TMJ
Temporomandibular Joint Disorders
TMJ Symptoms
With TMJ or TMD there are two types of symptoms that may occur. The first are pain-related symptoms which can include: - Headaches - Facial/Dental pain - Pain in the jaw joints (TMJ) or when moving jaw - Ear pain, tinnitus, feeling of ear pressure - Neck, back, shoulder and upper chest pain or muscle aches - Clicking and/or popping and/or grating of the jaw joint. The second set of symptoms have to do with the dysfunction caused by TMJ or TMD: - Jaw movement can be limited, deviated, slow or irregular - Head movement can have limited range of motion - Ears will experience muffling, clicking, even dizziness - Throat will have a difficulty swallowing, stuttering (prolonged speech) - Jaw Joint will feel locked or dislocated - Facial asymmetry Because of the many possible causes of jaw pain it also can be referred to as TMD, which means Temporo-Mandibular Disorders We have created a glossary of TMJ terminology in an effort to clarify what TMJ (Temporomandibular Joint Disorder) is and what it is not. Please refer to the sections below for a detailed discussion of TMJ.
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The Temporomandibular Joint acts like a hinge, allowing the jaw to pivot while maintaining alignment between the upper and lower sets of teeth.
Causes Of TMJ
Trauma to the head and neck is a more common cause of TMJ problems. This trauma can be in the form of auto accidents, sports injuries, slip and fall, chewing a bone or a stone in food, clenching during times of stress. Malocclusion (crooked bite) by itself may or may not cause tmj problems, but when it is combined with some type of trauma, tmj problems often occur. Back problems can lead to a change in the bite that results in tmj problems. Postural problems can contribute to tmj symptoms. Sleep position can contribute to tmj, especially sleeping on your stomach. Systemic conditions such as arthritis in its many forms can lead to severe tmj damage. This damage changes the bite and is very difficult to treat. Entire courses are given for the systemic causes of TMJ problems. There are some forms of cancer that can occur in the TMJ, but they are very rare. Inaccurate and/or incorrectly designed splints can cause a form of arthritis.
Tinnitus From TMJ
Tinnitus is a high pitched ringing in the ear. It is part of the loud noise syndrome (inability to hear high notes, difficulty understanding speech when there is back ground noise in the room, and ringing in the ears). It can also occur when the jaw is displaced. The difficulty is that sometimes the TMJ therapy can make it go away or decrease, and sometimes the jaw therapy has no effect, or the tinnitus increases. This is a difficult aspect of TMJ problems. Results with tinnitus are unpredictable.
Open Bite
The term “open bite” has three distinct meanings in dentistry. An open bite due to changes in the Temporomandibular Joint on one or both sides. This results in uneven contact only on the back teeth, but not in the front teeth.In this case, the back teeth touch and the front teeth don’t. It can be a slight opening or a very large one. If the lower front teeth are sharp and squared off, but the teeth don’t touch, it means that the open bite developed later in life due to changes in the anatomy of the TMJ. In an open bite where the front teeth don’t touch and the lower front teeth have rounded edges called mamelons means the open bite was always there. The front teeth never touched. This is a developmental problem. Open bite due to tongue thrust develops in children that suck their thumbs past the age of 3 ½. First the thumb goes between the front teeth. Later in life, the front teeth don’t touch because the tongue goes between the front teeth every time the patient swallows. There is also a very high palate where the thumb went during thumb sucking. This also causes difficulty in breathing and can lead to mouth breathing. That high palate effects the size of the nasal sinuses. Orthodontic patients that don’t stop the tongue thrusting habit will get a relapse of the open bite after it is closed with braces. A rare occurrence is the “lateral tongue thrust.” This occurs when a patient places the tongue on top of the back teeth when he or she is not chewing. This results in a “posterior open bite.” This means that the front teeth touch, but the back teeth do not. Patients with this condition have to move their jaw forward in order to chew their food. In some cases an improperly designed splint (orthotic) can cause the posterior open bite. Anterior open bite is the most difficult TMJ malady to treat. The Treatment results are unpredictable because the condition of the joint changes at an unknown rate of time for each patient.
Understanding and treating TMJ disorders begins with examining and recreating a persons' jaw motion and alignment.
Tongue Thrust
Does your tongue go forward between your front teeth when you swallow? When you bite into a sandwich, does the lettuce slip out? You have an “Anterior Open Bite.” This means the front teeth cannot touch at all. It is usually the result of Thumb sucking as a child. It also has the bad effect of creating a very high palate. The palate is below the maxillary sinus. So a high palate interferes with normal breathing. With normal swallowing, the tongue touches the roof of the mouth and the food is swallowed. With tongue thrusters, the tongue must go between the front teeth, so the food is not ejected out of the mouth during swallowing. Besides the anterior open bite, the child can become a “mouth breather” These conditions remain into adult life. The anterior open bite and the high palate are permanent problems. So it is best to get your child to stop sucking the thumb at age 2 1/2 to 3. This also applies to using a pacifier too much. The results are similar. Damage does not occur before 3 years of age. But after 4 years of age, the damage increases as long the child continues to suck the thumb. A good way to get rid of the pacifier is to tie it to a helium balloon, let it go, and tell the child it is going to heaven. Gentle, but persistent urging is the best way to get a child to stop sucking the thumb. If your front teeth touched when you were a young adult, and they gradually started to come apart, it could be the result of a degenerative arthritis. This diagnosis must be confirmed by CAT scans and medical testing. Arthritis patients usually don’t have the high palate. Both conditions are treatable. If jaw pain is also present, the treatment is more complicated.
