| Common
oversights when using the N.T.I.-tss
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| Posterior Inteferences in Excursive | |||
| DON'T MISS>>> Interpreting Patient's Responses and Effects of NTI-tss Therapy (click here) | |||
| If upon initial closure, the two lower centrals do not contact the DE simultaneously (first photo), the patient will exert an unconscious effort to "equilibrate" the forces (second photo), by shifting their jaw upon initial contact. Either the teeth (last photo) or the DE should be altered to allow forequivalent forces on both centrals upon initial contact. |
| In the
event the patient
habitually clenches in an excursive position (usually evidenced by
obvious
wear facets on the canine cusp tips), they may clench with a lower
canine
tooth on the DE of the maxillary NTI-tss (a). If
so (and this is determined after the patient presents with
"new"
symptoms after a week or so of use), using either a Standard
(pictured) or Universal NTI-tss on the mandibular incisors usually
avoids
contact with the maxillary canine
(b)
(This is quite rare. Just because a patient *can* clench their canine on the DE, doesn't mean that they do or will. Reproducing their discomfort by having them clench their canine on the DE is a good diagnostic method to determine if their new symptoms are from excursive clenching.) |
| By creating too much vertical opening with the NTI-tss (c), the condyle may experience significant translation during excursive movement, thereby exposing it to excess strain. The patient with "too much vertical" reports discomfort when clenching excursively with the NTI-tss in place, but is not uncomfortable when clenching in centric.The requirement to suppress muscular intensity is lack of canine and posterior contact, and the requirement for minimal joint strain is minimal (if any) translation. Therefore, for the patient who may be clenching in an excursive position, the DE should always be modified to provide only enough vertical opening to keep the canine teeth discluded when in excursive position (~1mm) (d). IMPORTANT EXCEPTION |
"Getting
in front of (or behind) the bump"
e) 
f)
g)
g)If the patient can get their lower incisors back to the "heal" of the
DE, extend the DE a couple of millimeters.
| If the lower incisors can "get in front of the bump" (e), and it hurts when the patient demonstrates this, the chances are that the patient does this while sleeping, causing neck, face and joint discomfort (typically, the patient will deny they would ever do such a thing).. The DE is extended accordingly (f). Likewise, if the patient is able to "get behind the bump", or occlude on the distal line angle (g), clenching forces will be directed in a superior-anterior direction, thereby perpetuating facial and neck symptoms. Extend the DE with acrylic as necessary. *To confirm that the patient may be "getting in front/behind the bump", paint one coat of fingernail polish on the occluding surface of the DE. After one to three nights, the opposing incisors will have scraped away the polish, providing a "tracing" of movement. |
Insight on DE
orientation
upon initial delivery
Excessive
vertical opening upon protrusion
(see also:
Don't
make this Goof-up)
h)
i)
| In the event the patient's parafunctional activity allows them to "get in front" of the DE, the DE must be extended to accomodate (as in "f" above). The DE must be extended as far as necessary. However, the extended DE must not increase the vertical opening as the mandible protrudes (an in "h" above). Doing so strains the joint, and syptoms will persist, or new symptoms will develope. Modify the DE to keep vertical opening to a minimum during protrusion (as in "i" above). Making this modification (from "h" to"i") on a patient with joint symptoms will usually provide immediate relief. |
| Not enough vertical. When treatment is intended to prevent migraine pain, there may be an occasion where little improvement is reported by the patient after two weeks. When all oversights are ruled out, increasing the vertical dimension by adding to the DE can be beneficial. Without the habitual excursive movements (that migraineurs commonly lack, because they're too busy clenching in centric), increasing vertical dimension is less risky, and may create an environment where the temporalis contraction intensity is less efficient, thereby initiating relief to the patient. See: Decreasing clenching intensity by increasing vertical. |
b)
d)