by Clayton A. Chan, DDS
Note: These ICAT images are of a 53 year old female who was experiencing TMD and facial pain. Bone on bone rubbing, scraping and grating sounds were identified and record using electrosonography confirming severe temporomandibular joint degeneration (abnormal condylar contours, anterior disc displacement, non reducing disc and degenerative osseous changes present).
Is bone on bone and severe condylar changes with an anteriorized disc a problem?
- Question: ”….but if you have joint damage how are your muscles suppose to calm down? I think all in all this is a difficult question to answer.”
Answer: That is easy…! Many dentist who understand the etiology of myofacial pain and TMD orofacial pain problems relax the masticatory muscles regardless of joint degenerative or derrangment problems first. Muscles can calm down regardless of joint conditions. Joints are not the controlling factor over muscles, nor are reliable references to establish a mandibular to maxillary position. That is a misnomer by many in dentistry. Spastic muscles is what causes havoc to both the occlusion and then to the joints.
The following images are of a sampling of variety of TMJ images of patients who presented with severe TMD, orofacial pain symptoms and also were cases that had previous unsuccessful TMJ Dysfunction treatment. Each one of these individuals were all successfully treated with a lower removable orthotic after an optimized physiologic bite relationship was determined using the K7 and TENS and are now pain free and comfortable.
If one focuses on the pathologic joints as the source to Temporomandibular Dysfunction (TMD) then one missed out on opportunity to resolve TMD and the associated cervical problems successfully. TMJ is not just a joint problem, but in fact, is a dysfunction of the whole cranio and facial neck structures and neuromuscular system. That has been proven for years. Some do not recognize how the muscles responds to abnormal occlusion that contributes to joint breakdown. One can even have joint surgery and or joint replacement and the muscles still could be unhappy.
Here is another way to look at this in this example:
Patient has occlusal problems, interferences in their bite or new crowns/fillings, teeth begin to rub and grind the teeth because of hypermuscle activity response as a feed back response to the abnormal fit of the bite….and they wear down. Muscles activate to cause clenching and grinding and headaches begin in the temporal regions. Teeth begin to also show periodontal bone loss over time. Gums receed. Neck and shoulder begin to ache and strain due to forward head posture and abnormal loads and imbalance of muscles…. resulting in loss of posterior vertical occlusal support.
Note: Although these teeth make appear to have well developed arches and well aligned teeth, but beyond what may appear to be healthy each of these individuals all experienced severe debilitating TMJ and orofacial pain problems. Each of them searched for answers within the medical and dental profession.
Condyles begin to show Wilkes III, IV and V levels of degeneration and disc displacement with further accompanying orofacial pain….now it becomes bewildering to the patient and doctors…the patient is given meds…but meds are not fully responding and are not helping the spastic muscle pain problems…patient discovers from doctors that he/she has “TMJ”.
The following case ICAT image is an example of severely damaged joints which show severe osseous degeneration of both left and right condyles, with discs perforated and anteriorly displaced with reduction. Sclerosing of both the articular eminence as well as the superior head of the condyles are clearly displayed. Bend in the neck of the condyles as well as beaking of the condyles show significant evidence of degeneration (bone on bone wear). Mandibular dysfunction during opening and closing movements of the mouth were present (mandible closed posterior to the neuromuscular trajectory). Optimized bite taking protocols were implemented with the K7 jaw tracking and TENs to improve joint space and resolve TMD pain symptoms. Patient is now wearing a lower removable GNM optimized orthotic and has avoided joint surgery.
ICAT Imaging of Severe Temporomandibular Joint Osseous Degeneration (Bone on Bone Scrapping with perforated and displaced disc)
Another view of the same joints: Right and left temporomandibular joints with orthotic in the mouth.
Patient presented with inability to bring her posterior into occlusion at the start of treatment due to severity of bone on bone degeneration of the condyles. Patient in severe pain. After orthotic treatment patient is able to open and close her jaw free of pain, free of joint symptoms as well as any other muscular problems. After 1 year and 7 months treatment the patient is considering orthodontics to complete her case.
