THE GOOD NEWS – no matter what treatment you receive, the symptoms are likely to go away in time. Except in cases of surgical failure, TMJ disorders are self limiting.  They are rarely symptomatic in older people, even though the anatomical structures of the TMJs (the temporomandibular joints) continue to deteriorate as seen on X-ray or MRI.  Studies of thousands of patients over long time periods have shown that, in the natural course of a TMJ disorder over time, the symptoms eventually “burn out” as the tissues of the TMJs undergo an adaptation characterized by fibrosis.

 

EVEN BETTER NEWS – in most cases, simple orthopedic support for the lower jawbone is all that's needed to enable damaged TMJs to adapt within days or weeks rather than months or years.   Thus there is no longer any justification for full mouth reconstruction (crowns on all the teeth), years of wearing braces, dozens of physical therapy visits, or long term pharmacologic “management” to treat TMJ disorder patients except in very rare cases.  The vast majority of people who develop TMJ disorder symptoms can permanently eliminate them by wearing the right type of oral appliance at night and ongoing  dental care which maintains a stable natural bite.   Only occasionally do people need a long series of office visits, extensive muscle work, a daytime appliance, or a complete change in the bite.

 

TREATMENT BY ENHANCING ADAPTIVE CAPACITY – Many treatments for TMJ disorders work by enabling you to better adapt to the ongoing stress of functioning with a dislocated TMJ or a strained bite rather than by eliminating the source of the stress. These types of treatment are often effective in the short run, because many people have a subclinical TMJ disorder for years until a loss of adaptive capacity due to central nervous system stress, injury, or some other disease condition causes the problem to become symptomatic.   After this triggerring of symptoms, the problem can often be returned to a subclinical state by any of a large variety of different treatments that serve to enhance adaptive capacity.  These treatments include relaxation, exercise, nutritional support, postural work, or eliminating the trigger.  If they eliminate the symptoms, they can feel like a cure.  However the stressor is still persnet and the symptoms can be triggered again at some later date.

 

MUSCLE TREATMENT – Until MRI became popular and showed that the vast majority of TMJ disorder patients have a dislocated disk in at least one of their TMJs, treatments for TMJ disorders were primarily directly at hte jaw muscles.  These treatments often provided short term relief, becauss the jaw muscles are directly responsible for most of the symptoms.  The muscles get involved, because they are responding organs.   Inflammation in a joint produces reflex  bracing in the muscles which cross that joint.  Thus TMJ inflammation produces reflex jaw muscle tension the same way that walking on a sore ankle causes reflex leg muscle tension, which we see as limping.  When this reflex jaw muscle bracing is maintained over time, the muscle fibers shorten in a process called contracture. Contracture interferes with resting circulation and causes waste products to collect in micropockets which clinically present as extremely tender pea shaped nodes commonly known as trigger points.  Mashing the trigger points aggressively or stretching and massaging the affected muscles usually produces short term relief, but long term relief requires permanently resolving the joint condition which set off the muscle tightness in the first place.

 

ORTHOPEDIC TREATMENT – Now that we understand how dislocated TMJ disks cause the vast majority of TMJ disorders, we recognize that eliminating TMJ disorders requires resolving the TMJ inflammation.  Resolving the inflammation can be accomplished relatively quickly by controlling the movement of the lower jawbone to prevent its back ends (the condyles) from continually bruising the TMJs which have been made vulnerable by dislocation of the disk.  Subsequently the jaw muscles can be rehabilitated by flushing out their tissues and giving them an exercise template which keeps them healthy.  In some cases the range of motion of the lower jawbone is increased, and in some cases the range of motion of the lower jawbone is limited in certain directions, depending on the direction and state of the disk dislocation.    

 

THE STABILIZATION APPLIANCE – In the vast majority of TMJ disorders, permanent relief can be obtained by simply wearing an upper stabilization appliance at night on a long term basis.  When you sleep, your jaw muscles clench or grind with huge forces.  During this workout, dental nightguards are effective at protecting the teeth against wear, while stabilization appliances also protect the TMJs.  In this way they function much like a brace used to protect an injured ankle. As long as you keep walking on an injured ankle, it won’t get better.  When you lie in bed for 8 hours, you get off your ankle and allow it to heal.  You don’t have a way to get off your TMJs. Even during sleep they are active due to clenching and grinding.  Stabilization appliances have carefully sculpted orthopedic bite surfaces which have the effect of getting you off your TMJs so they can heal naturally.  If properly made, a stabilization appliance should enable you to bite forcefully without pain.

