Current TMJ Treatment
Current treatment reflects the inability of dentistry to understand the cause of TMJ disorders. There are a number of very diverse and often opposite schools of thought about causes and treatments, most with a teaching academy and devoted followers. Each school of thought has a preferred oral appliance and a protocol for using it.
Dental companies take advantage of the confusion by marketing ineffective clinical tools that are advertised as "advanced diagnostics", but have no actual clinical usefulness. For example, diagnostic equipment that listens to joint noises with Doppler ultrasound, sonography, joint vibration analysis, and jaw velocity analysis claims to be able to scale the degree of arthritic damage; but none of these technologies has been shown to be more reliable than a simple stethascope; and, even if they could, such scaling gives no indications about which treatments are appropriate. The Myotronics diagnostic equipment (Las Vegas Institute) is supported by an extensive bite philosophy that was invented to rationalize using pulsing TENS to locate the ideal bite position, based on a mistaken assumption a half century ago that applying it over the motor root of the trigeminal nerve can stimulate all the jaw muscles evenly. The Spear institute (including Jim McKee) understands the importance of disk position, but they claim that the joint condition is the root cause of the bite problem, while actually both the disk position and the orthodontic problems are due to the influence of the bite on the facial growth pattern. The Dawson academy has misled dentistry for decades by blaming all problems on the lack of a centric relation bite, and then more recently with a surgeon (Dr. Mark Piper) warning that dentists should all be looking for loss of bone marrow in the condyles, a rare condition requiring surgery. Disclusion time reduction (DTR) is a bite adjustment technique based on a bite philosophy (immediate disclusion) that was invented to create a market for the use of pressure sensitive ink, which had already been developed for industrial uses, in a horseshoe shaped wafer that can be placed between the teeth to measure bite forces (Tek Scan); however, even if immediate disclusion were natural or desireable, the wafer is far too thick to provide clinically relevant information. Botox can temporarily relieve symptoms by breaking up the symptom generating cycle; even though it weakens the jaw muscles, which limits their ability to regulate subsequent (adult) facial growth, the failure of which is at the root of most TMJ disorders; and a front flat bite plate produces the same reduction of nocturnal bruxism forces without damaging the muscles. NTI and similar "anterior only" or "anterior jig" appliances are used widely and non-specifically, because they sometimes relieve headaches by reducing jaw muscle forces during nocturnal bruxism, just as Botox and front flat bite plate appliances do. The MORA appliance was designed by Harold Gelb to hold the mandible down and forward; however, except in people with a class 3 malocclusion, the MORA also confines bruxing forces to the posterior teeth, which intrudes them. In this manner, the MORA alters the bite in a way that moves the mandible further up and back when the appliance is removed and thereby shifts the bite in the wrong direction - leading to short term relief of symptoms but long term exacerbation of the root problem. Misinformation has created so much confusion in this field that the dental associations have been unable to agree on regulations or guidelines for treatment of TMJ disorders, except to be cautious. Well meaning dentists don't know what to believe.
One result of the lack of regulation is that patients often get treatment that is not appropriate for their condition. For example, many older patients with X-rays that show extensive arthritic changes get treatments directed at their TMJs (such as surgery and steroid or PRP injections), even though their arthritic TMJs healed long ago and were no longer causing or even contributing to their symptoms. Many younger patients, who have tight jaw muscles due to reflex protective jaw muscle bracing in response to an inflamed TMJ, receive treatments to try and loosen their tight jaw muscles without first eliminating the inflammation that is triggering the tightness, which is like massaging the sore tired leg muscles of someone who is walking around on a swollen ankle without first providing an ankle brace to walk on.
Thousands of adult patients every year undergo lingual frenectomy to treat a condition diagnosed as "tongue tie", even though their tongue has a normal range of motion and therefore is not symptomatic or problemmatic in any way. The promoters of this surgery claim that a patient should be able to hold their tongue up against the front of their palate even when their mouth is opened fully, although that is far beyond the tongue's functional range of motion and therefore clinically irrelevant. It's easy to understand that babies who never nurse on a natural breast may have a tongue that develops a limited range of motion, which could prevent the frenum from elongating properly, and tongue tie is a well known problem in children who cannot pronounce letters like R. However, in adults who can speak normally and lick their lips, the cause of the low tongue posture that produces scallop shaped indents in the sides of the tongue is usually the narrow palate, not a tight lingual frenum. No clinical studies show any benefit from tongue tie surgery, unless combined with muscle treatments such as myofunctional therapy. Also, tongue tie surgery could exacerbate sleep apnea in the future by removing one of the features (the lingual frenum) that prevents the tongue from dropping back posteriorly.
