I once took a course on airway management, during which, there was a lot of discussion about mandibular position and interdental vertical relation. “As vertical dimension between the arches is lost”, lectured the presenter,” the mandible over-closes and the condyle positions too far posterior and superior in the Temporal fossa close to the ear”.
He demonstrated this with what he called the “Pinky-Test”. He picked one of the attendees who he determined had a loss of vertical and, when asked, she has suffered from some TMJ-disorder (joint pain, clicking, limited opening and headaches). He had the young lady sit in a straight chair, teeth slightly apart. He put his pinkies into each ear and pressed forward. He asked the “patient” to close onto her back teeth and as she did, the condyles pressed into his pinkies and she felt pain. Then he asked her to bite onto her anterior teeth, onto the incisal edges, and slide back 1 mm so there was a 1 mm overjet and 1 mm overbite. She felt no pain but of course her posterior teeth did not touch.
His point was that if she had her teeth restored or orthodontically moved into this position, with the midlines aligned, she would not experience her TMJ-D symptoms.
DJ is a 35-year-old female patient suffering from chronic bilateral TMJ pain, clicking, headaches, ear pain and limited opening, which, when she opens, deviates to her right. She has a 6 mm overjet and a 4 mm overbite with a midline shift to her right. And, a positive Pinkie test.
Figure 1: Pre-treatment photo illustrating mandibular overbite and overjet
She was fitted with a Whole You Respire mandibular hard acrylic Bionator with an anatomic occlusal surface to create a positive seat when she closed. The Bionator was constructed so that when she was in occlusion, it would guide her into a 1 mm overjet and overbite with the midlines aligned. DR was instructed to wear this appliance 4 – 6 hours during the day. When she wears it, she has to place her Maxillary teeth gently into the occlusal surface.
Figure 2: Whole You Respire mandibular hard acrylic bionator with an anatomic occlusal surface
DR wore her Bionator appliance as instructed and within one week, the symptoms of her chief complaint we alleviated. DR is retuning for follow up care. After several month of wearing the Bionator, a long-term treatment plan will be determined.
Figure 3: Anterior view while wearing bionator
Figure 4: Alternate view of patient wearing bionator