(The forward bite is protected by US Patent D759,824)
This treatment is FDA cleared under K160477
Sleep bruxism is not the same as awake bruxism. The World Health Organization, in their 2015 release, classify awake bruxism as psychogenic and sleep bruxism as neurogentic as follows: (click to enlarge)
This places awake bruxism and sleep bruxism in to two and very different disease categories requiring different diagnostic testing and different treatments. Sleep related bruxism adversely affects the trigeminal cardiac reflex by increasing heart rate and blood pressure and is classified as a risk factor for heart disease.
There are a few considerations when treating sleep bruxism (SB):
- These patients usually present with jaw muscle pain, restrictions in mandibular mobility and often, TMJ pain or transitional TMJ locking.
- Research has shown and we have confirmed in our own research that a starting position of 75% advancement is the most effective starting point for SB. (See Section on Bite Registrations Here). This is a very comfortable position for these patients.
- Once they patient has been in treatment for a few weeks, their muscles with start to relax. This increases the mandibular range of motion and they will no longer be at 75% advancement due to muscle relaxation and muscles stretching, allowing the mandible to move more than before.
- Recall them every 7 days and re-measure their range of motion with special attention to protrusion. If the protrusive measurement increases, you will need to re-set the appliance position to the new 75% to maintain your treatment goal of 75%.
- A recent study found that a 50% advancement is ideal for the treatment of mild to moderate sleep apnea however a 75% advancement is ideal for severe sleep apnea. When a patient has sleep apnea and secondary sleep-related bruxism, regardless of the degree of sleep apnea, a 75% advancement is recommended. If not, the sleep-related bruxism will not be adequately treated and the patient will not tolerate the appliance well.
- How much to open the patient vertically? Deep overbites, when in protrusion, create ample space for the device with only a 2 mm opening. Patients with minimal overbites often require 3-4mm of opening to create enough space. Always keep the opening vertical as small as practical to encourage a proper lip seal. Patients with deep overbites require less opening, 2-3mm. Keep in mind, clearances is needed to allow the forward bite to work and posterior regions to be disclosed.
- Always inform your patients with sleep related bruxism that it is a life-long neurological condition and, if they discontinue treatment, they can expect the symptoms to rapidly return. We have confirmed this clinically on patients who have been comfortably treated for many years and interrupt their treatment. Fortunately, resuming the treatment almost always provides relief again.
- If the patient is taking an SSRI or SSNRI type medication (antidepressant), the sleep-related bruxism will be resistant and take longer to fully treat. This should be addressed i your informed consent.
The same records are needed as for an OSA appliance: casts/digital scans and a protrusive bite (at 75%).
Since sleep bruxism is a life long condition, you will need to follow up these patients on a regular basis. Ideally they should be seen every 6 months, to ensure compliance and check the appliance is fitting correctly. Always re-measure and record the patients range of motion and check their muscles (especially the lateral pterygoids).
Lateral Pterygoid Muscle:
- If an SB patient presents with unilateral jaw pain (muscle) this is a clear indication that the wings are not contacting evenly or they are biting harder on the sore side. Palpate the lateral pterygoid muscles and you will find that this muscle will be quite painful on the jaw pain side. The lateral pterygoid’s function is to advance the mandible forward and contralaterally. To palpate, ask the patient to open half way. Then slide your little finger upward behind the tuberocity. This will reach the region of the upper medial pterygoid and main body of the lower lateral pterygoid (and the ligament of the anterior temporalis). Gently press up and record your findings. Since the lateral pterygoid muscle is one of the few muscles involved in protrusion of the mandible, it is the best muscle to test for discomfort and is easy to access clinically. When a side is not contacting fully, the lateral pterygoid will be hyperactive, attempting to pul the side forward into equal contact.
The bite must be even on the two forward pads. Using bite paper, record the contact points and ask the patient how it feels. I find that doubling or tripling the paper gets a better result by marking
- These patients benefit from a home exercise program of jaw and neck stretches (click here for exercises).
- Once ideally adjusted and comfortable, this appliance does not need much adjustment for years.
- Caution your patients that SB is a lifelong neurological disorder. If they stop treatment, the symptoms will rapidly return.
- Always re-measure the range of motion and reset the device to 75% if the protrusion changes!!!
- A home exercise program is essential for sleep bruxism patients (and OSA /sleep bruxism patients). the following link has some useful exercises: