Internal Derangement of TM Joint

Head, neck and facial pain is among the more common complaints of patients who visit their primary care physician. Head, neck and facial pain is also one of the leading causes of visits to hospital emergency room. In addition, head, neck and facial pain patients report a very low level of satisfaction with the care they receive in so far as getting long term resolution of their problems.

The underlying problem is that there are so many separate reasons that patient might suffer from head, neck and facial pain that the odds of them landing in the right practitioners office the first few times is fairly low. After all, the first diagnosis is actually made by the patient themselves and then they refer themselves to the doctor that they think can help them. If the have ear pain, the might seek help from an ENT doctor. If it presents as headaches, they might seek help from the primary care physician or a neurologist. If it seems to be coming from the mouth, they might suspect a wisdom tooth and go to see an oral surgeon. If it seems like the neck, perhaps a chiropractor or a physical therapist.

Each of these specialists has extensive training in their area but as a result often lacks much exposure to other areas of medicine. As a result the patient in pain is ushered into the specialists office and after a brief history is taken the doctor arrives at the best likely diagnosis and makes the appropriate treatment recommendation and sends the patient off with the best intentions and with a small probability of a successful outcome.

In fact, the majority of my patients who come to me for diagnosis and treatment report that I am on average the 6th practitioner they have consulted with for this problem that has one on for an average of over 5 years and often over 10 to 15 or more.

The further complication is that even if the pain is due to a TMD there is the question of whether the pain is due to muscles, the soft tissue in the joint such as retro discitis or in the hard tissues such as osteo arthritis. Each of these sub categories of TMD are separate and need to be correctly diagnosed in order to provide treatment that will result in a successful outcome.

The following case study is an interesting one that describes one such patient’s odyssey through the medical system seeking help for a relatively simple to treat problem.

I first met John when he was referred to the office by his wife who had been my patient for many years. He had been seeing other dentists near his work but was not having success with a particularly troubling pain problem. Several months ago he was eating some hard bread and heard a loud crack and suddenly felt enormous pain in the ear. It hurt so much that combined with how it sounded he felt like his “jaw broke” so he went to the hospital ER where he was screened and told to get an x-ray of his jaw the next day and was give a codeine prescription for the pain.

The next day he went to an oral surgeon who did take a panoramic x-ray which did not reveal a fracture so he was told to stay on a soft diet and take pain meds as needed. After a week with little improvement he sought consultation from an ENT specialist because the pain seemed to be coming form his left ear. The ENT examined him and found nothing wrong but game him a prescription for an antibiotic in case there was a “sub-clinical infection”.

When this did not help he went to see his primary care physician who also found nothing but told him he might try a dentist if the pain did not resolve in a week or so in case it was a T M Joint problem. After a few more days of no improvement he did go to his dentist who looked at his bite and said it, “looked OK”.

By the time John came top see me it was nearly 10 weeks after the original incident and he was feeling almost as bad form his frustrations with the medical system as he was from his original problem.

After listening to the long story and the pain he was having with biting I knew that we needed to look for either muscle pain or pain from damage within the T M Joint because so many other issues had already been ruled out by other specialists.

The most common cause of pain relating to the T M Joint is actually pain from muscles that are hyperactive due to a conflict between the teeth and the centered position of the jaw joints. This type of pain is not easy to diagnose or treat because of several reasons:

• First pain in muscles is not constant so it can come and go unpredictably
• Second, this pain can radiate or refer to other regions of the head or neck.
• Third, the pain that is due to muscles makes diagnosis and treatment success difficult because unless the muscles can relax, the joints cannot center. If the joints do not center the muscles cannot relax, but it the muscles will not relax, the joints won’t be able to center, so the patient gets stuck in an endless loop of frustration and pain.

There are two possible paths out of the maze. The most common one is to use drugs and a combination of rest, heat and or cold and physical therapy along with muscle relaxants to stop the muscle spasm and let the joints come to normal position. The fallacy here is that the trigger to the muscle spasm is the conflict between the teeth and jaw joints that is continuously dislocating the joints from a centered position. The drugs would have to fight this biomechanical barrier that will not stop by itself, so a centered jaw joint position is impossible with the teeth in the present condition. And even if the muscle spasm would be reduced from the acute present condition to the prior chronic condition, the jaws would still not center and the stage would be set for the next acute event. The second option is to use the process of deprogramming the muscle to bio-mechanically to release the muscle, let the joints center and thereby stop the pattern.

