SUMMARY -
Seeking treatment for a TMJ condition can be frustrating, because there are so many different types of treatment that may be recommended. A TMJ disorder patient in a large city could see a dozen different dentists claiming to be TMJ specialists and receive a dozen different treatment plans. Some treat the jaw muscles, some treat the teeth, some use drugs to "manage" the symptoms, and some use oral appliances. Most of the dentists who use oral appliances only use one type of oral appliance for all TMJ disorder patients, because they learned one TMJ treatment philosophy. If that treatment is unsuccessful, the patient is led to believe that oral appliance treatment is ineffective for their particular condition, even though different types of oral appliances have completely different effects. In that same city there will be dozens of chiropractors and physical therapists who will treat the condition using manipulation, neuromuscular reprogramming, or direct muscle treatment instead of an oral appliance; and there will be many physicians who believe all that is needed is the proper medications and a soft diet.
At the Portland TMJ Clinic, we focus on eliminating the root cause of the symptoms and attaining a state of long term jaw system health that prevents them from returning. To avoid overtreatment, we begin with the simplest and least expensive treatment that is likely to provide relief. In the short term, we protect the TMJs by controlling the movements of the lower jawbone to prevent the condyles from accessing the bruised retrodiskal tissues, and we rehabilitate the jaw muscles by ensuring that the bite provides an ideal exercise template for them. The treatment usually requires at least some type of oral appliance to protect the system from the effects of the forceful clenching and grinding (bruxism) that occurs during sleep. In the long term, to prevent the symptoms from returning, treatment may also involve some stabilization or adjustment of the natural bite or adding functional orthodontic components to the oral appliance worn during sleep in order to improve the bite.
THE BAD NEWS
Due to all the controversies involved, government agencies have been unable to regulate treatment for TMJ disorders. One result is that any dentist can declare TMJ expertise, and some do so after taking a single weekend continuing education course. Another result is that treatments may be excessive, ineffective, or even counterproductive. Some dentists make oral appliances that inadvertently change the bite and thus later require extensive dental work just to restore chewing ability. Other dentists send all their patients who appear to have irregular bites to orthodontists for braces without understanding how straightening the teeth would affect their condition. Many dentists who claim TMJ expertise propose extensive treatment for people who are already largely in successful adaptation and have an excellent prognosis even without treatment. "Neuromuscular" dentists use diagnostic tools that have no clinical relevance and often indicate a need for extensive dental work to change a bite that may not be involved in the cause of the problem. Well meaning dentists getting mixed messages from so-called experts often don't know what to believe. To play it safe, they usually just "manage" the symptoms using nightguards, drugs, and physical therapy to get the patient through the severe bouts of symptoms that occur occasionally during the natural course of a TMJ disorder.
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 patients have shown that, in the natural course of a TMJ disorder, 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 some postural symptoms (muscle pain) and some ear symptoms (dizziness, tinnitus, and stuffy eustachian tubes) may persist, but the TMJ inflammation and associated acute pain symptoms resolve, even though the structural components of the TMJs continue to deteriorate with age as seen on X-ray or MRI.
EVEN BETTER NEWS
In most cases, simple orthopedic support is all that is needed to enable damaged TMJs to adapt 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” to treat TMJ disorder patients.
JOINT TREATMENT – In acute (inflammatory) TMJ conditions, resolving TMJ inflammation requires controlling the movement of the lower jawbone to protect the inflamed TMJ tissues until they can heal naturally. At the Portland TMJ Clinic, we control lower jawbone movement during sleep by oral orthopedic appliances that are designed to take the pressure off your injured TMJ, much like a crutch or a brace can take the pressure off an injured ankle, and we control lower jawbone movement during the day, if necessary, by adjusting the way the teeth fit and work together in the natural bite. If significant bite change is needed, it is first established and tested using an inconspicuous tight fitting daytime appliance that snaps in place and can be worn all day without impairing chewing or talking.
The particular type and design of orthopedic oral appliance that is needed during sleep varies in different facial growth patterns and different types of TMJ disorders. Some oral appliances increase the range of motion of the lower jawbone, while others decrease it in certain directions, depending on the direction of the disk dislocation and the condition of the disk. Once the chronic bruising of the TMJ retrodiskal tissues stops, the jaw muscles can be rehabilitated by providing a natural bite table that is conducive to healthy exercise. In non-inflammatory TMJ disorder conditions, the oral appliance can be designed to rehabilitate the jaw muscles and optimize the pattern of subsequent adult facial growth.
