Oral Orthotic Occlusal Appliance Therapy

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Continuing Professional Development (CPD) Module developed by TMJ Foundation Visit: https://tmjfellowship.org/oral-orthotics

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https://link.springer.com/article/10.1007/s12663-023-01939-y

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According to the American Academy of Orthopaedic Surgeons (AAOP), an orthosis is
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an orthopaedic appliance used to support or improve function of moveable parts of the body

an orthopaedic appliance used to restrict movement

an orthopaedic appliance used in surgery

an orthopaedic appliance used to evaluate bone

Orthotic Occlusal Appliance described by Ramfjord and Ash is
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Stabilization or Michigan Orthotic Occlusal Appliance

Repositioning Orthotic Occlusal Appliance

Soft Orthotic Occlusal Appliance

Night Guard Appliance

All of them are a type of occlusal appliance except:

Michigan Appliance

Jelenko appliance

Nociceptive Trigeminal Inhibition Tension Suppression System (NTI‑tss) Appliance

Anterior Repositioning Orthotic Occlusal Appliance

All are indications for flat plane stabilization appliance, except:
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Localized muscle soreness

Bruxism

Centrally mediated myalgia

Disc displacement

What is the therapeutic position of an anterior repositioning appliance
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At least 4 mm of mandibular advancement

The maximum patient’s protrusive position

With a slight retrusion of the mandible

The minimum protrusive position where the disc can be clinically reduced

Anterior Repositioning Orthotic Occlusal Appliance (ARA) is indicated for
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Painful disc displacement with reduction (DDwR)

Centrally mediated myalgia

Bruxism

Localized muscle soreness

Which of the following orthotic device is a partial coverage appliance
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Stabilization orthotic appliance

Anterior repositioning appliance

NTI-tss

Soft appliance

Which of the following options is not considered an optimal characteristic of a stabilization orthotic appliance
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Flat and smooth surface

Fabricated in hard acrylic

Indentations so the mandible remains static

Equal bilateral contacts

What is the primary indication for an anterior repositioning appliance
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Myofascial pain with referral

Disc displacement with reduction without limited opening

Painful disc displacement with reduction with intermittent locking

Subluxation of the TMJ

If you decide to fabricate an ARA in a patient with disc displacement without reduction, when is it preferable to initiate the treatment?

When the painful symptoms have improved

First few hours or days after the jaw locking (closed lock)/ Earliest possible.

When the patient has improved mouth opening (for prevention of a new locking).

It can be initiated anytime with the same outcome

As per the most recent evidence evaluated through meta analysis, the main indication for a NTI-tss appliance is
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Disc displacement with reduction with intermittent locking

TMJ osteoarthritis and good patient compliance

Myogenous pain and good patient compliance

When an anterior repositioning appliance is ineffective

In what situation there is strong evidence against the use of a soft full coverage appliance?
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Myalgia

Post arthrocentesis

Arthralgia

Post arthroscopy

Which of the following options can be a secondary effect of the stabilization orthotic appliance?
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Increasing of clenching episodes

Anterior open bite

Worsening of sleep respiratory disorders (snoring, sleep apnoea)

Intrusion of molars generating posterior open bite

According to the recent evidence and consort recommendations, select the best way to treat a painful TMJ internal derangement with acute onset disc displacement without reduction (DDwoR)
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First an orthotic appliance and delay as far as possible any minimally invasive procedure to the joint

Early minimally invasive disc recapture procedures accompanied by orthotic appliance and pharmacotherapy

Most of painful internal derangements (DDwoR) can be successfully managed with pharmacotherapy

Any occlusal orthotic device can be used successfully for these pathologies

In general, treatment with an occlusal orthotic device should last how long ?