The process of discluding the posterior teeth with an anterior guide plane to allow and encourage the condyles to center and release the muscles has many references in the dental literature. Dr. Long wrote about the leaf gauge in the 1920’s. Peter Neff wrote about this process in his book, T M Joint occlusion and function Georgetown university press 1975 and peter Dawson outlines his technique to create a custom deprogrammer in his textbook, Diagnosis and Treatment of occlusal Problems 1975.

This technique is highly predictable and is very reliable, just not that easy because you are fighting the muscles all the way. The technique developed and taught by Dr. Long was to use a series of leaf gauges… thin sheets of metal that could be inserted in between the upper and lower front teeth. They would let the back teeth separate and the patient could tap on the leaf gauge strip and if it was help steady and at the right angle the teeth would tend to gently glide up and back and let the jaw joints center. Once Dr. Long got the patient deprogrammed, he could fabricate a full coverage bite splint to cover all of the teeth and provide support for this centered jaw position. Because this method is so technique sensitive, many practitioners have not been able to duplicate this success and in addition, this technique did not have the ability to gain patient compliance because the patient could not use this device themselves at home.

The second generation deprogrammers were the custom ones taught by Dr. Peter Dawson that could be fabricated in the patients mouths without a laboratory procedure. This was a big improvement because the patient could take it home to use overnight. The disadvantage was that it was also quite time consuming and technique sensitive in that the patient had to be manipulated close to the centered position so that the custom deprogrammer could be formed out of cold cure acrylic in their mouth.

The third generation deprogrammer was the nti tss device that was designed to be more user friendly. It came in several sizes and shapes and was designed to be relined with cold cure acrylic. The bump in the incisal edge was designed to hit on the lower anterior teeth so as to discourage the patient from clenching their teeth. The advantage is that any dentist could keep a bunch of them in a drawer and fabricate them for the patients teeth. The disadvantage was that the acrylic liner was still time consuming to deal with, it shrunk on setting and was rather unpleasantly warm in the patients mouth as it set. In addition, the bump on the incisal edge became an interference in and of itself and it was time consuming to smooth and customize the bump. Although it was promoted as a take home wear at night bite splint, it fit on only the front teeth and had no safety mechanism to prevent dislodgement and possible aspiration if swallowed at night. In addition the acrylic liner material would stain and trap odors over prolonged use. That was overcome by having them custom fabricated in a dental laboratory, but that made it much more expensive, and time consuming requiring multiple visits and dental models to be taken. And since it was promoted as the final treatment, most practitioners objected to the fact that only the font teeth were covered, leading to likely tooth movement and possible joint damage associated with less than full coverage splints.

Recognizing that anterior disclusion is a great method and the disadvantages of other systems, a 4th generation deprogrammer was developed by the author. The Best-Bite system was designed to over come as many of the short comings of the previous designs.

It is a one size fits all device that is customized by lining it with PVS material so it can be fitted to the patients teeth in less than one minute. In addition, the incisal surface is flat side to side and front to back so there is complete freedom of movement but the surface has an 8 degree incline to direct the lower teeth up and back so as to guide the condyles to a centered jaw position. It incorporates a safety lash so that there is no danger of dropping or aspirating the device.

After an examination of the bite and jaw movements such as range of motion and degree of opening, I fabricated John a Best-Bite discluder to see if the pain would stop, indicating muscle pain. Unfortunately, with both biting and load testing, the pain did not stop. The meant that either the joint was internally damaged, or that there was still muscle spasm and splinting. After several more rounds of tapping his teeth and load testing I became convinced that the pain was not from muscles so the next step was to test the joint itself. Many cases of trauma result in damage and swelling in the retro-discal tissues so that when the patient attempts to bite down, the condyles are forced up into the inflamed retro-discal tissues which are quite painful. As a result, the “normally ideal condylar position” is quite unfavorable.

The methodology is quite simple. If the pain is from inflamed retro-discal tissue impaction, then the test is to simply have the patient slowly and incrementally move his lower incisor teeth forward one mm at a time and at each point, stop and clench his teeth.

If the pain is from inflamed retro-discal tissues, typically after 3-5 mm he will find a point where he can bite hard with no pain. In John’s case it took 4 mm of anterior movement to find a pain free position which we tested several times and found consistently pain fee.

• Make anterior position splint
• Wear 4-6 weeks
• Gets better and walk him back to Adapted Centric Posture (means that the condyles are centered and stable, but the disc is displaced and not recoverable)
• Then equilibrate to that position and the case will be complete.

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