BITES - The biggest source of confusion has always been bites. Most dental authorities today consider all bite treatments to be contraindicated, because they are not evidence-based. Even stabilizing a bite is discouraged; despite the facts that stabilization of joints reduces tonus in the muscles crossing them, and elevated jaw muscle tonus is a common problem in TMJ disorders. Dentists have excellent equipment for stabilizing bites with very little cost or effort; but there is no agreement regarding how to stabilize a bite, so dentists avoid even such basic joint treatment. Dental researchers cannot understand bites, because we can't collect evidence about a parameter we can't measure, and we've never been able to measure the functional aspects of bites. It's the inability of dentistry to understand the bite, rather than the lack of importance of the bite in the pathogenesis of TMJ disorders, that has prevented the widespread effective treatment of TMJ disorders.
Dentistry has always referred to the bite as the occlusion, because it occludes the space between the upper and lower teeth. However, biting is not just occluding space - it is closing a joint space, because the bite functions as a joint between the upper and lower jawbones. As a joint, its articular surfaces (the upper and lower bite tables) can profoundly influence the health of the jaw muscles and the other mandibular joints, the TMJs. Also those articular surfaces can be much more easily reshaped than other joints. However, dentistry has not been able to take advantage of our ability to reshape this dental maxillo-mandibular joint, because dentistry has never understood how bites work.
The goal of this website is to explain bites in function and dysfunction, so dentists can treat bites. The 5 chapters under the tab ETIOLOGY explain the way bites function in mammals and humans and how they dysfunction in modern societies today. Under the tab FOR DOCTORS, are 3 chapters discussing the clinical aspects of bites. BITES CURRENT CONCEPTS explain how and why bites are mistreated or not treated today. BITES ORTHOPEDIC ASPECTS explains how bites can be treated effectively by incorporating orthopedic principles. BITES AND POSTURE explains the important and generally unrecognized connection between the jaw system and the postural system.
ORAL APPLIANCES - commonly used today for treatment of TMJ disorders by dentists, usually just provide a stable bite at an increased vertical dimension when the mandible is in a relatively unstrained location at the back end of its normal range of motion, because those appliances make minimal changes to the bite and therefore are considered to be a safe option. Also the bite surface of the appliance improves as the teeth dig into the acrylic. The increased bite stability can relieve jaw muscle tension, and the increased vertical dimension can stretch tight jaw muscles. However these oral appliances lack orthopedic features to protect the TMJs, rehabilitate the jaw muscles, or redirect noctural bruxism to improve facial growth. The only appliances that claim to be orthopedic are the Farrar pull-forward appliance, the myomonitor lower appliance, and the MORA lower appliance. These appliances can provide short term relief, however the Farrar is only used for disk recapture, and the myomonitor and MORA when used in class 1 and class 2 occusions can shift the natural teeth in the wrong direction for long term relief and thus exacerbate the root problem. Also, commercially made oral appliances are unnecessarily thick and tight, both of which work against our goals, as explained in APPLIANCE FIT AND THICKNESS.
APPLIANCE DEPENDENCE - becomes a problem after an oral appliance has been worn full time, because the teeth shift to fit the surface of the appliance rather than the surfaces of the opposing dental arch. Then, removing the appliance leaves the patient without a bite, requiring extensive dental work to restore the bite that was eliminated by the appliance. Full time wear of any oral appliance should come with an exit plan, other than sending the patient to an orthodontist, who will probably just esthetically straighten the teeth.
LOWER APPLIANCES - such as MORAs (mandibular orthopedic repositioning appliances), frequently destabilize bites, so they should only be used in patients with a class 3 malocclusion (underbite). When used in people with a class 1 or class 2 occlusion, lower appliances confine the nocturnal bruxism that is forceful enough to depress the teeth to the posterior teeth, where they can then intrude and shorten the posterior teeth, while allowing the anterior teeth to supererupt (extrude) and get longer. Increasing the overbite drives the natural bite and the mandible further posteriorly. Thus a MORA appliance that shifts the mandible down and forward often relieves symptoms initially by correcting a previous excessively backward mandibular position, but over time it shifts the teeth in the wrong direction. The increasing of the overbite shifts the natural bite further backward, creating an increasing dependency on the appliance. When the appliance is removed, the symptoms return.
