U.S. patent application number 10/943396 was filed with the patent office on 2005-02-24 for method and device for treatment of temporomandibular dysfunction syndrome and facial/dental deformities.
Invention is credited to Mauro, Joseph V..
Application Number | 20050039759 10/943396 |
Document ID | / |
Family ID | 29399388 |
Filed Date | 2005-02-24 |
United States Patent
Application |
20050039759 |
Kind Code |
A1 |
Mauro, Joseph V. |
February 24, 2005 |
Method and device for treatment of temporomandibular dysfunction
syndrome and facial/dental deformities
Abstract
A method for treating maxilla/cranial base to mandibular axis
discrepancies in the temporomandibular joints (TMJs) of a patient
such as caused by mandibular, temporomandibular dysfunction
syndrome (MTDS) or developmental facial/dental deformities without
performing open jaw joint surgery. The method includes (1)
repositioning the patient's mandible into a stable relationship
with the cranial base using a craniomandibular orthopedic
repositioning orthotic which over time deprograms the patient's jaw
into the stable mandible to cranial base relationship; (2)
constructing a model of the patient's mouth on a jaw joint
simulator which replicates the patient's jaw joint true hinge axis
of rotation in the repositioned and stabilized mandible to cranial
base relationship; (3) planning on the model a surgical procedure
comprising total maxillary osteotomy which substantially treats the
MTDS or developmental facial/dental deformities; and (4) performing
the surgical procedure to treat the discrepancies.
Inventors: |
Mauro, Joseph V.; (East
Lansing, MI) |
Correspondence
Address: |
MCLEOD & MOYNE, P.C.
2190 COMMONS PARKWAY
OKEMOS
MI
48864
US
|
Family ID: |
29399388 |
Appl. No.: |
10/943396 |
Filed: |
September 17, 2004 |
Related U.S. Patent Documents
|
|
|
|
|
|
Application
Number |
Filing Date |
Patent Number |
|
|
10943396 |
Sep 17, 2004 |
|
|
|
10140093 |
May 7, 2002 |
|
|
|
6792952 |
|
|
|
|
Current U.S.
Class: |
128/859 |
Current CPC
Class: |
A61B 90/16 20160201;
A61C 11/00 20130101; A61F 5/05891 20130101; A61C 11/085 20130101;
A61C 7/08 20130101; A61C 11/02 20130101 |
Class at
Publication: |
128/859 |
International
Class: |
A61C 005/14 |
Claims
1 to 7. (Cancelled)
8- An orthotic for stabilizing the condylar positions in the
temporomandibular joints of a patient with temporomandibular
dysfunction syndrome comprising a base portion with an upper and a
lower surface, an anterior and posterior surface, and having a
generally U-shaped plan form and including opposite integrally
formed side arms adapted for location between the orthotic and
mandibular teeth of the patient, the base having an inner flange
along its trailing edge and an outer flange along its leading edge
wherein the inner flange and outer flange extend upward from the
base so as to form a channel for accepting the maxillary teeth of
the patient wherein the bottom surfaces of the maxillary teeth are
in contact with the surface of the channel, and wherein the width
of the channel is adapted to the width of the maxillary teeth of
the patient, and wherein the base has a vertical thickness
sufficient that when the maxillary teeth are engaged in the
orthotic there is complete disclusion of the posterior maxillary
and mandibular teeth during eccentric jaw movements, and wherein
the thickness of the base in the position where the anterior
maxillary teeth are engaged defines a downwardly extending ramp
with anterior and posterior surfaces of sufficient thickness to
allow the superior surface of the central and lateral incisors to
glide freely along the posterior surface of the ramp to simulate
the guidance of normal central and lateral incisors against the
lingual surface of normal anterior maxillary teeth in a condition
of no wear and normal vertical anatomy and to provide anterior
guidance of the patient's mandible in excursive movements by
contact of the superior surface of the central and lateral incisors
with the posterior surface of the ramp so as place the posterior
maxillary and mandibular teeth out of contact.
9- An orthotic for maintaining the mandible to maxilla/cranial base
alignment and stability in the temporomandibular joints of a
patient during or following a surgery which verifies stable
condylar position in the temporomandibular joints of the patient
comprising a base portion having a generally U-shaped plan form and
including opposite integrally formed side arms adapted for location
between the maxillary and mandibular teeth of the patient, the base
having an inner flange along its trailing edge and an outer flange
along its leading edge and extending upward and downward from the
base so as to form an upper channel for accepting the maxillary
teeth and a lower channel for accepting the mandibular teeth of the
patient and which when fitted to the patient's teeth maintains the
mandible to maxilla/cranial base alignment and stability in the
temporomandibular joints of the patient.
10- An apparatus for planning a surgical method for treating the
cranial base to mandibular axis discrepancies in a patient
comprising an artificial jaw simulator including an upper member
with a downwardly facing surface and having a pair of spaced
sockets at one end, which represent the sockets of the patient's
glenoid fossae, pivotally mounted on a pair of spaced spherical
styluses, which represent the simulated horizontal or hinge axis of
the patient's condyles, on a frame vertically mounted on one end of
a lower member with an upwardly facing surface, and a model of an
upper dental arch of the patient with a base, which is parallel on
all sides to the upper dental arch model and is delineated with
horizontal and vertical reference lines, mounted with a separating
media to a mounting stone mounted on an upper plate which is
mounted to the downwardly facing surface of the upper member of the
artificial jaw simulator, and a model of a lower dental arch of the
patient mounted on a mounting stone, which is parallel on all sides
to the lower dental arch model and is delineated with horizontal
and vertical reference lines, mounted using a settable material on
a lower plate which is mounted to the upwardly facing surface of
the lower member of the artificial jaw simulator, wherein the
relative motion between the upper and lower plates with the models
mounted thereon is the same as the relative motion between the
patient's upper and lower jaws, and wherein the true axis of
rotation of the temporomandibular joints of the patient have been
maintained.
Description
CROSS-REFERENCE TO RELATED APPLICATION
[0001] Not applicable.
STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH OR DEVELOPMENT
[0002] Not applicable.
REFERENCE TO A "COMPUTER LISTING APPENDIX SUBMITTED ON A COMPACT
DISC"
[0003] Not applicable.
BACKGROUND OF THE INVENTION
[0004] (1) Field of the Invention
[0005] The present invention relates to a method for treating
maxilla/cranial base to mandibular axis discrepancies in the
temporomandibular joints (TMJs) of a patient such as is caused by
mandibular, temporomandibular dysfunction syndrome (MTDS) or
developmental facial/dental deformities without performing open jaw
joint surgery. The method includes (1) repositioning the patient's
mandible into a stable relationship with the cranial base using a
craniomandibular orthopedic repositioning orthotic which over time
deprograms the patient's jaw into the stable mandible to cranial
base relationship; (2) constructing a model of the patient's mouth
on an artificial jaw simulator which replicates the patient's jaw
joint true hinge axis of rotation in the repositioned and
stabilized mandible to cranial base relationship; (3) planning a
surgical procedure comprising total maxillary osteotomy on the
model which substantially treats the MTDS or developmental
facial/dental deformities; and (4) performing the surgical
procedure on the patient based on the surgical procedure planned on
the model to treat the discrepancies.
[0006] (2) Description of Related Art
[0007] The surgical treatment of mandibular, temporomandibular
dysfunction syndrome (MTDS) or developmental facial/dental
deformities traditionally has centered on surgical manipulation of
the jaw joint structural components: disc, ligaments, and tendons
using open arthrotomy, arthroscopy, or partial or total jaw joint
replacement. The fundamentals of oral and maxillofacial surgical
procedures are standard and have been described in many texts on
surgical techniques. For example, see Atlas of Oral and
Maxillofacial Surgery (Keith ed., W.B. Saunders Company,
Philadelphia, (1992) pp. 201-216). In general, these surgical
procedures are performed with the jaw joints in an acquired bite or
position of maximum intercuspation of the teeth without reference
to the relationship of each mandibular condyle to its socket of the
glenoid fossa and without any attempt to place each mandibular
condyle in any stable, verifiable, and reproducible position in its
socket of the glenoid fossa. Furthermore, the surgical procedures
for treating MTDS or developmental facial/dental deformities are
not generally planned on a model of the patient's jaw joint in
which the model has replicated the patient's true hinge axis of
rotation in the stable condylar position. Because the mandible
condyles are not stably positioned within their sockets, the
mandible to cranial base relationship remains unstable. Therefore,
following a standard surgery for treating MTDS or developmental
facial/dental deformities, the unstable relationship between the
mandible and cranial base over time tends to develop into MTDS. As
long as the relationship between the mandible and cranial base
remains unaddressed in the standard surgical treatments for MTDS or
developmental facial/dental deformities, the unstable relationship
will remain and most likely render the surgical treatment merely
temporary in effect.
