Enter the Complex World of TMJ Therapy
Basic Anatomy | Intra-articular Disease vs MPD | Symptoms | Causes
Molar Fulcrums | Solutions | Splint Therapy | Instrumentation Used in TMJ Therapy | Treatment
Dr. Hafernik has trained and studied extensively in regards to this type of therapy.
(Dentists - for more information on TMJ therapy/occlusion knowledge - click here)
A partial list of those within dentistry and medicine that attempt treatment of this problem includes:
- Oral surgeons
- General practice physicians
- Physical therapists
- Biofeedback therapists
- and others
Within each of these specialties there are very different approaches depending on the particular practitioner seen and his or her specific training and experience. This leads a great deal of the time to differing diagnosis and very different opinions about therapy from each professional seen. Patients can become very confused about which opinion or therapy recommendation is best for them. Some of the greatest confusion comes from within dentistry, there are a number of approaches to treatment and each one is currently fighting for their own to be recognized as “THE” correct therapy. Therefore, at this time there is no "ONE" standard of care - and there most likely won't be for a very long time.
I tell patients that a great deal of the confusion arises from the fact that they have a medical problem (actually an orthopedic problem) that requires a dental solution.
To further highlight the confusion for patients receiving therapy...
In May, 1996, the National Institute of Health (NIH) put together a panel of professionals from medicine and dentistry and tried to seek some common ground in regards to therapy for TMJ problems. What they agreed to in the end was NOT TO AGREE on much of anything at all.
Some quotes from this conference:
- “Generally accepted, scientifically based guidelines for diagnosis and management of TMJ are still unavailable”
- “For the majority of TMJ patients, the absence of clear guidelines for diagnosis and full range of treatment means that many patients and practitioners may attempt therapy with new and inadequately tested approaches.”
- “There is too much misinformation by too many misinformed individuals.”
- “To an unprecedented degree patients are questioning treatment and they sense an uncertainty and clinicians are burdened by the same uncertainty”
- “Consensus has not been developed across the practicing community regarding many issues including which TMJ problems should be treated and when and how they should be treated”
- “We’re suggesting overuse of some more aggressive treatments... we say that not because we know those approaches don’t work but because we know that their superiority has not been demonstrated over the more conservative approaches.”
NOTE - I and many other dental practitioners do not consider the professionals asked to participate on this panel to be the correct people to answer questions concerning TMJ. There are several articles now published which dispute the findings of this panel.
Is any approach better than the others?
Do I and others that follow the same approach to therapy have better results?
First, no one with minimal symptoms should have any therapy performed. Many people have slight clicking within their joints and that in itself is not grounds for therapy.
Second, the ground work for the type of therapy I use was established in the 1920’s and 1930’s by brilliant dental practitioners who were not looking for a “cure” for TMJ, but rather the most naturally correct position for the jaw joint, muscles and teeth to work together. These pioneers did make mistakes but they left a legacy that is very sound physiologically and has helped many patients. In other words there is a track record of success.
Third, my best answer to the question is that IF the person truly has a TMJ problem, the answer will be correct physiologically. In other words, the solution will fit directly into how the joint, muscles and teeth should work together in the most naturally stable position. This position is not artificially created by the dentist, it is simply where that persons joint operates most efficiently with the least trauma being passed to the joint by the teeth and muscles.
Fourth, the solution will follow sound orthopedic principles (such as all joints within your body want to be in socket) and sound dental principles.
Fifth, the treatment will treat THE CAUSE... NOT THE SYMPTOMS (as many surgical approaches do).
If initial therapy is successful then the completion of therapy will most likely be successful. And most importantly, this is a complex problem with sometimes complex answers that must include some of the other specialties before and during therapy.
To define the term: TMJ stands for Temporo Mandibular Joint.
The way our muscles, teeth and joint work together is extremely complicated. In fact the TMJ is the most complicated joint in your body. No other joint you have moves in the intricate ways that they do. Think about one simple aspect... What other bone in your body has the right and left side joints connected and moving at the same time?
||The joint itself is located directly in front of the ears. Place your finger tips about 1/4 inch in front of the ear opening and open your mouth...you’ll feel the TMJ move under your finger tips. This joint moves in a very unusual manner...first it simply hinges open (like most all the other joints in your body), then it glides forward and down (unlike any other joint) to complete its full cycle.
MANDIBLE – the lower jaw.
CONDYLE – the “ball” end of the mandible.
DISC – a dense connective tissue pad that acts as a cushion between the condyle and the socket that it fits into. (Somewhat like the cartilage in your knees).
