Diagnostic Records for TMJ Dysfunction

There are many approaches to the treatment of TMJ dysfunction. Which modality is chosen depends on three things: the results of a comprehensive diagnosis, the personal circumstances of the person needing care, and the desired outcome of treatment. Depending entirely on the correct diagnosis, the actual treatment can range from very, very simple to extremely complex.

First, lets look at what is not an adequate diagnosis and or proposed treatment.

  1. Having the patient tap their teeth together on a piece of articulating paper see if there are any "high spots" and then indiscriminately grinding the to high spots down "to see if that will help."
  2. Doing an "occlusal equilibration" because the patients jaw pops.
  3. Deciding based on the patient's symptoms, that the patient needs an acrylic occlusal splint.
  4. Recommending that, because the patients teeth are "worn down" and the patient is having some TMJ symptoms, crowns should be placed on all the teeth to "build them up."
  5. Prescribing drugs because the patient is having TMJ symptoms and is "under a lot of stress."
  6. Referring the patient to an oral surgeon because "their jaw pops."
  7. Telling the patient they are clenching or grinding their teeth at night and should be wearing a "night guard."

Please don't get me wrong. Any, and maybe, all of the above actions may have a place, but absolutely not before an adequate diagnosis. Exactly what records are required in order to come to a thorough diagnosis.

Here they are.

  1. There must be a complete inventory of signs and symptoms and they must be recorded. A complete health history should be done or updated.
  2. A complete dental exam should be done.
  3. There should be a thorough exam of the soft tissue of the head and neck. It should include muscle palpitation, a search for trigger points, and range of motion studies for the lower jaw.
  4. Facial and cranial asymmetries must be ascertained and deviations from midline noted.
  5. A three-dimensional analysis of the position of the upper jaw (maxilla) must be done to determine slope, cants, slants, side-shifts and front-to-back (antero-posterior) position in the skull.
  6. Studies must be done to determine if the jaws are adequately developed.
  7. Impressions must be taken and accurate models must be made. The models must be poured in a hard material and accurately and precisely mounted on a programmable articulator using an acceptable transfer system (face bow, etc.) and jaw registration technique and material. Otherwise, it can not be seen if there is a harmony between how the jaw works and how the teeth occlude. Without knowing this it is any one's guess as to what should be done to create such a harmony.
  8. Radiographs should be taken. They should include either a complete series of dental x-rays or a panographic film, x-rays of the jaw joint in both an open and closed position, and both an antero-posterior and a lateral cephlametric x-rays. Analysis must be done on both cephlametric x-rays

All the above records are required in order to obtain a comprehensive diagnosis and must be accomplished before a treatment plan can be established. Depending upon the results of the evaluation process, there are a number of categories into which treatment may occur. Frequently, a combination of treatment modalities will be required.

Occlusal Adjustment

Rarely, it will be found, after a thorough evaluation, that a single tooth or a very few teeth are causing interferences which precipitate TMJ dysfunction. It can be a rotated tooth, a mal-posed tooth, a mal-formed tooth or a number of other possibilities. Provided it has been shown through the records process, that all the other criteria are within the range of physiological adaptation, then "spot grinding" of one or a very few teeth may be the indicated treatment. Discernment must be used in order to know which tooth to grind, so that relieving one interferences does not create a new one in a different place.

Occlusal Equilibration

Somewhat more frequently, it will be found after a thorough evaluation, that orthopedically, everything is within normal limits, but a good number of teeth just don't function well together. In this case, the treatment of choice may be to do an occlusal equilibration of the entire mouth. However, this should always be performed first on stone models of the mouth, which have been mounted on a properly programmed articulator so that the correct teeth and the precise areas of adjustment can be determined. In this way, the dentist knows before hand, not only where and how much tooth structure will have to be removed, but also, exactly what the resulting function of the occlusion will be after the equilibration.

Occlusal Splint Therapy

This form of treatment is directed toward symptoms only and rarely, if ever, is directed toward the cause of the TMJ dysfunction. As such, its primary use should be to get symptomatic relief right away in very acute TMJ cases just until proper diagnosis and treatment can be begun. Occasionally, an occlusal splint may be used to assist in the diagnosis when both the symptoms are vague or don't fit the clinical pattern and the diagnostic findings are not conclusive. In those cases, a substantial reduction of symptoms from the use of the splint may confirm the diagnosis of TMJ dysfunction.

Surgery

Surgery is an option that is rarely indicated for TMJ dysfunction. As a rule, it should be considered only as a last resort. If there has been an accident where the jaws have been fractured, then surgery is often indicated. Rarely, there will be a "bone spur" or some other anomaly of the bone, which can only be corrected surgically.

My experience has been that rarely, in the case of TMJ dysfunction, has surgical joint replacement or disc replacement resulted in a satisfactory condition. Occasionally, like the television shows have demonstrated, the results have been total nightmares for everyone involved.

Full Mouth Reconstruction

Sometimes cases present in which all the orthopedic and orthodontic records are within normal limits and the normal physiological adaptive range, but the teeth have worn excessively or for some other reason have lost vertical dimension. Loss of vertical dimension is one of the most important factors in TMJ dysfunction and it must be restored for optimal health to exist. Sometimes, the only and/or best way to acquire adequate vertical dimension is by placing crowns on all the teeth or occasionally only the posterior teeth.

Again in this instance, it is mandatory that before any teeth are prepared for crowns, a diagnostic wax-up is done on accurate dental models properly mounted on a programmable articulator. This must be done so that the final result can be visualized and examined prior to any irreversible changes have been made to the actual tooth structure.

Also, extreme attention to detail must be placed on the esthetics of the finished case, and care must be taken to make sure that the phonetics of the finished case is ideal. In other words, it is not acceptable for the patient to hiss or whistle when making "s" sounds in their normal speech. Also, extreme care must be taken to allow the "f" and "v" sounds to be normal and comfortable for the patient to make.

Cranial-Mandibular-Cervical (CMC) Orthodontics

CMC orthodontics is next generation of what is sometimes called gnathologic orthopedics or orthopedic gnathology or orthopedic orthodontics. It is the most advanced and comprehensive form of treatment on the planet for TMJ dysfunction and orthodontic correction. The differences between CMC orthodontics and traditional orthodontics are extensive. The initial phase of CMC orthodontics is devoted to getting the bones of the jaws and the skull in their proper position and in an orthogonal (right angle) relationship with each other. Rarely, if ever, are permanent teeth removed in CMC orthodontics, and the use of "headgear" is virtually non-existent. Additionally, many cases which are considered "surgical cases" can be treated very nicely in a non-surgical manner and with a superior result. Although, CMC orthodontics is generally a two-phase treatment (orthopedic and orthodontic), rarely is total treatment time longer than that of traditional orthodontics. The only exception to this would be when the treatment objective is one, which is completely unobtainable through traditional orthodontics.

Body structures are in a dynamic position. That position is such as it is because that is where all the forces, which come into play, are in equilibrium. All we have to do to effect the movement and or remodeling of the bone is to very lightly tip the balance of forces in favor of a more ideal or "correct position" for the bones of the skull and the entire masticatory system. Once movement and/or remodeling have begun, we orchestrate the movement of the bones into optimal relationships with each other and that results in a degree of function and comfort that is otherwise impossible to achieve.

The goals and objectives of this type of treatment can be found at this website under the titles "TMJ Dysfunction" or Cranio-mandibular-cervical Orthodontics" and the subtitle "Rational for Diagnosis and Treatment."