Bite Registrations for OSA and TMD appliances

The bite registration is the most important step in any appliance that changes the relationship of the upper teeth to the lower teeth. You are in effect providing the patient with a temporary biting position that must be in harmony with all of the components of the masticatory system or the patient will not have comfort. And treatment will fail.

Every patient has a range of acceptance for treatment and it varies considerably. Some patients can accept anything you put in their mouth while others accept nothing. This is based upon a number of factors:

  • Do they have pre-existing muscle problems? Conditions such as Fibromyalgia (FM)  and Chronic Myofascial Pain (CMP) have tight muscles by definition! UARS patients are particularly prone to muscle pathology including CMP!
  • Are they psychologically stable? Claustrophobic patients have a harder time with oral appliances than controls. Patients that deal poorly with stress are also harder to treat if they suffer from panic attacks in the night
  • Do they have healthy TMJ? You really need to check and document this before placing an appliance! But what should you be concerned with? If a patient opens 45mm -52mm with a straight opening pathway (mandible does not deviate to one side when open wide) you are fine to treat them. They should have 1/4 of this measurement in lateral movements to left and right as well as in protrusive. In protrusive, the mandible should slide forward without deviating to one side.
  • Clicking TMJ are a fact of life. More than 85% of a given population have clicking in their TMJ yet only about 10-15% are suffering due to it. What Is important is the timing of the click. An early click indicates that the disk is dislocated when biting, but quickly reduces to normal positioning when they open, and remains in normal position throughout most of the opening/closing cycle, only to slip off just before the teeth occlude. The later the click, the more damaged the ligaments that hold the disk onto the condyle are stretched. Patients with late opening/ early closing clicks are the riskiest to treat. When the bite registration is taken, great care must be made to ensure the disks are on the condyles or at least in a passive position. Don’t forget as well that disks do not just dislocate posteriorly, they also go medially.

The following guide to taking a bite registration that is balanced and accurate, the following is a step-by-step guide on how to accomplish this.

Step One: Know What You Are Treating

Your examination of the patient is critical. Assuming you have completed your examination and all indications are that this patient can be treated with an oral appliance, you can go to step 2

Step Two: Preparing the Patient for the Bite Registration

As sore muscles are very common, the first step that must be done is to relax the tight jaw muscles. Using a simple myofascial stretch technique, you can relax and stretch the massater muscles (the main culprit in clenching and bruxism).

Start by having the patient open slightly and relax. Slide your index finger on the left or thumb on the right inside the cheek just under the zygoma until you meet resistance. This places your finger over the attachment of the massater.

With your opposing thumb (or index finger) on the outside of the cheek, compress this area firmly. This often will result in a burning type pain for the patient, sometimes significant. Reassure the patient and then slide both fingers slightly down the muscle body while asking the patient to slowly open wider. You will likely run into lumps in the muscle body. These are trigger points and the source of phantom tooth pain, headaches, earaches etc. Continue compressing just above the trigger point and slowly move down onto it, compressing all the time. Hold this position until you feel the trigger point release. The trigger point often releases with a palpable snap! and the patient can open wider immediately. Continue down the muscle until you reach the attachment, on the mandible. Do this slowly, stopping to release any tension or trigger points in the muscle, all the while instructing the patient to remain open and to stretch the jaw as you release it. In stubborn cases, you may have to repeat this a second or even third time.

Right Side Left Side

This animation shows the position the thumb (or index finger) should be in (yellow arrow) and the direction you should be going down the muscle (green arrow).

Massater Stretch

If done correctly, the patient’s opening should increase significantly and they will report it feels more relaxed. Ask the patient to open and close slowly without biting while you get your George Gauge.

Correct Use of a George Gauge:

George Gauge

George Gauge

The first step is to fit the gauge without a bite fork to the lower incisors ensuring it is stable. Tighten the lower thumb screw to lock the position

Remove and place the appropriate bite fork into the gauge. Ensure you have enough posterior opening to accommodate the appliance.

Place the assembled gauge, with the grey upper thumb screw for the upper  loose (allowing free movement of the mandible anteriorly and posteriorly) onto the patient’s teeth.

