TMJ

by Clayton A. Chan, D.D.S.

“When the teeth do not properly fit together various degrees of structural deformities result in a domino effect of masticatory occlusal accommodations and postural compromises confusing the clinician as to why and how best to manage this exquisite detailed system.” – Clayton A. Chan, D.D.S. – General Dentistry, Las Vegas, Nevada

The following patient was involved in a motor vehicle accident (August 27, 1997) and became a TMJ pain victim after a car reared ended her vehicle at 45-50 miles per hour while stopped.  She reports having her head turned to the right side while being hit from behind sustaining whiplash injuries.  Pain started immediately after being in shock.  The jaws started to ache the next day.  She initially saw her general dentist who recommended icing and physical therapy.  After numerous referrals to 27 doctor/specialists she was referred to a neuromuscular physiologist/dentist who also made her a flat plane splint which she found in effective in resolving her pain.  A K6i kineseograph/ jaw tracking, TENS, electrosongraphy and EMGs were used at this time, but diagnosis was inconclusive and also unable to resolve her debilitating muscular pain problems.  Other neuromuscular dentists also attempted to use TENS, NM instrumentation as well as night splints, but were unable to get her to a pain free position.  Physiotherapy along with massage therapy every 2 weeks over an 8 year period did not seem to resolve her problem.  She also reports having accupunture therapy daily along with supportive chiropractic treatment.  She reported that massage therapy was helpful and was continued until after her long search ended – finding another way.

More information on Facial Pain in the Side of the Face
Read more on: Dentist’s Scope of Care in Treating TMD Disorders: Occlusal Signalling Effects on the Cervical Neck

Patient: Age 37 female from Alberta, Canada

Initial Main Complaints:

• Headaches – both sides mainly right side severe
• TMJ Pain – severe shooting pain in morning
• Difficulty opening severe
• Slight clicking popping
• Right ear congestion feelings (a lot of ear aches)
• Vertigo – sometimes severe and cant drive
• Very sensitive teeth bilaterally
• Clenching severe – all the time
• Neck and shoulder pain – severe have to crack neck all the time.
• Pain in the temples – constant and severe
• Frontal headaches – severe
• Pain in shoulders – moderate (yoga has helped) – massage effective.
• Occasional nausea – moderate
• Difficulty sleeping – temperpedic pillows and bed, effective – severe
• Masseter facial pain – bilateral (between cheek and eye brows) – severe and constant
• Posterior open bite with edge to edge anterior bite which resulted from over 7 years of full time splint wear after a motor vehicle accident.

Findings:

Right Class III molar occlusion, left side Class III molar occlusion, right Class I canine occlusion, left Class II canine occlusion, upper midline coincedent with facial midline, lower dental midline shifted to the right, edge to edge incisor relationship, less than -1 mm to 0 mm overbite, bilateral cross bite.  Upper and lower incisors are protruded with mild crowding.

Patient has numerous appliances, splints, bionators, upper splints, lower splints, soft and hard. Of the course of years seeking treatment seeing numerous health professionals they prescribed various night time and day time wear appliances. She reported that should could not function without an orthosis, because without it within 20 minutes pain would come back.

Patient was unable to open her mouth completely due to strained muscles. 2 finger wide opens was all that she could do prior to treatment. Normal opening would be 3 fingers wide.

Note: Posterior open bite when patient removed her orthotic. The posterior teeth could not come together. Only the front teeth touch on habitual closure.

Previous History of 35 Doctor/Health Care Specialists Seen:

• 4 Physiotherapist
• 2 Massage
• 2 Colonoscopy doctor
• 4 Orthodonists
• 7 General dentist
• 2 Medical doctor
• 2 Maxiofacial Surgeons
• 2 Periodontist
• 1 Opthamologist
• 1 Chiropractor
• 1  TMJ Specialist Dental
• 2 Acupuncturist
• 1 Radiologist physician
• 2 Psychologist
• 1 Family Physician
• Dr. Clayton Chan – Neuromuscular Dentistry

Radiographic Findings:

PANORAMIC PROJECTION AND NEW TOM9000 VOLUME SCAN – March 29, 2004 (Oral & Maxillofacial Radiologist)

Observations: The superior surface of the condyles showed signs of flattening sclerosis and possibly surface irregularities. When the mandible was in the closed position the condyles were located in the posteriorsuperior region of their fossa and the resultant posteriorsuperior joint spaces were thin.