 

THE TEMPORARY STABILIZATION APPLIANCE – When we don’t know if your symptoms are due to a TMJ disorder, we can make a temporary diagnostic version of a stabilization appliance at chairside on the first appointment.  For example, severe headaches (including migraines)  may be caused by a TMJ disorder or they may be caused by a problem such as a tumor or a neuralgia which is not related to the TMJs.  A simple way to determine if your TMJ condition is the cause of your symptoms is to wear a temporary stabilization appliance every night for a week or two.  If  it provides significant relief, there’s a good chance that all you need to eliminate the symptoms and prevent them from ever returning is a hard plastic stabilization appliance to wear at night on a long term basis.  If it  provides only limited relief or causes other signs or symptoms, you may need a different kind of oral appliance or a change in your bite.  If it provides no relief or other change to your condition, your symptoms are probably not due to a TMJ condition.

 

DISK  RECAPTURING - In some TMJ disorder patients, the dislocated disk can still be restored to its proper position between the bones in a non-surgical orthopedic lower jawbone repositioning process known as disk recapturing.  This treatment usually provides rapid and permanent relief, but it requires significant dental work to permanently change the bite, so the expense of treatment and the condition of the teeth needs to be weighed against the severity of the symptoms and the prognosis.  If your disk can be recaptured and you have an unstable bite or will later need major dental work to replace fillings anyway, you can have the disk recaptured first so the dental work can be made to reinforce the correct disk position instead of the dislocated disk position.  Disk recapturing requires a very protective (telescopic) night appliance and two very small unobtrusive day appliances which are snapped onto the teeth as soon as the night appliance is removed and then worn all day (including during eating) until the night appliance is put back in at the end of the day.  To help understand how anatomical factors affect the prognosis for disk recapture, Dr. Summer collaborated with the world's leading TMJ radiologist to perform and publish a clinical study of disk recapturing treatment on 119 TMJs using before and after MRIs.

 

ADAPTATION IN ARTHRITIC JOINTS - In TMJ disorders which have advanced beyond the point where disk recapture is possible or when the symptoms are not severe enough to warrant such extensive treatment, our treatment focuses on enabling the body to build a new disk out of the fibrosed scar tissue present where the old disk had been.  This new disk (called a pseudodisk) functions very much like a natural disk and can allow a damaged TMJ to remain asymptomatic for the rest of your life.  Building a pseudodisk usually just requires maintaining a stable bite and wearing a TMJ protective night appliance.  The TMJ protective appliances used are frequently telescopic appliances, because they provide more protection than stabilization appliances.  Each side is individually micro adjustable, and the joint protection is maintained even when the mouth is open.  In contrast, single arch appliances function only when the mouth is closed far enough to engage their orthopedic bite surfaces.  

 

FUNCTIONAL ORTHODONTICS uses removeable oral appliances to support the lower jawbone in a proper position while moving the teeth in a way that will keep it there.  Braces are powerful tools for perfectly aligning the upper teeth and perfectly aligning the lower teeth until they look just like  a textbook, but braces can't do much to control the way the upper and lower teeth fit together.  In contrast, functional orthodontic appliances are used to reshape the dental arches and align the jawbones in order to improve jaw muscle development and optimize TMJ function.  In this way, they treat the whole jaw system rather than just the teeth, correcting the structural deficiencies which cause the bad bite rather than just straightening the teeth.  Studies have shown that well developed jaw muscles create symmetrical harmonious growth of the jaws, while underdeveloped jaw muscles cause narrow and retrusive growth of the jaws.   Braces cause sore teeth which automatically diminish chewing forces and thereby inhibit jaw muscle development.  In contrast, functional orthodontic appliances can stimulate jaw muscle development and thereby promote harmonious facial growth.  Functional orthodontic appliances can also include expansion screws to widen the dental arches and thereby make room for crowded teeth or enlarge a narrow nasal airway.

 

ESCAPING FULL TIME APPLIANCE WEAR is necessary for a number of TMJ disorder patients who have been previously treated by a dentist and left with an oral appliance which they must wear continuously to have a stable bite.  If they remove the appliance, they are unable to chew and may experience a return of their symptoms because they no longer have a natural bite.  However, their situation is unsustainable, because wearing any oral appliance full time will eventually cause cavities and gum disease.  In such cases, the first goal is to establish a healthy natural bite which eliminates dependence on a daytime appliance.  This may require functional orthodontics, reshaping teeth, or rebuilding teeth as explained in the paper entitled THE FRONT FLAT PLATE APPLIANCE in the drop down menu under the heading entitled SPECIFIC TREATMENTS and the paper entitled THE ROLE OF THE BITE in the drop down menu under the heading entitled WHAT IS TMJ..