The subject of “Treatment for TMJoint Problems” covers a wide range of treatments and a variety of practitioners. Dentists are the most common and most logical Doctors to treat TMJ.

Only properly trained Dentists can provide the comprehensive treatment and case management needed to help patients suffering from TMJ. Since most TMJ patients have musculoskeletal problems too, the Dentist may work with massage therapists, chiropractors, physical therapists and physicians to treat the areas of the body that are outside of the realm of dentistry. Our goal is to get the body as pain-free and healthy as possible. It is important to remember that 100% relief of discomfort may not be possible. Just as with the person who has torn up a knee (like me), a TMJ patient may have some occasional flare-ups of their symptoms or can be prone to re-injury. Soft tissues never “heal” as completely back to their original condition.

Treatment of TMJ is divided into three phases, Phases I, II and III. The Phase I goal is to reduce and eliminate joint and muscle pain, addressing structural problems throughout the body, and by educating the patient as to how to help themselves. The most common form of treatment is with a splint. A splint is a custom designed and fitted plastic mouthpiece. Splints come in a variety of shapes and designs. However, all splints fall into three main categories. The first type is a Nightguard. A nightguard is commonly an upper appliance designed only to prevent damage to teeth from nocturnal grinding. It can also be worn during the day if the patient is experiencing severe stress. Nightguards are not normally helpful in treating TMJ.

The second type of appliance is a Superior Repositioning Appliance. The purpose of this splint is to allow muscle relaxation and to decompress the TMJoints. This appliance is usually helpful when the TMJ problem is of recent origin and muscular in nature. These appliances are generally worn for 6-12 months to allow healing of the TMJoint tissues. If the patient improves well on this appliance, then a gradually weaning off the appliance may be attempted. These appliances can also be useful if the internal dislocation or Internal Derangement is slight in nature. With slight dislocations, almost any type of appliance can help some people. This has been the cause of great controversy throughout the TMJ community over the years. The success of these appliances led to confusion among many practitioners as to the cause and mechanisms of TMJ. Since most TMJoint problems are cause by posteriorly displaced condyles, any type of splint might help a slightly displaced condyle.

The third type of TMJ appliance, and usually the most effective, is the Anterior Repositioning Appliance. This appliance brings the lower jaw forward; recapturing the articular disc and preventing repeated dislocations. The appliance is worn 24 hours daily to prevent more damage and to allow maximum healing of the damaged joint tissues. By preventing the crushing of the retro-discal tissues, the anterior repositioning appliance allows “hot” nerve pathways to calm and the central nervous system aspects of chronic pain to cool down. The inflamed joint tissues can now heal. Our office takes the anterior repositioning appliance further. We use our BioResearch jaw tracking and electromyographic equipment to find the most neuromuscularly compatible jaw position. This jaw position is most in harmony with the patient’s own muscle and joint structures. Only the use of neuromuscular techniques can determine the most stable and stress free jaw position. Patients employing neuromuscular techniques routinely achieve the fastest and best results. Phase I is also where associated musculoskeletal problems are addressed. Many patients have postural distortions that left untreated will limit the success of TMJ treatment. We work with chiropractors, physical therapists, neuromuscular (medical) massage therapists and acupuncturists to improve the overall health of the patient. It is essential to the long-term success and stability of treatment that any postural distortions be addressed.

Once the patient has reached the point of maximum improvement and is stable and pain-free, Phase II can begin. The goal of Phase II therapy is to maintain the support of the TMJoints by the teeth in a pain-free position. Depending on where the pain-free position of the jaw lies, several different types of therapy are available for Phase II treatment. The vast majority of symptoms must be resolved before Phase II therapy can commence.

Long-term Splint Use:

Some patients may be able to be weaned from full-time use of the splint. Often, these patients have suffered a traumatic injury to the TMJoints and had few or no previous symptoms of TMJ. The patient will stop wearing the appliance for increasing periods daily. If no symptoms return, then the patient will wear the splint at night or during periods of severe stress.

If the patient can not be weaned off the splint, then long-term splint wear is an option. The splint will last 2-3 years but will slowly wear, risking bite closing and a return of symptoms. A semi-permanent splint can be made with a metal framework. This can last many years with minimum maintenance.

Bite Adjustment:

For many years, there was a philosophy that adjusting the bite to remove tooth structure that was interfering with the smooth movement of the jaws could solve TMJ problems. Sometimes this was the first choice of treatment, instead of the use of a splint. In some cases, this can be helpful. However, some patients have had this treatment done excessively and have ended up worse than they started. When only a limited amount of tooth structure is causing the distalizing force on the jaw, bite adjustments are sometimes used. This treatment is not reversible and should be considered only after the symptoms have been resolved through use of a splint. Bite adjustment is helpful only in specific cases.

Orthodontics:

Orthodontics is the treatment of choice for many TMJ patients. Because the prime underlying factor with TMJ is distalized condyles grinding on the nerves and blood vessel complex at the back of the TMJoints, treatment usually brings the mandible forward to relieve pressure on these delicate tissues. Orthodontic treatment brings the teeth together in a position that supports the pain-free jaw position.

Dental Reconstruction:

Some patients may not want, or be good candidates for orthodontics. Another option is to use crowns, bridges and other dental restorations to provide support for the jaw in the pain-free position. The skill level required to restore a mouth to this new jaw position is very high. Be certain that the dentist has a very strong background in reconstructive dentistry and understands the special needs of a TMJ patient.

TMJoint Surgery:

TMJoint surgery should be the last resort for treatment! A very high percentage of TMJoint surgeries are failures. In his outstanding book, TMJ: Its Many Faces, Dr. Wesley Shankland, President of the American Academy of Head, Neck and Facial Pain recommends three criteria be satisfied before TMJoint surgery is tried. The criteria are:

All conservative treatment was a failure. If splint therapy is a failure once, it should be repeated, with a different splint design, or by a different doctor.

There has to be a demonstrable physical or structural explanation for the patient’s complaints. A physical problem can be seen with an MRI, x-rays, or with dye injections into the joint (arthograms). Make certain that this is not an exploratory surgery or that the surgeon “thinks” this surgery will help.
Patients must be suffering so much that they must take strong pain medication, and their life-style is greatly altered. In other words, the patient must be desperate and at the “end of their rope” before surgery is attempted.

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