by Clayton A. Chan, D.D.S., M.I.C.C.M.O.
There are several different aspects to consider regarding the use of orthotics.
1.) Medico-legal – standard of care is that occlusal therapy be reversible as per ADA statement, removable orthotic appears to fit this criteria better. Especially, to the non NM clinician. It looks more mainstream to the traditional clinician. Much less likely to damage the patient’s own structures when the appliance is removed, whether the patient takes it off or we dentists take it off. Which would make you feel more comfortable if your TMD pain patient ever decided to leave your practice for whatever reason…Leaving your practice with a fixed orthotic in the mouth or with a removable?
2.) DOT Occlusal Management – Significantly easier to adjust the bite outside the mouth than in the mouth, especially with paining TMD patients that are not yet committed to phase II treatment.
3.) When patient not yet committed to phase II level therapy, removable is less likely to cause a more permanent joint change, because of the capability to remove the appliance when the patient wants to. With fixed the patient has no control of the situation and you own the bite (patient now controls you)! If patient is having difficulties with their bite using fixed on a weekend you have to go in and help, if removable they can take it, see them on Monday. Harder to divorce from a patient who has been in fixed vs. a patient in removable.
4.) Removable is safer for the doctor in patient management: The patient can always pull it out of the mouth if the bite is bothering them, with the fixed orthotic the patient can’t do that and will require doctor help and assistance. Haven’t we all had a patient who told us that they could not tolerate their new bite?
5.) After 30 day fixed orthotic trial period and patient is not ready to proceed forward with finalizing treatment, what do you do then?
6.) Paining TMD patient is not always prepared to move forward with a phase II finalizing mode of treatment after 3 months of orthotic therapy. Most of my TMD pain cases are not ready for phase II for at least 1 year, I don’t want the liability for hygiene issues or any other things that would happen underneath the fixed orthotic.
7.) Bite Management is much easier and simpler when setting up the case to transition into Phase II. (Any mandibular shift/change that occurs during the course of treatment is easily transferred without the worries of having to cut off the fixed orthosis to get a lower arch wax up. You don’t have the worries to cut off orthotic, maintain and record the bite for the lab, and then place another fixed orthotic which must be exactly and identical to the same orthotic position you just cut off.
8.) Removable orthotic is less hard work vs. fixed orthotic with TMD pain patient. Do you like to adjust bite in a laying down position intra orally or a sitting up position extra orally? Is coronoplasty/ micro occlusion easier intra orally or extra orally?
9.) When you need to resurface the orthosis. Which is easier fixed intra orally or removable extra orally?
10.) After resurfacing how much energy is required to coronoplasty intra orally or extra orally? Think of the emotional stresses on yourself when dealing with a high proprioceptive paining TMD patient?
Ask yourself several questions:
Why do many prefer the removable orthotic rather than a fixed orthotic?
Is it really easier to manage the TMD paining case with a removable or fixed orthotic?
Why does the dental profession (as a Standard of Care) recommend conservative and reversible therapy especially amongst TMD/occlusal philosophies?