CAUSES OF TMD

The temporomandibular joints are among the most utilized joints in the body, due to their prolonged use during chewing, talking, singing, yawning, etc. Jaw dysfunction (TM dysfunction) means that the lower jaw is not in its proper relationship to the upper jaw. This frequently results in a dislocation of the protective disc anteriorly as the lower jaw assumes a position further back than normal.

SOME OF THE MOST COMMON CAUSES

1. Lower Jaw Too Far Back

• Deep dental overbite
• Upper front teeth tipped backwards
• Back teeth missing

  Result: causes dislocation of the protective disc anteriorly

2. Unbalanced Muscles

• Clenching or grinding habits
• Bad posture

3. Trauma

• Automobile accidents
• Whiplash injury
• Intubation procedures in hospitals
• Trauma to the head or jaw

Condyles Too Far Back: The Main Cause of TMD

Normal Joint	Dislocated Jaw Joint Disc Displaced Anteriorly

The temporomandibular joint is affected like no other joint in the body. Behind the condyle (top of lower jaw), there are several structures that affect the health of the jaw joint itself. One is the posterior ligament which acts as a rubber band to pull the disc backward during closing of the jaw. Like all joints, the TM joints contain a large amount of nerves and blood vessels that on a subconscious level give the brain information about the position and condition of the joint. When the jaw is closed, the disc, which has no feeling, acts as a shock absorber to prevent the nerves and blood vessels from being compressed. When the mouth opens and the condyle and the disc move forward, the blood vessels expand to fill the vacated space. When the condyle is pushed too far backwards in the joint, it can slip off the cartilage disc and into these nerves and blood vessels. When nerves and blood vessels are compressed, the whole structure is unbalanced, affecting the nerves, the ligaments and the muscles of the head, neck and face. This dislocated jaw causes pain and other symptoms, which affect health and a person's quality of life.

DISLOCATED JAW JOINT, DISC DISPLACED ANTERIORLY

The treatment of choice for a patient with a dislocated jaw due to the lower jaw (condyle) being positioned too far back would be to use a lower splint, orthotic or functional jaw orthopedic appliance to reposition the lower jaw forward.

UNBALANCED MUSCLES

Unbalanced muscles can be a result of clenching or grinding of the teeth. If a muscle is overworked or becomes fatigued due to a structural imbalance, other muscles must compensate. This compensation causes the body to adjust to an abnormal postural state. Compensation means the body adapts to a state that is unhealthy. The body will start to experience symptoms on a mild level, such as occasional headaches. Slowly the symptoms start to occur on a more frequent level until eventually you are experiencing pain on a daily basis.

Whether you have a slightly displaced disc, a dislocated disc, unfavorable head posture or body posture, the abnormal forces and strain produced by tired, spastic muscles can refer pain into the neck, face or head. These muscle tension headaches can be so severe that they are confused with migraine headaches. Unfortunately, patients are often not examined for TMJ disorder and the "migraine" treatment works poorly.

The treatment for patients with migraine headaches is often the prescribing of pain medications such as Imitrex. This medication is ineffective in solving problems relating to dislocated jaw joints (TM dysfunction). Patients are advised to contact a dentist who utilizes appliances designed to reposition the lower jaw forward or to control parafunctional habits to try and solve the problem as early as it is diagnosed.

An overwhelming majority of patients who sustain whiplash injuries in motor vehicle accidents (MVA) also dislocated one or both temporomandibular joints at the same time without having impacted their face or head against the steering wheel, door column, windshield or other parts of the car.

Whiplash typically occurs if the head is thrown backward and forward while riding in a car that is hit from behind or the side. Extensive research has well documented the fact that most flexion-extension injuries occur following what is called "minor head injuries." This means that it is not necessary to suffer a fracture or even a direct head impact. In fact, most patients report that their head was simply snapped backward and forward or side to side. This motion causes damage to the muscles and ligaments which support the jaw joint. When these muscles and ligaments are injured, this can cause an anterior displacement of the protective disc and result in a dislocated jaw joint on one or both sides.

