Butterfly deprogrammer

This page is technical and meant to be read by dentists

The butterfly deprogrammer is an extremely simple device, fabricated in about 20 minutes at chairside, for the immediate relief of recurrent tension headaches and the acute symptoms of temporomandibular dysfunction. It is useful as an aid in the diagnosis of TMD, and in the fabrication of a functional laboratory processed splint. It allows the general dentist to obtain a relaxed centric mandibular relation in which the condyles are located superiorly in their fossae without forceful manipulation.

The butterfly is unique among deprogramming devices in that it does not cover the maxillary occlusion and thus allows the practitioner to retrieve an accurate, totally relaxed bite registration while the patient is wearing the appliance. This bite registration can be used to mount study models for further treatment planning and for the fabrication of a uniquely comfortable bruxing guard. Most important, this form of therapy is non invasive and completely reversible.

Because it is quick and easy to make, inexpensive and well accepted by patients, the butterfly deprogrammer is an excellent first step in the empirical diagnosis and treatment of TMD. It is made with light cured composite used in the fabrication of provisional bridges and crowns (Triad from Dentsply), but could be fabricated from cold cure acrylic directly in the patient's mouth. The light cured variety is given its initial cure in the mouth by hand held VLC unit and its final cure in the light curing oven.

I first learned about the concept of deprogramming as an aid in the treatment of the symptoms of TMD in 1981 while attending a seminar given at Walter Reed Army Hospital by professor Peter A. Neff, who was at that time the chairman of occlusion at Georgetown University. The original deprogrammer is built using a stone model of the maxillary teeth. A vacuum formed splint is fabricated to cover the maxillary occlusion, and further modified with clear cold cured acrylic. The acrylic is used to create a small bite ramp (now called a discluding element) which makes contact at only one point, in the midline of the lower incisors. All posterior teeth are discluded by two or three millimeters. This disclusion, and single point contact on the mandibular incisal midline is maintained through all protrusive mandibular movements.

The rational for this form of treatment for TMD is well explained in lay terms in my page on TMJ. I hope you will take the time to read this page. Not all dentists will agree with me, but I have had great success using the butterfly deprogrammer if the patients are given a good explanation of its purpose and the type of results that are expected. The relief of symptoms is the result of a forced relaxation of the muscles of mastication, which in turn brings about relief of pressure on all anatomic structures including the TMJ, the muscles of mastication, the teeth and supporting structures. Deprogramming frequently brings about a shift in the position of the lower jaw leaving the joints in a more relaxed functional position which probably corresponds fairly closely to Dawson's definition of centric relation. The position thus obtained may correspond to the patient's centric occlusion, but frequently does not. The point here is that the condyles occupy a more centric and relaxed position in the fossae. This position is reproducible without forceful manipulation by the dentist. The patient simply taps the lower incisors lightly on the point of plastic several times and holds this position gently while a polysiloxane bite registration paste is injected between the teeth. Injection of the bite registration is possible because there should be approximately 2 to 3 mm between the upper and lower teeth when the patient is occluding on the deprogrammer.

Why Deprogram?

An anterior midline contact produces minimal temporalis contraction intensity and minimal joint strain, and tends to allow the TM Joints to translate slightly forward to rest against the eminence. Furthermore, an attempt to brux against an anterior midline discluding element produces sore lower incisors, which discourages further bruxing. Thus deprogramming is a simple trick to produce a forced relaxation of the temporalis, masseter and pterygoid muscles allowing the TM Joints to rest in a functionally comfortable position in the fossa. The butterfly deprogrammer, followed by a bruxing guard built using the new functional (deprogrammed) bite registration can bring about immediate and permanent relief of pain in a majority of TMD cases. Symptoms relieved include a reduction in tension headaches, ear aches and the neck stiffness associated with parafunction. Sensitive teeth and "phantom toothaches" in otherwise healthy teeth frequently respond to this form of treatment. Crepitus and popping of the temperomandibular joints may be lessened or relieved.

The deprogrammer accomplishes three goals

The deprogrammer should bring about nearly immediate relief of acute symptoms. In general, pain is reduced or eliminated within one or two hours of insertion of the deprogrammer. Muscle relaxants, analgesics or other drugs are generally unnecessary.
The butterfly deprogrammer helps to confirm the diagnosis of TMD, and the appropriateness of jaw repositioning as a treatment. I have found that in cases where the butterfly deprogrammer does not bring about sufficient relief from pain, the construction of a functional appliance will be of little benefit. While this does not mean that jaw repositioning therapies are entirely inappropriate, it does imply that the practitioner should be wary and rule out other causes for the patient's pain before proceeding with expensive therapies.
The butterfly deprogrammer brings about relaxation of masticatory structures, and allows for the determination of a functional centric jaw relation and the construction of a "deprogrammed" bite appliance. Any symptoms of TMD that have been relieved by the use of the deprogrammer should be also be corrected by a properly fabricated deprogrammed bruxing guard. Unfortunately, bruxing guards, even deprogrammed guards, do not always relieve tension headaches since the patient can still clench against the guard. Even so, patients often experience a reduction in the frequency and intensity of tension headaches.

