Case Study 1
 
The Clinical Management of Basic Maxillofacial Orthopedic Appliances
 
(BY JOHN W. WITZIG/TERRANCE J. SPAHL)
 
VOLUME Ⅲ TEMPOROMANDIBULAR JOINT
 
PATIENT: Age 50 years, 1 month
 
MAIN PROBLEM:
 
 1. Frequent, reoccurring headaches, so severe that patient was going 
 
     to stop working.
 
 2. Pain in right TMJ.
 
 3. Constant discomfort.
 
FINDINGS:
 
1. Right TMJ very painful to palpation.
 
2. Right and left TMJs locked.
 
3. Class Ⅱ/Div. Ⅱ malocclusion.
 
4. Incisal interference forcing the mandible posteriorly in occlusion.
 
RADIOGRAPHIC FINDINGS:
 
1. Right TMJ - Posterior superior displaced condyle.
 
    - Flattening of condyle.
 
    - Large bone spur on condyle.
 
2. Left TMJ - Posterior superior displaced condyle.
 
    - Flattening of condyle.
 
3. Right TMJ arthrogram
 
    a. Disc perforation.
 
    b. Severe degenerative change.
 
    c. Late stage internal derangement.
 
DIAGNOSIS: Internal derangement with degenerative arthritis, both left 
 
                      and right TMJs, advanced stage. 
 
                      Right TMJ has a documented perforation.
 
TREATMENT:
 
1. Sagittal splint (Sagittal Ⅱ appliance) - 8 months.
 
2. Transverse splint (Transverse appliance) - 6 months.
 
3. Orthopedic Corrector I - 6 months.
 
4. Retainer splint - Wear at night indefinitely (to prevent upper anterior
 
    teeth to returning to former position.)
 
RESULTS:
 
1. Terrible headaches eliminated.
 
2. Patient said, " I don't have headaches anymore."
 
    Patient said, "I feel good with my lower jaw biting forward."
 
3. No pain or problems.
 
4. Mary was examined and TMJs x-rayed, 6 1/2 year post treatment. 
 
    a. No headaches, pain or problems.
 
    b. Wears retainer when sleeping.
 
    c. Opening: 39 mm.
 
Left lateral: 11 mm.
 
Right lateral: 12 mm.
 
    d. TMJ x-rays showed condylar remodeling.
 
    e. TMJ x-rays showed condyles are no longer posterior-superior 
 
        displaced
 
Figure 1A-1P
 
                                           
 
                   The Gothic arch trap. (1 A and 1 B) Pretreatment facial views. 
 
                
 
                                      (1C - 1E) Pretreatment models.
 
                                          
 
(1 F) Note the Gothic arch appearance of the outline of the maxillary arch 
 
         that forces the slightly wider mandibular arch to close further back to 
 
         where upper and lower arch widths coincide, another form of the
 
         NRDM/SPDC phenomenon (neuromuscular reflexive displacement 
 
         of the mandible causing superior posterior displacement of the 
 
         condyles). 
 
                      
 
(1 G) Transcranial radiograph of the right TMJ before treatment. There is 
 
         a 2.8-mm posterior joint space at rest, but 0.8-mm posterior joint 
 
         space at full intercuspation. 
 
                         
 
(1 H) Tomogram of the right TMJ pretreatment at full intercuspal occlusion. 
 
                         
 
(1 I) Arthrogram with dye initially injected only into the lower compartment 
 
        of the right TMJ. 
 
        Note how the day has gone through the perforation in the posterior 
 
        attachment to fill the upper compartment (white). 
 
                                         
 
(1 J) Sagittal II appliance to (1) move the front teeth forward out of the way
 
        of the future advanced mandibular arc of closure and (2) act as a TMJ
 
        splint by virtue of occlusal 
 
        coverings of acrylic over the upper back teeth. 
 
                                          
 
(1 K) Next a transverse appliance (splint) was used to develop the upper
 
         arch laterally. A wider upper arch would allow eventual advancement 
 
         of the currently wider lower arch and still permit proper dental interdigitation
 
         of the upper posterior teeth with the newly advanced lowers. 
 
         Wire (cut at midline) on the appliance helps prevent the newly advanced 
 
         upper anteriors from relapsing in lingually again during the transverse
 
         appliance phase of treatment. Acrylic coverings of the transverse appliance
 
         help prevent TMJ pain and headaches in a splintlike fashion similar to the 
 
         action of the acrylic occlusal coverings of the sagittal (splint) appliance. 
 
                                                 
 
(1 L) The patient is wearing a splint and is free of TMJ pains or headaches.
 
                                             
 
(1 M) Orthopedic Co2/1rrector I (OCI) appliance to increase the vertical
 
        permanently and reposition the mandible down and forward as per 
 
        standard OCI technique. 
 
                                            
 
(1 N) Mandatory HS (hour of sleep) bite guard and retainer worn at night 
 
        only during sleep indefinitely.
 
                               
 
(1 O) Six and one-half years posttreatment, on a transcranial radiograph, 
 
          note the large posterior joint spaces as compared with pretreatment 
 
          films. 
 
                                                   
 
(1 P) At 6 1/2 years posttreatment there are no myofascial pains, headaches, 
 
         or TMJ problems. (Courtesy of Dr. John Witzig.)

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