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TMJ Ligaments In Males
Men have an extra ligament in the Temporomandibular Joint (TMJ). This ligament helps to resist condylar displacement. This explains why women have TMJ problems 8 or 10 times more often than men. This ligament was discovered by a dentist. Terry Tanaka, DDS found the extra ligament in men when he was studying TMJ anatomy on cadavers. Appropriately, it is called the “Tanaka Ligament” in anatomy textbooks.
TMJ Vs Malocclusion
Not all TMJ problems are connected to a bad bite. But most of them do have a significant connection to the problem. Dr. Yamamoto does a complete bite analysis on every TMJ patient. His expertise with the bite allows him to inform the patient if the TMJ problem is not connected with the bite. There are some TMJ patients that require a multi-disciplinary approach. This means that more than one Doctor needs to be involved with the diagnosis and treatment planning.
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By modeling a patient's bite and jaw motion, TMJ issues and treatment can be planned outside of the dental chair for implementation on subsequent visits.
What is “Occlusal Analysis”?
We have years of experience with occlusal analysis using a dental articulator. Occlusal Analysis is an evaluation of how the teeth come together (occlude) with the use of an articulator. An articulator is an instrument that simulates the patient’s jaw movements with the use of dental models. The goal is to see how the teeth occlude and see if there are any negative tooth contacts when biting up & down, and grinding the teeth backwards and forward, and left and right. Two sets of mounted dental casts are made. One set is kept as a record of how the patient presented for treatment. The second set is used to analyze and adjust the occlusion. Negative occlusal contacts wear the teeth and cause the jaw joints (TMJ) to displace. A video is made of how the jaw displaces and how the teeth are modified to create an ideal, stable bite (occlusion). Some teeth are re-shaped, while others may need additions. This is a very accurate and conservative way to diagnose occlusal disharmony (malocclusion), and formulate a treatment plan. No procedures are done until the patient understands and approves of the treatment plan. In TMJ patients and complicated restorative cases, a CONE BEAM CT SCAN is done to check the condition and the position of the TMJs (temporal mandibular jaw joints). Correlating the Occlusal Analysis with the CT SCANS enhances the diagnosis and treatment plans.
TMJ Cure
There are many types of treatments that are aimed at “curing” TMJ problems. But, since there are many types of TMJ problems, there is no one cure for TMJ. The “cure” means some treatment that is aimed at reducing the painful symptoms. Sometimes the TMJ symptoms may only be discomfort or a bothersome clicking or grating of the jaws. There may be a painful displacement of the jaw that leads to damage in the joint itself. The “cures” could vary from a simple orthotic (splint, mouth guard, bite plate, night guard). These are names for the same type of stage one treatment. Each theory involves some special type of appliance. In lieu of some type of appliance therapy, bite analysis and occlusal adjustment is another form of TMJ cure. This form of TMJ treatment can also lead to full mouth reconstruction if it is indicated. Some highly respected TMJ clinics ignore the occlusal aspects of TMJ problems and choose to treat TMJ symptoms with different types of potent pain medication. This is not a “cure.” It is only symptomatic treatment. In some cases where the patient has tense muscles that don’t allow the mouth to open, a muscle relaxer may help the immediate symptoms, but the problem will return if it is not treated properly. Each TMJ patient is unique. The best way to “cure” each individual is to take an in depth history, analyze the bite, take tomograms of the joints, and find an accurate diagnosis. The diagnosis dictates the treatment. Without a diagnosis, there can be no “cure.” It should be noted that some conditions are of a nature that a complete “cure” is not possible. There are some cases in which a reduction of the symptoms is the best that can be done. For example: in some cases a reduction of pain is the best that can be hoped for. Clicking of the TMJ may be reduced, but not completely eliminated. Any treatment that is aimed at correcting any of the elements of TMJ syndrome is part of TMJ therapy. The industry standard is the splint (orthotic, mouth guard, bite plate, etc). This separates the painful jaws. Physical therapy is useful in cases of painful muscles of mastication and/or head and neck muscles. Complicated cases may require orthodontics, occlusal correction, or fullmouth reconstruction. Occlusal correction (bite correction) is often needed, but not performed because few dentists can do an accurate bite correction.
TMJ Surgery
TMJ Surgery is a very complicated topic that could take pages of information. Oral surgeons perform this type of surgery. The least invasive is arthroscopic surgery. This is similar to surgery done on shoulders and knees with a thin catheter like instrument. There is also open joint surgery that is more invasive. In rare instances, “Botox” injections can be given to extremely painful muscles. Not all oral surgeons perform TMJ surgery. It takes additional training and expertise. It is important to note that surgical intervention for a TMJ problem is most often a last resort. Surgery is usually the last resort treatment. The most important step in TMD treatment is the diagnosis. In some cases, surgery would be an earlier option, but not usually. When surgery might be an option, an oral surgeon is always consulted.