THE JOINT PROTECTIVE STABILIZATION APPLIANCE, – a unique design of the Portland TMJ Clinic, is the simplest and cheapest way to relieve an inflamed TMJ. Dental nightguards and even oral appliances that are commonly called stabilization appliances can stretch out contracted jaw muscles and can protect the teeth from wear, but they are not really orthopedic in nature. Some are completely flat, some have contours that mimic those of a natural bite, and some contact only the front teeth. However, they are not designed to protect the TMJs. In contrast, a joint protective appliance prevents your lower jawbone condyles from accessing the bruised TMJ tissues. As a result it should allow you to bite forcefully without pain. It is usually only needed during sleep, when the jaw muscles clench or grind forcefully while gravity pulls backward on the lower jawbone due to the weight of all the tissues hanging from it.
JOINT PROTECTIVE TELESCOPIC APPLIANCES provide more TMJ protection than possible with a stabilization appliance or any other single arch appliance. These dual arch (upper and lower) appliances employ tubes and rods that act on each side like a straight arm to hold the lower jawbone as far forward as needed, even when the mouth is partly open. The amount of jaw protrusion they provide is determined by the set point of the tubes and rods. Telescopic appliances used to protect injured TMJs are not set to hold the lower jawbone further forward than its habitual bracing position, but simply to prevent the lower jawbone from retruding excessively. In adjustable versions, the set point can be moved by the patient at home without special tools.
DISK RECAPTURING - In some patients in early phases of disk dislocation, orthopedic treatment with telescopic and bite restoring appliances can be used to set the lower jawbone forward permanently as part of an orthopedic disk recapturing process. The protocol requires faithfully wearing either a precisely fitting inconspicuous daytime appliance and a foolproof night appliance (telescopic appliance) continuously until the previously dislocated disk stabilizes in its proper position between the bones, and then restoring the bite to hold it there permanently. Recapturing a dislocated disk can only be accomplished when the disk still has a good biconcave shape and the ligaments are not too stretched out. The process usually provides rapid and permanent relief; however the finishing phase of the disk recapturing process can involve dental work that can be expensive. If you will eventually need major dental work to replace fillings anyway, you can have the 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 you already have crowns on all your teeth, the dental work required to complete disk recapturing is an otherwise unnecessary expense. Thus, in considering disk recapturing, the condition of the teeth needs to be weighed against the severity of the symptoms and the prognosis. Dr. Summer has published the largest study of this treatment to date with before and after MRI of 119 TMJs.
ADAPTATION IN ARTHRITIC JOINTS - In TMJ disorders that have advanced beyond the point where disk recapture is possible or when the symptoms are not severe enough to warrant extensive dental work, 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 a stable healthy bite and a TMJ protective appliance to wear during sleep for long enough to allow full adaptation. The adaptation process can also be facilitated by a variety of supportive treatments.
MUSCLE TREATMENT – is highly effective after the TMJs are no longer inflamed. Once jaw muscle tightness is no longer continuously triggered by neuromuscular reflexes, the muscles can be treated by a number of different methods to restore resting circulation and normal resting length. These can include exercises, stretching, manipulation, mechanical stimulation such as massage, and various forms of electrical stimulation.
Until MRI showed that the vast majority of TMJ disorder patients have at least one dislocated TMJ articular disk, dentists managed virtually all TMJ disorders by treating the jaw muscles using physical therapy, medications, simple bite raising oral appliances, or drilling away high spots on back teeth (occlusal equilibration). These muscle treatments often provided short term relief, because the jaw muscles are directly responsible for many of the symptoms. However, the role of the jaw muscles was secondary, not primary, in most of the patients. As a result, their symptoms usually returned - prompting dental authorities to advise dentists to warn TMJ disorder patients that their condition can be managed but not cured.
The jaw muscles become involved in TMJ disorders, because muscles are responding organs. Inflammation in any joint produces reflex bracing in the muscles which cross that joint. In this manner, TMJ inflammation produces reflex jaw muscle tension the same way that walking on a sore ankle causes reflex leg muscle tension, which results in limping.
Treating the jaw muscles usually provides some short term relief of pain, but it has little effect on TMJ inflammation. Many TMJ disorder symptoms are produced by muscle tightness, and stretching or massaging the muscles feels good. However, if TMJ inflammation is the cause of the jaw muscle tightness, simply treating the jaw muscle tightness is not addressing the root problem.
