Orthopedic Treatment

While TMJ disorders are self-limiting, there is no need to wait for natural adaptation, because the symptoms can be eliminated in both long and short term by orthopedic treatments that address the symptom generating process and the strained facial growth pattern that maintains it. Our orthopedic treatments are summarized below and described in separate files under TREATMENTS. They include:

Joint protective stabilization appliances
Joint protective telescopic appliances
Pivoting for unilateral condylar distraction
Disk recapturing
Flat bite plate (deprogramming) appliances
Rubber bite cushion appliances
Bite restoring appliances
Bite stabilization
Functional orthodontics

JOINT PROTECTIVE STABILIZATION APPLIANCES carry bite surfaces that have been sculpted to prevent the condyles from access to the chronically bruised retrodiskal tissues in inflamed TMJs. Steep anti-retrusive ramps are used to protect severely inflamed TMJs, and shallower ramps are used when muscle tightness is a factor.

JOINT PROTECTIVE TELESCOPIC (HERBST) APPLIANCES provide even more protection for inflamed TMJs, because their protection continues even as the mouth opens. They can also contain orthopedic mechanics such as a front flat bite plate, opposing inclines that engage (dual blocks), laterally directed inclines to correct the mandibular midline, or a unilateral pivot to distract a condyle from an inflamed TMJ. Dr. Summer's new high-push double-tube Herbst device (FDA # K243752) is virtually unbreakable; laterally unrestrictive, and infinitely adjustable without tools.

PIVOTING can be added to any type of joint protective appliance to provide quick short-term relief for an acutely inflamed TMJ. The pivot must be unilateral and located behind the first molar, where the central line of force of the jaw closing muscles is located, so that biting forcefully serves to distract the condyle from the area of inflammation. Biting on the pivot should immediately relieve the pain that is experienced when biting on the natural teeth. However pivoting can place a lot of pressure on a single molar, therefore it is only used as a temporary intervention.

FRONT FLAT BITE PLATE APPLIANCES perform the same function as Botox (reducing the strength of bruxism) without damaging the muscles, and the effect does not wear off. It persists as long as the appliance is worn. Also flat front bite plates are useful tools for facilitating horizontal jawbone growth by gradually reducing restrictive overbites and for managing most myogenous TMJ disorders, as long as there is no TMJ inflammation present. The plane of the front flat bite table is parallel with the pull of superior lateral pterygoid muscles, which facilitates their ability to position the mandible horizontally. The patients can only bite with about half of normal forces during nocturnal bruxism, and those forces are repurposed to reduce the overbite. Also, the perfectly flat bite plate reveals the location of the mandible that would be preferred by the myofascial forces of the postural system, which can be used to evaluate the health of the bite. A temporary chairside version is a good diagnostic tool.

FULL ARCH FLAT PLATE APPLIANCES, rather than front flat bite plate appliances, are used when there is little or no overbite, to prevent the development of a negative overbite (an open bite), which eliminates the ability to incise effectively. They do not reduce the force of bruxism, but they apply it evenly, and they stretch the muscles by their height.

RUBBER BITE CUSHION APPLIANCES are tight fitting rubber shells that are used during the daytime to provide a stable cushion for the mandible to rest on for people with unstable bite tables or to relieve jarring bite impacts for people with hypersensitized neuromuscular systems.

BITE STABILIZATION may be necessary to give 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 their fully seated (braced) positions, because a stable bite is fundamental to jaw system and TMJ health. Joint stability is at the heart of orthopedics. An unstable joint triggers increased resting tonus in the muscles which cross that joint. The bite functions as a joint between the jawbones. If the bite is unstable, the jaw muscles automatically become undergo increased resting tonus and become tight (hypervigilant). In many TMJ disorder patients, the bite has been destabilized by disk dislocation or degenerative remodeling, both of which effectively shorten the condyle of the affected side, or by TMJ swelling which effectively lengthens the condyle of the affected side. Sometimes the bite keeps changing due to periodic shifting between these conditions. After any inflammation is resolved, the bite can be restabilized by reducing high areas, building up low areas, and/or moving teeth. The choice depends on the facial growth pattern and dental needs.

BITE RESTORING is often needed in patients who have worn an oral appliance full time or a lower nightguard for long enough to make the teeth of the opposing arch shift until they fit the surface of the appliance. When they remove the appliance, they have no bite. In these cases, we make small tight fitting unilateral removable bite restoring appliances that don’t impair speech and can be worn all day, including while eating, so you can try out or "test drive" the new bite. The new bite should provide widespread support for the mandible within a small central bracing area (about 4 square mm), surrounded by gradually inclined slopes that provide support (not guidance) for the mandible in all directions of movement away from that small central bracing area, which enables the teeth to dig into the resin along their functional range of motion and thereby fine-tune the new bite. Then the proposed new bite is transferred to the teeth by bonded composite resin onlays for further refinement and testing prior to finalizing it in gold or porcelain, usually performed by the patient’s general dentist, with Dr. Summer providing any support required. If finishing needs to be delayed for dental or financial reasons, the unilateral removeable bite restoring appliances can be reinforced with embedded stainless steel mesh.

ORTHOPEDIC DISK RECAPTURE may be needed when nothing provides relief as long as a TMJ disk keeps shifting in and out of its place; but successfully completing the treatment requires changing the bite, which can involve extensive dental work. 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 bite that maintained the correction. Frequently the teeth need contours that are slightly different from those seen on natural teeth, requiring extensive communication with the dental laboratory. 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. It's now clear that disks can be recaptured if the right anatomical factors are present and the bite is finalized correctly, but most patients with reducing dislocated disks do not need such extensive treatment to eliminate their symptoms, and most dentists still don't understand how to finalize the bite to sustain the disk recapture.

FUNCTIONAL ORTHODONTICS, using removeable oral appliances, has advantages over esthetic orthodontics (braces and invisalign) for treating and preventing TMJ disorders, because it can hold the mandible in an orthopedically improved position while realigning the teeth to support it there. In contrast, esthetic orthodontics usually retracts the mandible to facilitate aligning the teeth. Functional orthodontic appliances can also stimulate jaw muscle development by protecting damaged TMJs while giving the jaw muscles an ideal exercise template to work out against. Palatal expansion can be added to enlarge the nasal airway or increase the space available for crowded teeth.