TO VIEW PHOTOS OF AN ACTUAL HUMAN TMJ (dissection), click here: TMJ Disection
MUSCLES – there are numerous muscles that “power” the TMJ.
The two illustrated here are the two most frequently involved in soreness / pain.
Intra-articular disease vs Myofascial pain disease (MPD)
* Intra-articular disease - this is the damaging changes that occur directly to the jaw joint, such as degenerative joint disease (DJD), unusual growth and development, and other rarer changes. These are changes to the bony and soft tissue components of the joint - changes that for the most part are irreversible. These are the developments that most often are considered for surgery. For a discussion on TMJ surgery - TMJ Surgery.
* Myofascial pain disease (MPD) - in a very simple explanation - the muscular and ligamental pains that occur due to overuse and tearing. This is quite often reversible.
These are often both referred to as "TMJ" but are actually VERY different. In the remainder of this section you will read about causes, symptoms, therapies and other topics.......they may be either intra-articular, MPD or a combination of both.
When people exhibit a problem with their TMJs, it is most often exhibited as;
1. Problems associated with the jaw joint itself.
|Quite often, the disc is displaced to a position in front of the condyle. This results in first a “clicking” or “popping” sound. The disc at this stage is still able to slip or pop back onto the top position on the condyle during the open / close cycle.
||Some people may then experience “locking” of the jaw joint. This occurs because the disc is no longer able to slip or pop back on top of the condyle during the opening or closing cycle. (It is perpetually trapped forward). Because this occurs, the mandible opens only in the first part of its motion and is not able to complete a full cycle - the person often exhibits a limited opening of their mouth.
2. Pain emanating from the jaw joint itself
* usually either an inflammatory response within the joint and /or
* highly innervated tissue being compressed.
3. Problems associated with the muscles.
* Sore muscles (usually in the temple or cheek areas). Headaches that can be actually muscle soreness.
* Limited opening.
4. Problems with the teeth.
* Loose teeth.
* Sore teeth.
* Excessively worn teeth.
* Loss of bone support.
5. Ear problems.
* Hissing or ringing.
* Ear pain, ear ache (in the absence of infection).
* Vertigo, dizziness.
There can be numerous causes for TMJ to occur, but the most common is the simple fact that when the teeth come together, the TMJs are not in socket. This can be a hard concept to understand......some basic thoughts may help explain this.
Move your lower jaw forward.....now left.....now right......as you can see, the jaw joint can move in and out of socket freely. This is an unusual movement for a joint (what if your knees could come out of socket?). Now that you can see there is movement allowed in the joint it is important to understand that there is actually one position when closed that is a correct and stable socket position. In this position the powerful muscles that move the joint are at 'rest' and there exists no damaging forces being applied to the joint, teeth or muscles. Now throw in the teeth.......what if in the position of maximum tooth contact the jaw joint had to come out of the 'rest' position to accommodate? The result is that the jaw joint is not in its 'rest' position when the teeth come together and the muscles 'know' this. The muscles will try to get the joints to the 'rest' position but in this scenario they can't. Most commonly this results in muscle hyperactivity usually exhibited as bruxing (nightgrinding) and day clenching.
People do not notice that they have this discrepancy present. The reason for this is that the muscles that control the joint position shift the jaw down (out of socket) just before the teeth make contact. This is known as an "avoidance pattern" - the muscles move the joint so that the teeth won't crash into each other.
Therefore the determining factors for which symptoms or problems a person may acquire is usually a combination of several factors....
- How far their teeth are misdirecting their TMJs.
- How much they brux (grinding of the teeth at night while sleeping).
- How much stress they're under - stress increases bruxing DRAMATICALLY.
- How much clenching they do during the day.
- How genetically susceptible they are. Many people have a bite that is "off", yet they do not show any TMJ symptoms.
It is VERY common to find that a person with TMJ problems exhibits a MOLAR FULCRUM
The following images and narratives will attempt to explain and demonstrate this condition.
||In this image a correct position for the jaw joint and teeth is demonstrated. Here the teeth make simultaneous and equal contact at the exact moment that the jaw joint is seated in its most stable 'rest' position. The black arrows show that the force being applied to the joint is directly across the disc. Also, in this stable position, the muscles are at 'rest' (not firing) and there exists no damaging forces to either the disc, the bony components of the joint nor the teeth.
