Our TMJ Treatment - An Overview

Below is a discussion of our TMJ treatment philosophy followed by a summary of the TMJ treatments we provide.  Each of these treatments is also described in more detail in a separate file on this website.  To find a summary of treatments offered by other TMJ practitioners, see CONVENTIONAL MEDICAL TREATMENT and CONVENTIONAL DENTAL TREATMENT. 

THE GOOD NEWS – Any kind of treatment, or even just lack of treatment, will eventually bring relief, because TMJ disorders are self limiting.  Longitudinal studies of tens of thousands of untreated patients have shown that the symptoms eventually “burn out” because the TMJs undergo adaptation characterized by fibrosis of the retrodiskal tissues. This adaptive fibrosis may require anywhere from days to decades, but it almost always occurs by middle age.  Afterwards, people may experience postural muscle pain that includes the jaw muscles (myofascial pain), ear symptoms (dizziness, tinnitus, and stuffy eustachian tubes), and some difficulty chewing (like operating a door off the hinges); but they are unlikely to develop severe persistent symptoms, and any symptoms they do experience respond quickly to simple treatment. 

 EVEN BETTER NEWS
In most cases, the right kind of orthopedic support is all that is needed to enable adaptation to occur within days or weeks rather than months or years.  There is rarely any need for surgery, full mouth reconstruction (crowns on all the teeth), years of wearing braces, dozens of physical therapy visits, multiple dental office visits for appliance adjustments, or long term pharmacologic “management”.   At the Portland TMJ Clinic, we have pioneered the art and science of providing orthopedic support for the TMJs.
 
INFLAMED TMJS – require mechanical protection, especially during the nightly clenching or grinding that we all experience during sleep.  An oral orthopedic appliance can protect the injured TMJ like a crutch or a brace can protect an injured ankle.  If the symptoms return every morning after removing the oral appliance, the natural bite may need adjusting.  If significant bite change is needed, it is first established and tested on inconspicuous tight fitting daytime appliances that snap over the back teeth of each side so they can be worn all day without impairing chewing or talking.
 
While nearly all dentists who advertise TMJ treatment only offer one or two types of oral appliances, because they only learned one treatment philosophy, we make a wide variety of different oral appliances for different types of TMJ disorders. The appliance may increase the range of motion of the lower jawbone in all directions or decrease it in some directions, depending on the direction of the disk dislocation, the condition of the disk, your dental condition, and your facial growth pattern.  The oral orthopedic appliances we most commonly use and the rationales for each are summarized below and described in separate papers on this website.
 
THE JOINT PROTECTIVE STABILIZATION APPLIANCE,  – an original design of the Portland TMJ Clinic, is the simplest way to relieve an inflamed TMJ.  Dental nightguards and even oral appliances that are commonly called stabilization appliances can protect the teeth from wear, and some also stretch contracted jaw muscles by their height; but these oral appliances are not really orthopedic.  Their contours just mimic those of a natural bite, - they are not specially designed to protect the TMJs.  In contrast, a joint protective stabilization appliance has contours that are orthopedically sculpted to prevent your lower jawbone from accessing the bruised TMJ tissues.  It should allow you to bite forcefully without pain. In most people with inflamed TMJs, it is only needed during sleep.
 
THE JOINT PROTECTIVE TELESCOPIC APPLIANCE provides more TMJ protection than possible with any single arch appliance, including a joint protective stabilization appliance.  A telescopic appliance involves complete upper and lower appliances connected by telescoping tubes and rods that prevent the jaw from retruding beyond the set point, even when the mouth is part way open.  However, the most commonly used telescopic appliance, the Herbst appliance, was designed more than half a century ago for use in children undergoing orthodontics.  When used in adults, it is bulky and restrictive.  We have modified it by flattening the components to better fit the space between the teeth and the cheeks, flexibly mounting the components to allow free movement laterally for TMJ health, and making the length of the components patient adjustable.  
 
THE RUBBER BITE CUSHION APPLIANCE is a thin inexpensive rubber shell that fits over the lower teeth and is worn during the daytime to soften the impacts of biting.  It does not affect speech and is very durable.  However rubber appliances worn during sleep can make TMJ problems worse, because they evoke chewing activity, usually accompanied by dreams of eating.
 
DISK  RECAPTURING 
 In some early phases of disk dislocation, telescopic appliances can be used together with daytime bite restoring appliances in order to set the lower jawbone forward to "recapture" the disk and thereby restore proper TMJ anatomy. The protocol requires faithfully wearing either the day or night appliance at all times until the previously dislocated disk stabilizes in its proper position.  Then, after the disk recapture has been stable for at least a couple of months to make sure the treatment is successful, the new bite that has been well established and tested on the daytime appliance is transferred to the natural teeth using crowns, onlays, or tooth colored filling materials (composite resin) that bond to the tops of the involved teeth in order to keep the disk in place permanently.  
 