INTUBATION PROCEDURES

Patients that undergo surgical procedures with general anesthetic are usually intubated through the mouth. Intubation is the procedure by which a tube is placed down the throat to keep the airway open during surgical procedures. Occasionally, the jaw can be dislocated during this procedure due to the forced opening of the mouth and the hyperextension of the ligaments and tissues in order to insert the tube. Some patients may experience clicking in the jaw, limited opening of the mouth, facial pain, and headaches post surgically. Those patients who have already been diagnosed with a TM disorder should advise the anesthetist that they wish to be intubated through the nose during any surgical procedure to prevent further damage to the joint and its surrounding structures.

TRAUMA TO THE HEAD AND JAW

A severe blow the head or the jaw can cause the disc to be dislocated due to the force of the impact on the jaw. Patients may experience swelling, limited opening and clicking in the joint. Patients with this acute injury should seek emergency treatment immediately to avoid further damage to the joint.

FOODS AND DRINKS KNOWN TO AGGRAVATE HEADACHES FOR SOME PATIENTS

• Alcohol
• Tobacco
• Caffeine Coffee,tea, soft drinks, chocolate
• M.S.G. Flavor enhancer user to preserve foods
• Artificial Sweeteners Aspartame, Nutrasweet
• Vegetable Oil Fried or greasy foods should be avoided
• Milk and Cheese
• Nuts
• Raw Beans
• Pork

 TREATMENT OF TMD

Discussion and examination take place at the initial consultation appointment when the patient reports time of onset, duration and intensity of pain in the affected area. The examination explores the pattern of jaw movement to detect sounds and tenderness to gentle pressure.

Further diagnostic testing is indicated the presence of jaw joint dysfunction is suspected. Further testing is designed to properly diagnose the patient's problem and to try to reduce the signs and symptoms of the dysfunction. To determine if the lower jaw and the disc of the TM joints are in the correct position, the following diagnostic tests are used:

• Medical and Dental History as well as an examination of the teeth and the dental arches

• TMJ Health Questionnaire
  Patients are asked questions regarding possible TM dysfunction symptoms. If the patient answers "yes" to any of the symptoms and "yes" to clenching and bruxing, then further tests are required to confirm the presence of a jaw joint problem (TM disorder).

• Range of Motion
  Patients are checked for how wide they can open, slide left and right, move the jaw forward, and whether or not there is a deviation or deflection of the jaw upon opening. If there is a problem achieving normal range of motion, there is usually a structural problem within the joint.

• Muscle Palpation
  Excessive muscle contractions and trigger points indicate a problem with the chewing muscles of mastication. This causes the muscles of the head and neck to be sore when pressed by the dentist. This usually means that the lower jaw is not in the correct position.

• TMJ X-Rays
  TMJ x-rays are important to see if the condyles (top of the lower jaw bone) are too far back where they would be impinging on the nerves and blood vessels at the back of the socket where the jaw bone fits into the skull. In cases where the lower jaw is too far back, dentists find a significant reduction in the signs and symptoms of TM disorders when the jaw is repositioned forward with a splint or a functional orthopedic appliance.

Tomogram X-Ray Machine

(TMJ X-Rays)

• Computerized Joint Vibration Analysis
  This is specialized equipment used to take readings of the noises or vibrations occurring within the jaw joints upon opening and closing movements. The JVA is simply a 3-minute, non-invasive test where headphones are placed on both jaw joints and the patient is instructed to open and close six times. An abnormal or dislocated joint has distinctive vibrations which can be analyzed to help diagnose the seriousness of the problem.

  There are basically 5 stages of disc displacement. Ideally, if there is a jaw problem you would hope that the patient is in Stage 1 or Stage 2 where the disc can be recaptured. If the JVA reveals that the patient is in Stage 3, 4 or 5, this is a much more serious problem and the prognosis is not as good for resolution of all the symptoms.

