The Joint Protective Stabilization Appliance

 

The Portland TMJ Clinic's joint protective stabilization appliance is a simple and effective way to provide rapid symptom relief when there is inflammation present in one or both TMJs.  It fits over all the upper teeth and contacts all the lower teeth on a bite surface that has been orthopedically sculpted to prevent the condyle from access to the inflamed portion of the TMJ during the large biting forces that affect everyone in nocturnal bruxism (clenching and grinding during sleep).  In this manner, the joint protective stabilization appliance acts like a brace to protect an injured TMJ during its workout, much like you might wear a brace to protect an injured knee during sports.  The first couple of nights of wear should eliminate all the pain and inflammation, and two months of wear should ensure that the damaged TMJ has completely healed by pseudodisk formation (anatomical adaptation) and functions like a normal TMJ. At that point, your TMJ will no longer need protection, and your joint protective stabilization appliance can be converted into a muscle treatment and long term facial growth appliance to prevent the problem from returning. To make the appliance comfortable, we build in a perfectly passive fit. To promote healthy tongue posture, we hollow out an area in the front of the palate to fit the tip of the tongue. The cost of the appliance is $1500.

NIGHTGUARDS, made by almost all general dentists, are designed to protect the teeth from wear by interposing a layer of plastic between them.  When a relatively soft material (plastic) is placed between two harder materials (teeth), all wear occurs on the softer material.  However, excessive wear of teeth is rarely the cause of a TMJ disorder, because teeth are made for wear.  In fact, teeth with wear are healthier than teeth without wear. Nightguards are not designed to protect the TMJs or treat the jaw muscles, so their effect on a TMJ disorder is random. They could make it better, they could make it worse, or they could have no effect on it.  

COMMON STABILIZATION APPLIANCES, made by most TMJ dentists, contact the teeth more evenly than simple nightguards, which helps relax the jaw muscles, but they are still not designed to protect the TMJs. Instead, their contours reproduce those of a natural bite at an increased height, with canine guidance in front and relatively flat contacts in back.  The increased stability can reduce muscle tonus, and the height can stretch the jaw closing muscles; but their main orthopedic effect is just propping the jaw open.  If the symptoms are due to overclosure of the jaw, (usually from old dentures or severely worn down teeth), this orthopedic "lift" (propping the jaw open) can provide significant relief.  However few TMJ disorders are due to loss of teeth height from overclosure or wear.  

OUR JOINT PROTECTIVE STABILIZATION APPLIANCES - have a bite surface that has been orthopedically sculpted to prevent the condyle from accessing the bruised retrodiskal tissues of the damaged TMJ. These retrodiskal tissues are very vascular, because they were designed to supply circulation to the metabolically active TMJs. When first dragged into the joint space by dislocation of the disk, they acquire all the characteristics of a chronic bruise - with blood leaking out of vessels, swelling, heat, and pain. Joint protective appliances protect the bruised retrodiskal area during their nightly workout by means of anti-retrusive ramps, like the one shown below.  

Anti‐retrusive ramps are usually located just behind the upper front teeth, where they engage the lower front teeth when the jaw closes far enough, as seen in the illustrations and the photo below, which show an anti-retrusive ramp just beginning to engage the front teeth as the patient closes into the appliance.  Further closing will slide the mandible forward away from the inflamed TMJ.

Anti-retrusion ramps are also occasionally located behind the molars or around missing teeth if there is space available.  The optimal location of the ramps for each patient depends on the direction of the TMJ dislocation, the disk shape, and the condition of the teeth. 

The angle of the anti‐retrusive ramps determines the degree of TMJ protection they provide. Shallow ramps are used when inflammation is minor and the symptoms are more muscular, because muscles benefit from freedom of movement.  Steep ramps are used when more TMJ protection is needed, such as when a TMJ is acutely inflamed.   Correctly designed anti-retrusive ramps should enable you to clench forcefully in any jaw position without experiencing the pain that you experience when you clench forcefully against your natural teeth. If the damaged TMJ requires more joint protection than the anti-retrusive ramps can provide, you'll need a telescopic (Herbst) appliance.

PIVOTING can be added to the appliance over the last molar on the side of the inflamed TMJ to provide quick temporary relief.  The pivot is a little high spot that should hit slightly before all the other teeth and thereby distract the inflamed joint.  The relief of pain from biting on the pivot should be immediate, but pivoting is only a short-term measure, because the pivot will wear down quickly or traumatize the supporting teeth.  

FOLLOW-UP - Initially, it may help to wear your appliance on and off during the first few days; however, after that, you should only need to wear the appliance at night; and you should be able to bite down forcefully on your teeth without causing facial or TMJ pain anytime day or night.  Adjustments should not be needed, because small improvements in the stability of the bite surface occur naturally during the first week anyway due to the hard teeth digging into the plastic.  

CONVERTING TO A LONG-TERM USE APPLIANCE – After the damaged TMJ has not been inflamed for at least two months, it should be fully healed and no longer needing mechanical protection.  At that point, your joint protective appliance can be converted into an appliance that treats your jaw muscles while repurposing the nightly clenching and grinding to optimize your slow adult facial growth pattern in a manner that moves you away from the strain that caused the problem and thereby prevent your symptoms from returning.  The orthopedics that you need depend on your facial growth pattern and the state of your teeth. The jaw muscles are generally stretched and/or provided a therapeutic exercise template to use for bruxism. In addition, various orthopedic features can be added to promote horizontal facial growth in a manner that reduces resistance to airway flow or eliminates growth restrictions.

Flat bite plate appliances allow the mandible a full range of motion, which promotes muscle health.  Front flat bite plate appliances can gradually and steadily reduce restrictive overbites.  Full arch flat bite plate appliances are preferred in the few people who have little or no overbite.  The conversion to a flat plate appliance can be made using our in-house lab for $350. 

In people with narrow palates, the joint protective stabilization appliance can be converted into a palate expansion appliance.  Wires and springs can be added to straighten individual teeth.  Later any of these appliances can be easily adjusted to fit around new dental work or implants if necessary.