[0008] Therefore, there is a need for a surgical method for
treating MTDS or developmental facial/dental deformities in a
patient wherein the method restores a functional bite to the
patient while maintaining the patient's jaw joint in its stable
condylar position. In particular, there is a need for a method
wherein the surgery to treat the MTDS or the developmental
facial/dental deformities is planned on a model which replicate's
the patient's true hinge axis of rotation in which the mandibular
condyles are in a stable condylar position.
SUMMARY OF THE INVENTION
[0009] The present invention provides a method for treating
maxilla/cranial base to mandibular axis discrepancies in the
temporomandibular joints (TMJs) of a patient such as is caused by
mandibular, temporomandibular dysfunction syndrome (MTDS) or
developmental facial/dental deformities without performing open jaw
joint surgery. The method includes (1) repositioning the patient's
mandible into a stable relationship with the cranial base using a
craniomandibular orthopedic repositioning orthotic which over time
deprograms the patient's jaw into the stable mandible to cranial
base relationship; (2) constructing a model of the patient's mouth
on an artificial jaw simulator which replicates the patient's jaw
joint true hinge axis of rotation in the repositioned and
stabilized mandible to cranial base relationship; (3) planning a
surgical procedure comprising total maxillary osteotomy on the
model which substantially treats the MTDS or developmental
facial/dental deformities; and (4) performing the surgical
procedure on the patient based on the surgical procedure planned on
the model to treat the discrepancies.
[0010] Therefore, the present invention provides a method for
treating maxilla/cranial base to mandibular axis discrepancies in
the temporomandibular joints of a patient comprising (a) fitting an
orthotic to the maxillary teeth of the patient so as to allow full
coverage of all the maxillary teeth, wherein the orthotic has an
anterior ramp to provide anterior guidance of the patient's
mandible in excursive movements by contact of the superior surface
of the anterior mandibular teeth of the patient with a posterior
surface of the anterior ramp of the orthotic so as to allow for
complete disclusion of the posterior mandibular teeth of the
patient from the orthotic during eccentric jaw movements which over
time deprograms the temporomandibular joints of the patient into a
stable condylar position by stabilizing the condyles in their
corresponding glenoid fossa sockets in the maxilla/cranial
base;
[0011] (b) determining alignment of the mandible to the
maxilla/cranial base in the temporomandibular joints of the patient
after each condyle has been stabilized in its corresponding glenoid
fossa socket by the orthotic;
[0012] (c) constructing a model of an upper dental arch of the
patient with a base, which is parallel on all sides to the upper
dental arch model and is delineated with horizontal and vertical
reference lines, and a model of a lower dental arch of the patient
with a base, which is parallel on all sides to the lower dental
arch model and is delineated with horizontal and vertical reference
lines;
[0013] (d) mounting the base of the upper dental arch to an upper
plate with mounting stone of an artificial jaw simulator and
mounting the base of the lower dental arch to a lower plate with
mounting stone of the artificial jaw simulator such that the true
axis of rotation of the temporomandibular joints of the patient
with the temporomandibular joints in the stable condylar position
has been maintained and wherein the sides of each base are parallel
and confluent to the artificial jaw simulator mounting plates;
[0014] (e) determining on the artificial jaw simulator mounted with
the upper and lower dental arch models an amount of maxillary bone
to be removed from the patient's maxilla in a surgical procedure
wherein the maxilla is cut along a transverse plane superior to the
maxillary teeth to separate the maxilla into an upper and a lower
part which is sufficient to allow a jaw position in the patient
when the upper and lower parts are joined after the amount of
maxillary bone has been removed wherein the maxillary and
mandibular teeth of the patient are re-approximated into a position
coincidental to the stabilized jaw joint position with a functional
bite wherein the anterior maxillary teeth provide anterior guidance
of the mandible in excursive movements by contact of the lingual
surface of the anterior maxillary teeth with the superior surface
of the mandibular anterior teeth while allowing complete disclusion
of the posterior maxillary and mandibular teeth during eccentric
jaw movements and which at the same time maintains the
temporomandibular joints in the stable condylar position;
[0015] (f) constructing a surgical stint of the functional bite in
which the temporomandibular joints are in the stable condylar
position to act as a guide for relating the maxilla to the mandible
during the surgical procedure for removing the amount of maxillary
bone from the patient determined in step (e);
[0016] (g) fitting the surgical stint into the mouth of the patient
and performing the surgical procedure for removing the amount of
maxillary bone from the patient's maxilla determined in step (e);
and
[0017] (h) immobilizing the patient's jaw following the surgical
procedure with the surgical stint fitted to the patient's teeth so
as to maintain the functional bite wherein the temporomandibular
joints are in the stable condylar position and fixating the
patient's mouth shut for a time sufficient for the upper and lower
parts of the maxilla to heal, which treats the cranial base to the
mandibular axis discrepancies in the temporomandibular joints.
[0018] In a further embodiment of the method, the surgical
procedure further includes an interim surgical procedure selected
from the group consisting of widening the patient's mandible,
widening the patient's maxilla, retruding the patient's mandible,
advancing the patient's mandible, retruding the patient's maxilla,
advancing the patient's maxilla, and combinations thereof and an
intermediate surgical stint is made to act as a guide for relating
the maxilla to the mandible during the interim surgical
procedure.
[0019] In a further embodiment of the above methods, the
temporomandibular joints of the patient are stabilized by
sequentially fitting orthotics to the patient's mouth wherein the
anterior ramp of each orthotic in the sequence has been
progressively elongated or wherein the orthotic is modified by
elongating the anterior ramp or reducing the thickness of the
orthotic covering the posterior maxillary teeth when needed to
maintain complete disclusion of the posterior maxillary and
mandibular teeth of the patient during eccentric jaw movements
during the period of time for deprogramming the temporomandibular
joints into the stable condylar position.
[0020] The present invention further provides a surgical method for
treating the cranial base to mandibular axis discrepancies in a
patient comprising:
[0021] (a) constructing a model of an upper dental arch of the
patient with a base, which is parallel on all sides to the upper
dental arch model and is delineated with horizontal and vertical
reference lines, and a model of a lower dental arch of the patient
with a base, which is parallel on all sides to the lower dental
arch model and is delineated with horizontal and vertical reference
lines;
[0022] (b) mounting the upper dental arch to an upper plate with
mounting stone of an artificial jaw simulator and mounting the
lower dental arch to a lower plate with mounting stone of the
artificial jaw simulator such that the true axis of rotation of the
temporomandibular joints of the patient with the temporomandibular
joints in the stable condylar position has been maintained and
wherein the sides of each base is parallel and confluent to the
artificial jaw simulator mounting stones;
[0023] (c) determining on the artificial jaw simulator mounted with
the upper and lower dental arch models an amount of maxillary bone
to be removed from the patient's maxilla in a surgical procedure
wherein the maxilla is cut along a transverse plane superior to the
maxillary dentition to separate the maxilla into an upper and a
lower part which is sufficient to allow a jaw position in the
patient when the upper and lower parts are joined after the amount
of maxillary bone has been removed wherein the dentition of the
patient is reapproximated into a functional bite wherein the
anterior maxillary teeth provide anterior guidance of the mandible
in excursive movements by contact of the lingual surface of the
anterior maxillary teeth with the superior surface of the central
and lateral incisors while allowing complete disclusion of the
posterior maxillary and mandibular teeth during eccentric jaw
movements and which at the same time maintains the
temporomandibular joints in the stable condylar position;
[0024] (d) constructing a surgical stint of the functional bite in
which the temporomandibular joints are in the stable condylar
position to act as a guide for relating the maxilla to the mandible
during the surgical procedure for removing the amount of maxillary
bone from the patient determined in step (c);
[0025] (e) fitting the surgical stint into the mouth of the patient
and performing the surgical procedure for removing the amount of
maxillary bone from the patient's maxilla determined in step (c);
and
[0026] (f) immobilizing the patient's jaw following the surgical
procedure with the surgical stint fitted to the patient's teeth so
as to maintain the functional bite wherein the temporomandibular
joints are in the stable condylar position and fixating the
patient's mouth shut for a time sufficient for the upper and lower
parts of the maxilla to heal, which treats the cranial base to the
mandibular axis discrepancies in the temporomandibular joints.
