Last week I talked about working with the provisionals on a patient I believe has a restricted envelope of function, mentioning that he reported waking with a headache the first few mornings after we placed the provisionals. I believe he needs more freedom in the anterior, and breaking the provisionals and the morning headaches support this theory. Patients who need more anterior freedom can present with signs and symptoms that affect their teeth, muscles, joints or all three. I find it helpful to puzzle through what is happening anatomically as a way to make sense of signs and symptoms I see.
Patients who are trapped or locked in the anterior can either spend significant time in this position with their posterior teeth touching, try to create more space, or move their mandible forward and rest in a forward position. Each of these adaptive strategies and the amount of time the person does each one create the patient’s presentation. The next question to ask yourself is what is the position of the condyle , is it being pushed posteriorly, and what are the muscles doing to protect the joint and the teeth? Each patient presents with a unique combination of signs and symptoms, but their combination can be overlaid on their occlusion and what they do with their teeth. Here is a list of the most common signs & symptoms I see in patient’s with a restricted envelope of function.
- Upper Anterior lingual wear
- Lower Anterior incisal edge and labial wear
- Upper anterior lingual ledging
- Anterior fremitus/mobility
- Anterior diastema opening
- Upper anterior flaring
- Loosening or fracturing anterior provisionals/restorations
- Retrodiscal tenderness/pain
- Digastric tenderness/pain
- Posterior Temporalis tenderness/pain
- Elevator Muscle tenderness/pain