. This little appliance fills the bill.

And second, if there are periodontal problems affecting the anterior teeth, especially if there is tooth mobility, I avoid all force on the anteriors. Of course, I make sure that the perio problem has been addressed, or that there is a plan to do so. But in the meantime, I want no force on those teeth from any appliance. Again, this one works. It is comfortable. There is no molar contact whatsoever, and there is smooth gliding movement of the mandible in all excursions. For certain patients, this is the one that works.

Dentists and patients alike do have one more question: do I prefer a hard or soft

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appliance? And the answer is nearly always, hard not soft.

A hard appliance can be precisely adjusted. A soft appliance has too much give and there’s no telling where the occlusal forces really are. Also, I believe that if you put a soft appliance in the mouth, the patient will unconsciously think it is something to chew, and so she will. She’ll chew it as if it’s a big wad of gum and work the muscles of mastication all night long. Not a good scenario.

Having said that, I have made a couple of soft night appliances. In both cases, I did this because the patients requested it. Neither of these is a typical night guard however. Both are anterior deprogrammers with soft discluding elements. Needless to say, this wasn’t my first choice. And yet, both patients are happy with the comfort of the appliances, so who am I to complain.

But two soft appliances out of more than 1,000 hard ones compute to less than 1/10th of one percent. I don’t recommend soft appliances as a general rule.

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So, are night guards a bad idea or are they just badly done? I hope you’ve seen that the answer is both!

I hope I’ve given you a reasonable road map to help you avoid some of the pitfalls. When you consider a night guard for a particular patient, give it some thought. And when you proceed with doing the appliance, use some care in selecting the design. And bear in mind that it is not a “one size fits all” world. You will occasionally have to go back to the drawing board.

It will be helpful if you communicate with two people. First, the lab technician. Did you give him what he needed to do a good job? Does he have comments on the impressions, models, and bite registration? Your lab tech can be very helpful and instructive if you will let him.

And second, communicate with the patient. When I fabricate and deliver a night appliance, I always include at least one no-charge follow up appointment within a week or two. How is it working? Are you sleeping comfortably? Is it fitting well? Then I check patient range of motion, palpate muscles and carefully check the appliance again with articulation paper. If there’s no follow up, you won’t even know if the person is benefitting. Indeed, you won’t know if the appliance is just sitting in a drawer somewhere.

I always welcome feedback from you, the reader, so feel free to email comments, questions and suggestions for additions or clarifications for future editions. I appreciate the time you have taken with this material. I hope you refer back to it often, and that it helps you in your endeavors to give the best service to your patients.

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About the Author

William F. Halligan is a 1972 graduate of the University of Southern California’s School of Dentistry. He practiced general dentistry during most of his career with an emphasis on restorative dentistry. He is a member of the American Academy of Craniofacial Pain and a founding member of the Academy of Clinical Sleep

Disorders Dentistry. Dr. Halligan’s practice is located in San Diego, California and is focused on treating TMJ disorders.

www.HalliganTMJ.com

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