[0027] In a further embodiment of the method, the surgical
procedure further includes an interim surgical procedure selected
from the group consisting of widening the patient's mandible,
widening the patient's maxilla, retruding the patient's mandible,
advancing the patient's mandible, retruding the patient's maxilla,
advancing the patient's maxilla, and combinations thereof and an
intermediate surgical stint is made to act as a guide for relating
the maxilla to the mandible during the interim surgical
procedure.
[0028] The present invention further provides a method for
stabilizing the condylar positions in the temporomandibular joints
of a patient with temporomandibular dysfunction syndrome
comprising:
[0029] (a) providing an orthotic to the maxillary teeth of the
patient so as to allow full coverage of all the maxillary teeth,
wherein the orthotic is designed with an anterior ramp to provide
anterior guidance of the patient's mandible in excursive movements
by contact of the superior surface of the mandibular anterior teeth
of the patient with a posterior surface of the anterior ramp of the
orthotic so as to allow for complete disclusion of the posterior
mandibular teeth from the orthotic of the patient during eccentric
jaw movements which enables deprogramming the temporomandibular
joints into stable condylar position;
[0030] (b) fitting the orthotic into the patient's mouth for a
period of time sufficient to deprogram the temporomandibular joints
into the stable condylar position;
[0031] (c) modifying the orthotic when needed to maintain complete
disclusion of the posterior maxillary and mandibular teeth of the
patient during eccentric jaw movements during the period of time
for deprogramming the temporomandibular joints into the stable
condylar position; and
[0032] (d) measuring during the period of time for deprogramming
the temporomandibular joints into the stable condylar position pain
caused to the patient by the temporomandibular dysfunction,
reproducibility of the patient's bite on the orthotic,
neuromuscular tension of the patient's facial muscles, and the
patient's condylar position indices, wherein the condylar positions
in the temporomandibular joints of the patient are determined to be
stabilized when the patient is free of the pain and has a
reproducible bite on the orthotic, there is complete release of
neuromuscular tension whereby the patient's facial muscles upon
palpation show no signs of guarding, splinting, or tension, and the
patient's condylar position indices are less than about 1 mm.
[0033] The present invention further provides an apparatus for
planning a surgical method for treating the cranial base to
mandibular axis discrepancies in a patient comprising an artificial
jaw simulator including an upper member with a downwardly facing
surface and having a pair of spaced sockets at one end, which
represent the sockets of the patient's glenoid fossae, pivotally
mounted on a pair of spaced spherical styluses, which represent the
simulated horizontal or hinge axis of the patient's condyles, on a
frame vertically mounted on one end of a lower member with an
upwardly facing surface, and a model of an upper dental arch of the
patient with a base, which is parallel on all sides to the upper
dental arch model and is delineated with horizontal and vertical
reference lines, mounted with a separating media to a mounting
stone mounted on an upper plate which is mounted to the downwardly
facing surface of the upper member of the artificial jaw simulator,
and a model of a lower dental arch of the patient mounted on a
mounting stone, which is parallel on all sides to the lower dental
arch model and is delineated with horizontal and vertical reference
lines, mounted using a settable material on a lower plate which is
mounted to the upwardly facing surface of the lower member of the
artificial jaw simulator, wherein the relative motion between the
upper and lower plates with the models mounted thereon is the same
as the relative motion between the patient's upper and lower jaws,
and wherein the true axis of rotation of the temporomandibular
joints of the patient have been maintained.
[0034] The present invention further provides an orthotic for
stabilizing the condylar positions in the temporomandibular joints
of a patient with temporomandibular dysfunction syndrome comprising
a base portion with an upper and a lower surface, an anterior and
posterior surface, and having a generally U-shaped plan form and
including opposite integrally formed side arms adapted for location
between the orthotic and mandibular teeth of the patient, the base
having an inner flange along its trailing edge and an outer flange
along its leading edge wherein the inner flange and outer flange
extend upward from the base so as to form a channel for accepting
the maxillary teeth of the patient wherein the bottom surfaces of
the maxillary teeth are in contact with the surface of the channel,
and wherein the width of the channel is adapted to the width of the
maxillary teeth of the patient, and wherein the base has a vertical
thickness sufficient that when the maxillary teeth are engaged in
the orthotic there is complete disclusion of the posterior
maxillary and mandibular teeth during eccentric jaw movements, and
wherein the thickness of the base in the position where the
anterior maxillary teeth are engaged defines a downwardly extending
ramp with anterior and posterior surfaces of sufficient thickness
to allow the superior surface of the central and lateral incisors
to glide freely along the posterior surface of the ramp to simulate
the guidance of normal central and lateral incisors against the
lingual surface of normal anterior maxillary teeth in a condition
of no wear and normal vertical anatomy and to provide anterior
guidance of the patient's mandible in excursive movements by
contact of the superior surface of the central and lateral incisors
with the posterior surface of the ramp so as place the posterior
maxillary and mandibular teeth out of contact.
[0035] The present invention further provides an orthotic for
maintaining the mandible to maxilla/cranial base alignment and
stability in the temporomandibular joints of a patient during or
following a surgery which verifies stable condylar position in the
temporomandibular joints of the patient comprising a base portion
having a generally U-shaped plan form and including opposite
integrally formed side arms adapted for location between the
maxillary and mandibular teeth of the patient, the base having an
inner flange along its trailing edge and an outer flange along its
leading edge and extending upward and downward from the base so as
to form an upper channel for accepting the maxillary teeth and a
lower channel for accepting the mandibular teeth of the patient and
which when fitted to the patient's teeth maintains the mandible to
maxilla/cranial base alignment and stability in the
temporomandibular joints of the patient.
OBJECTS
[0036] It is an object of the present invention to provide a method
for treating maxilla/cranial base to mandibular axis discrepancies
in the temporomandibular joints of a patient such as is caused by
MTDS or developmental facial/dental deformities without performing
open jaw joint surgery.
[0037] It is a further object of the present invention to provide a
method for treating maxilla/cranial base to mandibular axis
discrepancies in the temporomandibular joints of a patient such as
caused by MTDS or developmental facial/dental deformities by
performing total maxillary osteotomy either alone or in conjunction
with mandibular osteotomy.
[0038] It is a further still object of the present invention to
provide a method for treating maxilla/cranial base to mandibular
axis discrepancies in the temporomandibular joints of a patient
such as those caused by MTDS or developmental facial/dental
deformities wherein the surgical procedure for treating is planned
on a model of the patient's mouth wherein the true axis of rotation
of the patient's jaw joint in a stable condylar position has been
replicated.
[0039] These and other objects of the present invention will become
increasingly apparent with reference to the following drawings and
preferred embodiments.
DESCRIPTION OF THE DRAWINGS
[0040] FIG. 1 illustrates schematically a side view of a part of
the skull 34, maxilla 18, and mandible 14 of a particular patient
10 that has MTDS. The dotted line indicates where the maxilla 18 is
to be surgically cut to enable the maxilla 18 to be disarticulated
from the skull 34 during total maxillary osteotomy.
[0041] FIG. 2 illustrates schematically the maxilla 18
disarticulated from the skull 34 of the patient 10 shown in FIG. 1.
The shaded portion 100 illustrates the amount of maxillary bone to
be removed to restore a functional bite to the patient 10 in FIG.
1.
[0042] FIG. 3 illustrates schematically a side view of a part of
the skull 34, maxilla 18, and mandible 14 of the patient 10 shown
in FIG. 1 after total maxillary osteotomy to restore the functional
bite to the patient 10.
[0043] FIG. 4A shows a graph 50 of a measurement of a patient's
left jaw joint C.P.I. using a Panadent C.P.I. apparatus showing
that the dots, each representing the condylar position of the
patient recorded at a particular time, produces a C.P.I. of greater
than about 1 mm indicating that the patient's condylar position has
not reached stability.
[0044] FIG. 4B shows a graph 54 of a measurement of a patient's
left jaw joint C.P.I. using a Panadent C.P.I. apparatus showing
that the dots, each representing the condylar position of the
patient recorded at a particular time, produces a C.P.I. of about 1
mm indicating that the patient's condylar position has been
stabilized.
