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A Joint Exam

Part 3 - Cotton roll test and anterior deprogrammer

Lee Ann Brady, DMD
Dr. Brady discusses and demonstrates the use of a roll test and an anterior deprogrammer.

So what we're going to do is, in office, we can try a few things to actually release her lateral pterygoid. First one is we're going to try a cotton roll test. And so what I'm going to do is Crystal is going to give me two cotton rolls. These cotton rolls are going to go on Katie's most distal tooth in her case that's the second molar. Go ahead and open really wide and bite together. And now I'm going to ask Katie to clench and release as hard as she can five times. And open. And as soon as she's finished we're going to redo the load test. So I'm going to put my leaf gauge back in with the same number of leaves. And bite together Ms. Katie and go forward and back. And I want you to lightly squeeze for me and we're going to have our hold and see whether or not that discomfort has gone away. How does that feel Katie? It feels better but I still notice it more than the left side. Got you. So we've released them some because it feels better. So maybe where she said a 2 before now it would be a 1. But she's still cognizant that it feels different than the left side. By the way a positive load test isn't always a response of pain or tenderness. Very often what patients will tell you is that it feels tight or they felt tension or even sometimes they say they feel a little burning sensation as that muscle is letting go. Some of the same things we feel when our other muscles are sore after working out. So the cotton roll test didn't release it completely but it helping.
Now what does that tell me? A it's more evidence that this is lateral pterygoid because the cotton roll test really would have no impact if she was pinching retrodiscal tissues. But I also want to see if I can get it also release. If I wanted to get bite records today I'd love to be able to get a completely negative load test. So the next thing I'm going to try is I'm going to actually make Katie an anterior deprogrammer. And we're going to allow her to rest on that for about 10 or 15 minutes so that we could then come back and do the load test. Now at this point if your schedule is such that you don't have 10 or 15 minutes to wait and then come back and repeat the load test this is the place where it'd be totally appropriate to make patient an anterior bite plate appliance given the rest of the exam all fits that diagnostic use of that appliance and send her home and let her sleep with that for a week or two, bring her back in so that we could then get those records. But given the time in my office if my schedule allows and I could get those records Lucia jig is a great next diagnostic test and a way to see if we could get those muscles to release. What we're going to do is we're going start out with just an anterior deprogrammer. People called them Lucia jig. You can get them in a lot of different places. So this particular Lucia jig comes from the bookstore at the Pankey Institute. We also have some from Great Lakes Orthodontics. Crystal, do you still have that one out? We'll get one so that we can show you the difference. But basically all anterior deprogrammers and all Lucia jigs are design to do the same thing the leaf gauge did. It's design to create only anterior tooth contact. No posterior tooth contact. Why do we do that? Because it's the PDL the proprioceptors reception of the posterior teeth sending the message to Katie's brain having her muscles, her positional muscles and elevator muscles fire without that message from her back teeth those muscles will release over time. Sometimes 10 or 15 minutes is enough. Other times it takes an anterior bite plate. So just to show, just the variety. Now this is a Lucia jig or anterior deprogrammer that you can get from Great Lakes Orthodontics. The concept is the same. It's a piece of preformed plastic but then we're going to customize using bite registration paste. So the trick is to have this over Katie's teeth and what I want to make sure I'm doing is I want to make sure that in an AP direction that it's a flat plane. I don't want to form this and have it tip so that it's tipping up toward the lingual because now I've created a ramp. So I needed to make sure that it stays completely flat. How we're going to do this is I'm just going to use bite registration paste material. I'm just going to fill the center portion of the Lucia jig and you want to not over fill it. I'm going to seat it partially on Katie's teeth so I didn't push it all the way up. I'm going to hold it on the labial and ask Katie to bite. So she's going to seat it but she can't tip it to create that ramp in an AP direction because I've got my finger firmly on the labial plastic of the Lucia jig so that I'm making sure it's a nice flat plane. Other ways you can do this, I've seen people do this with a tongue depressor. So they actually place the wooden blade across the plane of the Lucia jig and have the patient bite into it to keep it flat. You can also; Great Lakes Orthodontics makes a tool called the whale tail so you can actually keep it flat with a whale tail. Once I got this in place and it usually depends on your bite registration paste, we just use Flexitime by Heraeus. It takes about 45 seconds to set completely. So now I can take my finger off. You need to know with your bite registration paste cause any will work for this purpose, how long it takes to set. You don't want to take your finger off the labial until it's fully set. And now we can see, Katie I'm just going to hold your lips out of the way for the camera, so now we can see we have a Lucia jig. Okay. And it's flat in an AP direction. Now Katie happens to have very flat, very even lower incisors. So I know that when she goes in a