What happened here?
A young lady came into my practice last week complaining of pain on the right side of her face. Her discomfort had been growing in intensity since she finished her orthodontic treatment a few days before.
She had pain on loading in the right side and pain to palpation behind the right condyle when her jaw was open. The right masseter, temporalis, medial pterygoid and splenius capitus were painful to palpation and she described the degree as a seven out of 10. The same muscles on the left side are slightly tender to palpation.
There is no noise in either joint; she had no history of joint signs or symptoms, no deviation on opening and a normal range of motion. Her CBCT shows normal joint anatomy and condylar position.
The images of the models were made after she was in an anterior deprogrammer for 15 minutes. At that time she could squeeze with no discomfort in the joint, although the muscles were still very sore. The only teeth in contact are the right canines.
So the question is: What the heck is going on?
Is this an orthodontic misadventure or all muscle contraction that is causing the posterior open bite?
Maybe the posterior teeth re-intruded after the ortho was taken off- based on the posterior open bite and the slight discrepancy in the occlusal plane of the molars to premolars. Loss of posterior support, joint loading, compensating and antagonistic muscles firing to try to regain contact- leading to muscle and joint pain.
Can you show us the CBCT image of the condylar position? Was the orthodontics done with centric relation in mind or arbitrarily?
Is provocation test positive? Possible pain originationg in inferior lateral pterygoid.muscles may cause an acute malocclusion.
Is there a picture shows the bite before using the deprogramer? Thank you
Dislocated disc with muscle splinting.
Update, I’ve talked to a couple of orthodontists who are heavily involved with invisalign. They tell me that a posterior open bite is not an uncommon problem with Invisalign. It is due to improper preparation of either the interproximal areas of the posterior teeth or to inadequate attachments on those teeth. It is particularly common in Cl II malocclusions where teeth are erupted for various reasons. If the posteriors are not properly prepared, the aligners don’t attach well and those teeth may not move–resulting in the open bite.
Not sure that is what happened here but it is an interesting theory.
If you try to hand articulate the models do they fit well together?
Another question to consider in this case:
What is the best immediate treatment in such cases? At the end of the evaluation, what can you send the patient home with ?
We can send the patient home with an Equalizer and then to fabricate an equilibrated bite splint.
that’s exactly what I did, sent her home with an aqualyzer and a prescription for 5mg of flexeril at bedtime. She came back four days later feeling much better. Now what should I do?
Keep the patient using the aqulizer. Try to equilibrate the models to get an idea if the problem would be solved.If not ,bring the teeth which are out of occlusion by adding composite resin to make the teeth touching evenlyor fabricate an equilibrated bite splint.
@ Arnie Mirza: Great Points. I know you have likely figured this out already but for the purpose of our learning here, let me ask a question
When we try to equilibrate the models how do we know the initial articulated position of the models match with clinical position of patients teeth?
Now that the patient is comfortable, shouldn’t you consider discussing the findings with the orthodontist? Were they aware of the patient’s discomfort? How was the patient treated? What occlusal scheme were they trying to establish? Can additional ortho treatment correct the discrepancies that are present?
Stephanie, you are absolutely correct and that is the plan. I have the orthodontist’s records but we haven’t talked about what the treatment goals were. I don’t indict anyone until all the facts are in and I don’t know what transpired from that person’s perspective.