The jaw muscles can also become involved in TMJ disorders due to bite instability. Without a stable platform on which to rest and exercise the lower jawbone, the jaw muscles automatically go into a guarded state. They hold themselves in a slightly tightened state of bracing.
When reflex jaw muscle bracing is maintained over time, the muscle fibers shorten in a process called contracture. Contracture of muscles interferes with their resting circulation and causes waste products to collect in micropockets that clinically present as pea shaped nodes that are extremely tender to pressure. These nodes are commonly known as trigger points. Forcefully compressing (mashing) the trigger points or stretching and massaging the whole muscle usually produces short term relief. Long term relief requires permanently resolving the TMJ condition that triggers the muscle tightness.
Botox is now being used for treating TMJ problems based on the assumption that weakening the jaw muscles will relieve symptoms by decreasing the bruxing forces which can be exerted by the jaw muscles during sleep. Weakening the jaw muscles can relieve some TMJ related headaches by diminishing the forces that the jaw muscles can apply to the head, and it can also relieve some TMJ related face and neck pain by interrupting a pain-muscle tightness-pain cycle. However, in the long term, Botox injections may increase the likelihood of undergoing TMJ disorder symptoms; because weakening the jaw closing muscles reduces their ability to regulate subsequent facial growth, and a strained adult facial growth pattern is the ultimate cause of TMJ disorder symptoms in most adults.
THE FRONT FLAT PLATE APPLIANCE - The simplest and most effective method for restoring jaw muscle health is usually wearing an upper front flat plate appliance every night. Because this appliance dramatically reduces the nightly grinding or clenching (bruxism) forces, it is often effective at relieving headaches and idiopathic 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 the forces of nocturnal bruxism upward on the upper front teeth and downward on the lower front teeth. This is a muscle treatment appliance. It does not provide significant joint protection. If TMJs are inflamed, it can increase the pain.
STABILIZING THE BITE - may be needed after a bite has been destabilized by dislocation of a disk, arthritic changes in a TMJ, or shifting teeth. A stable bite is a fundamental requirement for TMJ health, because it gives the lower jawbone a consistent home base which 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 bite strain if the symptoms return every morning after the night appliance is removed. If an asymmetrical facial growth pattern has forced the lower jawbone to grow toward one side, even a slight change in the bite can restore a more symmetrical facial growth pattern. The bite may also be shifted forward to assist with treatment of forward head posture. Shifting the bite can involve extending it or moving it. Extending it can be performed gradually. Moving it is performed first on a temporary basis with little removeable bite restoring appliances that don't impair speech and can be worn all day including eating to make sure that the new bite eliminates the symptoms and to refine the exact contours of the proposed new bite before it is finalized. After a couple of months to fine tune and test the new bite, it is transferred to the natural teeth provisionally with composite resin for further refinement. Finally, only after several more months of stable relief, the new bite can be made permanent with crowns or onlays, usually performed by the patient's general dentist with Dr. Summer providing any support needed.
Dentists are trained to duplicate bites, not to change them. For that reason, your general dentist will feel much more comfortable if your new bite is established in composite resin or some other semi-permanent material and proven effective before making it permanent with gold or porcelain.
RE-ESTABLISHING A BITE - is frequently needed in TMJ disorder patients who have worn a lower nightguard or a partial coverage oral appliance for long enough to make their bite fit the surface of the oral appliance rather than the surface of their natural teeth. After the appliance is removed, there is no longer any natural bite. The process of re-establishing a healthy natural bite usually involves wearing an oral appliance during sleep while establishing the new bite in a temporary material like coposite resin to test and refine it before finalizing it. The process of re-establishing a bite can also be accomplished with functional orthodontics at any age.
FUNCTIONAL ORTHODONTICS - unlike esthetic orthodontics (braces and invisalgn) 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 and the lower teeth into smoothly curved arches that look just like a textbook; but braces can't do much to control the way the upper and lower dental arches fit together. The main problem with braces is that the sore teeth they create inhibits jaw muscle development; and they are usually employed shortly after puberty, when the jaw muscles should be undergoing their most rapid development and are thereby most vulnerable to arrested development. In contrast, functional orthodontic appliances are used to align the jawbones in order to optimize TMJ function and enhance jaw muscle development. In this way, functional orthodontics attempts to treat the whole jaw system rather than just straighten the teeth.
Functional orthodontic 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. Since the roof of the mouth is the floor of the nose, widening the palate widens the base of the nasal airway. The resulting decrease in nasal resistance facilitates nasal breathing and can thereby end the detrimental effects of mouthbreathing on the back of the throat.