UPPER NIGHTGUARDS rarely destabilize bites, unless they fail to cover the second molars. The increased vertical dimension and bite stability they provide can often relieve myogenous symptoms, but these appliances are designed to protect the teeth rather than the TMJs, and they are not designed to consider their long-term effects on facial growth.
ESTHETIC ORTHODONTICS, in the form of braces, usually waits for the second molars to erupt and then uses pre-fabricated arch wires locked into brackets located on the exact center of each tooth to drag the teeth slowly through the bones until they achieve the same perfect curve as the arch wires. The upper teeth can be aligned into a perfectly shaped arch, and the lower teeth can be aligned into a perfectly shaped arch that fits just inside the upper arch so the teeth all interdigitate for chewing; however there is very little ability to control where these arches fit together to position the mandible, the key feature in the development of TMJ disorders. Even the position of the mandibular midline cannot be well controlled and is often left displaced a few mm to one side.
FUNCTIONAL ORTHODONTICS attempts to address facial growth, which is at the root of most orthodontic problems. It has been popular in Europe for decades, but it has not been widely practiced in the US. Recently, as a result of recognizing the importance of facial shape and airway preservation, some dentists now understand the importance of functional orthodontics. However, some of the functional orthodontic appliances they employ have been rebranded for sales in the US, along with misleading sales claims. For example, ALF (advanced lightwire functional) appliances, are bent wire appliances that employ low forces for long periods of time to gradually move teeth and bones, and they are easy to wear; but the proponents make ridiculous claims like, "they allow for a greater range of neurological regulation to occur, especially through the cranial nerves and the autonomic nervous system." Light gentle forces are certainly more biologically acceptible than strong forces, but forces from wires cannot regulate neurologic activity. DNA and RNA appliances are simple expansion-screw palate expansion appliances with finger springs that are being aggressively marketed today as a new type of treatment for sleep apnea, although the expansion occurs too far from the obstruction to have a predictable benefit. Also, these appliances are marketed as having epigenetic benefits, which is misleading, because there is no evidence or likelihood that straightening the teeth or widening the palate in an adult will lead to straighter teeth or wider palates in their offspring.
NON-DENTAL TREATMENT - A reflex response of many health care providers (including dentists) to TMJ pain is to suggest a soft food diet, because the standard medical model for an acute injury is rest of the affected part. For example, an acutely injured knee or shoulder needs rest. However, most TMJ disorders are not acute injuries. They are chronic conditions, which require rehabilitation rather than rest.
Both physicians and dentists use standard medical treatments that work in other parts of the body. Some now manage TMJ disorders by injecting the TMJs with steroids or platelet rich plasma or fibrin, which is approriate if the TMJ is inflamed, but not if it has already healed and is simply labeled as arthritic due to previous loss of its original rounded bone shapes from adaptive remodeling. Chiropractors and physical therapists rehabilitate muscles using various electrical and thermal modalities as well as exercises and stretches. Chiropractors make cervical adjustments which can improve mandible and head posture, at least until the old habitual bite drives the mandible back to its old habitual posture. Myofascial release and forceful compression of trigger points can temporarily reduce muscle tightness. Applied kinesiology attempts to determine the ideal bite position by measuring postural muscle resistance. Massage can flush out capillary beds to improve resting circulation in muscles that have accumulated waste products due to high tonus. Cranial and craniosacral treatments use light manual pressure to manipulate the skull and spine in order to free up blockages to cerebrospinal fluid circulation, as described in CRANIAL AND CRANIOFACIAL under the tab TREATMENTS.
A SELF LIMITING CONDITION - Fortuntately, TMJ disorders are self-limiting problems because of natural adaptation. Longitudinal studies of tens of thousands of untreated patients have shown that the symptoms eventually "burn out", especially by middle age. Older people may experience jaw muscle tightness as a subset of postural muscle tightness, difficulty chewing due to lack of a good bite, or ear symptoms that persisted from earlier injuries; but they only sustain TMJ inflammation when maintained by extreme loss of vertical dimension (usually in worn out dentures), a systemic arthritis (such as rheumatoid) that attacks their TMJs, or an oral appliance that is excessively tall, thick, or poorly designed.