I had the great fortune to be invited as a guest to one of the most exclusive study clubs in the country last week. Hosted by Drs. Jim McKee and Mark Piper, DMD, MD, it’s a group focused on treatment planning with an emphasis on joint based occlusion; in their words, they start with the position and condition of the joints. While it may seem excessive to only sit in on their case planning sessions, you quickly realize how many of these unstable joint cases are out there and how many are being missed every day. While the topics discussed were varied, two in particular were of extra interest to me. The “growth disturbance” implications for kids with repetitive use type injuries from soccer, football, gymnastics, etc. and the effects on the facial/skeletal development were scary. Seeing case after case of kids with severely displaced discs as teen and even preteens, and the resulting facial asymmetry (and in some instances even deformities) was really frustrating. How many of those cases could have been corrected or possibly prevented with better information to the parents?
The other topic I found especially timely was on sleep apnea and the effects down and forward sleep appliances are having on the joints. Apparently for some, perhaps with already partially displaced discs, the sleep appliance is just enough down and forward repositioning to create instability in the joint. Patients end up not being able to get their teeth together due to shortening of the lateral pterygoid. The whole discussion of the airway problem, sleep apnea, and treatment options was extremely informative. Dr. Piper is treating such cases with splints – opening the bite approximately 15mm, but till in CR, not down and forward. He feels the results are as good or better in treatment of the apnea, but without the potential risk of creating joint instability. We will try some of this as an option too. To Mark’s point, we have had many calls here to the lab for cases where the patient was wearing the traditional down and forward appliance, only to end up unable to get their back teeth together when they take it out.
Most of the two days was spent reviewing treatment plans for real cases brought in by the study club members. The workups were very impressive with thorough case histories, mounted casts in CR, complete photo series, MRIs, and detailed treatment plans. I was shocked to hear case after case of Piper 4A and 4B joints, they referred to it as 11:00 joints, relating to the position of the posterior band over the head of the condoyle. I know there are a lot of these cases out there but they are generally the most unstable joints and therefore the most difficult to treat so it was challenging to work through one after another and then another. No easy veneer cases, no easy implant cases, just people that were in chronic pain and needed help.
Something new Mark and Jim were using that I found really helpful was a different articulator from Great Lakes called a Sam MPV (Mandibular Position Variator), which allowed us to dial in vertical and horizontal changes of the condylar elements to evaluate the change in arch relationship on the teeth. It was an extremely valuable tool in assessing future occlusal changes in anticipation of changes in the joints.
The other impressive tool they utilized is a new software program Mark is developing for diagnostics and patient education called Anomalous Medical. It is not for sell yet, but when it is, it will be a most interesting tool in illustrating what’s going on between the joints and the teeth. More on this as it becomes available.
On a final note, I was really encouraged to hear Mark continues to have a very high success rate with the “fat grafts” as joint repairs. He has been doing these for almost 20 years now and still nothing better has come along.
The doctors in the study group were very warm and engaging, including me in the discussions as one of their own. I appreciated it greatly and had a terrific time throughout the two days.