What Happened Here?

Maybe the posterior teeth re-intruded after the ortho was taken off- based on the posterior open bite and the slight discrepancy in the occlusal plane of the molars to premolars. Loss of posterior support, joint loading, compensating and antagonistic muscles firing to try to regain contact- leading to muscle and joint pain.

Can you show us the CBCT image of the condylar position? Was the orthodontics done with centric relation in mind or arbitrarily?

Is provocation test positive? Possible pain originationg in inferior lateral pterygoid.muscles may cause an acute malocclusion.

Is there a picture shows the bite before using the deprogramer? Thank you

Dislocated disc with muscle splinting.

Update, I've talked to a couple of orthodontists who are heavily involved with invisalign. They tell me that a posterior open bite is not an uncommon problem with Invisalign. It is due to improper preparation of either the interproximal areas of the posterior teeth or to inadequate attachments on those teeth. It is particularly common in Cl II malocclusions where teeth are erupted for various reasons. If the posteriors are not properly prepared, the aligners don't attach well and those teeth may not move--resulting in the open bite. Not sure that is what happened here but it is an interesting theory.

If you try to hand articulate the models do they fit well together? Another question to consider in this case: What is the best immediate treatment in such cases? At the end of the evaluation, what can you send the patient home with ?

We can send the patient home with an Equalizer and then to fabricate an equilibrated bite splint.

that's exactly what I did, sent her home with an aqualyzer and a prescription for 5mg of flexeril at bedtime. She came back four days later feeling much better. Now what should I do?

Keep the patient using the aqulizer. Try to equilibrate the models to get an idea if the problem would be solved.If not ,bring the teeth which are out of occlusion by adding composite resin to make the teeth touching evenlyor fabricate an equilibrated bite splint.

@ Arnie Mirza: Great Points. I know you have likely figured this out already but for the purpose of our learning here, let me ask a question When we try to equilibrate the models how do we know the initial articulated position of the models match with clinical position of patients teeth?

Now that the patient is comfortable, shouldn't you consider discussing the findings with the orthodontist? Were they aware of the patient's discomfort? How was the patient treated? What occlusal scheme were they trying to establish? Can additional ortho treatment correct the discrepancies that are present?

Stephanie, you are absolutely correct and that is the plan. I have the orthodontist's records but we haven't talked about what the treatment goals were. I don't indict anyone until all the facts are in and I don't know what transpired from that person's perspective.

As an orthodontist myself, I have had experience with this type of situation. When any major tooth movements occur, including the initial bracket placement or removal, the potential to cause stress within the TMJ's is always there, so if is sub-clinical problem happens to be present but not obvious to the patient or the doctor, the problem could 'suddenly' appear at that time. This happens due to the slight shifting of teeth and the accommodation that occurs within the muscles and TMJ's. A good analogy would be that the most dangerous time of an airplane flight is at takeoff and landing. I would bet that the occlusion, the muscles and TMJ's were not in very good balance when the orthodontic treatment (braces removed?) was completed. This probably precipitated muscle hyperactivity (clenching) which resulted in intrusion of the posterior teeth, deepening of the bite and a shifting of the mandible posteriorly. I would also like to see the CBCT scans, as there are still disagreements and changes of definitions about CR, so what really is normal condylar position? When was the scan taken; with the posterior teeth in occlusion, or after deprograming? Also, what type of retainers were places after the orthodontics? What does the rest of the occlusion look like? Was there a lateral tongue habit in play? Based on what I know, the orthodontist should consider using a Hawley type retainer with an anterior bite ramp, which would slightly advance the mandible giving protection to the TMJs, reduce the clenching tendency and allow super eruption of the posteriors, bringing them back into occlusion. If this is not successful, and tongue posture is a problem, consider seeking help from an orofacial myologist. The picture of the models make me question if the maxilla could be slightly narrow and not in good balance with the lowers. If this is the case then maxillary expansion should also be done to give a long term solution. If the CBCT scan shows posterior displacement with the posterior teeth in occlusion and I would suspect it does, then Class III elastics may be needed to allow the person to bite with condyles in a more forward position. The orthodontist may need to rethink the "finished her orthodontic treatment" position and make additional changes to correct the situation.

Sorry! This was a very old discussion, but I just saw it.