In the case of an ARA it must be used 24/7 as long as the patient can endure

An NTI-tss must be worn 24/7 for 6 months at least

A stabilization orthotic appliance may be worn only during the night for the minimum of days until symptoms improve notably (Not more than 3 to 12 months)

Any orthotic appliance can be used during long periods of time without the fear of secondary effects

Which of the following is true for mechanism of action for stabilization appliance

Increase brain modulation of muscle activity

Reduction of electromyographic activity

Regression to the mean mechanism

All of the above

All of the following is true for stabilization orthotic appliance except

Recommended molar region thickness of 2-3mm

Commonly made up of PMMA

Also called inclined plane splint

May increase VOD

Which of the following is not true for anterior repositioning orthotics

Indicated in painful disc displacement with reduction (with/without intermittent locking)

Guides the mandible to a protruded position

Therapeutic position recommended is 2 mm of mandibular protrusion or minimum protrusive position where the disc can be clinically reduced

Secondary occlusal changes following indefinative use results in anterior open bite

CAD-CAM polycarbonate based orthotic appliances has the advantage of

More accurate with superior surface microhardness

Higher fracture toughness

Lower water sorption

All the above

Which of the following is the choice for immediate interim orthotic appliance post arthrocentesis/ arthroscopy

Soft full coverage orthotic appliance (which may be replaced with ARA, when required)

Pivotal appliance

Stabilization orthotic appliance

NTI-tss

Which Oral Orthotic Occlusal Appliance Therapy is indicated for pain related to myogenous origin *

Stabilization orthotic appliance

Anterior repositioning orthotic appliance

NTI-tss

Full coverage soft splint for indefinite time

Which Oral Orthotic Occlusal Appliance Therapy is indicated for pain related to arthrogenous origin, with a definitive diagnosis of internal derangement
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Nociceptive Trigeminal Inhibition Tension Suppression System (NTI‑tss) Appliance

Anterior Repositioning Orthotic Occlusal Appliance (ARA)

Stabilization Orthotic Occlusal Appliance (SA)

Soft Full Coverage Orthotic Occlusal Appliance for indefinite period

Anterior Repositioning Orthotic Occlusal Appliance (ARA) was popularized by
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Michigan

Farrar

Ramfjord

Ash

Possible mechanisms involved in improving symptoms
of TMD with the use of a SA include "Howthorne phenomenon", which is
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Change in behavior or perspectives to treatment, secondary to the awareness of being monitored

Decrease joint loading

Decrease joint inflammation

Regression to mean

Which is true about Orthotic Occlusal Appliance Therapy *

Can be used for indefinite period

Should be used only for the shortest period, required to relive the patient's symptoms

Should be compulsorily utilized for 6 to 12 months

Can be utilized for all TMD related conditions, irrespective of the diagnosis

The type of the Orthotic Occlusal Appliance Therapy should be based on the
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Appropriate diagnosis of the conditions

Intensity of pain

Patient's choice

Fabrication material based patient comfort

An established temporomandibular joint disorder, irrespective of its initiating factor (inclusive of dental etiology), should have a holistic multidisciplinary treatment approach with interventions involving sound principles of orthopaedic science rather than occlusal centric archaic management concepts.
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True

False

Required

For the symptomatic (painful) intra-articular derangement with loss of synchrony in disc movement or a displaced disc without reduction, simultaneous or postintervention orthotic occlusal appliance therapy in more beneficial in combination with early minimally invasive procedures (arthrocentesis or arthroscopy), and adjuvant pharmacological therapy. In case the orthotic occlusal appliance therapy is instituted as the primary conservative modality in such cases, it should be utilized for a shortest possible duration (not more than 4-6 weeks) and should be response based. In non-responsive cases, resort to disc recapture with minimally invasive procedures (arthrocentesis or arthroscopy) at the earliest possible instance.
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True

False

Required

An oral orthotic occlusal appliance is utilized to produce
a permanent changes in occlusion or mandibular position
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True

False

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Oral appliances (orthotics) can be a part of a noninvasive management plan for NOT ALL but certain patients with musculoskeletal TMJ disorders, with specific indications.
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True

False

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