protrusive right and left she'll have a nice flat plane to guide it on. If I have somebody that had maybe one really tall incisor I might want to adjust this with a hand piece. The next part of this is just to give Katie some instruction and then to leave with her be with a magazine or a movie or something in the office for 10 or 15 minutes. And I usually do that and I actually leave the room because I'll never wait the 10 minutes or the 15 minutes if I'm sitting with the patient cause I get anxious. So the directions for the patients are she doesn't have to keep her teeth against the Lucia jig. The design is to keep her teeth apart in the back so she can let her jaw lap loose or she can touch the plastic platform whatever she wants to do. That if at any point while Crystal and I are out of the room, she starts to feel discomfort in front of her ear she is to reach up with fingers and pull the device out of her mouth and that's great diagnostic information that we'll be able to use when we come back into the room. And that we're going to come back in about 10 or 15 minutes and we'll actually going to see if this device is going to work. Okay. So Katie the deprogrammer has been in for about 15 minutes now. How are you feeling? A lot better. Okay so a lot better. You're not feeling anything over here at the moment or do you still feel some tenderness over there? It feels a little bit different than the left side but is completely no tenderness there. Okay. So when you say it's different, how would you describe it? I notice it on the right side, the left side I don't notice. Okay. So we spend about 15 minutes with Katie on the anterior deprogrammer and it's definitely made an improvement. But she can tell a difference between the right and left side. Let's go ahead and now what we would do is we will repeat our load test. I can tell you honestly that if Katie is still reporting it feels a little bit different, I don't know if I would repeat the load test at this point. I would be thinking about getting impressions so I could get an anterior bite plate. It's a quick and easy appliance to make for this exact purpose releasing muscles and seating condyles. We actually do have a companion video here on HDiQ on fabricating an anterior bite plate appliance on Katie that you all can watch. For the sake of the exam if I had walked in and Katie said, nope, it feels great. Nothing is bothering me. Just feeling great on the deprogrammer isn't the final pass to being able to do those bite records or knowing that that muscles has released. We would want to repeat the load test. So we would simply, open Katie for me, take out the anterior deprogrammer. Put our leaf gauge back in. Have her bite, go forward and back lightly squeeze and now again give us a report. Now I already know Katie is going to tell me that she still feels some tenderness here because she did even with the anterior deprogrammer in. Thank you, Katie. We don't want to make you seat on that. So what would you expect to find by doing this particular task. If Katie still has some discomfort. Let's say it hadn't change at all. It hadn't lessened at all. It was the same from the vey first load test to the very end, I still have no idea. Is that coming from the lateral pterygoid muscle or is it coming from the condyle-disc assembly. I might have some suspicion by putting together the rest of my muscle and my joint exam but I would definitely want to get Katie into an appliance so that we can get to the bottom of that diagnostically. In Katie's situation where it was getting better, the cotton rolls release it a little bit then the anterior deprogrammer release a little bit. Really where my head is going is this is muscular to my lateral pterygoid but I can't take centric relation bite records yet until she tells me she doesn't feels anything. It feels identical. So we might make her an anterior bite plate. In my case I would definitely make her an anterior bite plate if I needed those diagnostic models mounted in centric relation. What about the patient who it actually gets worst and not better on an anterior deprogrammer? If you classically see a positive load test then you'd see no change from the cotton rolls and then the anterior deprogrammer. You might come back in and the patient has actually taken it out of their mouth or they're actually telling that it actually feels more uncomfortable that now it is aching and just sort of hurting in front of their ear. Now I still don't know. It could be a lateral pterygoid. I have had a number of patients who have a lateral pterygoid that are so chronically contracted that when you try to seat them with a [rapidity] that comes from leaf gauge or an anterior deprogrammer or any anterior only appliance that lateral pterygoid really resist and go into spasm. It can be very uncomfortable. It also could be at that point that it is retrodiscal tissue being pinged. So how would I move forward? I would move forward in that situation by making the patient an appliance but I would make them a full coverage appliance and I would actually try to gradually walk them back from intercuspal position into a seated condylar position so that if it's a lateral pterygoid muscle we give it time to release and if it's a retrodiscal tissue we'll know that were pinching, we're getting some discomfort and then we may have to switch appliance design. So that's my information for load test. Why is that important from the standpoint of restorative dentistry? It's really important because there are a lot of things we see every day in our dentistry where we're doing dentistry and people have more than one bite or it looks like they only have one occlusion and you prep a second molar and suddenly things are totally different. Understanding the condition of that lateral pterygoid muscle is critical in predictability in restorative dentistry.