Play Inside the Box
By Richard Drake, DDS – May 2019 DSM Insider
Did you have a sandbox when you were a kid? Some nice clean sand mixed with a little water and some of mom’s Tupperware, all the ingredients to build an awesome castle. For reasons to complex to figure out, this got me thinking about titrating our dental devices. Remember the envelope of function as taught in freshman dental school, and that from a full protrusive position you lose the ability to move forward as you open more? You do recall that, right?
IWhen you think about what you have control over with OAT, it’s not much; the fit, the vertical, and the protrusion. So all your perfectly fitted device needs now is the correct vertical and protrusive position. Therein lies the challenge.
Imagine placing a dot on the lower incisor, open a little; move the jaw forward as far as you can; open a few millimeters more and then move the jaw back all the way. There you have it. Our final treatment position will be somewhere within that rectangle. I’ve heard it called many things, but “Drake’s Box” seems to have a musical ring to it, don’t you think?”
So, until I have littered that box with multiple points, I do not concede that a dental device “just isn’t working.” Armed with this knowledge, be sure to pass that along every time you do a lunch and learn for a physician. Just yesterday I said to an MD, “I’m pretty good at helping the patient find the sweet spot, but often times I need more than a single guess.” Only allowing the patient to test at a single jaw position is like having a CPAP machine that is stuck on 7cm of H2O. Please don’t tell the patient that it’s not working. Instead, explain that we simply need to adjust her device. Don’t be afraid to pick up a pen and draw Drake’s Box (hoping that with repetition it’ll catch on!) and explain this to your patients, to physicians, NPs and PAs.
In summary, the best advice I can pass on for now:
- Less vertical is more comfortable, but MOST people require more vertical
- Large tongues and males require more vertical
- Mouth breathers require more vertical
- Elastics and chin straps are aids to control the vertical
- Sometimes, opening vertical is ALL you need to do
- If you start at 70% of max, you’ve gone too far
- Some patients do better with less protrusion
- Slow, slow, slow titration is the key
- No cats allowed in Drake’s Box!
