In this series I have discussed what appliance options exist, why we typically use occlusal appliances and the potential theory of how they impact muscles or joints, recognizing that not all patients respond to appliances the same way. This article describes what appliances I personally would use for different purposes, starting with diagnosing the etiology of facial pain.
What Is Causing the Pain?
Pain is a particularly confusing entity for clinicians because of the sheer number of possible etiologies. The pain could be from muscle, joint, or other, with other being a huge category. As a clinician, I want to know whether the pain could be reduced with an occlusal appliance or not.
Every patient with facial pain needs to know in advance that three things could occur following wearing a diagnostic appliance: they get better, they stay the same, or the appliance makes them worse. All three answers are helpful in making a diagnosis as to the etiology of the pain and in determining what appliance may ultimately be fabricated for the management of their pain.
How to Find Out?
One of the challenges with appliance therapy is how to charge for it. If you make models, send them to the lab, pay for the appliance, take the time to adjust it, and then discover the patient doesn’t improve, the patient is frustrated and so are you. My preference is to explain to patients in pain that I want to make a diagnostic appliance as a tool to attempt to identify the cause of the pain prior to fabricating and adjusting an expensive appliance only to find out it may not be effective.
The first appliance I use for diagnosis is an anterior bite plane. I make this chairside on a pressure formed thermoplastic baseplate and add composite to it to create the bite plane (Figure 1). After you have a maxillary or mandibular model the bite plane can be fabricated in roughly 15 minutes. I usually make it on the upper arch.
The reason I use the bite plane is because of the minimal time and expense to make it, and it’s a near perfect appliance to aid in diagnosing muscle versus joint issues. For most patients an anterior only appliance has a significant impact at reducing muscle activity levels. For most patients with muscle only pain, they experience significant pain relief in a day, or certainly less than a week. If the bite plane resolves the pain, it’s probably their long-term appliance of choice for nighttime wear (Figure 2).
For patients with intracapsular joint pain, the anterior bite plane may actually increase their level of discomfort. It is important to realize that if the bite plane increases a patient’s pain, it is a useful diagnostic finding, as it probably indicates some joint involvement.
What About a Second Appliance?
If the bite plane can’t be worn because of pain, the second appliance I use is an Aqualizer from Great Lakes Orthodontics (Figures 3 and 4). It is a premade posterior only appliance that consists of two fluid filled reservoirs in the posterior, connected by a tube running across the anterior. It is essentially a fully balanced, self-equilibrating appliance with minimal or no anterior tooth contact.
Because the Aqaulizer has occlusal contacts in the posterior in all but the most extreme mandibular positions, it’s an excellent appliance to test a patient's response to see if posterior occlusal support can reduce their pain. In my experience if a patient can’t wear an anterior bite plane, but loves an Aqaulizer, they almost always have disc displacement issues within one or both joints. If the Aqaulizer provided significant pain relief, the patient will need a full coverage appliance long term, and it will likely need to provide posterior occlusion in excursions as well as the intercuspal position.
If Neither Appliance Helped?
If neither appliance had any impact on the patient's pain, I would be concerned that occlusal therapy will not be adequate for their treatment, and other etiologies should be considered. At this point you will need to decide if you desire trying additional modalities, such as physical therapy, biofeedback, massage, muscle relaxants, or refer them for further diagnosis to someone who manages facial pain on a regular basis.
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