In the end, the ability to register an accurate functional centric jaw relation without the use of fully adjustable articulators, face bow transfers or passive manipulation by the dentist is probably the most important advantage of using this simple appliance.

Fabrication of the butterfly deprogrammer

The advent of light cured composites that do not shrink or distort upon curing has made it possible to build the butterfly deprogrammer at chairside. I use the Triad system (Dentsply). The composite most suited to this appliance is the VLC provisional crown and bridge material. It is tooth colored and comes in ropes of convenient length. Its putty-like consistency and its slight stickiness allow it to be molded (with lubricated fingers) without sagging or falling away from the teeth provided that the teeth and palatal gingiva are fairly dry. One half rope is sufficient to build the appliance for most patients.

First ask the patient to close their teeth together in their normal centric occlusion. Note the depth of the bite and the alignment of the upper and lower midlines. Also note the degree of overjet. This will give you a general idea of the position and height of the bite ramp. (This will be in contact with the lower midline, or if the lower teeth are very uneven, the point will be broadened to contact several lower incisors.) The bite ramp will open the bite two or three millimeters.
Dry the patient's upper teeth thoroughly with the air syringe. SEVERE undercuts such as those found under a pontic or under extremely tilted teeth should be blocked out with soft wax. Lubricate your own gloved fingers with petroleum jelly, or with the patient's own saliva, or with the model separating medium that is supplied with the Triad system.

Begin by applying 1/2 rope of uncured tooth colored provisional crown and bridge material to the palatal gingiva and the lingual aspects of the dried teeth. Start just distal to the second bicuspid on both sides. Be sure to press it into all embrasures and undercuts on the palatal aspects of the teeth.

Try not to bring the material over the occlusal surfaces of the teeth. Any material covering the occlusion will be trimmed away later. Continue pressing the material anteriorly and around the palatal of the arch, in a horseshoe shape. There should be ample material in 1/2 rope to leave a substantial bulk built up on the lingual aspects of the teeth, and over the palatal gingiva.

Now begin to bring some of the bulk forward toward the midline. It should be built up into a pointed ramp which in most cases lies in the midline between the maxillary central incisors.

The ramp will make contact with the lower anterior midline, provided that the lower incisors are not too uneven.

The point should be broadened into a plane contacting as many incisors as necessary to prevent the ramp from locking the lower teeth into any fixed lateral position, or otherwise interfering in any way with the free movement of the lower jaw as it slides over the ramp. The finished ramp should completely disclude all posterior teeth during all functional jaw movements. Most of the time, the length of the discluding element should allow for a minimum freeway space, however, relief of tension headache sometimes requires an elongation of the discluding element beyond the minimum required to provide for a minimum freeway space. Sometimes as much as 2 to 3 mm.
After initial shaping, the appliance can be light cured right in the mouth. Since I do all my fillings in light cured composite, I use high powered PAC lights which shorten my curing time considerably. In any case, It is necessary to cure the material only to a medium stiffness so that it can be removed from the teeth, and then replaced and cured further. This step allows for a well adapted appliance that is not locked into undercuts. When the deprogrammer can be removed from the mouth, and then replaced several times without distorting, it is ready to be placed in the light curing oven. Cure the appliance in the oven for about 5 minutes.

After curing in the light oven, cool the deprogrammer under running water and reinsert it into the patient's mouth.

Check to see if the posterior teeth are discluded when the patient bites on the ramp. Upon occasion, the shift in the position of the mandible can be so great that one side or the other of the posterior teeth can still make contact in some excursions. If this happens, the ramp can be modified after it is cured.

It generally does not have enough retention yet to remain in place, but it should fit into the embrasures and over the palatal gingiva , and not rock or cause pressure that the patient finds uncomfortable.

In order to make the appliance snap snugly into the palatal aspects of the patient's teeth, it is usually necessary to reline it.

There are a number of options for this step, but I use the Triad LiteLine gel. Dentsply sells this material to fabricate removable appliances on plaster models. Two tubes come with the light, so anyone who uses the triad system usually has some on hand.

A dab of the gel is placed into each tooth indent in the appliance, the patient's teeth are wet with water or saliva, and the appliance is replaced on the teeth. Intraoral curing of this material is done with the VLC light through both the plastic of the appliance and through the teeth. Note that the Lite-Line material gets hot while curing, however I have never found this to present a problem.