Our office has the knowledge and experience needed for proper, thorough diagnosis and treatment of temporomandibular joint dysfunction.

TREATMENT

Since the teeth, jaw joints and muscles can all be involved, treatment for this condition varies. Typically, treatment will involve several phases. The first goal is to relieve the muscle spasm and pain as well as establish normal range of motion of the lower jaw. Then, your dentist must correct the way the teeth fit together. Often a temporary device known as an orthotic or splint is worn over the teeth until the bite is stabilized. Permanent correction may involve selective reshaping of the teeth, building crowns on the teeth, orthodontics or a permanent appliance to cover the teeth. If the jaw joint itself is damaged, it must be specifically treated. Although infrequent, surgery is sometimes required to correct a damaged joint. Ultimately, your dentist will stabilize your bite so that the teeth, muscles and joints all work together without strain.

Once a thorough diagnosis has been made, the dentist will begin a personalized treatment program. Patients benefit from the non-surgical, conservative treatment our office provides. Individualized therapy will include muscle spasm reduction treatments in conjunction with an easy to wear, comfortable dental orthotic, referred to as a splint. The orthotic covers the lower teeth holding the jaw in proper alignment, reducing tension in the muscles of the jaw joint, allowing healing to take place. Once pain is controlled and the jaw joint is stabilized, the bite is balanced so the teeth, muscles and joints all work together in harmony.

It is important to assess the posture of each patient to determine whether or not the shoulders, pelvis and hips are level. Photos are taken of each patient to check for the above as well as to check for forward head posture. If there is a problem with the shoulders, hips or pelvis or if one leg is longer than the other, then a referral to a chiropractor would be necessary.

To solve the problem of forward head posture which can cause cervical (neck) problems, referral to a dentist or orthodontist who uses functional jaw orthopedic appliances should be made. These appliances such as the Twin Block, MARA or Herbst Appliance successfully reposition the lower jaw forward and eliminate the forward head posture.

For most patients, treatment is divided into two stages:

PHASE I DIAGNOSTIC PHASE (Temporary Solution)

Diagnostic Splints

If there is an improper relationship between the upper and lower jaws and/or the upper and lower teeth, the patient will be required to wear temporary oral appliances (orthotic or splint). This TMJ splint is usually worn over the lower teeth until the bite and position of the lower jaw is stabilized. The objective of the lower splint is to try and establish the correct position of the mandible to the maxilla in three dimensions; namely, transverse, sagittal and vertical. The goal is to try and find a comfortable position for the lower jaw so that the patient can get some relief from the pain and muscle spasms. If the patient has a denture or a partial denture, the splint may be constructed over them similar to the method with natural teeth.

Lower Day Splint

Upper Night Appliance

HOME CARE FOR YOUR SPLINT

Since most head, neck and shoulder pain originates from muscle instability or swelling and inflammation of the joints, we may employ various physical modalities to treat and help normalize these structures. This includes such things as transcutaneous electrical nerve stimulation (TENS), moist heat therapy, vapor coolant sprays, and infrared treatments. These joints often get very tight in people with dysfunctions and various types of mobilization or stretching techniques are employed to gain normal function of these tissues.

Infrared Treatment for TMJ

Sometimes it will be necessary to refer patients to other health care practitioners to help relieve some of the muscle spasms including chiropractors, massage therapists, physical therapists, craniosacral therapists, etc. The patient must be made aware of the fact that, although the majority of patients do improve substantially, there are still a small number of patients whose treatment is not effective. The longer the disc is out of position anteriorly, the more the posterior ligaments get stretched and the more difficult it becomes for the posterior ligaments to reposition the disc to its correct position on the head of the condyle.

Some of these patients may have suffered traumatic injuries such as a blow to the head or have been involved in a car accident, which caused a whiplash injury. If the posterior ligaments, which help position the disc between the condyle and the temporal bone, have become stretched or torn as a result of a serious injury, then the prognosis for successful treatment is diminished. Obviously, the sooner the patient can be treated, the higher the success rate.

