When TMJs are inflamed, mandibular orthopedics can protect the bruised retrodiskal tissues, eliminate the inflammation and thereby stop the reflex jaw muscle bracing. Once the TMJs are no longer inflamed and the occlusion is stable, direct treatment of the jaw muscles can eliminate any remaining myogenous symptoms, and the whole masticatory system can be rehabilitated to acquire healthy function. Healthy function then produces stable adaptation that is resistant to injury.
Different types of TMJ disorder conditions require different types of mandibular orthopedic appliances and treatment modalities. Our most commonly used are outlined in the following text and described in detail elsewhere on this website. These include:
- Joint protective stabilization appliances
- Joint protective telescopic appliances
- Pivoting for unilateral condylar distraction
- Orthopedic disk recapturing
- Maxillary front flat bite plate appliances
- Thin rubber occlusal cushion appliances
- Bite restoring appliances
- Occlusal stabilization
- Occlusal alteration
- Functional orthodontics
TELESCOPIC APPLIANCES have several advantages for protecting damaged TMJs. The hardware that provides the protection is located between the teeth and the cheeks where it cannot interfere with normal tongue posture. Having all upper and lower teeth embedded in acrylic prevents any unwanted tooth movement. In addition, telescopic appliances can include a stabilization type of bite that contacts all around the dental arch, a front flat plate type of bite that hits only the mandibular anterior teeth, a unilateral pivot to distract a condyle from an inflamed TMJ, and other therapeutic occlusal surfaces.
Unlike the Herbst (and SUAD) appliance telescopic hardware, which was designed more than a half century ago for orthodontic bite jumping in children with class 2 malocclusions, we use telescopic hardware that was designed for adults. Its advantages include a lower profile for comfort because the components are flattened to fit the buccal vestibule, freedom of mandibular movement laterally to ensure long term TMJ health, and micro-adjustability on each side by the patient at home in .014” increments without special tools.
Upper front flat plate appliances worn during sleep have short term and long term effects. From the first night they are worn, they significantly reduce the strength of nocturnal bruxism. Over the course of weeks, they deprogram the jaw muscles in order to reveal an unstrained mandibular closing trajectory that can be used to evaluate the health of the occlusion. Over the course of years, they redirect the large compressive forces of nocturnal bruxism onto the anterior teeth in order to intrude them and thereby gradually reduce overbite.
When the joints are no longer inflamed, front flat plate appliances often eliminate headache. We don't understand much about the mechanisms behind headaches, but we do know that the elevator muscles can apply significant pressure to the head during nocturnal bruxism, and front flat bite plate appliances reduce those forces by about half. Compared to the NTI appliances, which also eliminate posterior occlusal contacts in order to diminish the jaw muscle forces during nocturnal bruxism, the front flat plate appliance is more stable and less likely to cause unwanted tooth movement.
BITE RESTORING APPLIANCES usually take the form of two unilateral acrylic segments that fit tightly over the posterior teeth and are used to refine and try out a new proposed occlusion. In most people they are worn for at least a couple of months to be sure the new occlusion is effective and to allow a little wearing in that improves the fit, especially in lateral excursions used for chewing.
RUBBER OCCLUSAL CUSHION APPLIANCES are used days to relieve jarring occlusal impacts in people who have neuromuscular systems that have been sensitized by chronic pain and to cushion the exercise template in people who clench on unstable occlusions. These inexpensive appliances do not impair speech. However, rubber appliances should not be worn during sleep, because they evoke chewing activity, usually coupled with dreams of eating.
OCCLUSAL STABILIZATION may be needed for long term TMJ health, because a stable occlusion gives the mandible a consistent home base that enables the TMJs to acquire the same goodness of fit found between the articulating components of all healthy joints. In TMJ disorder patients, occlusions are frequently destabilized by disk displacement or degenerative remodeling, both of which shorten the affected condyle, or by TMJ swelling which effectively lengthens the affected condyle. Frequently TMJ disorder patients notice occlusal fluctuations due to periodic shifting between these conditions. After the inflammation is resolved and the joint surfaces are stable (no longer degenerating), restabilizing the occlusion may involve reducing high spots, building up low spots, moving teeth, or any combination of these. The choice depends on face height and the condition of the teeth. Stabilizing bites is discussed in THE ROLE OF THE BITE under TMJ DISORDERS. Occlusal stability and other aspects of occlusion are explained in great detail in the OCCLUSION files.
OCCLUSAL ALTERATION by changing the location of the central bracing position of the mandible (ICP or MI), involves dental work that can be expensive, therefore this modality is only used when it is necessary to relieve the symptoms or when the occlusion needs reconstruction anyway. It can be necessitated by iatrogenic dentistry, loss of tooth structure, or symptomatic bite strain.
OCCLUSAL REBUILD is frequently needed in patients who have been previously treated with an oral appliance that they were told to wear on a full time basis and which they wore for long enough to cause the opposing dentition to shift until its occlusal contours fit the surface of the appliance rather than the surface of the opposing natural teeth. When the appliance is removed, there is no longer a stable natural occlusion. In treating these cases, providing sufficient occlusal support to allow freedom from daytime wear of the oral appliance is the first step toward finishing the TMJ treatment. Occlusal rebuild can also be necessitated by excessive wear, tooth loss, or the mandible outgrowing the occlusion as is occasionally seen after using a jaw protrusion appliance to treat sleep apnea.
We allow a period of time during which the patient can wear in and test out the new therapeutic occlusion before making it permanent by transferring it to the natural teeth. First the proposed new occlusion is created on a provisional basis using tight fitting unobtrusive unilateral removable bite restoring appliances that don’t impair speech and can be worn all day including while eating. After that new occlusion has proven effective at eliminating the symptoms for at least a couple of months, it is usually transferred to the teeth by bonded composite resin onlays for a provisional period. Finally, after more stabilizing and refinement of the new occlusion, the composite resin is replaced with gold or porcelain, usually performed by the patient’s general dentist with Dr. Summer providing any support required.
ORTHOPEDIC DISK RECAPTURE may be needed for patients who find that nothing provides relief as long as a TMJ disk keeps shifting in and out of place. Finishing a disk recapturing case requires permanently changing the occlusion, so this treatment is only used when simpler treatments have failed and the prognosis for recapture is excellent or when most of the posterior teeth need restoration anyway. To help identify anatomical features affecting the prognosis for disk recapture, Dr. Summer collaborated with the leading TMJ radiologist to perform and publish a study using before and after MRI on 119 joints undergoing this treatment. Reprints of this study are available by request.
Many of the early attempts at orthopedic disk recapture in the 1980's and 1990's failed, because the treating dentists did not understand how to reconstruct a new occlusion that maintained the correction. Frequently the teeth need contours that are at least slightly different from those seen on natural teeth, requiring extensive communication with the dental laboratory.
For treating and for preventing TMJ disorders, functional orthodontics has important advantages over esthetic orthodontics (braces and invisalign). Removeable oral appliances can support the mandible in an orthopedically ideal position while simultaneously moving the teeth into positions which can produce a stable intercuspal position there. The appliances can also stimulate jaw muscle development by protecting damaged TMJs and providing an ideal template for jaw muscle exercise. Palatal expansion can be added to enlarge the nasal airway or to increase the space available for crowded or newly erupting teeth. Gradual palatal expansion can be accomplished effectively and retained in adults if the post treatment occlusion is stable and functional.