Removal of the appliance from the patient's mouth is accomplished by inserting a heavy instrument such as a crown remover between the palatal tissues and one of the posterior flanges of the appliance and pulling. I have never actually had to deploy the spring in the crown remover to supply a shock to remove the appliance.

Once removed, the appliance is trimmed, polished and the patient instructed in its use. The patient should be able to insert the appliance by lining up the ramp with the incisal midline and snapping it in. Removal is accomplished by slipping a fingernail under a posterior palatal flange and pulling down.

Within a few minutes of inserting the deprogrammer, the dentist may notice that the position of the lower jaw begins to shift as the muscles relax.

In extreme cases, the entire mandible may tilt and shift to one side necessitating a change in the position and length of the ramp so that it again occludes with the mandibular midline and all posterior teeth are out of occlusion. This is easily accomplished by applying Triad bonding agent and additional composite to the ramp.

How to use the butterfly deprogrammer

The butterfly deprogrammer should relieve the symptoms, confirm the diagnosis and assist in the construction of a permanent bruxing appliance. I consider the butterfly deprogrammer to be a disposable appliance, so I generally tell the patient that it is to be worn only during the course of active phase I dental treatment. It may be worn while sleeping and at other critical times of day when the patient is likely to be bruxing or clenching. Since it is a "throw away" appliance, it may be modified and "refitted" to accommodate changes in the dentition during the weeks or even months it may take to do fillings and produce an overall state of good oral health.

It should be worn continuously for the first 24 hours except when eating or performing dental hygiene. After that, the deprogrammer may be worn while sleeping and at times when the patient is likely to be bruxing or clenching her teeth, such as while working at a computer terminal, driving a vehicle, or concentrating on a task. Patients generally learn quickly when to wear the appliance. If the deprogrammer has been properly constructed, the patient's symptoms should be reduced or eliminated within 24 hours. In most cases, symptoms abate within one hour. The relief can be so dramatic that patients don't seem to mind the appearance and they quickly learn to speak while the programmer is in place.

Three days of conscientious use of the butterfly deprogrammer should be enough time to evaluate the case. A majority of cases will clear completely while a few will have no demonstrable relief from symptoms. It can be assumed that any symptoms relieved by the deprogrammer will be permanently relieved by a deprogrammed bite guard, and the decision of whether to proceed or to refer will be based upon the dentist's clinical judgment modified by the patient's informed consent. If the deprogrammer produces little benefit, proceeding with a guard or other jaw repositioning therapies may be ill advised.

Update: Since the introduction of the NTI-TSS device, many dentists have become familiar with the concept of deprogramming. Over the past few years, many dentists have come to the conclusion that a deprogrammer, such as the butterfly deprogrammer presented here, may be used as as a permanent appliance for the suppression of bruxing and the treatment of TMD. The discluding element (the point that makes contact with the lower incisors) has been found to replicate an alternative incisal bite which allows the joint to be seated in a natural loading position. The advantage that deprogrammers have over and above even a deprogrammed bruxing appliance is that they tend to reliably reduce or eliminate tension headaches as well as symptoms of TMD.

Taking and using a bite registration

The patient should be allowed to wear the deprogrammer on and off for several days prior to taking a bite registration. Just before the bite is to be registered, the patient should wear the deprogrammer continuously all day until the appointment time. We usually schedule this appointment for the first thing in the morning instructing the patient to sleep with the deprogrammer in place and remove it only to eat and brush the teeth. Otherwise, the patient's posterior occlusion should be discluded for as long as possible before the appointment.

With the deprogrammer in place, have the patient sit in an upright position and gently tap the lower teeth against the bite ramp a few times. NOT HARD! when the dentist is satisfied that the position of contact of the ramp with the lower teeth is stable and reproduced with each tap, have the patient hold the lower teeth gently against the ramp. Now begin injecting the Blue Mousse (or Regisil) between the teeth starting on the posterior teeth on one side, and continuing anteriorly being sure to overlay the buccal cusp tips and incisal edges of all teeth while injecting around the arch to the posterior teeth on the other side.

With the deprogrammed bite in hand, remove the deprogrammer and take alginate impressions of upper and lower teeth to send to the lab. Ask them to mount the teeth using the Regisil bite, and not to change the vertical dimension when building the bruxing guard. I prefer a hard acrylic flat plane guard for heavy bruxers, although the newer Thermoflex or ValPlast materials make fitting the guard much easier since warm water softens the plastic and allows the appliance to self adjust to any discrepancies in the exact fit to the teeth. In situations involving intractable hard bruxing, however, flexible plastic may be too easily indented to retain a flat plane over the long haul.