[0045] FIG. 4C shows a graph 60 of a measurement of a patient's
condylar true hinge axis and condylar pathway of the patient's left
jaw joint using a condylar axis tracking apparatus.
[0046] FIG. 5A is a perspective view of the upper side of a
craniomandibular orthopedic repositioning orthotic 300 for
deprogramming a patient's jaw into a stable condylar position.
[0047] FIG. 5B is a perspective view of the underside of the
orthotic 300 of FIG. 5A.
[0048] FIG. 6 is a perspective view of the upper dental arch 400
and lower dental arch 402 of a particular patient with MTDS.
[0049] FIG. 7 is a perspective view of a preferred prior art
artificial jaw simulator 500.
[0050] FIG. 8 is a perspective view of the upper dental arch 400
and lower dental arch 402 of a particular patient in a jaw joint
artificial jaw simulator 500 set at the patient's true hinge axis
and stable condylar position wherein the teeth 409 have been
arranged in a skeletal and dental Class I relationship which
reapproximates a functional bite. The Figure shows that to
reapproximate the functional bite in the patient, a portion of the
posterior maxillary bone has to be removed.
[0051] FIG. 9 is a perspective view of the upper dental arch 400
and lower dental arch 402 of the patient shown in FIG. 8 after
sufficient maxillary bone has been removed to reapproximate the
functional bite in the patient.
[0052] FIG. 10 is a perspective view of the upper dental arch 708
and lower dental arch 712 of a patient showing a surgical stint 700
between the teeth 702 of the upper dental arch 708 and the teeth
702 of the lower dental arch 704.
DETAILED DESCRIPTION OF THE INVENTION
[0053] All patents, patent applications, government publications,
government regulations, and literature references cited in this
specification are hereby incorporated herein by reference in their
entirety. In case of conflict, the present description, including
definitions, will control.
[0054] The present invention provides a method for surgically
treating maxilla/cranial base to mandibular axis discrepancies in
the temporomandibular joints of a patient such as caused by
mandibular, temporomandibular dysfunction syndrome (MTDS) or
developmental facial/dental deformities wherein the maxillary teeth
are out of alignment with the mandibular teeth and wherein the
misalignment is caused by one or more defects in the structural
arrangement of the patient's upper jaw (maxilla) to the patient's
lower jaw (mandible).
[0055] For example, if the patient's anterior maxillary teeth do
not overlap the anterior mandibular teeth (central and lateral
incisors) when the patient's mouth is in the closed position, the
patient's mandible can be pushed forward with the posterior
mandible going downward and backward, particularly if the patient's
posterior maxillary and mandibular teeth are in contact. The
misalignment destabilizes the patient's jaw joint: the mandibular
condyles are not stably positioned in their respective sockets of
the glenoid fossa (jaw joint) and as the patient opens and closes
his mouth, the condyles rotate and translate inappropriately in and
out of their sockets. Because the patient's jaw is not in its
stable condylar position, the ligaments in the jaw joint become
stretched, endema and/or inflamation of the jaw joint usually
occur, and the patient experiences problems of sustained muscle
contractions and related spasms and internal derangement of the jaw
joint meniscus/disc. As a consequence, the patient cannot maintain
a functional bite and depending on the degree of jaw joint
instability, the patient can experience severe and persistent pain
and/or severe headaches, ear aches, neck and shoulder pain, and
tinnitus.
[0056] The present invention provides a method for treating
maxilla/cranial base to mandibular axis discrepancies in the
temporomandibular joints of a patient such as is caused by TMDS or
developmental facial/dental deformities for realigning the maxilla
in relationship to the mandible such that the realigned maxilla and
mandible maintain each condyle in a stable position in its socket
of the glenoid fossa, which restores a functional bite to the
patient. The resolution and treatment is achieved by orthognathic
surgery (corrective jaw surgery) which includes total maxillary
osteotomy with or without mandibular osteotomy to restore a
functional bite to the patient.
[0057] Hereinafter, the term "surgical procedure" refers to
orthognathic surgery which includes total maxillary osteotomy,
mandibular osteotomy, or both.
[0058] The term "functional bite" refers to an appropriate bite
wherein the teeth are in a skeletal and dental Class I
relationship, with the jaw joint in a stable condylar position with
appropriate anterior guidance.
[0059] The term "treating" includes managing or correcting.
[0060] The novel features of the method are that (1) a
craniomandibular orthopedic repositioning orthotic is used to
deprogram over time a patient's jaw into a stable condylar position
wherein each mandibular condyle is stabilized in its socket of the
glenoid fossa (stable condylar position), which then enables the
patient's jaw joint true hinge axis to be measured, (2) the
surgical procedure for treating, managing, or correcting
maxilla/cranial base to mandibular axis discrepancies in the
temporomandibular joints of a patient such as is caused by MTDS or
developmental facial/dental deformities in the patient is planned
on a model of the patient's mouth in which the patient's true hinge
axis in the stable condylar position has been replicated, and (3)
the surgical procedure uses total maxillary osteotomy, with or
without mandibular osteotomy, to treat, manage, or correct the
maxilla/cranial base to mandibular axis discrepancies in the
temporomandibular joints of a patient such as is caused by MTDS or
developmental facial/dental deformities. A further novel feature of
the present invention is that the method provides for the
treatment, management, or correction of maxilla/cranial base to
mandibular axis discrepancies in the temporomandibular joints of a
patient such as is caused by MTDS or developmental facial/dental
deformities without involving surgery on the temporomandibular
joint itself. In other words, the method of the present invention
enables a surgical procedure to be planned, which instead of
relying on open or closed jaw joint surgery to treat, manage, or
correct maxilla/cranial base to mandibular axis discrepancies in
the temporomandibular joints of a patient such as is caused by MTDS
or developmental facial/dental deformities, uses total maxillary
osteotomy, mandibular osteotomy, or both.
[0061] The method of the present invention, which provides a means
for treating, managing, or correcting maxilla/cranial base to
mandibular axis discrepancies in the temporomandibular joints of a
patient such as caused by MTDS or developmental facial/dental
deformities, comprises the following four steps.
[0062] (1) Stabilizing over time the mandible in relation to the
cranial base, i.e., stabilizing each condyle in its socket of the
glenoid fossa over time, by using a craniomandibular orthopedic
repositioning orthotic which is applied to the maxillary teeth
(dentition) of the patient so as to allow full coverage of all the
teeth. The function of the orthotic is to over time allow the
mandible to realign to the cranial base in the patient and to
restore the facial muscles to their proper physiologic resting
length by removing the neural inputs of the teeth to the brain in
determining the position of the mandible in relation to the
cranium. When the orthotic is applied to the maxillary teeth, the
primary determinant of mandible position is provided by the
orthotic and neural inputs from the temporomandibular joint to the
brain and not the neural inputs of the teeth. Removing the neural
inputs of the teeth reduces problems of sustained muscle
contraction and related spasm and joint inflamation which enables
each condyle over time to become stabilized in its socket of the
glenoid fossa, thus stabilizing dislocation of the articular disc.
After the patient's condyles have been stabilized in their sockets
of the glenoid fossa (stable condylar position), the jaw joint is
in its true hinge axis of rotation and healing of the jaw joint
occurs.
[0063] (2) Replicating the patients' jaw joint true hinge axes of
rotation in the stabilized condylar position on an artificial jaw
simulator (articulator) containing plaster casts of the upper and
lower dental arches of the patient mounted thereon. It is important
that the mounting plaster casts of the patient's upper and lower
dental arches on the articulator is performed in such a manner so
as to transfer the true axis of rotation of each jaw joint from the
patient to the articulator while maintaining the stable condylar
position in each jaw joint. By transferring the true axis of
rotation of the patient's jaw joints, a surgical procedure can be
accurately planned to treat, manage, or correct vertical jaw
discrepancies causing MTDS or which are a result of developmental
facial/dental deformities. Articulators have been disclosed in U.S.
Pat. No. 4,034,475 to Lee, U.S. Pat. No. Re. 31,615 to Lee, and
U.S. Pat. No. 4,909,737 to Lee. However, the preferred articulator
is that disclosed in U.S. Pat. No. 6,109,917 to Lee et al. and
which is commercially available from Panadent Corporation, Grand
Terrace, Calif.
