TMJ Dysfunction Therapy

(Lifting the Fog of Confusion)

A question I am frequently asked is "How do you treat TMJ?" My opinion is that there is not a single "best" way to treat it. The type of treatment should depend entirely upon a correct diagnosis, and the correct diagnosis will dictate the type of treatment that is best suited to the particular problem. Unfortunately, very few practitioners have an eclectic enough background, to select the most effective treatment modality for every patient. What I mean is that a restorative dentist will look for a restorative answer; an oral surgeon will look for a surgical answer; an orthodontist will look for an orthodontic answer; and so on. This is not to say that they don't have an honorable desire to help the patient!

Before we look at the possible solutions, lets review the symptoms of TMJ dysfunction.

The symptoms of TMJ dysfunction are unbelievably diverse, both in nature and in severity. The most common symptoms are migraine-like headaches, which seem to come from behind the eyes or the side of the head. Also, there are the headaches or neckaches, which occur at the back of the head right where the neck attaches to the skull. People usually describe these neckaches as "tension headaches", as they are often associated with stress. The pain often radiates down into one or both shoulders. Another type of headache associated with TMJ dysfunction may occur in the area of the cheekbones, resembling a "sinus headache." Still other types of TMJ headaches are those, which occur right in the top of the head, or in the area of the jaw joint, or fan out over the side of the head. These types may be either continuous or sort of come in waves.

Slightly less frequent, but occasionally more severe symptoms include vertigo (dizziness), ringing in the ears, lancing pain in one or both ears or in the jaw joint itself, hearing difficulties, stuffiness in one or both ears, light sensitivity in the eyes, ulcer-like pains in the stomach, low back pain, and poor posture. Occasionally there will even be tingling or numbness in the fingertips of one or both hands.

More obvious, but less severe TMJ symptoms include clicking, popping, and/or grinding (crepitus) in the jaw joint; tenderness or pain in the jaw joint; sore or painful muscles in the head, face, or neck; difficulty in chewing; fatigue of the jaw muscles after prolonged chewing or talking; limitations of the range of motion of the lower jaw; locking of the jaw in either the open or closed position; clenching or grinding the teeth; sensitivity of the teeth; nibbling or chewing on the inside of the cheek; and deviation of the jaw when opening or closing the mouth.

The treatment modalities I will discuss below deal only with the structural component of TMJ dysfunction, and do not address the stress component at all. The stress component of TMJ dysfunction was featured in a previous article, and will be elaborated on again in future writings. This article also does not address adjunctive therapies like physical therapy, cranial therapy, and chiropractic that may play an important role in a comprehensive treatment objective.

Occlusal Adjustment

Occasionally, 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 diagnostic 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 (upper or lower) to grind, so that relieving one interference does not create another one in a different place.

Occlusal Equilibration

Somewhat more frequently, it will be found after a thorough evaluation and diagnostic records, that orthopedically, everything is within normal limits, but that 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 need to be removed, but also, exactly what the resulting function of the occlusion will be after the equilibration is completed.

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 and used only until proper diagnosis and treatment can be begun. Occasionally, an occlusal splint may be used to assist in the diagnosis when the symptoms are vague or don't fit the typical clinical pattern, and the diagnostic findings are not conclusive. In those cases, if the use of an occlusal splint results in a substantial reduction in the patient's symptoms, then it may actually 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, and then only rarely. If there has been an accident in which the jaws have been fractured, then surgery is often indicated and may be the treatment of choice. Occasionally, there may be a "bone spur" or some other anomaly of the bone that 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 all structures are within 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 the teeth.

Again in this instance, it is mandatory that, before any teeth are shaped for crowns, a diagnostic wax-up be done on accurate dental models properly mounted and correctly programmed on an articulator. This must be done so that the final result can be visualized and examined prior to creating any irreversible changes 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 normally formed and comfortable for the patient to make.

Cranial-Mandibular-Cervical (CMC) Orthodontics

CMC orthodontics is the next generation of what is sometimes called gnathologic orthopedics, 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 (with the possible exception of wisdom teeth) in CMC orthodontics, and the use of "headgear" is virtually non-existent. Additionally, many cases that are considered "surgical cases" by some orthodontists 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.

Body structures, including the bone, are always in a dynamic position, which means that there is always change and movement occurring. No matter what position a structure is in, it is there because all the forces that come into play upon it are in equilibrium. Therefore, all I have to do to effect the movement and/or remodeling of the bony structures is to very lightly tip the balance of forces in favor of a more ideal or "correct position." Once movement and/or remodeling have begun, I can orchestrate the movement of the bones into optimal relationships with each other and one that results in a degree of function and comfort that is otherwise impossible to achieve. All this is accomplished non-surgically and with minimal or no discomfort.

Additional information and previously published articles can be viewed at the www.tmjhealth.com website. Also, if you suffer from any of the symptoms mentioned earlier in this article, you can receive a complementary evaluation by calling (281) 837-9090 and mentioning this article.