TMJ Disorder Treatment

1/10 | http://www.docshop.com/education/dental/general-dentistry/tmj/treatment
BY
Ettienne Van Zyl, DDS
SENIOR SECTIONAL EDITOR
updated March 12, 2015
Source: http://www.docshop.com/education/dental/general-
dentistry/tmj/treatment
Temporomandibular joint (TMJ) disorder affects an estimated 10 million
Americans. TMJ disorder is characterized by pain relating to the joints
on either side of the jaw, or a compromise in the ability to make normal
jaw movements. It can occur for a number of reasons, and there is a
range of TMJ disorder treatments, both conservative and extensive,
designed to address patients' specific needs.
Neuromuscular dentistry focuses on discovering the optimal positioning
of a patient's jaw, and achieving harmony between the jaws, muscles,
TMJ Disorder Treatment

nerves, and soft tissues. I have been incorporating neuromuscular
dentistry techniques in my practice since 2003, and this discipline is
making tremendous strides in helping many patients find solutions for
TMJ disorder.
If the misalignment of the jaws is found to be the cause of a patient's
TMJ disorder, treatments like coronoplasty (reshaping of tooth enamel),
placement of certain dental restorations, and even simple lifestyle
changes can potentially provide relief. As with any health condition,
patient education is a fundamental element of treatment. If you
familiarize yourself with the basic principles TMJ disorder, and how
specific treatments apply, you and your dentist or physician can
determine a way to successfully restore your comfort, peace of mind,
and quality of life.
Anatomy of the Temporomandibular Joint
The TMJs connect the jaw to the skull, and they are the most frequently
used joints in the body. The part of the jaw bone (mandible) that
connects to the skull is called the mandibular condyle. The two
uppermost points on either side of the jaw resemble a horseshoe, and
the mandibular condyle is side of the horseshoe that reaches the
highest. The section of the skull that connects to the mandibular
condyle is called the articular surface of the temporal bone, and it lies
parallel to the ear. The articular disk, which consists of flexible
cartilage, acts as a cushion between these two surfaces as the jaw
opens and closes. It could be compared to what happens when you
stand on the ball of your foot: the ground is like the temporal bone, your
foot is like the condyle, and the sole of your shoe is like the disk,
providing a buffer between the two components. A capsule, or fibrous
membrane, surrounds both joints, and an intricate system of muscles
and tendons controls their movement, allowing the jaw to open, close,
and move side to side.
Causes of TMJ Disorder
One of the most common causes of TMJ disorder is an eroded or
misaligned articular disk, and it can occur for a number of reasons,

including arthritis and trauma. The disk itself can move forward from
its proper position, pulling sensitive connective tissue (retrodiscal
tissue, which carries the blood supply to the disc) into the point of
connection between the mandible and skull. When this happens, the
condyle must move over the back end of the disk as the jaw opens,
resulting in a clicking or popping sound. The disk itself does not contain
nerve endings, but the retrodiscal tissue does. Therefore, when the disk
becomes fully dislocated and fails to return to its proper position, it can
be quite painful. However, in many cases, a process called natural
adaptation occurs. The retrodiscal tissue can develop scar tissue that
gives it the same fundamental consistency as the disk. At this point, the
tissue can serve the same purpose as the disk, cause little or no pain,
and allow the jaws to open and close as normal. A physician may
prescribe various pain management strategies as natural adaptation
takes place.
In other cases, symptoms of TMJ disorder occur because the upper and
lower teeth do not meet properly, and the muscles governing the
movement of the jaw must overcompensate to create the best balance
possible. This requires prolonged strain that can eventually result in
headaches, as well as neck, shoulder, and facial pain. Often, an
imbalanced bite is the result of nighttime teeth grinding that places
considerable stress on the jaw muscles, and eventually damages the
structure of the teeth. It can also occur as a result of natural dental
misalignment.
Treating TMJ Disorder: The
Neuromuscular Dentistry Approach
As a neuromuscular dentist, I primarily treat patients whose TMJ
disorder symptoms are caused by a misaligned bite. I studied
neuromuscular dentistry with Ralph Garcia Jr., D.D.S., who practices in
Tampa and mentors dentists in TMJ disorder treatment. He says in his
39 years of practicing dentistry, the outlook has never been better for
those suffering with TMJ disorder.
"Due to the advances in electrodiagnosis, magnetic resonance imaging,
and computerized tomography, along with a better understanding of the
problems that beset the TMJ disorder patients, the future for these