Impressions: The osseous components of the TMJs were evaluated and the findings noted above were consistent with advanced remodeling but may overlap with a minor expression of degenerative joint disease. The narrowed superior joint spaces increase the probability of bilaterally displaced discs and/or thinning of the soft tissues separating the superior and inferior joint compartments.

MRI SCAN OF TEMPOROMANDIBULAR JOINTS – March 29, 2004 (Radiologist MRI Physician Report)

Right Temporomandibular Joint revealed: A small focus of altered marrow signal is seen in the subchondral bone of the mandibular condyle in its lateral aspect, over an area of 0.4 x0.6 cm. This has the appearance of osteochondritis dissecans. The cartilage overlying this area appears grossly intact, though subtle irregularities or defets of the cartilage could not entirely be excluded. Bony contours remain normal on both sides of the joint showing no evidence for remodeling as of yet.

On the mouth-closed position, the articular disc is anterior displaced with the posterior band located at about the 8 o’clock position. This reduces to anatomic alignment in the mouth-open position. The posterior band shows increased signal and a thin line of low signal extends into the bilaminar zone indicating slight fibrosis.
A small effusion is present in the superior compartment. This may be related to a small perforation within the bilaminar zone, although such is not directly seen.

No bone marrow edema is seen.

On one view only, there is an equivocal 2 mm loose body in the anterior aspect of the joint as seen in the mouth-closed position. With mouth open, the condyle translates to articulate with the antero-inferior aspect of the articular eminence of the temporal bone.

Left Temporomandibular Joint revealed: Bony contours are normal. The articular disc is anatomically seated in both the mouth-closed and open position. With mouth opening, the mandibular condyle translates anteriorly to a symmetric degree compared with the right side, translating about 1.5 cm bilaterally. No effusion is seen.

No bone marrow edma is seen.

IMPRESSIONS: 1) Osteochronditis dissecans in the mandibular condyle of the right temporomandibular joint. Equivocally, there may be a tiny 2 mm loose body in the joint. 2) The right-sided articular disc is anteriorly reduced, and the reduces with mouth opening. 3) The left joint is normal.

K7 Instrumentation Recordings:

Computerized mandibular scanning (CMS) using the K7 kineseograph (Myotronics-Noromed, Kent, WA) indicates abnormal mandibular jaw closure pattern posterior (1.6 mm) to an isotonic path of closure and laterally to the right (1.2 mm). Abnormal protrusive pattern indicative of no overjet or overlap. Electromyographic (EMG) recordings indicate an abnormal hyper muscle activity in the anterior temporalis anterior and cervical group regions. (These EMG recordings support chronic facial and cervical neck and shoulder pain patterns).

“Several studies have suggested the jaw-muscle spindle as the receptor responsbile for regulating and maintaining the occlusal vertical dimension (OVD). This study, investigated changes in masseter muscle spindle function under an increased OVD (iOVD) condition. After iOVD, masseter muscle spindle sensitivity gradually decreased. Primary and secondary spindle endings were affected differently.
We conclude that iOVD caused reduction in masseter muscle spindle sensivity. This result suggest that peripheral sensory plasticity may occur following changes in OVD. Such changes may provide a basis for physiological adaption to clinical occlusal adjustments.”

Reference: T. Yabushita, JL Zeredo, K Toda and K Soma: Role of Occlusal Vertical Dimension in Spindle Function, J Dent Res 84(3):245-249, 2005.

Gneuromuscular (GNM) Orthotic Occlusal Adjustments:

Orthotic Stabilization Treatment Time: 13 months

Occlusal adjustment and anatomical micro occlusal refinements of is required of all orthotic appliances if the clinical goal and objectives of TMD treatment is to calm and quiet the spastic muscle tension and pain syndrome. The elimination of occlusal prematurities can be determined using involuntary Myomonitor TENS pulse stimulus to identify first tooth contacts that contribute to micro muscle responses that cause strain and torque to the skull and mandibular joint structures. Voluntary tapping on fine articulating paper can also be used, but is not always dependable when masticatory muscles are strained and hyperactive. It is common that muscles can strain, skew and torque more on one side than the other. Because of these recognized muscle pulls, it is advised to use micro occlusion and coronoplasty techniques to avoid the common pitfalls of adjusting the seemingly obvious articulating paper marks during habitual closure vs. the involuntary jaw closure of the bite.

Improved mouth opening one day later occured when a “physiologic” jaw position was determined with a properly occlusally adjusted orthotic.

