The TMJ (temporomandibular joint) is the joint that links your jaw to the base of your skull. When subjected to forces outside the range of adaptability, it is said to be in dysfunction. This causes an irritation of the trigeminal nerve that can lead to severe acute and chronic pain. The dysfunction can be seen as a non-painful deviation of the jaw during opening or closing, clicking noise when the jaw moves, limited opening or lockjaw. The most common symptoms and discomforts associated with TMD (temporomandibular disorder) are:
- Jaw tenderness
- Earpain
- Neck and shoulder pain
- Frequent headaches
- Muscle tenderness
- Limitation of the opening of the mouth
- Difficulty eating
- Changes in occlusion
- Dizziness
Phase 1: Myofunctional therapy with EMG
Our approach to the problem begins with a diagnosis based on history, physical examination and objective biomedical tests. We employ 3D radiographs (CBCT) of the teeth, jaws, airway and jaw joints. The advanced biomedical tests mentioned above are Electromyography (EMG); to ascertain the status of the muscles of the jaws while at rest and also in function. Transcutaneous Electric Nerve Stimulation (TENS) is used to relax the muscles, Electrosonography (ESG) and Computerized Mandibular Scans (CMS) used to track the movement of the jaws through time and space. Diagnostic models and photographs are also taken to complete our initial evaluation. Once the data is gathered and analyzed, a treatment plan will be created and may include:
- A precision oral orthotic
- Dental work to correct the bite
- A nightguard
- Craniosacral therapy
- Prolozone
Most often (approximately 90%) a precision orthotic is fabricated. It is made out of a clear vinyl that is low in toxicity. The orthosis is worn for as much as possible (ideally twenty-four hours a day) except to brush your teeth and clean the appliance.
Once you begin the treatment process, the following steps occur:
1) Two weeks from the diagnostic appointment, you will return for the fitting of the appliance. You will start wearing in on a daily basis to restore your normal vertical dimension of occlusion (VDO) and relax your head and neck muscles. An appointment will be scheduled one week after the initial one to ensure your comfort.
2) During your one-week follow up, we will assess any positive benefits or negative side effects. The introduction of the orthotic to your system can be quite a shift and we want to ensure that we monitor its effects closely in the beginning. After your appointment, we will schedule another follow up in one month.
3) At your one-month appointment, the appliance is checked for form, fit and comfort. We will also be monitoring what your body is doing and how are you reacting. You will grade yourself on a scorecard called the Kinnie-Funt index. This same process is followed at the next few appointments. During these visits, we may recommend some type of bodywork to help you with your recovery. This can be massage therapy, chiropractic, craniosacral therapy or osteopathic care.
4) At the end of 3-6 months of visits you are then put back on the EMG diagnostic system for a “check-out” session. Here you are given a battery of tests similar to the initial set on the first visit. The difference now however is that you should be healthier.
We will usually find one of two things happening at this visit. They are:
You are stable with your orthosis (this is our hoped for outcome) or
You have made strides in positive change and now need to have the orthosis altered so the muscles can function at an even better position. This will result in either a new orthotic or a “re-topping” of the existing orthotic. That decision is made at the time the testing is completed.
Phase 2: Replacing the orthotic with a permanent solution
Once we have met the criteria for a successful outcome and you are pain-free, we want to transition into what we call phase 2. We want to keep the progress made with the appliance and transition you permanently in this position without the need to wear the orthotic. Here are the ways to achieve that goal:
- Equilibration or Coronoplasty – this is the reshaping of the biting surface of the teeth to be in better harmony and improve the occlusion
- Semi-permanent removable overlay orthotic – this is similar to the appliance you may have had but is made from a more durable material that will not wear down as readily as the vinyl or acrylic one has. This appliance may also be wean off and be transitioned only to be a night-time appliance
- Fixed Rehabilitation – this is the permanent altering of your teeth by resurfacing them. This will be either with crowns, veneers, or bridges. For most cases, this is the ideal solution to achieve the new position of the teeth and the TMD.
- Orthodontics – the moving of your teeth to a more ideal position to fit your specific needs. This is a good solution if there was no major dental work done previously.
- Oral Surgery– in a very small fraction (<1%) of the cases this is needed when there is a major discrepancy between the maxilla and the mandible.
- Combination Therapy – any of the above to achieve the desired results.
There is a book we highly recommend called “Solving the Pain Puzzle,” by Mary Lynn Pulley. This booklet is very informative. Please call the office and we can arrange for one to be sent to you.
Vivos
Vivos is another alternative to treat temporomandibular disorders (TMD). It is especially efficient for patients with narrow jaws, crowded teeth and restricted airway. In addition to being a TMD appliance, it also helps to treat obstructive sleep apnea (OSA) and was recently approved by the FDA. This type of appliance needs to be worn for 12 to 18 months at least 14 hours per day. It will help to stimulate jaw grow and at the same time open the airway.
