Consultation: The patient is encouraged to come in for a consultation to discuss their symptoms, report what treatment was tried to date, and explore treatment options.
Examination: Before any treatment is started, Dr. Dorothy Kassab will perform a thorough examination and gather supporting diagnostic information to help to determine if the patient is a candidate for Neuromuscular treatment of TMD. During this exam, we will obtain X-rays, pictures, perform computerized myography (muscle testing). Once Dr. Kassab establishes that treatment should be beneficial to the patient, the patient will proceed to the appliance fabrication.
This process consists of several steps:
1. Obtaining a physiological relaxed bite registration that is deprogrammed from the neuromuscular daily engrams of a pathological bite. This bite provides the relationship between the top and bottom jaws during the appliance fabrication by the laboratory. This position can not be arbitrary and is obtained after 45 minutes of TENs of the facial muscles.
2. Molds to send to the laboratory so that an appliance can be made.
Detailed Treatment Description: The treatment plan involves utilizing low frequency TENS (transcutanous electric neural stimulation) prior to a passive bite registration in a resting mandibular neuromuscular position to create a medically necessary orthopedic repositioning appliance. This device is used to position the condyles in the fossa in a less pathological, more true anatomical position, reduce stress to the jaw joint, increase joint space, allow remodeling of the condyle, heal retrodiscal tissue, re-capture the dislocated articular discs, provide proper alignment of the mandible to the skull, reduce myospasm and pain, and maintain the muscles of mastication at their proper physiologic resting length. Please note that all treatment is neuromuscular and orthopedic in nature and necessitated by a medical condition resulting in head and neck pain and should be considered as a medical necessity. At this time, the treatment does not involve the teeth, periodontium, or surrounding structures, but is for a structural, orthopedic, neuromuscular problem that must be stabilized (Phase I). The teeth may be treated at a later date (Phase II) to hold this new, stable orthopedic position.
Treatment Goals: The treatment goal is to improve bilateral condylar position of the TMJ and, subsequently, improve the symptoms originating from the TMD. Patient is informed that clicking/popping may not resolve if there is a stretched disc ligament and if the disc lost its biconcave form since recapture of disc will be unstable and that the goal of treatment is geared towards pain control and intervention in joint degeneration.
Treatment Plan Summary:
Phase I-establishment of neuromuscular bite registration at physiological rest using a mandibular repositioning orthotic appliance, TENs, and K7 computerized myography scanning and jaw tracking. There will be a requirement to wear removable orthotic for 4 months to obtain condylar changes in new position.
Phase II- may be proposed at the end of Phase I
Retention Phase-Very often, TMD patients also have sleep apnea. If sleep apnea is diagnosed by the patient's physician, an EMA sleep appliance will be used during the retention and maintenance Phase. If the patient does not have sleep apnea, the orthotic will be worn at night.
Treatment Plan & Treatment Duration: A Neuromuscular TMD removable mandibular orthotic is discussed with our patients, full time wear for up to 4 months then weaning off into nightly wear. We inform the patient that the goal is to resolve symptoms originating from TMD and then evaluate which symptoms persist after TMD therapy is completed so that the physicians can treat those independently. The patient will come in at least monthly for appliance adjustments, muscle testing, and monitoring by Dr. Kassab of symptoms resolution.
TENs is an acronym for Transcutaneous Neuromuscular Stimulation. With a TENS unit, the facial muscles are stimulated to provide increased blood flow to the muscles. This allows for toxins "flushing" out of the area and allows for rest position of the muscles. Once the muscles are relaxed, a bite can be taken for the TMD appliance. The patient's bite holds the jaws in a certain position in space. If the bite holds the jaw in an unbalances position, the muscles are in disharmony and myofacial pain starts. The inflammation of the muscles, from fatigue or hyperactivity, causes pain. The TENs unit is a crucial aid in the Neuromuscular approach of TMD treatment. We can provide a TENs home unit rental ($85 per week) or a home unit can be purchased through our office ($350).
Many TMD patients, as well as the general population, experiences sleep disturbance, clenching & grinding, and snoring, due to a compromised airway. Very often, the sleep partner is affected and their sleep is compromised. Excellent treatment modalities are now available. Dr. Dorothy Kassab uses Glidewell Dental Laboratory for the fabrication of sleep apnea and snoring oral appliances.
The mechanism of action of the sleep and snoring appliances is to advance the mandible forward, open the trachea, and move the tongue away from compressing on the upper airway. The Nightguard (anti-clenching and grinding appliance) provides a flat, hard surface, between the maxilla and mandible, and protects the teeth from the lateral and protrusive grinding forces that lead to enamel destruction, gingival recession, bone loss, tooth mobility, teeth cracks, facial muscle soreness, headaches, and pain. The acrylic encases the teeth in one arch protecting the enamel. The opposite arch has a slippery sliding surface to bite on.
Patients interested in airway-reducing appliances for sleep apnea will need to have a previous sleep study (within the past 6 months) prior to treatment. Sleep apnea needs to be diagnosed by a physician or pulmonologist, and a recommendation for oral appliance vs the C-PAP alternative MUST be recommended by the treating medical Doctor. Dr. Kassab will work with and guide the patient to obtain the proper information prior to treatment. Patients interested in snoring treatment MUST have sleep apnea ruled out prior to treatment with a Snore Guard.
Snore Guard: $900
Sleep Apnea Appliance: $1,800
Nightguard Anti-Grinding/Clenching Appliance: $450
OneGuard Bite Acquisition for Oral Appliances to help:
Improve your physical activity and performance in sports with Athletics Optimization
Optimization with oral appliances has proven to improve head position over the spine.
This eliminates a head forward posture that is responsible for breathing difficulties, sleep apnea, decreased head rotation range of motion, decreased torso rotation and range of movement, pain from poor body posture, and other debilitating symptoms. Symptoms include headaches, ear congestion, neck pain, popping and clicking in the jaw.
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