By Dr. Mark Corn, DDS

Our patient, True, found sedation helped her relax during her rehabilitation appointments. In the following article, the treatment sequence and the use of sedation to give maximum comfort during treatment is examined.

Certified TMJ assistant: Patty Hoover, CTA

Master of Dental Ceramist: Dylan Joe, MDC

Thanks to the skills and experience of our new executive director, Patty Hoover, our office recently opened a TMJ/Sleep Department. Now, we’re able to screen our patients more effectively and transfer our patients to be treated in-house. Patients with TMD and those undergoing comprehensive treatment receive a thorough TMJ exam. 

Patient Assessment

Our patient, True, presented with TMD symptoms that she experienced for years. True was waking up daily with bilateral jaw pain, neck, and generalized head pain. She was also waking up clenching every night, and her range of motion readings indicated 52mm interincisal opening with somewhat limited lateral excursion. Noted was an early bilateral click that was worse in the right joint.

Palpation indicated mild tenderness of both anterior, middle, and posterior temporalis. Moderate tenderness right side deep and superficial masseters along with trapezius, sternocleidomastoid, and stylomandibular ligament. Severe tenderness when palpating deep and superficial masseters on the left and lateral pterygoid bilaterally. True presented with cl2, div1 dental relationship, wear facets, and bruxism were revealed upon examination. In addition, she presented with facial asymmetry, a heavy overbite, and a scalloped tongue. True also reported she snores.

Treatment

We directed treatment toward improving myalgia, jaw posture, reducing adverse joint loading, patient education, and reducing inflammation and pain. Therefore, we began treatment with orthopedic realignment of the mandible with a daytime mandibular orthopedic repositioning device and a nighttime therapeutic night guard to reduce the muscle tension caused by clenching. After approximately 60 days of therapy, True was asymptomatic with her initial chief complaints including the internal derangement she was experiencing. 

The TMJ scale was included as part of her diagnostic records. TMJ compare was used at the end of phase 1 of TMD treatment. All areas showed a significant percentage of improvement from pain report to joint dysfunction.

After her jaws were comfortable, it was time to devise a treatment plan for either continued removable splint therapy, or an investment in porcelain crowns. At her follow-up consult, True was given options for maintaining her new joint position and occlusion. She chose a fixed crown and bridge treatment plan for a more long-term, comfortable, and predictable bite.

A review of True’s oral health revealed healthy periodontal tissues, multiple units of existing crowns showing recession, and porcelain wear. Several years prior, she had a smile makeover with new veneers and a crown lengthening procedure. True decided to include the anterior teeth in her treatment plan for a more consistent color match, with a lighter shade of porcelain.

The new treatment plan would remove all the existing crowns both posteriorly and anteriorly, replacing those with new Zirconia crowns throughout. Choice lab in St. Joe Michigan was chosen to develop and engineer the crowns, and they mounted the prepped maxillary on a semi adjustable articulator using Multi-layered Zirconia. The porcelain was finished using the MiYO technique, which applies porcelain in super fine increments.

Sedation Use

True was then introduced to our sedation program, which included oral medications. She desired to be most comfortable for these lengthy procedures. Her medical history was evaluated, and it was determined that her ASA classification was II. At age 51, True weighed 182 pounds, and her Mallampatti tongue classification was II. All of her medications were cross referenced with our selected oral sedation medications. These medications were Valacyclavir, Neuro 5 HTTP forte, and she reported latex allergies. Baseline BP recorded as 139/71, pulse 60, and oxygen saturation of 96% (SaO2).

Because there were no drug interactions to any oral sedation medications, incremental protocol #1 was chosen for treatment sedation, and we used triazolam 0.25mg and diazepam 10mg. True was instructed to take the diazepam at bedtime and the triazolam one hour before the appointment. All consent form and review papers were discussed and signed by the patient. These included oral sedation consent, driver companion forms, after sedation instructions, a sedation appointment checklist, and pre-appointment instructions. True’s husband drove her to our office and was responsible for post-op care at home. Intraoperatively, True was analyzed for her level of sedation by checking her speech patterns and observing the opening and closing patterns of her eyelids. From that, it was prudent to administer another 0.25mg of triazolam sublingual, and 1-hour nitrous was introduced at 30%. After the anesthetic was administered, the nitrous was discontinued.

During this five hour procedure another dose of triazolam 0.25mg was administered two hours after the first dose, and True was calm and responsive through the treatment. At dismissal, she was asked questions to assess her level of awareness and the post-procedure treatment instruction were reviewed with her driver.

In Conclusion

Full arch treatments were completed under oral sedation without complications. True was happy to report no more TMJ pain and her bite is stable. She continues to wear the Bryan Ramp therapeutic night guard to protect her damaging parafunctional habits.

Author: Mark Corn, DDS and his friendly team are committed to helping you receive the personalized sedation dentistry care you need. At Mark A. Corn, D.D.S, our staff is trained in the latest techniques.

The information contained in this, or any case study post in Incisor, should never be considered a proper replacement for necessary training and/or education regarding adult oral conscious sedation. Regulations regarding sedation vary by state. This is an educational and informational piece. DOCS Education accepts no liability whatsoever for any damages resulting from any direct or indirect recipient's use of or failure to use any of the information contained herein. DOCS Education would be happy to answer any questions or concerns mailed to us at 3250 Airport Way S, Suite 701 | Seattle, WA 98134. Please print a copy of this posting and include it with your question or request.
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