Part IV/IV Post OJW examination and removal of the appliance.
After being in OJW for five weeks the patient removes the wires for five days during which time the patient is advised to do exercises (such as those described previously), in order to keep the TMJ limber (chewing gum is an excellent one). If the patient returns to your office still wired after a period of being wired for five weeks or longer you should remove the wiring and not replace it for at least five days of rest/exercise or until the patient is asymptomatic (assuming your exam reveals signs of joint stiffness).
WHAT TO DO FOR THE OJW PATIENT AT THE FOLLOW UP APPOINTMENT:
1. Check for any stiffness or other dysfunction in the joint. If the joint is stiff (use the 3 fingers vertical placed 1" into the oral cavity as a definitive test). If the patient experiences no discomfort you are at liberty to rewire them for another five week period.
2. Check the ease with which the patient can make all other excursions (centric occlusion, protrusive and right and left lateral with teeth together, and with the mandible at about .5" (15mm) open. Any limitations or discomfort should be noted and the operator should carefully decide whether to rewire the patient or delay rewiring another five days, or until the patient is asymptomatic.
3. The inside of the teeth should be given a prophylaxis and a scaling of the lower anterior teeth may also be indicated.
4. The gingiva should be examined to determine the extent to which poor oral hygiene may have contributed to deterioration of gingival health.
5. The teeth should be examined for mobility or soreness since parafunctional occlusal activity like bruxing may have been initiated by the presence of the OJW appliance and the proximity of the upper and lower teeth to each other.
6. If you have initially recorded the patient's weight you should now record it again. Remember it is NOT your responsibility if the patient loses weight or not. It is your responsibility to recognize and correct any conditions that the OJW appliance may have caused to the patient's hard or soft tissues.
7. Any brackets that have detached are replaced.
8. The jaws are rewired in "Rothstein's OJW rest position" with .014"-.016" dead soft stainless steel wire. In this position the upper and lower teeth do not touch each other and the mandible is allowed to move 1.5-2.0 mm in all directions This position is easier to achieve with .014 wire, the size of wire I prefer to use most often. In addition, the patients who you teach to do the jaw wiring at home will have an easier time rewiring themselves when using .014 wire.
It is judicious practice to send a reminder note to those patients who miss their appointment. Such a note would remind the patient that they must remove the wiring to allow their jaw joints to be exercised and that by not doing so they risk incurring harm to their teeth, gums or jaw joints.
In essence your OJW patients should be treated and cared for in the same way as any other of your orthodontic patients, and those who have neglected to keep their appointments are patients that should concern us and propel us to take action lest harm come to them.
Your OJW patient's office visit should be recorded in their treatment record and they should be advised when you believe they should discontinue the OJW method of control of overeating. If you do believe that rewiring is contraindicated then do not rewire them until that time comes that you would consider it is in their best interest to do so.
REMOVING THE APPLIANCE
Most often the patient will simply let you know in advance that they wish to have the OJW removed. In my office I make no charge for removing the twelve brackets that I placed on their teeth. I remove the brackets, the adhesive and prophy the teeth. I am careful to examine the patient in the same manner as I have done in previous visits and to let the patient know if I noted anything that might be of consequence to them. I chart the findings of my final exam. I do not take another panoramic X-ray.
Brackets can be easily removed most often with minimal, or no distress at all to the patient using a variety of instruments. However, the "bracket removing" instrument offered by 3m Unitek or Ormco, or many other orthodontic pliers companies are the recommended instruments to peel the brackets off.
April 6, 2005.