[0064] (3) Planning the surgical procedure (total maxillary
osteotomy with or without mandibular osteotomy) on the articulator
with the patient's dental arch casts mounted thereon wherein the
surgical procedure for correcting the maxilla/cranial base to
mandibular axis discrepancies in the temporomandibular joints of a
patient such as caused by MTDS or developmental facial/dental
deformities reapproximates the patient's maxillary and mandibular
teeth into a position coincidental to the stabilized jaw joint
position with a functional bite which at the same time maintains
the jaw joint in a stable condylar position. The articulator with
the patient's dental arch casts mounted thereon is also used to
design and construct surgical stints to serve as guides for
relating the maxilla to the mandible during the surgery.
[0065] (4) Performing the surgical procedure on the patient based
on the surgical procedure planned on the artificial jaw simulator
with the patient's dental arch casts mounted thereon to treat,
manage, or correct the maxilla/cranial base to mandibular axis
discrepancies in the temporomandibular joints of a patient such as
caused by MTDS or developmental facial/dental deformities of the
patient wherein the surgical procedure reapproximates the patient's
maxillary and mandibular teeth into a functional bite while at the
same time maintaining the stable condylar position in the jaw
joint.
[0066] FIGS. 1, 2, and 3 illustrate the basic principle of jaw
realignment using total maxillary osteotomy in a surgical procedure
for treating, managing, or correcting maxilla/cranial base to
mandibular axis discrepancies in the temporomandibular joints of a
patient such as caused by MTDS or developmental facial/dental
deformities in a patient wherein the surgical procedure had been
planned on a model which replicates the patient's jaw joint in a
stable condylar position as determined by the prior step of
deprogramming the patient's jaw into the stable condylar position
with a craniomandibular orthopedic repositioning orthotic. The
fundamentals of total maxillary osteotomy (often referred to as Le
Fort I) are standard and have been described in many texts on
surgical techniques, for example in the text by Kelly in Atlas of
Oral and Maxillofacial Surgery (Keith ed., W.B. Saunders Company,
Philadelphia, (1992) pp. 73-86).
[0067] FIG. 1 shows the jaw alignment of a particular patient 10
with a discrepancy caused by MTDS. In the figure, the posterior
mandibular teeth 12 on the mandible 14 are in contact with the
posterior maxillary teeth 16 on the maxilla 18. As a result of the
contact of the posterior mandibular teeth 12 and the posterior
maxillary teeth 16 and the neural inputs from the contact, the
mandible 14 in relation to the cranial base 20 is destabilized. In
particular, the condyle 22 on the mandible 14 is not stably
positioned in the socket 24 being positioned inferiorly and
posteriorly of the glenoid fossa 26, i.e., the temporomandibular
joint (jaw joint) 33. Further, as shown in the figure, the anterior
maxillary teeth 28 are not properly positioned to be anterior to
and overlap the mandibular anterior teeth (central and lateral
incisors) 30 thereby providing anterior guidance.
[0068] In a normal person, the anterior maxillary teeth 28 overlap
the anterior mandibular teeth 30 which during opening and closing
of the mouth 32 the anterior maxillary teeth 28 propreoceptively
guides the position of the mandible 14 thereby maintaining a stable
condylar position, i.e., each condyle 22 is in a stable position in
its socket 24 of the glenoid fossa 26 at the maxilla/cranial base
20. However, in a patient with MTDS, the anterior maxillary teeth
28 are unable to act as a guide when the mouth 32 is opened or
closed in maintaining the condyle 22 in a stable position in the
socket 24 of the glenoid fossa 26. As a result, in a patient with
severe MTDS, the pressure on the posterior teeth (16 and 12), which
causes the condyle 22 to be pulled from the socket 24 as the jaw
joint 33 is closed, causes pain to the patient. In milder MTDS
cases, the jaw joint 33 makes a clicking sound as the condyle 22
slips in and out of position with the articular disc (not shown) in
the socket 24 when the mouth 32 is opened and closed. Traditional
attempts to treat, manage, or correct maxilla/cranial base 20 to
mandible 14 axis discrepancies in the jaw joint 33 of a patient
such as is caused by MTDS or facial/dental deformities involved
surgery on the jaw joint 33 without taking into consideration the
role the relationship of the maxillary anterior teeth 28 to the
mandibular anterior teeth (central and lateral incisors) 30 and the
jaw joint 33 in a stable condylar position, for example see Keith
in Atlas of Oral and Maxillofacial Surgery (Keith ed., W.B.
Saunders Company, Philadelphia, (1992) pp. 201-216). Therefore, jaw
joint surgery provides only a temporary respite because over time,
the patient's mandible 14 relationship to the maxilla/cranial base
20 eventually becomes destabilized and the discrepancies
remanifest.
[0069] The surgical procedure in the method of the present
invention treats, manages, or corrects maxilla/cranial base 20 to
mandible 14 axis discrepancies in the jaw joints 33 of a patient
such as is caused by MTDS or facial/dental deformities by
repositioning the mandible 14 and mandibular anterior teeth (30)
with respect to the maxilla (18) and maxillary anterior teeth (28)
so as to stabilize the condyle 22 in the socket 24 of the glenoid
fossa 26 which stabilizes the mandible 14 relationship to the
cranial base 20. First, a stable condylar position is induced over
time by the use of a craniomandibular orthopedic repositioning
orthotic, which is worn continuously by the patient for a time
sufficient to deprogram the jaw joint 33 into the stable condylar
position with subsequent healing of the jaw joint 33, and the
surgical procedure to reposition the maxilla 18 is planned on a
model of the patient's jaw in the stable condylar position. induced
by the orthotic. To reposition the maxilla (18) and maxillary teeth
(16 and 28) with respect to the mandible (14) and mandibular teeth
(12 and 30), the maxilla 18 is surgically cut along a transverse
(horizontal) line (dotted line shown in FIG. 1) and the maxilla 18
disarticulated from the remainder of the patient's skull 34.
[0070] FIG. 2 shows the disarticulated maxilla 18. The figure shows
the amount of maxillary bone for the illustrated patient of FIG. 1
that is to be removed 100 in order to place the patient's maxillary
teeth (16 and 28) in a position that maintains the stable condylar
position in the patient when the disarticulated maxilla 18 is
reattached to the patient's skull 34 as shown in FIG. 3. In
general, the effect of the bone removal 100 is that when the
maxilla 18 is reattached to the skull 34, the posterior maxillary
teeth 16 are elevated with respect to their position prior to
surgery and in some cases, the anterior maxillary teeth 28 are also
lowered with respect to their position prior to surgery.
[0071] FIG. 3 shows the particular patient 10 after the maxilla 18
has been repositioned by surgery. In the figure, the maxilla 18
with the amount of bone removed as shown in FIG. 2 has been
reattached to the patient's skull 34. Preferably, surgical plates
200 are used to keep the maxilla 18 reattached to the skull 34 and
to facilitate healing of the maxilla 18 and skull 34 across the
cut. As shown in the Figure, when the patient's mouth 32 is in the
closed position, the anterior maxillary teeth 28 are now anterior
to and partially overlap the anterior mandibular teeth (central and
lateral incisors) 30 and the posterior maxillary teeth 16 are not
in contact with the posterior mandibular teeth 12. Because of the
guidance provided by the anterior maxillary teeth 28 and the lack
of contact between the posterior maxillary teeth 16 and the
posterior mandibular teeth 12, the condyle 22 is maintained in its
stable position in the socket 24 of the glenoid fossa 26 comprising
the jaw joint 33 which stabilizes the mandible 14 in a stable
relationship to the cranial base 20.
[0072] Thus, FIGS. 1, 2, and 3 illustrate the basic surgical
procedure comprising total maxillary osteotomy for treating,
managing, or correcting maxilla/cranial base to mandibular axis
discrepancies in the temporomandibular joints of a patient such as
caused by MTDS or developmental facial/dental deformities. However,
in particular cases the surgical procedure can further include
mandibular osteotomy. The surgical procedure can further include
widening or narrowing the maxilla or widening or narrowing the
mandible so as to place the maxillary teeth in a stable lateral
relationship over the mandibular teeth. The surgical procedure can
further include retruding or advancing the maxilla or mandible with
respect to each other so as to minimize deharmonizing effects on
facial soft and hard tissue.
