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  • #21058

    Ari Forgosh
    Participant

    I saw a new patient today who has a TAP appliance since 2014 (mild OSA, titration confirmed affective with follow up PSG in 2015). Her chief complaint is that her teeth don’t come together anymore (she was hitting on just one spot until an endodontist took 31 out of occlusion – Now she has bilateral posterior open bite). She also has loud joint noises and occasional limited ROM. Her muscles were not terribly tender (right deep masseter was a 2/3, other muscles were 0-1/3) and she does not get headaches. I could load the joints fully without tension or tenderness, but I’m not convinced I had her in CR. First point of contact on #10 (class II mobility) with posterior open bite.

    I referred her back to her sleep doc to see if she could be fitted for a CPAP that she can tolerate. I also sent her to my orthodontist for CBCT and for him to scan her arches for virtual orthodontic treatment planning and printed models. We will send her images to Beam Readers.

    My question is, IF the joints are intact, can I use the TAP appliance to walk her back to CR? My theory is, if I turn the set screw back slowly, the anterior bar on the appliance will guide the mandible back into CR, stretching the lateral pterygoid to its original length. However, I worry about forcing the the joint back, and I’m not sure how I will be able to tell when we get to CR since I can load the joint where she is now. My alternate plan would be to make a deprogrammer and hope the joint seats passively, or a full arch appliance, monitored for stability, and treat her in Adapted Centric. Thoughts?

    #21114

    MatthewWolfe
    Participant

    Hey Ari,

    This is a crazy situation!  I’ve actually seen this exact scenario 1 time in my office.  I don’t have very many patients wearing MAD’s, but this one patient had an appliance fabricated by another dentist 5 years ago.  She came in for a hygiene appointment and was complaining about her back teeth not touching anymore.

    In regards to your situation, I agree that I would definitely like to see a CBCT of the joints.  Assuming the condyles are being held down and forward by a tense lateral pterygoid, “walking” the patient back or trying to deprogram the patient may work.  I have heard, from Dr. Cranham I think, that if a lateral pterygoid is active over a long period of time, the muscle can actually undergo irreversible changes.  In this case, I don’t think stretching or deprogramming will be successful.

    Another situation I’ve heard about (again, from Cranham) is that as the condyle is held down and forward, the retrodiscal space becomes permanently filled with blood and tissue which will eventually become fibrotic.  When this happens, the condyle will never return to it’s original CR position.

    I know John has patients like this in his practice.  He is questioning how stable these situations can be over time.  If there is long-term stability in the changed condylar position, you could restore the posterior teeth back into contact.

    I think having Cranham chime in on this wold be best……

    #21115

    Ari Forgosh
    Participant

    Thanks Matt. I think we will see this more and more as people are making these appliances without monitoring the occlusion. I have another patient with a similar situation, except he is perfectly content and unaware of the open bite (until I pointed it out to him). In that case we discontinued the appliance and are waiting to see if things return to normal.

    I agree with you that senior faculty might have some good insight to share on this issue.

    #21713

    Kimberley Daxon
    Participant

    Hi Ari,

    I just finished restoring a patient who had significant bite changes post TAP appliance (anterior contact only, end to end, and bilateral posterior open bite).   I was fortunate to obtain pre-TAP photos and models of this patient for comparison.   As part of his diagnostic work up, we obtained MRI imaging and confirmed condyle/disk assembly was intact.  CR was verified.   I referred him to the orthodontist and it was determined that patient had segmental movement of the teeth – retraction of max anterior teeth and forward movement of lower anterior teeth.   Contacts opened posteriorly on the mandible.     This orthodontist also treats airway issues and evaluated the TAP appliance and determined it was not fitting properly – concluded that the misfit moved the teeth over time.   Patient went thru ortho, we restored his anterior teeth and some posteriors to obtain adequate centric stops and fabricated a NG.  I can send you photos if you’d like.   So I guess the point of my story is, in addition to TMJ and muscle limitations, we need to consider actual movement of the teeth and remodeling of the aveolar structures if these appliances are not adequately fitted or maintained properly.   Kim Daxon

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