ELECTRO-SONOGRAPHY (ESG) – JOINT SOUND ANALYSIS
Joint sound analysis (same female patient above) is able to record and objectively measure particular temporomandibular joint sounds and location during opening and closing cycles of the mouth. Abnormal joint vibrations (sound patterns) can be distinguished as high and low frequency sound patterns (scrapping, crepitus, grating sounds) as well as high and low amplitude sound indicators (clicks and pops). Location, amplitude as well as frequency of joint sounds can be measured and recorded with today’s electrosonographic technology.
This analysis is able to confirm during four mouth opening and closing mouth cycles of the above shown ICAT TMJ images whether there exists any scrapping, crepitus and or grating sounds (bone on bone) during this patients opening and closing cycles. It also is able to scientifically and objectively confirm like sonar what quality of sound patterns are present which further is helpful in indicating whether TM Joint degeneration is present.
The following joints records severe joint degeneration of both left and right joints with more severity of the right TM joint – Confirming bone grating and scrapping against bone during all opening and closing cycles.
Left boxes display open and closing joint sounds in jaw tracking mode (sweep mode). Right group of boxes also displays the same four open and closing of the mouth and joint sound patterns displayed in jaw track and velocity mode.
The left box number 3 (blue) is the opening jaw joint sounds of the right joint displays high frequency, high and low amplitude signature patterns indicative of scrapping and grating patterns (bone on bone). Box 4 in the right group displays the closing jaw joint sounds of the right joint (blue) and left joint (red), also recording high frequency low amplitude crepitus signature patterns (bone on bone).
The left box number 7 (blue) is the opening jaw joint sounds of the right joint displays high frequency, low to moderate amplitude signature patterns indicative of scrapping and grating patterns (bone on bone). Box 8 in the right group displays the closing jaw joint sounds of the right joint (blue), low frequency moderate to high amplitude signature sound patterns and left joint (red), also recording high frequency, low amplitude crepitus signature patterns (bone on bone). In all four records of these particular sound prints the fast fourier analysis graphs (blue and red) patterns above show average peak patterns not returning to baseline, another indicator of degenerative joint changes present on both left and right joints.
Patient experiences ear congestion feelings, stuffiness, pressure behind the eyes, pain behind the neck, etc. tingling in the hands and fingers, severe orofacial pain (the signs and symptoms of this “Great Imposter”) because of compromising muscles and forward rolled shoulders result. Teeth begin to be mobile and the further wear and chipping of cusps and fillings…..condyles are noted to be up and back within the glenoid fossa with the existing habitual bite in MIP…there is clicking and popping of joints since the disc is no longer interposed between the eminence and condylar head…its anteriorizing some doctors say…it may even indicate grating sounds…. due to loss of posterior vertical…the patients head is showing a forward head posture..they also continue to experience neck and shoulder pain…the PT is trying to help the muscles…but after each visit the tender muscles keep coming back…more office visits…..eventually the back molars are extracted due to hyperactive muscle activity…they are loose and wabbly, then the bicuspids are lost… .front teeth further wear down, more bone loss and recession, teeth begin to loosen and also are extracted…too expensive to replace….muscles still keep hammering away at the remaining teeth…muscles are winning, yet not happy because they don’t have a biting support nor stable condylar position or home base…condyles are now beaked, showing sclerosis and flattening with further grating sounds to the patient…the neck of the condyles now show a bend in the neck due to abnormal hyperactive masseter muscles forces that have gone on for years with antigonial notching at the corner of the mandible (seen on panoramic x-rays)…. once the front are removed the mandible comes down and forward, muscles begin to relax…but the patient has no teeth….the patient is now edentulous…”Look ma no teeth”…but I am happy says the patient….with happy calm muscles…joints are still flattened…teeth are no longer present to create occlusal interferences……
In dentistry dentists all know that muscles always win over joints, teeth and bones….If we get the muscles happy first, we can save the teeth and we save the joints. This is what doctors do who specialize in the field cranio-orofacial neurovasomuscular cervical dentistry. It’s not too complicated once one has opportunity to objectively measure and see muscles alive with EMGs.
To read more see: Intermediate or Late Stages of Internal Derangement
© 2009 Clayton A. Chan, DDS. All Rights Reserved.