This is where most TMD patients find themselves, the teeth are in a position where they make simultaneous and equal contact, BUT the jaw joint is pulled out of socket to make this happen. This position for the jaw joint leads to increased bruxing (night grinding), increased muscular activity and damage to some or all of the following - the disc, bony components of the joint, teeth or bone supporting the teeth.
||In this image the jaw joint pivots into a correct joint position with the forces now directed correctly across the disc and bony components of the joint, BUT the teeth do not strike together correctly. NOTE that the point of contact (green area) is at the last molar and therefore the term - "molar fulcrum".
Molar fulcrums are revealed through splint therapy (see section below). During splint therapy, the muscles will relax and the "avoidance pattern" will diminish over time until the "true" occlusion (bite) is revealed.
So what is the solution? What will make TMJ problems go away?? If you have followed the discussion above on 'CAUSES' then the answer is most often to provide an occlusion (bite) so that when the teeth come into full contact, the joints are not forced out of their 'rest' position.
A very important aspect of this type of therapy is to understand that TMJ therapy is not a CURE ! It is much more a MANAGEMENT of the problem. The jaw joint is easily damaged and NO ONE is going to ever make it perfect again. If a person has sustained joint damage successful treatment means that the damaged joint is put into the least traumatic position so that future damage will be minimized. If the symptoms are primarily muscular pain, therapy can be most often 100% effective.
If someone is truly having a problem that is associated with their TMJs..........then ..........providing a correct bite would be a big step in the right direction. A bite such that the "molar fulcrum" is eliminated and the TMJs remain in the 'rest' position. This is where splint therapy comes into the picture. A splint (when made correctly) is a physiologically correct bite. In other words..........when the splint is placed over the upper teeth it instantly provides a bite where the muscles, joint and teeth do not antagonize each other, rather they work in harmony with each other as nature intended. So.........IF symptoms diminish while wearing a splint, then it can be assumed that the problem truly was TMJ in nature, and definitive treatment can be performed to minimize future problems.
For a detailed discussion on Splint Therapy (Splint Therapy)
Instrumentation Associated with TMJ Therapy
The relationship of the jaw joint (TMJ) to the bite is the "cornerstone" of a healthy stable function. Making models of the upper and lower teeth and then holding them by hand, where most teeth mesh together, as most dentists do, tells us nothing about this most important relationship. This is where articulators come in to play. With a simple manipulation of the lower jaw and warmed wax, a set of models of the teeth, can be related to reveal how the teeth come together when the joint is in its most correct functioning position.
An articulator is an instrument that functions as a bite simulator and relates models of teeth to the jaw joint.
Example of the Above Discussion
In the case shown below, the patient came in for an orthodontic evaluation. Her needs appeared uncomplicated initially. Then when a simple manipulation of the lower jaw was performed, it became obvious that there was a more complex problem. Her jaw joints and teeth were working against each other. Upon further questioning, it was discovered that this 13 year old female had excessive tooth wear for her age and a history of head/jaw pain. Jaw joint x-rays revealed that her left joint had suffered structural degenerative changes. All this as a result of her teeth and her jaw joints not functioning in harmony.
Splint therapy was prescribed as the most conservative diagnostic and therapeutic approach. A splint would reveal the true magnitude of the discrepancy (the diagnostic part) as well as slowing her tooth wear and relieve her discomfort (the therapeutic part).
In the photos below, the left side is shown with the models on the articulator (bite simulator) demonstrating her actual bite after splint therapy. The right photos are those of her models being held in the bite where she closed to (her 'regular bite') the day of her initial exam. This 'regular bite' was the cause of her TMJ symptoms.
It was determined that splint therapy would assist in diagnosing her TMJ problems, orthodontic needs and bite therapies required.
|Photo #1 the articulated models (arrows are pointing to the simulated jaw joint elements of the articulator).
||Photo #2 demonstrates very simply where the patient closes her teeth together all the time - thus in her case, forcing the jaw joint into a very harmful position.
|The red lines above show how the upper and lower front teeth line up. In Photo #4, the patient is practically perfect when she closes. When her models are correctly related with the articulator (#3), the lower jaw is shifted to the left about 6 mm or 1/4 inch. Notice also how her right back teeth do not line up at all. So, this young girl is putting very harsh pressures on her jaw joint when she closes - this is not something that is noticeable to the patient, but none-the-less is causing considerable harm.
|Again views showing the difference between the position where the joints fit (#5) and where the teeth fit (#6). Only diagnostics utilizing articulators can uncover these discrepancies.
|The overbite difference is significant. NOTE the first contact on the last molar - a "molar fulcrum". The position where the joints fit (#7) and where the teeth fit (#8).
