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.
A SUMMARY of the TMJ treatments we provide and the reasons for them is described below. Treatments offered by other TMJ practitioners are described in CONVENTIONAL MEDICAL TREATMENT and CONVENTIONAL DENTAL TREATMENT.
INFLAMED TMJS – require mechanical protection, especially during the nightly clenching or grinding (bruxism) that we all experience during sleep. An oral orthopedic appliance can protect an injured TMJ during nocturnal bruxism much like a brace can protect an injured knee during sports. 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 or decrease it in some directions, depending on the direction of your disk dislocation, the condition of your 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 fact, if you can produce pain when biting forcefully, the appliance needs adjusting. In most people with inflamed TMJs, the appliance is only needed during sleep.
THE JOINT PROTECTIVE TELESCOPIC APPLIANCE involves complete upper and lower appliances connected by telescoping tubes and rods that prevent the lower jawbone from retruding beyond a set point, which can be adjusted. Telescopic appliances provide more TMJ protection than possible with any single arch appliance (including a joint protective stabilization appliance), because their protective effect continues even when the mouth is part way open, while single arch appliances lose their therapeutic effect as soon as the mouth opens past their inclines.
We've redesigned the telescopic appliance for use in adults. 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.
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 far enough 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 (the joints themselves) 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 TMJs and the jaw muscles caused by 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 corrections made in other locations of the postural system 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 in various ways, depending on dental conditions and costs. In most people, the bite is initially transferred to the natural teeth by means of composite resin onlays which can be bonded to the tops of the teeth without requiring drilling or shots. Subsequently, after further refinement and testing of the new bite, some of the composite resin onlays can be replaced with gold or porcelain crowns or onlays, usually performed by the patient's general dentist with Dr. Summer providing any support needed. A less expensive alternative, the bite restoring appliance, is described below.
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. The process of bite destabilizing in these situations usually takes months or years, but it may happen more quickly during a period of high stress and powerful clenching or grinding. 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 into positions 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.