Our unique niche in the treatment of TMJ disorders is using orthopedic principles to control the mechanics in the joints.  Because the movements of the mandible are affected by the contours of the bite platform as well as the TMJs, applying orthopedic principles frequently involves altering or at least understanding the bite.  Our philosophy regarding treatment of the bite is explained in the paper entitled THE ROLE OF THE BITE under the drop down menu entitled WHAT IS TMJ.  

In contrast, most other health care practitioners treat TMJ disorders by palliative methods such as oral appliances which stretch the mandibular elevators by creating a temporary increase in the vertical dimension of the bite, restoring the ranges of motion and resting postures of the mandible and the cervical spine, and advocating soft foods or lifestyle changes that enhance overall adaptive capacity.  These therapies are used to “manage” the disorder.  They often create temporary reduction of symptoms, but they don't create lasting resolution of the underlying condition, because they don't address the cause of the problem.  

The vast majority of TMJ disorder patients originally develop symptoms as a direct result of the displacement of the articular disk in at least one TMJ and the subsequent bruising of the retrodiskal tissues which got pulled into the space between the bones where the disk had been.   When the disk is in place, it functions as a cushion and a lubricant in the TMJ.  After a disk has been dislocated, the involved TMJ functions without normal cushioning and lubrication, and even normal function can result in damage.

The muscles get involved, because they are responding organs.  Triggered by an arthrokinetic reflex, inflammation in any joint produces protective bracing in the muscles which cross that joint.  Protective bracing causes increased resting tension and reduced functional tension.  The muscles hold themselves tight at rest, and they fire weakly during function - as if they were constantly on guard.  An inflamed TMJ produces protective jaw muscle bracing, just as an inflamed ankle causes protective leg muscle bracing, which we see as limping. 

Longstanding muscle bracing can cause pathologic muscle tissue changes which may be difficult to reverse.  Individual muscles lose resting length, develop trigger points, and cause pain in a surprisingly wide variety of locations (known as referred pain).  Indeed, muscle tension is directly responsible for many of the symptoms of TMJ disorders.  The balance among muscle groups is also affected, causing postural strains which can affect the whole body.

Fortunately, there are many health care workers well qualified to treat muscles. Physical therapists, chiropractors, and massage therapists are especially well trained to treat tight muscles. For that reason, we leave the muscle treatment to them.

Like jaw muscle treatment, more general medical treatments that work by increasing overall adaptive capacity also can temporarily eliminate symptoms without addressing or resolving the underlying cause of the problem.  Better enabling the patient to adapt to the strain can provide relief of the effects of the strain without ever removing or diminishing the strain.  If the enhanced adaptive capacity leads to structural adaptation (such as pseudodisk formation), the relief can last.  However, with the strain still present, a minor injury or a period of high central nervous system stress can re-trigger the symptoms. 

Treating the muscles without also eliminating the cause of the muscle tightness is like using massage or physical therapy to treat the leg muscles of a patient walking around on a damaged ankle.  The therapeutic treatment of the muscles provides good short term relief, but the problems return shortly after the patient gets off the massage table and resumes walking on the damaged ankle. 

At the TMJ clinic, we address the root of the problem by using orthopedic mechanics to protect the TMJs, eliminate the inflammation, and thereby stop the reflex jaw muscle bracing.  Once the joints are no longer inflamed, direct treatment of the jaw muscles can provide relief that lasts, and the whole masticatory system can be rehabilitated to acquire healthy function.  Healthy function produces stable adaptation that is resistant to injury. 

Because even untreated TMJ disorders naturally resolve in time due to fibrosis of the retrodiskal tissues, we keep the treatment proportional to the symptoms.  Most people with TMJ disorders don't need extensive or expensive treatment to eliminate the symptoms on a long term basis.  Most need only a stable natural bite and the right kind of oral appliance to wear during sleep.  Some also need muscle work such as trigger point treatment, and a few need changes to the bite.  We always start with the simplest treatment which is likely to provide relief in each case.