[0073] The craniomandibular orthopedic repositioning orthotic is an
important element in the method of the present invention. The
orthotic is designed to place the patient's mandible in a stable
relationship with the cranial base by removing the neural inputs
from the teeth which enables the jaw joint over time to be
deprogrammed into a stable condylar position. The design of the
orthotic further includes an anterior ramp with a posterior surface
defining an anterior guide plane and an anterior surface. The
anterior ramp enables the orthotic to provide anterior guidance of
the mandible in excursive movements by contact of the superior
surface of the anterior mandibular teeth against the posterior
surface the anterior ramp of the orthotic. The anterior guide plane
of the orthotic is designed to allow for complete disclusion of the
posterior teeth during eccentric jaw movements, i.e., protrusive,
right, and left lateral positioning.
[0074] In the protrusive position, the superior surface of the
anterior mandibular teeth (central and lateral incisors) contact
the posterior surface of the anterior ramp only, with all posterior
maxillary teeth and posterior mandibular teeth about 5 mm out of
contact. In right and left lateral excursive movements, the
anterior guide plane of the maxillary orthotic allows the
mandibular cuspid (canine) teeth to guide the mandible to
disclusion of the maxillary and mandibular posterior teeth. The
anterior guide plane of the anterior ramp is designed to be passive
in its affect on mandibular position. Because the anterior guide
plane of the anterior ramp is designed to be passive in its effect,
it allows the mandibular anterior teeth (central and lateral
incisors) to glide freely along the posterior surface of the
anterior ramp, which simulates the guidance of normal anterior
mandibular teeth (central and lateral incisors) against anterior
maxillary teeth in a condition of no wear and normal vertical
anatomy.
[0075] FIGS. 5A and 5B illustrate a craniomandibular orthopedic
repositioning orthotic for deprogramming the jaw joint into a
stable condylar position. FIG. 5A shows an above perspective view
of the orthotic 300 with a base portion 310 with an upper surface
312 and a lower surface 314, an anterior surface 316 and posterior
surface 318, and having a generally parabolic or U-shaped plan form
and including opposite integrally formed side arms 320 adapted for
location between the maxillary and mandibular teeth of the patient.
The base 310 has an inner flange 322 along its trailing edge and an
outer flange 324 along its leading edge wherein the inner flange
322 and outer flange 324 extend upward from the base 310 so as to
form a channel 326 for accepting the maxillary teeth of the patient
wherein the bottom surfaces of the maxillary teeth are in contact
with the surface 328 of the channel 326. The orthotic 300 is
specially designed for each patient so that the width of the
channel 326 is adapted to the width of the maxillary teeth of the
patient and the ramp is of a length sufficient to provide a guide
plane which allows for complete disclusion of the posterior
maxillary teeth and posterior mandibular teeth during eccentric jaw
movements.
[0076] FIG. 5B shows a bottom perspective view of the orthotic 300.
The base 310 has a vertical thickness 330 sufficient that when the
maxillary teeth are engaged in the orthotic 300 there is complete
disclusion of the upper and lower posterior teeth during eccentric
jaw movements. Also shown is the anterior ramp 332 wherein the
thickness of the base 310 in the position where the anterior
maxillary teeth (central and lateral incisors) are engaged defines
a downwardly extending anterior ramp 332 with an anterior surface
334 and a posterior surface 336 of sufficient thickness to allow
the superior surface of the anterior mandibular teeth (central and
lateral incisors) to glide freely along the posterior surface 336
of the anterior ramp 332 to simulate the guidance of normal
anterior mandibular teeth (central and lateral incisors) against
normal anterior maxillary teeth in a condition of no wear and
normal vertical anatomy and wherein in a protrusive position the
superior surface of the anterior mandibular teeth (central and
lateral incisors) contact the posterior surface 336 of the anterior
ramp 332 and the posterior maxillary teeth and posterior mandibular
teeth are placed out of contact.
[0077] Deprogramming the jaw joint into a stable position using the
orthotic entails an adjustment process which can extend over a
period of time. The goal of the adjustment process is to eliminate
all posterior contacts in lateral excursions on the posterior of
the orthotic while allowing the condyles to passively seat to a
stable position in their respective sockets of the glenoid fossa.
During the adjustment process, the patient is required to wear the
orthotic 24 hours a day, seven days a week except when it is
removed for cleaning. When the orthotic is removed for cleaning,
the teeth should not be allowed to come into contact. As the
adjustment process proceeds, it will become necessary to remove
acrylic from the posterior of the orthotic in order for the
condyles to reach their stable position in their sockets while
maintaining complete disclusion of the posterior maxillary and
mandibular teeth during eccentric jaw movements. For some patients,
as the adjustment process proceeds, in addition to removing acrylic
from the posterior of the orthotic, it can become necessary to add
acrylic to the anterior ramp of the orthotic to extend the anterior
guide plane to maintain proper guidance. Alternatively, orthotics
are sequentially fitted to the patient wherein the posterior of
each orthotic in the sequence has been progressively decreased in
thickness and where appropriate, the anterior ramp of each orthotic
in the sequence has been progressively elongated to extend the
anterior guide plane.
[0078] The time of the adjustment process for deprogramming the
patient's jaw into a stable condylar position and the number of
adjustments that may be needed to enable the patient's jaw to
deprogram into a stable condylar position will vary from patient to
patient. However, for all patients, determining when the jaw is in
its final stable condylar position is when all three of the
following stable condylar position criteria are satisfied.
[0079] First, the patient is pain free and has a consistently
reproducible bite on the orthotic.
[0080] Second, there is complete neuromuscular release whereby the
muscles upon palpation show no signs of guarding, splinting, or
tension to the palpation or application of bimanual manipulation
procedures on the mandible by the operator (bimanual manipulation
procedures are described in Dawson, a treatise well known to those
skilled in the art).
[0081] Third, the patient has a condylar position index (C.P.I.) of
less than about 1 mm using a commercially available Panadent C.P.I.
apparatus such as the CPI-III-H (Panadent Corporation, Grand
Terrace, Calif.) or equivalent containing models of the patient's
upper and lower dental arches mounted therein with the patient's
orthotic fitted on the teeth of the upper dental arch for measuring
condylar positions in a patient during opening and closing of the
model of the patient's mouth. A condylar position index of less
than about 1 mm means that the difference between the position of
the condyle within the socket when the jaw is closed with the teeth
in contact and the position it is in the stable condylar position
is less than about 1 mm. FIG. 4A shows a graph 50 of a measurement
of a patient's left jaw joint C.P.I. using a Panadent C.P.I.
apparatus showing that the dots, each representing the condylar
position of the patient recorded at a particular time, produces a
C.P.I. of greater than about 1 mm indicating that the patient's
condylar position has not reached stability. FIG. 4B shows a graph
54 of a measurement of a patient's left jaw joint C.P.I. using a
Panadent C.P.I. apparatus showing that the dots, each representing
the condylar position of the patient recorded at a particular time,
produces a C.P.I. of about 1 mm indicating that the patient's
condylar position has been stabilized.
[0082] After the patient's jaw has been deprogrammed and the
patient's C.P.I. is less than about 1 mm, the condylar true hinge
axis of rotation and condylar pathway of each jaw joint (axes of
rotation and shape of the patient's sockets) are determined using
codylar axis tracking apparatus disclosed in U.S. Pat. No. Re.
31,615 to Lee or other condylar tracking apparatus well known in
the art such as the commercially available AXI-PATH recorder
available from the Panadent Corporation. The shape of the patient's
sockets and true hinge axis of rotation are transferred to the
artificial jaw articulator (FIGS. 7 to 9) which is used for
planning the surgical procedure to treat, manage, or correct
vertical jaw discrepancies causing MTDS or which are a result of
developmental facial/dental deformities. FIG. 4C shows a graph 60
of a measurement of a patient's condylar true hinge axis and
condylar pathway of the patient's left jaw joint using a condylar
axis tracking apparatus. Line 62 traces the path of the condyle in
the socket as the patient's mouth opens. Where line 62 intersects
line 64 is the position of the condyle when the patient's mouth is
closed. The angle between lines 62 and 64 is the patient's condylar
true hinge axis.