Ask the patient retrude as far as possible and record this number:

Min

Measure the Retruded (Minimum) Position = -8 mm

The ask the patient protrude as far as possible and record this number:

Max

Measure the Protruded (Maximum) Position = +3 mm

Add the two numbers together. This is your protrusive range (11 mm in the example above)

A guide for the Luco Hybrid OSA Appliance:

  • Sleep Bruxism: 75% advancement with 4mm anterior opening is the most effective treatment position
  • Sleep Apnea: 70% advancement with 4mm anterior opening is the most effective treatment of mild to moderate OSA
  • Sleep Apnea with  Sleep Bruxism: 75% 4mm treats both

It should be noted here that a pilot study provided to the FDA in the 510(k) application for sleep bruxism, the 75% 4mm was used on 51 patients, all of which demonstrated a significant reduction in sleep bruxism, tension/migraine headaches and muscle pain by the 14 day reassessment. This included TMJ pain and an increase in range of mandibular motion, all within 14 days. Some patients have been in treatment over 14 years with the device and have remained symptom free. The Luco Hybrid OSA Appliance is the only FDA cleared treatment of sleep bruxism and the only OSA appliance FDA cleared to use in OSA patients who suffer from both conditions. 

(Please note: any bite registration may be used at any advancement)

Set the George Gauge to the desired protrusion and tighten the upper (grey) thumbscrew to lock the position:

Treatment Position 85

Locked at desired Protrusion

This example sets the protrusion at 85% (a severe OSA patient).

Place into the patient’s mouth. Ask them how it feels. They should report that their jaw feels forward but they should not report and muscle discomfort. Inject fast set vinylpolysiloxane bite registration material between the teeth above and below the bite fork and stabilize until set.

IMG_1074

Recording the Position

Remove the registration and inspect for accuracy:

Bite 2

Completed Bite Registration

IMPORTANT NOTES ON BITE REGISTRATIONS:

  • If the position is not comfortable. you may need to work on loosening their musculature further. This is especially important in patients with sleep related bruxism.
  • Make sure to inject enough VPS to fully record all of the teeth. This ensures an accurate mounting of the casts when constructing the appliance.
  • Hold the George Gauge level while the VPS is setting to ensure accuracy. Patients will often try to shift their mandible forward or backward trying to help. TMD patients will often try to force their mandible back into their clenching position. If the George Gauge is raised, the mandible comes forward. If it is lowered it goes back. Your 85% can quickly go to 90% or 75% simply by not holding the gauge level.
  • Instruct the patient to gently bite. I have lost many  lower blue bite sticks to patients that bite on it like there was no tomorrow only to hear a crack! I always keep a half dozen spares on hand.
  • Make sure that when they are biting, both upper and lower incisors are seated fully into the grooves of the bite sticks. Sometimes patients will open slightly allowing the mandible to retrude. This would result in a very poor fitting appliance.
  • As they say in woodworking, measure twice, cut once. Make sure your protrusive position locked into the George Gauge is what you intend it to be.
  • Always remember that the bite registration is the most critical step in designing the appliance for patient comfort. By ensuring that their muscles are loose and relaxed and that your casts and bite registration are accurate, you are ensuring the appliance you deliver to your patient will be comfortable and effective. After all, they will be wearing this every night for the rest of their life!
  • Don’t forget to document these numbers in the patient’s file, this provides documentation of how you treated your patient.

 Bite Registrations for TMD Splints: The Luco Technique

This technique produces TMD or bruxism splints that require no adjustment once inserted and provides a very comfortable lower appliance for your patients that works for most TMD appliances.

The first step is stretch the masseters as above.

The second step is to take a small ball of Triad the size of a large pea and place it on the incisal edges of the upper incisors. Have the patient open wide, slowly close without biting, then gently move their mandible side to side. This re-seats the disks on the condyles. The should now have a symmetrical movement side to side. Have them gently open one more time and, while gently stabilizing their mandible, ask them to slowly close (into the Triad) until there is about 1 mm of opening. At this point have your assistant light cure the Triad. Once it is cured, with the patient holding very still, inject super fast set VPS material between all the back teeth. Once set, remove the triad and VPS all together. You now have a proper TMD bite registration with the muscles relaxed and the disks on the condylar head. At this point your assistant can take upper and lower impressions and pour the casts. Try the casts into the bite and verify everything fits.

Write your prescription and order your appliance. We recommend a lower appliance in all cases to accommodate the activation of the pharyngeal reflexes that this position will result in.  Upper appliances can restrict the tongue movement. The Luco Splint, available from a number of labs in the US and Canada, is ideal for day and night wear. For day wear, the anterior can be left off and for night wear, used with full lower incisor coverage. These work well for mild sleep related bruxism as well as for awake bruxism. They have no material on the lingual and provide maximum room for the tongue.