Disk recapturing usually provides rapid and complete relief, however it is only appropriate in certain situations.  It is unlikely to succeed if the disk has become misshapen or dislocated sideways.  In addition, the finishing phase of the disk recapturing process can involve expensive dental work.  If you will eventually need major dental work to replace fillings anyway, you can have your disk recaptured first so the subsequent dental work can be made to reinforce the correct disk position instead of the dislocated disk position.   However, if you have "virgin" teeth or recent crowns, the dental work required to complete disk recapturing may be a considerable and otherwise unnecessary expense.  Thus, in considering disk recapturing, the condition of your teeth needs to be weighed against the severity of your symptoms and your prognosis.  
 
ADAPTATION IN ARTHRITIC JOINTS 
When disk recapture is no longer possible or when the symptoms are not severe enough to warrant such extensive treatment, we focus on enabling the body to adapt anatomically by building a pad of disk-like tissue called a pseudodisk out of the fibrosed scar tissue present where the old disk had been.  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 a stable healthy bite and a TMJ protective appliance to wear during sleep for long enough to allow full natural adaptation.  This adaptation process can also be facilitated by a variety of supportive treatments.

 

THE FRONT FLAT PLATE APPLIANCE  - When the TMJs have already achieved full adaptation and the only remaining cause of symptoms is muscle tightness, wearing an upper front flat plate appliance on a long term basis during sleep is usually the simplest way to provide lasting relief.   Because this appliance dramatically reduces clenching and grinding forces, it is often effective at relieving headaches and idiopathic (unexplained) dental problems.  Over the course of weeks, it deprograms the jaw muscles so we can evaluate the health of your bite. Over the course of years, it gradually reduces overbite (the vertical overlap of the front teeth) by redirecting all clenching and grinding forces upward on the upper front teeth and downward on the lower front teeth.  This is a muscle treatment appliance. If TMJs are inflamed, it can increase pain.

STABILIZING THE BITE  -  may be needed after it has been destabilized by dislocation of a disk, arthritic changes in a TMJ, or shifting teeth.  A stable bite is required for long term TMJ health, because the lower jawbone needs a consistent home base and healthy functional range of motion which can serve as a steady target for the type of bone remodeling that enables the TMJs to acquire the same goodness of fit seen in all healthy joints.  Restabilizing a bite may involve grinding down high spots, building up low spots, moving teeth, or any combination of these. 
 
CHANGING THE BITE may be needed to reduce strain in the way the natural teeth fit together if the symptoms return every morning after the night appliance is removed.  If a backward bite is causing forward head posture, allowing the bite position to shift forward slightly can relieve postural symptoms or prevent other postural corrections from relapsing.  If a sideways bite has produced an asymmetrical facial growth pattern, allowing the lower jawbone to shift even slightly toward the midline can make subsequent facial growth more symmetrical and also help correct a sidebent head posture. 
 
Any significant change to the bite is made first on a temporary basis using removeable bite restoring appliances that don't impair speech and can be worn all day including eating.  The goal is to make sure that the new bite eliminates the symptoms and to refine its contours.  Then the well established and tested new bite can be transferred to the natural teeth provisionally with composite resin for further refinement or permanently with crowns or onlays, usually performed by the patient's general dentist with Dr. Summer providing any support needed.    
 
A BITE RESTORING APPLIANCE - is frequently needed in TMJ disorder patients who have worn a lower appliance at night or any appliance full time for long enough to move the teeth until they fit the surface of the appliance rather than the surface of their natural teeth.  After the appliance is removed, there is no longer any natural bite.  In these cases, the process of re-establishing a healthy natural bite usually involves wearing a removeable appliance that establishes a proposed new bite on a provisional basis for testing and refining before determining how to transfer it to the natural teeth or a partial denture.
 
FUNCTIONAL ORTHODONTICS -  is another way of re-establishing a bite.  Instead of braces or invisalign, functional orthodontics employs removeable oral appliances to support the lower jawbone in the proper position while moving the teeth in a way that will keep it there.  The appliances frequently contain expansion screws to widen a narrow upper dental arch in order to make room for crowded upper teeth or enlarge the nasal airway. They can often be made by modifying the same oral appliance that relieved the symptoms.  This type of orthodontics is described in THE ROLE OF ORTHODONTICS under TMJ DISORDERS.