In addition, we tailor our treatment to the needs of each patient.  Unlike most TMJ practices which provide one type of oral appliance or one basic treatment plan for everyone, we use a number of different treatment modalities and oral appliances, depending on the needs of the patient.  Some of the treatments we employ include:

• Stabilization Appliances
• Anterior Flat Plate Appliances
• Telescopic Appliances
• Pivoting for Unilateral Condylar Distraction
• Stabilizing the Existing Bite
• Establishing a New Bite
• Orthopedic Disk Recapturing
• Functional Orthodontics

STABILIZATION APPLIANCES fitting on the upper teeth and worn during sleep, are the simple path to long term relief in most cases.  A carefully sculpted bite table with freedom of movement centrally and localized anti-retrusive inclines provides an articular surface against which the jaw  muscles can exercise and brace without driving the mandibular condyles into the chronically bruised retrodiskal tissues.  Steep slopes on the anti-retrusive inclines are used for pure joint problems, shallow inclines or flat surfaces are used for pure muscle problems, and various combinations are used for everything in between.  When patients have severe symptoms such as headaches or ear problems that may have other causes, temporary stabilization appliances can be made chairside using a thermoplasic (rather than boil-and-bite rubber) to determine which symptoms are due to the TMJ condition before we undertake treatment for the condition.  Temporary thermoplastic stabilization appliances can also be used to provide inexpensive short term  relief for TMJ disorder symptoms due to a recent triggering episode such as a traumatic event or a long dental procedure.

ANTERIOR FLAT PLATE APPLIANCES are used to deprogram the jaw muscles to locate an unstrained jaw closing trajectory, to rapidly diminish the jaw closing muscle  forces applied during nocturnal bruxism, or to redirect the jaw closing muscle forces during nocturnal bruxism to gradually reduce overbite.  If  the joints are no longer inflamed, front flat bite plate appliances often eliminate headache.  Compared to the NTI devices which also eliminate back teeth contacts in order to diminish the jaw closing muscle forces applied during nocturnal bruxism, the front flat plate appliance is more stable, safer, and less likely to cause unwanted tooth movement.

TELESCOPIC APPLIANCES  maintain protection for the TMJs even when the mouth is open.  We use extremely sophisticated and versatile telescopic appliances.   In contrast to the commonly used Herbst telescopic appliances which were designed for bite jumping during orthodontics in children, our telescopic appliances have a low profile because the components are flattened, allow freedom of movement laterally to ensure long term TMJ  health, and can be adjusted on each side by the patient at home in .014” increments over a 1/2” range without tools.  Because the TMJ protection is provided by the telescopic components located between the teeth and the cheeks, there is no interference with normal tongue posture.  Having all upper and lower  teeth embedded in acrylic prevents any unwanted tooth movement.

 PIVOTING  can be added to almost any type of appliance to provide quick relief for an inflamed TMJ  by distracting the affected condyle.  To be effective, the pivot must be unilateral and located distal to the first molars.  A correctly placed pivot allows the patient to bite forcefully without the pain which is experienced by biting forcefully on the natural teeth.
                                                                   
STABILIZING THE EXISTING BITE may be needed for long term TMJ health.  A stable bite gives the lower jawbone a consistent home base which enables the TMJs to acquire the same goodness of fit seen in all healthy joints.  In TMJ disorder patients, bites are frequently destabilized by disk displacement or degenerative remodeling, both of which shorten the affected condyle.  Bites can also be destabilized by TMJ swelling which effectively lengthens the affected condyle.  Frequently TMJ disorder patients notice fluctuations in the bite as swelling in the TMJs fluctuates.  Stabilizing of the bite cannot be successful until the inflammation is resolved.  Subsequently, restabilizing the bite may involve reducing high spots, building up low spots, moving teeth, or any combination of  these three.  The choice depends on face height and the condition of the teeth.

ESTABLISHING A NEW THERAPEUTIC  BITE may be needed if the symptoms return every morning after the night appliance is removed.  Changing a bite can require dental work which is expensive, so we are careful to  establish, test, and refine the new therapeutic bite before transferring it to the natural teeth.  The process involves first creating the proposed new bite with tight fitting unobtrusive unilateral removable bite restoring appliances which don’t impair speech and can be worn all day including eating. After that new bite has proven effective at eliminating the symptoms, it is then transferred to the teeth using composite resin or provisional restorations.  Only after several more months of stable relief, the now well established new bite is made permanent with crowns or onlays, usually performed by the patient’s general dentist with Dr. Summer providing any support required.  The miconceptions associated with the major bite philosophies are described in the paper entitled THE ROLE OF THE BITE in the drop down menu underneath the heading WHAT IS TMJ.

Re-establihsing a  stable bite is the path to freedom from reliance on full time wear of an oral appliance for many patients who have been previously treated with an oral appliance which they were told to wear on a full time basis.  In many of these patients, the biter has adapted to fit the appliance, and there is no longer  a stable natural bite when the appliance is removed.  Freedom from the need to use the appliance during daytime hours is necessary for long term dental health.  This freedom may be accomplished with functional orthodontics or building up some of hte teeth to stabilize the natural bite.