Patient’s Subjective Responses the Next Day:

• No headaches – improved
• Slight frontal right side throbbing and frontal
• TMJ pain – no pain on closing, pulling
• No clicking popping only crunching sounds on right side only. With slight deviation.
• No pain in ears
• Slight ear congestion feeling in the right.
• Slight pain behind eyes – better than yesterday
• Neck pain same
• Shoulder pain same
• No dizziness yesterday
• Slight pain in right jaw joint
• No pain in ear – slight stuffy
• Dull ache across the front –
• Temple strain with improvement
• No pain of facial muscles

Note: Based on my clinical experience resolving neck and shoulder pain requires attention to removing posterior torquing occlusal prematurities in the lateral excursive movements.  Gnathic anterior disclusion is another key aspects in the design of any orthotic if the clinician desires optimal results.  Canine rise should occur during lateral excursions which reduces the cervical neck and shoulder strains.  Zygomatic facial masseter pain will also reduce and be eliminated if this one key aspect is acknowledged and understood clinically by the treating dentist.  If this aspect is not understood and practiced continual upper trapezius muscle shoulder pain, cervical neck pain, sternocleidomastoid and scalene muscles will continue to strain along with the pain at the corner of the lower posterior border of the mandible.

As the muscles begin to neutralize the mandible also continues to balance.  The head posture as well as the shoulder and neck posture begins to realign.  The dentist is required to identify the micro occlusal prematurities using involuntary TENS to identify the “true” occlusal prematurities.  Green wax can also be used when necessary to better visualize the thinning surfaces through the wax which indicates incline occlusal surfaces that cause proprioceptive muscles strains if not removed properly.  Marks should be balance and the patient will  recognize that the bite feels comfortable.  When this occurs, the patient will be able to function, chew food and wear the orthotic as indicated comfortably.  Following these micro occlusal principles as taught and Occlusion Connections will enhance TMD success and pain resolution.

Occlusal Adjustments Affects Cervical Neck EMG Recordings:

Typical electromyographic (EMG) signature patterns of consistently hypertonic, signals from unresolved craniomandibular and cervical complex are recorded.  Functional EMG accurately measures the activity in muscles in microvolts.

Note: Clinical experience has shown that cervical dysfunction can be resolved with keen occlusal understanding and awareness of the occlusal prematurities often overlooked by the dentist. These lack of occlusal understanding by most dentist relegates this kind of problem to the ascending disorder category, where in reality there is an underlying missed opportunity to remove the occlusal problems that are contributing to the cervical neck and shoulder dysfunction and pain.

ORTHODONTICS PHASE 2:

Orthodontic/Orthopedic Verticalization Treatment Time: 3.5 years

Finishing K7 Computerized Jaw Track and EMG Recordings:

For treating clinicians “objective documentation” must be presented in arbitrating conflicting subjective opinions”, beyond a reasonable medical certainty. Hard core proof (evidence) is often irrefutable.
Objective documentation regarding damage is of utmost importance if reasonable settlement is to be obtained for those trauma-induced head, neck, facial pain victims. Computerized mandibular scanning (Jaw tracking) with the K7 kineseograph is able to record and document fine positional and functional movements of the jaw within 0.1-0.3 mm accuracy.

Functional Computerized Mandibular Scanning (Jaw Tracking) measures vertical dimension, extent of lateral deviation upon opening and positioning where the deviation occurred, mandibular opening and closing movement and pattern during function from a frontal and a sagittal view, velocity of jaw motion from an incisal reference point during jaw opening and closing movements, and evenness or smoothness of jaw movement as opposed to jerking or uneven motion. This series is necessary to determine the quality of the finishing of the bite and quality of the functional status of the muscles to determine whether the TMD dysfunctions were effectively resolved.

EMG tests objectively verify as well as quantify the level of occlusal balance and support is established in the completing of this orthodontic case. Clench tests (Scan 11) shows irrefutable evidence that the patient is able to clench her teeth together and recruit the temporalis anterior and massetter muscles beyond 250mV which is excellent muscle retruitment in a natural tooth clench and with cottonrolls used as a control. Synchronous sharp/even balance occlusion is achieve and recorded with instantaneous EMGs activation (Scan 12 Early or late tooth contact). Calm muscle activity immediately prior to muscle clench of the temporalis anterior and massetter muscle groups is another indicator of the quality of the patients muscle resting mode. The quality of the finished bite (occlusion) and jaw posture can be measured and objectively measured with instrumentation by observing the EMG patterns.

© 2009 Clayton A. Chan, DDS. All Rights Reserved.

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