[0083] The stable condylar position criteria must be met before
patient's jaw relationship, i.e., true hinge axis of rotation, can
be transferred to an artificial jaw simulator comprising a model of
the patient's mouth. A comprehensive understanding of orthotic
fabrication, adjustment, C.P.I. measurements as well true hinge
axis determinations and transfers is known to those in the art and
can be obtained by the level I and II courses taught by Orognathic
Bioesthetics International, Salem, Oreg. Preferably, the patient
has worn the orthotic for a time sufficient for healing of the jaw
joint to occur which includes tightening of the ligaments in the
jaw joint and cessation of endema and/or jaw joint inflamation.
[0084] Once the patient has undergone the adjustment process and
the patient's jaw joint has been stabilized as determined by
satisfaction of the stable condylar position criteria, the surgical
procedure for treating, managing, or correcting the maxilla/cranial
base to mandibular axis discrepancies is planned. The surgical
procedure is planned on a model of the patient's mouth which
comprises an artificial jaw simulator with casts of the patient's
maxillary and mandibular dental arches mounted thereon wherein
model replicates the patient's true hinge axis of rotation
determined with the condylar axis tracking apparatus as
follows.
[0085] Dental arch casts of the patients upper (maxillary) and
lower (mandibular) dental arches are fabricated in dental stone.
The upper dental arch cast includes a base about 10 mm thick and
parallel on all sides. The dental arch casts are split cast mounted
to bases on the articulator. In the appropriate mounting stone on
the artificial jaw simulator; the lower dental arch cast is mounted
to the lower mounting plate and the upper dental arch cast is
mounted to the upper mounting plate with the sides of the upper
dental arch cast base parallel and confluent to the upper mounting
plate. Prior to mounting the upper dental arch cast, a separating
media is placed between the base of the upper dental arch cast and
the upper mounting stone. Horizontal reference lines are scored
into the base of the upper dental arch cast delineating 5 and 10 mm
of vertical height on the base and vertical lines are scored to
traverse the base and upper mounting stone at three positions
around the casts: right and left posterior and midline anterior.
The horizontal and vertical reference lines enable the amount of
maxillary bone to be removed during surgery to be determined.
[0086] FIG. 6 illustrates upper and lower dental arch casts made
from a patient with MTDS. The Figure shows upper dental arch cast
400 and lower dental arch cast 402. The upper dental arch cast 400
is mounted on a base 404. The base 404 with upper dental arch 400
mounted thereon is mounted to the upper mounting stone 410 with
upper mounting plate 411 using separating media (not shown) which
enables the base 404 to be easily mounted or dismounted. The base
404 has scored thereon horizontal reference lines 406 and vertical
reference lines 408. The vertical reference lines 408 traverse the
junction 409 between the base 404 and the upper mounting stone 410.
The lower dental arch 402 and lower mounting stone 412 is mounted
to lower mounting plate 414 using settable material 416 (e.g.,
plaster).
[0087] FIG. 7 shows a perspective view of an artificial jaw
simulator 500 as disclosed in U.S. Pat. No. Re. 31,615 to Lee which
is suitable for planning the surgical procedures. The Figure shows
artificial jaw simulator 500 with upper member 502 with upper
mounting plate 411 and stone 410 comprising upper dental arch 400
mounted thereon and lower member 504 with the lower mounting plate
414 and stone 412 comprising lower dental arch 402 mounted thereon.
Other artificial jaw simulators which enable the patient's true
hinge axis and a stable condylar position to be replicated can be
used for planning the surgical procedure.
[0088] With the dental arch casts mounted in the artificial jaw
simulator in the patient's true hinge axis and in a stable condylar
position in a split cast fashion, the upper dental arch cast is
then disarticulated from the upper mounting plate and stone. The
upper dental arch cast is related to the lower dental arch cast,
which is still mounted to the lower mounting plate and stone of the
artificial jaw simulator, in a skeletal and dental Class I
relationship allowing for about 4 mm of vertical overlap of the
maxillary anterior teeth over the mandibular anterior teeth
(central and lateral incisors). The cuspid relationship is such
that the cuspids fit vertically in the embrasure between the
mandibular cuspids and the first premolars, assuming the
appropriate normal anatomic height of the cuspid teeth. When the
proper relationship is determined, the upper and lower dental arch
casts are luted together with wax to maintain the above
relationship. The relationship represents the desired post-surgical
position of the upper and lower teeth. The presence and severity of
wear on the teeth and anatomic abnormalities of the patient's teeth
are noted. However, all surgical procedures are planned to allow
for jaw repositioning with teeth of normal anatomic form, because
basing the surgery on worn teeth or teeth of abnormal anatomic form
will alter the vertical relationship of the jaws, particularly
after the teeth have been repaired. Therefore, the method of the
present invention includes allowances and timing for the
restoration of the worn teeth or removal of anatomical
abnormalities of the teeth, e.g., straightening, lengthening,
shortening, or repositioning the teeth.
[0089] Next, with the dental casts still luted together in the
desired post-surgical position, the upper member of the artificial
jaw simulator is closed against the base of the upper dental arch
cast so that the upper mounting stone is in contact with the base
of the upper dental arch cast. This is shown in FIG. 8 which shows
the upper dental arch 400 luted to the lower dental arch 402
mounted on lower mounting stone 412, which is mounted using
settable material 416 to lower mounting plate 414 on lower member
504 of artificial jaw simulator 500, in the desired post-surgical
position and the artificial jaw simulator 500 closed such that the
upper mounting stone 410 with upper mounting plate 411, which is
mounted on upper member 502 of artificial jaw simulator 500, is in
contact with the base 404 attached to upper dental cast 400. The
Figure also shows the horizontal reference lines 406 on the base
404 and the vertical reference lines 408 on both the base 404 and
the upper mounting stone 410. In general, the posterior end 600 of
the upper mounting stone 410 will contact the posterior end 602 of
the base 404 attached to the upper dental arch 400 at an angle with
the bottom surface 604 of the upper mounting stone 410 extending
upward and away from the upper surface 606 of the base 404. The
slope of the angle that is formed is noted. The slope of the angle
reflects the amount of maxillary bone that will have to be removed
to place the patient's maxillary and mandibular teeth in the
desired post-surgery position. The amount of maxillary bone to be
removed is determined by dry planing away the upper surface 606 of
the base 404 attached to the upper dental cast 400 using a model
trimmer, file, sandpaper, or the like (not shown) at the same slope
as the angle formed by the bottom surface 604 of the mounting stone
410 as it extends away from the upper surface 606 of the base 404,
until enough material from the upper surface 606 of the base 404 is
removed such that the entire bottom surface 604 of the upper
mounting stone 410 contacts the entire upper surface 606 of the
base 404 attached to the upper dental arch cast 400 evenly while
still maintaining the teeth in the desired post-surgical
position.
[0090] FIG. 9 shows the upper surface 606 of the base 404 with
upper dental arch cast 400 in even contact with the bottom surface
604 of the upper mounting stone 410 with upper mounting plate 411
mounted to the upper member 502 of the artificial jaw simulator
500. The Figure also shows that in the desired post-surgical
position, there is an offset between the vertical reference lines
408 on the base 404 and upper mounting stone 410. The amount of
offset indicates the distance to which the maxilla has been
advanced in order to achieve the desired post-surgical
position.
[0091] Next, as illustrated by FIG. 9, the upper surface 606 of the
base 404 attached to the upper dental cast 400 is then luted to the
lower surface 604 of the upper mounting stone 410 with a thin film
of wax (not shown). Measurement is then made from the horizontal
reference line 406 on the base 404 near or at its posterior end 602
vertically to the where the luted upper mounting stone 410 contacts
the base 404 and this measurement is subtracted from the original
vertical height of 5 or 10 mm on the base 404. The difference is
the amount of posterior maxillary bone that is to be removed in
order to restore a functional occlusion to the cranial base to
mandible discrepancy in the patient, i.e., the amount of posterior
maxillary bone that is to be removed in order to restore to the
patient a functional bite while maintaining the stable condylar
position criteria.
[0092] The above description illustrates the general planning
procedure for determining the amount of posterior maxillary bone to
remove to restore a functional bite to the patient. However, the
above planning procedure can reveal other discrepancies in the
mouth of the patient which must also be treated, managed, or
corrected if a functional bite is to be restored to the patient.
