In my practice, I first meet with a new patient to review medical and dental history as well as gain some understanding of current symptoms.
Patients who have night guards often complain to me that symptoms are worse in the morning with increased clicking and sometimes even jaw locking. The locking may go away after a several minutes and a few gently forced jaw openings.
What is going on here? There are a few possibilities. What I find most often is a night guard that is poorly balanced, with one side hitting much too hard when the person closes. It’s not unusual to see one tooth, usually a lower second molar, in heavy contact with the night guard. This is a recipe for a night guard spending its nights alone in a dresser drawer. But let’s assume that the patient has a night appliance that is well balanced right to left and also has proper anterior-posterior contact as well. Now, what’s going on?
In this situation, I ask the patient a few additional questions. When you wake up and you’re clicking or locking, which side is affected? And tell me about sleep posture? Stomach sleeper? Side sleeper? Which side?
The common scenario? The person sleeps on her stomach with her head turned to the left. The right side of the face or chin is either supported by her hands or the pillow or both. And which side clicks and locks? The left.
Assuming the locking and clicking goes away with a few mouth openings, this describes the Piper stage II disc displacement—the earliest and least serious displacement. See the following link: http://www.piperclinic.com/classifi.htm
Obviously, when I’m dealing with a stage III or IV or even arthritic situation, I recommend 24 hours per day stabilization: a day positioned orthotic plus a night appliance of appropriate design.
As part of my new patient interview, I always want to know about sleep posture. For the people who state they are side or stomach sleepers and also have significant clicking and locking upon awakening I generally make a special night appliance designed to prevent significant lateral movement.
For a time, I used the SomnoMed snoring/apnea appliance in this situation, but then came up with a simplified, one-piece design that accomplished the same lateral stabilization.
For the person who displaces to the side due to pressure on the side of the face either from hands or pillows, this design has been the answer—it’s very comfortable and patients report no morning clicking or locking.
It should be possible for any laboratory that has experience in the fabrication of oral appliances to duplicate this design; however I send these cases to True Function Lab in Southern California.
Keep this design in mind. In certain situations, it is the key to all night comfort without morning clicking and locking.