•
patients is extremely optimistic," he said. "Neuromuscular
electrodiagnostic equipment provides a more scientific and
comprehensive evaluation of the TMJ disorder patient that helps
unearth any muscle dysfunction, and any qualitative or quantitative
anomalies in jaw movement or function."
The ultimate goal of a neuromuscular dentist is to help the patient find a
permanent solution that relies on his or her own teeth, usually by
making alterations to the bite. I begin by using advanced diagnostics to
identify any undue strain on the muscles and tendons.
Diagnosis: Identifying the Cause of TMJ
Disorder
Your body is obsessed with what goes on with your teeth at all times. In
fact, about 45 percent of the entire motor center for the upper brain
controls what happens on the face, and most of that activity is
dedicated to maintaining a comfortable balance between the upper and
lower jaws.
Because the muscles suffer the greatest in cases of TMJ disorder
relating to jaw misalignment, I use special software to track how the
muscles behave when the patient moves his jaw. As with an
electrocardiogram, which uses special leads to read heart activity, I
place leads on the temple and neck. Using a K7 biomonitor, I can
accurately detect overactivity in the upper jaw. I look to see what those
muscles are being asked to do in order to maintain the balance of the
jaw. This involves three primary components:
Computerized mandibular scanning (CMS) assess the precise
movements of the jaw. It guages both lateral and vertical tension, and
can determine if the jaw is following a smooth path, or a path
I use special software to track how the
muscles behave when the patient
moves his jaw

•
•
compromised by tension or friction.
Electromyography (EMG) measures the activity of muscles at various
jaw positions. EMG can detect if muscles are tense when they should
be relaxed, and helps determine the proper jaw position.
Sonography measures the sound of the TMJ as it opens and closes,
and can detect friction or sudden shifting of jaw components.
When we determine those values, we place the patient on
transcutaneous electrical nerve stimulation (TENS). This device
delivers a very mild electrical charge that calms the muscles. This
overrides short-term muscle memory, allowing these muscles to fully
relax.
At this point, I can analyze the true relationship of the upper and lower
jaws, and determine how the jaws should meet in order to avoid
straining these muscles. I recommend subsequent treatment based on
the conditions obstructing the proper meeting of the jaws.
Orthotics: Re-educating the Muscles and
Tendons
Once the proper positioning of the jaws has been determined, they must
remain in that position for a period to allow the muscles and tendons to
heal. Orthotics are custom-made appliances that fit over the patient's
teeth, keeping the jaws in their proper position. They are completely
ergonomic, and designed to look like the patient's natural teeth. They
can be either fixed or permanent. A fixed orthotic will help the patient
heal faster, because it does not allow the teeth to return to the improper
position. Healing takes longer with a removable orthotic, though this is a
more affordable option. Some patients just want a crutch so that they
don't hurt every day, and decide that they would rather have a
removable orthotic.
When the muscles and tendons have completely healed, it is time to
consider making a permanent change to the bite in order to maintain
comfort and oral health. The orthotic serves as a guide during the next

stage of treatment, which will involve either reshaping the teeth, placing
prosthodontics, using orthodontics, or combining these procedures for
full mouth reconstruction.
Coronoplasty: Changing the Shape of the
Teeth
In some cases, the shape of a tooth can affect the alignment of the jaws.
Coronoplasty is a process of removing some tooth enamel to refine the
shape of the tooth, allowing the jaws to meet properly. However, very
few cases can be treated with tooth reshaping alone.
Orthodontics: Moving Teeth into Proper
Alignment
Straight teeth are an aesthetic asset, but more importantly, they
contribute to good oral health, and allow the jaws to meet properly.
Orthodontics involves using various appliances to gradually guide the
teeth into proper alignment. The traditional method uses metal brackets
and wires that apply gentle pressure to the teeth, usually over a period
of one to two years. Tension is adjusted over the course of treatment,
correcting malocclusions. Often, orthodontics are combined with
coronoplasty to help the jaws achieve proper alignment.
Prosthodontics and Full Mouth
Reconstruction
Custom dental restorations, or prosthodontics, can make a significant
difference in how the jaws meet. Crowns are tooth-shaped caps most
often used to restore a tooth after it has been treated for trauma or
decay. If a patient is missing a tooth, a crown can be used to restore a
dental implant, which is a titanium post surgically inserted in the jaw to
replace lost tooth roots. Bridges (also called partial dentures) are
similar to crowns, but are designed to replace several consecutive
teeth.