Near the end of Phase I, which usually lasts four months, the clinician and the patient will evaluate the success of the treatment. The patient will take the same diagnostic tests, clinical examinations, and fill out the appropriate TMJ progress report to see what improvement there is in the signs and symptoms of TM dysfunction. If the tests, including the Joint Vibration Analysis and the tomograms (TMJ x-rays), reveal that the condyle is related properly to the glenoid fossa of the temporal bone and the disc has been restored to its proper position, we would assume there would be a reduction of the signs and symptoms. A consultation appointment is held with the patient to discuss the success of Phase I and the various options for Phase II.

The vast majority of symptoms must be resolved in Phase I Diagnostic Phase prior to the initiation of Phase II Treatment Phase.

PHASE II TREATMENT PHASE JAW STABILIZATION
(Permanent Solution)

1. Orthodontics
2. Crown & Bridge
3. Overlay Partial Dentures
4. Complete Dentures
5. Partial Dentures

The important aim of correcting your bite is to ensure optimal long-term health. If you have any of the signs or symptoms mentioned, discuss them with your dentist.

Your health is your most priceless possession. It is worth the investment!

SELF-ASSESSMENT TEST

Here are a few questions you may want to ask yourself, to help determine if you have any symptoms:

Here are some ways you can visually check your TM joint:

Check for muscle sensitivity:

Place your fingers in front of your ears on the joint and apply pressure.

HOME CARE FOR YOUR SPLINT

To Remove
With your fingertips, pull up or down on the back outside edges of the splint, just under the plastic layer.

To Place in Your Mouth
Place the splint over your teeth in the correct alignment and push into place with your thumbs or forefingers.

To Clean
Remove the splint when brushing your teeth and brush it with the brush provided. Be sure to support the splint evenly while brushing. For removal of odor and stains, soak the splint in any of the following solutions:

1. ½ vinegar and ½ cool tap water for 20-30 minutes.
2. 2 tablespoons of baking soda in ½ cup tap water for 20-30 minutes.
3. Cool tap water and a denture cleaning solution like Polident or Efferdent for 15 minutes.

Note: Heat will cause your splint to warp. Therefore, do not use hot water when cleaning the splint. If the water is too hot for your fingers, it is too hot for your splint. Do not leave your splint in a car or next to a heater. However, as long as your splint is in position in your mouth, hot food or drink will not damage it.

Special Notes

1. You must wear your splint all the time and remove it only to brush your teeth (unless told otherwise). It is especially important to wear your splint when you are concentrating on something such as driving, exercising, paperwork, etc. These times are when you are most likely to subconsciously grind your teeth.

2. At all times try to condition yourself to keep your teeth slightly apart, even when wearing the splint. Your teeth should only touch when you swallow or eat. Separating the teeth will help your muscles to relax and reduce the stress on the jaw joints.

3. In the beginning, you may find that you have more saliva in your mouth. This is your mouth getting used to having something in it all the time. After awhile, this should return to normal.

4. You probably will have sore teeth, a sore tongue and some muscle pain after getting your splint. This is only the muscles and your teeth becoming accustomed to the splint. These symptoms should subside in a few days.

5. The best way to learn to speak with your splint is to start right away enunciating more dramatically and reading or singing aloud to practice. It may take a few days to become accustomed to speaking with it. Remember, you sound worse to yourself than you do to others.

6. You should brush after every meal. Since your teeth and gums are covered by the splint, your tongue is unable to remove any food particles and we do not want you to develop cavities or gum problems. When you brush your teeth, also take the time to clean your appliance.

7. Be careful with your splint. Keep your splint away from dogs!!! Dogs love to chew on splints. Try not to drop your splint as it may break. Never wrap your splint in a paper napkin or tissue and lay it on the table. Someone may throw it away. Don't put it in your pocket because you might break it. Avoid flipping the splint with your tongue as that can damage your splint.

If you have any additional questions, please feel free to call us. We want this to be as pleasant an experience for you as possible and are anxious to assist you in adjusting to this therapy.