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 bite, so this treatment is only used when simpler treatments have failed and the prognosis for recapture is excellent or when most of the back teeth  need  restoration anyway.  Most of the early attempts at non-surgical disk recapture in the 1980's and 1990's failed because, due to the extensive confusion in dentistry regarding the bite,  the treating dentists didn't understand how to reconstruct a new bite which maintained the correction.  To help identify anatomical features which affect 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 available.

FUNCTIONAL ORTHODONTICS  uses removeable oral appliances to align the jawbones as well as the teeth.  Compared to esthetic orthodontics (braces and invisalign), functional orthodontics has important advantages. 

One important advantage of functional orthodontics is that it can maintain the ideal mandibular bracing position while moving the teeth to support the mandible in that position.  Braces make it impossible to wear any kind of oral appliance at night when most TMJ disorder patients need support for the mandible.  Therefore if braces are used to finish a TMJ disorder case, the patient must give up wearing an oral orthopedic appliance at night  for the couple of years it takes to align the teeth.   In contrast, when functional orthodontics is used to finish a TMJ disorder case, the same appliance which relieved the TMJ disorder symptoms is often modified to also move the teeth into positions which permanently support the mandible in its corrected posture.  Thus the TMJ protection can be maintained during the orthodontics.  Invisalign can also be incorporated into some TMJ protective oral appliances.  

A second important advantage of functional orthodontics is that it can be used  to stimulate jaw muscle development by protecting damaged TMJs and providing an ideal template for the jaw muscles to exercise against.  Functional orthodontic appliances were originally designed to stimulate jaw muscle development.  They were called "activators" because they activated the jaw closing muscles.  Activating the jaw closing muscles was a way of stimulating their development.  Studies have shown that jaw muscle development is important for healthy facial growth and that facial growth continues throughout life.  Strong jaw muscle development increases bite stability and diminishes the asymmetrical and retrusive facial growth patterns which frequently produce TMJ disorders.  In contrast, braces cause a loss of jaw closing muscle forces automatically in response to the sore back teeth which result from each tightening of the braces.  This effect has even been shown to result from the separators which are used at the first appointment to make room for the bands which will need to be attached to the teeth.

A third important advantage of functional orthodontics is that palatal expansion can be added to enlarge the nasal airway or to increase the space available for crowded or newly erupting teeth.  The roof of the mouth is the floor of the nose, and consequently expanding the palate widens the base of the nasal airway passage.   For some obligate mouthbreathers, palatal expansion can correct the structural problem which prevents normal nasal breathing. 

THE NEW MULTILEVEL ORAL APPLIANCE FOR MORE EFFECTIVE TREATMENT OF OBSTRUCTIVE SLEEP APNEA
Current oral appliances have not been effective enough to cure most cases of sleep apnea, because they have only been available as a single level therapy, while most sleep apnea is characterized by multiple sites of obstruction at different levels of the pharynx.  Current oral appliances can either hold the mandible forward, hold the tongue forward, or hold the back of the tongue down.  Each of these three treatment modalities operates at a different level of the pharynx.  The three treatments are synergistic because of the anatomy of the pharynx. The mandible is the base of operation for the tongue which has no bone of its own.  Therefore protruding the tongue helps protrude the mandible, and protruding the mandible helps protrude the tongue.  Protruding the tongue makes the tongue rear more accessible for tongue rear depression, and depressing the tongue rear helps hold the body of the tongue in protrusion.  Thus combining the three treatment modalities can increase the effectiveness of each treatment modality without compounding the discomfort of each. However until now the three treatment modalities have never been combined, because the mechanics they require have been incompatible - until now.

We’ve developed and tested a novel tongue holding device (THD) which is entirely made of dental acrylic and grips the tongue between thousands of miniature plastic bristles all slanted forward like directional Velcro. The tongue can easily slide forward into the THD, but it cannot be pulled out of the THD until the mouth is opened wide enough to activate the tongue release mechanism.  A pilot study for the FDA showed the THD was tell tolerated, safe, and effective.
    
In the first multi-level oral appliance (ML-OA), the THD is combined with titrated jaw protrusion and tongue rear depression to extend airway protection to all levels of the pharynx.  The protrusion of the mandible and the THD along with the tongue is maintained by a telescopic (Herbst type) appliance which has been redesigned for use in sleep apnea with a lower profile for increased comfort, a free lateral range of motion to ensure TMJ health, and micro-adjustability in .014” increments over a one inch range without tools for easy titration of mandibular position.  The tongue rear depression is provided by a smooth tongue contacting portion extending from the posterior end of the upper tongue gripping surface on an adjustable arm.  With all three of these treatment modalities operating simultaneously at different levels of the pharynx, we expect the ML-OA to eliminate sleep apnea in most patients.  In addition, we use home monitoring equipment to adjust each of the three treatment modalties to best fit the needs of each patient.