In addition to replacing or restoring teeth, crowns and bridges can
correct the balance of your bite. Crowns and bridges are specially
crafted to achieve a natural appearance and a shape that achieves
harmony with the opposing teeth, resulting in a balanced bite.
In some cases, the placement of crowns and bridges alone can help
patients achieve the balance necessary to treat TMJ disorder. However,
more frequently, they are combined with some tooth reshaping or
orthodontics treatment to best meet the patient's specific needs.
Case Study: Helping Amanda Overcome
Migraines and Muscle Paralysis
Amanda is a patient who came to my office because she needed a
dental crown. When I first met her, I noticed that her face had begun to
slide down on the left side. She had been tested for Bell's Palsy (a form
of facial paralysis) and undergone MRIs, but in the end, she was told
she had neuropathy (dysfunction of the nerves), and there was nothing
more that could be done. She also explained that she had suffered with
migraine headaches for many years. I suggested that she undergo a
TMJ screening with me, and I detected severe alignment issues in her
bite due to improper positioning of teeth in the lower jaw.
"I had braces when I was a kid,"
Amanda said. "The doctors just
made my teeth look good, but
they didn't make my bite work for
me."
She remained skeptical that TMJ
disorder was to blame for her
migraines and the issues with
her facial muscles, but she was
willing to wear a custom orthotic that would place her jaw in the proper
position.
"Within two months, I had no more headaches," Amanda said. "My face
also started getting better a little at a time. I just didn't have an issue
I had braces when I was a
kid...The doctors just
made my teeth look good,
but they didn't make my
bite work for me

when I wore the orthotic. The pain would come right back when I'd
remove the orthotic to eat. I decided I would never be able to wean
myself off of it."
I prescribed braces to achieve permanent realignment of her teeth. She
completed orthodontic treatment last fall, and is continuing to live free
of of migraines. Meanwhile, her facial muscles have almost completely
returned to their proper position.
"If you have consistent migraines, neuromuscular dentistry is perhaps
an opportunity to get rid of them permanently," she said.
After TMJ Disorder Treatment:
Maintaining Relief
Bruxism is the clenching or grinding of the teeth. It can be an
unconscious function, and can occur during the day or night. In many
cases, bruxism is the cause of the dental damage or skeletomuscular
strain that accompanies TMJ disorder. Often, when a patient has
completed treatment for TMJ disorder, I will provide a custom sleep
appliance that fits over the teeth and any restorations, protecting them
from the effects of bruxism and helping the patient to achieve more
restful sleep. TMJ disorder treatment is a significant investment in your
health and quality of life, and a sleep appliance can help you maintain
your refined bite.
Managing Pain
TMJ disorder can cause serious physical and emotional pain for
patients. The headaches, neck and shoulder pain, and other symptoms
can make patients feel irritable and depressed, in addition to feeling
physically uncomfortable. Many patients who begin TMJ disorder
treatment continue to experience painful symptoms in the early stages
of treatment.

In some cases, muscle relaxers or pain medication may be the best
solution. However, I am personally more inclined to prescribe pain
management solutions such as hot and cold compress therapy.
I sometimes prescribe dry needling, a technique similar to acupuncture,
in which a very thin needle is inserted into a trigger point, or muscle
knot, to relieve generalized musculoskeletal pain. Wet needling, a
variation of this treatment involving the injection of saline through the
needle, may be recommended in some cases. Ultrasound can also be
very effective in relaxing strained muscles. Sometimes simple changes
such as eating softer foods can cause a significant reduction in pain.
Meanwhile, it is important that TMJ disorder sufferers take measures to
maintain a positive mental attitude. I tell patients that if they start
obsessing about their pain, they should engage in a healthy distraction,
such as taking a walk outside. I often recommend making simple
changes in a patient's daily routine to engage the mind and avoid
concentrating on their discomfort.
These changes often include starting to exercise or enjoy other relaxing
activities. You have probably noticed that in times of tension or anxiety,
you clench your jaws. By taking time to exercise or become immersed
in tranquil hobbies like painting or playing a musical instrument, patients
can actually lower their overall stress level, resulting in reduced strain
on the TMJs and their governing muscles and tendons.
Surgery
It is possible that a patient will not achieve relief through dental, non-
invasive, or minimally invasive treatments. There are surgical
treatments for TMJ disorder, but they are controversial because there
Many patients who begin TMJ disorder
treatment continue to experience painful
symptoms in the early stages of
treatment

•
•
•
are no long-term clinical studies to determine the effectiveness or
safety of this approach. If your dentist or physician recommends
surgery, make sure the procedure and its risks are fully explained, and
consider soliciting a second opinion.
Achieving Relief from TMJ Disorder
TMJ disorder is complicated, and its symptoms can take a significant
toll on your quality of life. If you are experiencing a popping or clicking
sound in your jaw, headaches, facial pain, back and neck pain, or other
symptoms that seem to have no clear cause, it is definitely worth
discussing with your dentist. Today, more dentists are becoming
educated in TMJ disorder. If your dentist is unable to diagnose TMJ
disorder, he or she may be able to refer you to a physician or specialist
who can identify the cause of your symptoms. Your best bet is to seek
treatment as soon as you notice symptoms. With early diagnosis, your
dentist or physician can help restore your comfort and your peace of
mind.
References & Resources
Source: http://www.docshop.com/education/dental/general-
dentistry/tmj/treatment
Author: Ettienne Van Zyl, DDS
Publisher: DocShop

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