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, electrosonography, 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) 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 bite problem and its influence 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 diminishes 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, but it confines bruxing forces to the posterior teeth, which can intrude them and thereby alter the bite in a way that moves the mandible further up and back when the appliance is removed, leading to short-term relief of symptoms but long-term exacerbation of the root problem. Despite claims by the manufacturers that some equipment, such CBCT and acoustic pharyngometry, can determine if people have small airways; measurements of the pharyngeal airway space are unreliable, because pharyngeal airways are far too dynamic to measure with currently available technology. Misinformation has created so much confusion in this field that the dental associations have been unable to agree on regulations or guidelines for treatment, except to be cautious. As a result, well meaning dentists don't know what to believe.
One result of the confusion 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 "tongue tie", even though their tongue has a normal range of motion and is not symptomatic or the cause of their narrow palates or low tongue posture. The promoters of this minor 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; and the cause of the narrow palate is inadequate jaw muscle development, not lack of proper tongue posture. No clinical studies have ever shown any benefit from tongue tie surgery, unless combined with muscle treatments such as myofunctional therapy, because strengthening the muscles helps everything. The only advantage of lingual frenectomy is probably that the tongue becomes better able to clean out food from between some of the teeth, which can be a significant benefit for some people. A disadvantage of lingual frenectomy is that it 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. Dentistry has always treated the bite like a stop along a hinge type of jaw closure, but the bite is far more dynamic. The bite functions as a joint between the upper and lower jawbones, and the contours of 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. Dentists don't even recognize the ability of deep or steep overbites to limit mandibular advancement, because they simply learn that overbites are normal.
The bite functions as a joint between the jawbones, and its articular surfaces (the bite tables) can be much more easily reshaped than the articular surfaces of other joints, without risk of infection; but there is no agreement regarding how, when, or why they need reshaping; so dentists avoid altering them in any way. Even stabilizing a bite is rarely practiced, despite the fact that an unstable joint reflexively triggers increased tonus in the muscles crossing that joint, and most of our patients suffer from increased jaw muscle tonus. Most dental authorities today consider all bite treatments to be contraindicated, because they are not evidence-based; but the reason for that is we can't collect evidence about a feature we cannot 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.
To remedy this situation, this website explains all aspects of 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 - are commonly used today for treatment of TMJ disorders by dentists, but they 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 naturally stabilizes, as the teeth dig into the acrylic. The increased bite stability of an oral appliance 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 oral appliances that claim to be orthopedic are the Farrar pull-forward appliance, and two types of lower appliances - the myomonitor and the MORA (mandibular orthopedic repositioning appliance). The Farrar is used for disk recapture, which is only needed occasionally. The myomonitor and MORA appliances fit on the lower teeth, which makes them easier to wear, because they don't crowd the tongue as severely as upper appliances, and the lower teeth are less sensitive to pressure from the tightness of an oral appliance. However, 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, thereby increasing the overbite. Increasing the overbite shifts the natural bite further backward, creating an increasing dependency on the appliance. Then, when the appliance is removed, the symptoms return. Thus, these lower appliances can produce short-term relief while exacerbating the root problem, and they should only be used in patients with a class 3 malocclusion (underbite). Also, commercially made oral appliances are still unnecessarily thick and tight, both of which work against our goals, as explained in APPLIANCE FIT AND THICKNESS.
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.
APPLIANCE DEPENDENCE - becomes a problem after an oral appliance has been worn full time, because the teeth shift to fit the surfaces of the appliance rather than those 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.
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. Conventional orthodontists generally assume that their job is just to straighten the teeth, not to improve the facial growth pattern, which they don't even attempt. They have been accused of adversely influencing growth due to techniques like premolar extractions to treat crowing, and their defense has been that their work does not inflence growth. Their white paper of 2019 states, "Craniofacial morphologies that may predispose to OSA include retrognathia, long and narrow faces, dolichocephalic facial type, narrow and deep palate, steep mandibular plane angle, anterior open bite, midface deficiency, and lower hyoid position." But then they go on to say, "While the skeletal boundaries of the airway are increasing, the major lymphatic tissues of the upper airway (tonsils and adenoids) are shrinking. This combination of increases in skeletal dimension along with decreases in soft tissue mass results in enormous increases in the size of the upper airway over infancy, childhood, and adolescence. These changes in airway due to growth far exceed any orthodontic or orthopedic effects on airway shape or size."
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 are beginning to understand the importance of functional orthodontics. To meet the demand, some companies market some functional orthodontic appliances 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 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 to create a one-size-fits-all model that is 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 - The response of many health care providers (including dentists) to their patients reporting 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, the vast majority of TMJ disorders are not acute injuries. They are chronic conditions, which require rehabilitation rather than rest.
Both physicians and dentists use common medical treatments that work in other parts of the body. Some 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.
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 rarely sustain TMJ inflammation unless they suffer from extreme loss of vertical dimension (usually in worn out dentures), a systemic arthritis (such as rheumatoid) that attacks their TMJs, or long-term wear of an oral appliance that is excessively tall, thick, or poorly designed.