For example, if during the above planning procedure, horizontal
discrepancies in the patient's jaw alignment are found which do not
allow for the positioning of the upper dental arch cast of the
maxilla over the lower dental arch cast of the mandible in a stable
lateral relationship with the maxillary teeth over the mandibular
teeth, then the upper dental arch cast of the maxilla is widened
through the midline. This is done by sawing the upper dental arch
cast of the maxilla through the midline between the central incisor
teeth and widening the upper dental arch cast of the maxilla to the
desired width by placing dental boarder wax between the two
segments of the maxillary upper dental arch casts. The upper dental
arch cast of the maxilla is then related to the lower dental arch
casts of the mandible in the same manner as described above and the
amount of midline maxillary bone that is to be added or removed to
place the maxilla in a stable lateral relationship with the
maxillary teeth over the mandibular teeth is noted.
[0093] As noted above, a review of the vertical reference lines on
the model is performed to determine the degree of offset. If the
offset shows that the upper dental arch cast of the maxilla has
been retruded then the lower dental arch cast of the mandible is
advanced the corresponding distance while leaving the upper dental
arch cast of the maxilla in its original relationship. However, if
the relationship demonstrates that the upper dental arch cast of
the maxilla has been advanced then this advancement, in
millimeters, must be assessed for its affects on facial soft tissue
harmony when the advancement is performed on the patient. The
required maxillary advancement may result in a deharmonizing effect
on the facial contour of the patient in which case a surgical
procedure is planned which will retrude the mandible as well as
remove posterior maxillary bone. The same holds true for the
previously described mandibular advancement procedure. As a general
rule, it is preferable that surgical procedures not be planned
which will result in retraction of the maxilla.
[0094] The importance of the model for planning the surgical
procedure is that all measurements and determinations for restoring
a functional bite in the patient while maintaining the stable
condylar position are performed on the model. No adjustments are
required to be made during the surgery itself. By planning the
surgical procedure on the model reduces the likelihood of errors
during the surgery and provides the surgeon with an exact procedure
for performing the surgery.
[0095] Once the final jaw position for the patient has been
established on the above model comprising the artificial jaw
simulator with the patient's dental arch casts mounted thereon in
the patient's true hinge axis of rotation and stable condylar
position, then a surgical stint is fabricated for use in the
operating room using the above model with the dental arch casts in
the desired post-surgical position. The surgical stint acts as a
guide to help the surgeon relate the patient's maxilla to the
mandible in the desired post-surgery position during the surgery.
The surgical stint is made with a cold-cure acrylic. A mixture of
monomer and polymer is formed to a doughy consistency and a
separating media is placed on surface of the upper and lower dental
arch casts. The doughy acrylic is rolled into the shape of a solid
cylinder long enough to follow the patient's entire maxillary
dentition on the upper dental arch cast, i.e., from the patient's
most posterior right tooth to the patient's most posterior left
tooth. The artificial jaw simulator in which the dental arch casts
are on is then closed and the acrylic allowed to harden.
[0096] After hardening, the hardened acrylic is then removed from
the dental arch casts as a hard solid horseshoe shaped wafer that
fits over the upper and lower teeth of the patient and which
approximates the patient's jaw into the desired post-surgical
position. The wafer is trimmed with an acrylic bur so that about a
1 to 2 mm flange of acrylic is left on the external periphery of
the wafer. FIG. 10 shows a surgical splint 700 in position between
the teeth 702 of the upper dental arch cast 708 mounted on base 706
which is mounted on upper mounting stone 710 and the teeth 704 of
the lower dental arch cast 712 mounted on lower mounting stone 714
and then mounted to lower mounting plate 716 using settable
material 718.
[0097] If two jaw surgery is required, then two surgical splints
are made: a final position surgical splint as described above for
relating the maxilla to mandible following the final surgical
procedure and an interim splint which is used to relate the
mandible to the stable condyle-axis position for an interim
surgery. The interim surgery is generally a surgical procedure for
advancing or retruding the mandible in relation to the maxilla
while maintaining the stable condylar position and the final
surgical procedure is removing sufficient maxillary bone to restore
a functional bite to the patient while maintaining the stable
condylar position. The intermediate splint is made by relating an
unaltered upper dental arch cast (no material representing
maxillary bone has been removed from the base mounted to the upper
dental arch cast) to the lower dental arch cast, which has either
been advanced or retruded in order to achieve the stable jaw joint
relationship. The upper and lower dental arch casts are then
related to one another by means of the artificial jaw simulator in
the manner as described above and an interim acrylic wafer or
splint is fabricated as described above.
[0098] The fundamentals of the surgical procedure for Le Forte I
osteotomy and Intraoral Sagittal Split osteotomy are standard in
the art and are described in many texts on jaw surgery. In general,
the maxilla is disarticulated from the skull using standard
surgical methods and the amount of posterior maxillary bone
determined on the model is removed from the posterior end of the
maxilla. Additional surgery on the maxilla, e.g., widening the
maxilla, or surgery on the mandible, e.g., lengthening or
shortening the mandible, can be performed in the same surgery or in
a prior surgery. After the appropriate amount of maxillary bone has
been removed from the posterior end of the maxilla, the maxillary
teeth are related to the mandibular teeth using the final position
surgical stint, the maxillary bone attached to the skull with
surgical plates, and with the final position surgical stint in
place, the mouth is fixated shut for a time sufficient to enable
healing of the maxilla to the skull.
[0099] After removal of the surgical stints, the patient is fitted
with a post-surgery verification orthotic (which is the same or
similar to the initial orthotic worn by the patient) to stable
condylar position criteria, which the patient wears for time
sufficient to verify that the surgery has properly related the
maxilla and mandible to the stable condylar position.
[0100] In particular cases, after surgery it will be necessary to
modify the patient's anterior maxillary teeth to achieve the proper
overlap (anterior guidance) with the anterior mandibular teeth
(central and lateral incisors) for effecting proper guidance of the
mandible during mouth opening and closing. In some cases, the
anterior maxillary teeth are elongated using tooth restoration
methods well known in the art. In further cases, teeth with
excessive or abnormal wear patterns are reconstructed. One skilled
in the art would be able to readily determine what modifications to
the teeth will be necessary to maintain the functional bite and
stable condylar position post-surgery.
[0101] The novel element of the method of the present invention is
that all surgical moves in the surgical procedure are predicated on
the measurements obtained on the above model for the surgery
wherein the model comprises an artificial jaw simulator with the
patient's dental arch casts mounted thereon in the patient's true
hinge axis of rotation and stable condylar position. By performing
the surgical procedures based on the measurements determined on the
model, no adjustment need be made at the time of the operation that
has not been prescribed by the model for the surgery. The position
of the jaw joints is not determined by manipulation of either the
maxilla or mandible at the time of surgery except for that which
has been determined on the model.
[0102] To summarize the general elements of the method for treating
maxilla/cranial base to mandibular axis discrepancies in the
temporomandibular joints such as caused by MTDS or facial/dental
deformities: (1) all patient assessments and measurements are made
from a jaw joint position which is the result of deprogramming the
jaw joints into a stable condylar position using the
craniomandibular orthopedic repositioning orthotic and which has
meet the criteria of stable condylar position, (2) planning a
surgical procedure comprising total maxillary osteotomy for
realigning the patient's jaw joint into a functional bite while
maintaining the stable condylar position on a model of the
patient's mouth comprising an artificial jaw simulator and the
patient's dental arch casts in the patient's true hinge axis of
rotation in a stable condylar position and optionally wherein the
tooth structure has been restored to normal biologic form, (3)
preparing a surgical stint from the model in the desired
post-surgical position for relating the patient's maxilla to the
patient's mandible in the desired post-surgical position following
the total maxillary osteotomy, (4) performing the surgical
procedure on the patient as planned on the model and using the
surgical stint prepared from the model to relate the patient's
maxilla to the patient's mandible following the total maxillary
osteotomy, and (5) following the surgery with a post-surgery
verification orthotic (which is the same or similar to the initial
orthotic worn by the patient), which is worn for a sufficient time
by the patient post-surgery to stable condylar position criteria to
verify that the surgery has properly related the maxilla and
mandible to the stable condylar position. When necessary, the
method further includes dental restoration of the anterior
mandibular teeth (central and lateral incisors) to provide proper
anterior guidance.
[0103] While the present invention is described herein with
reference to illustrated embodiments, it should be understood that
the invention is not limited hereto. Those having ordinary skill in
the art and access to the teachings herein will recognize
additional modifications and embodiments within the scope thereof.
Therefore, the present invention is limited only by the claims
attached herein.
* * * * *