In summary, this patient wore a splint full time (24 / 7) for approximately 5 months. During this time, the splint was being adjusted at regular intervals and the jaw joints (TMJs) slowly assumed a correct functioning position. Her symptoms diminished and eventually passed completely. Now with this accomplished, it was time to determine what if any treatment is appropriate for this patients needs. The possible treatments are described in the next section.
PHOTOS COURTESY - David R. Nelson, D.D.S.
Definitive treatment is performing the steps necessary to take someone from the splint they are wearing, back to their teeth touching - while VERY carefully keeping their “system” in balance by maintaining the correct relationships between joint, muscles and teeth.
Since each case is different, this transition to no splint can consist of any one or combination of the following:
- Reshaping the teeth to allow a function joint with an acceptable tooth fit. Very accurate.
- Restorative dentistry. This is crowns, bridges, partials, etc designed to facilitate healthy function. Very accurate.
- Orthodontic treatment. This is braces to move the teeth so they fit in a healthy functioning position. Moderately accurate.
- When the magnitude of correction exceeds all three of the above outlined treatment modalities, a surgical resolution may be required. This type of surgery is not joint surgery but jaw surgery. That is this surgery (orthognathic) is used to reposition the upper and lower jaw structures to allow functional stability. Least accurate.
- The fifth and last option is no further treatment. That is continue long term splint wear to slow tooth and jaw joint degradation while maintaining an acceptable level of comfort.
* 4 and/or 5 could require the addition of 1 and/or 2 to be complete. This is due to the inherent accuracy of the different treatment modalities.
OTHER POSSIBILITIES OF THERAPY
As previously stated, there are times where splint therapy alone will not accomplish all that we would like, in those cases it may be necessary to perform other adjunctive therapy such as
- Physical therapy
- Biofeedback therapy
- Jaw joint surgery (only in very limited circumstances)
- Muscle relaxers and /or anti-inflammatory drug therapy.
Jaw joint dysfunction treatment is complex and individual. A successful treatment is designed for each individual patient. The design takes the form of careful analysis and production of a splint using every possible piece of information available.
Implant Supported Dentures
Typically the lower denture is the most problematic. For individuals who have had the teeth removed for years, the bone slowly has diminished and with this change, the denture is more difficult to wear. Sore spots and difficulty chewing are usually the result of a mobile (bouncing) denture.
Upper dentures can be difficult to wear too! Gagging, looseness and chronic sore spots are all reasons to consider implants in the upper arch. The upper although less problematic, can be retained much more securely via implants. This adds great confidence with the individual that there will be no "embarrassing" moments and often the palatal (part covering the roof of the mouth) area of the denture can be entirely removed. This adds to a more comfortable adaptation to the denture.
Simply stated, dental implants provide a stable foundation for patients to regain nearly 90% of their chewing ability. Never having to experience a limited diet or the embarrassment of and ill-fitting denture.
Implant Supported REMOVABLE Dentures
Dental implants are placed and covered over. They then heal and integrate with the jaw. After healing, a top/extension is screwed onto the implant that most often has a snap head or ball. The dentures have a matching piece that engages with the implant snap. There can be as few as 2 or as many as 6 (4 being the typical) implants placed. The more placed, the greater the stability.
Lower implants with snap heads placed
Over the past decade, these type of implants have grown increasingly popular. Term "mini" refers to the diameter of the actual implant root form being placed into the bone. Any implant diameter less than 3 millimeters is considered a "mini".
The differences between the traditional approach (above) and these are -
- The implants come in one piece with the ball in place.
- There is no healing time.
- The snaps in the dentures are placed immediately. (NOTE - Upper denture placement can vary slightly on this)
- Less expensive !!
Implant Supported FIXED Dentures
The term "fixed" refers to the fact that these cannot be removed by the patient. Removal is accomplished by loosening the screws and is only needed occasionally for maintenance and sometimes for more thorough cleanings. These tooth replacements are as solid as the original teeth. The chewing power of this denture is much greater than a conventional/removalble denture.
Standard implants are placed. The upper usually requires six to eight, the lower four to five plus.
Implants with Healing Abutments Before Fixed Denture
Fixed Denture screwed in position with access holes filled
Patients who have dental implants are thrilled by the improvement in every aspect of wearing a denture!
- Better ability to chew - Eat what you want!
- Improved appearance - Restore a youthful, vigorous appearance!
- Be more confident - Don't be afraid to smile!
- More healthy diet - Eat what you should!
- Be happy - Feel better about yourself!
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