TMJ - Advanced Cosmetic Dentistry

Intro: What Is TMJ & TMD

TMJ = Temporomandibular Joint
TMD = Temporomandibular Disorders

The bones of the TM joint are separated by a disk and are held together by muscles and ligaments. The temporomandibular joint connects the lower jaw, called the mandible, to the temporal bone at the side and base of the head. The anatomy of the TM joint is complex, especially because there are two joints working together and the alignment of both of the TM joints is set by the location of your teeth.

If you place your fingers just in front of your ears and open your mouth, you can feel the joint on each side of your head. If you bite or clench you can palpate and determine the origin and insertions for many of the muscles that control jaw function. These muscles are located on the lower jaw and side of your head. Because TM joints are flexible, the jaw can move smoothly up and down and side to side, enabling us to talk, chew and yawn.

Signs and Symptoms of Tm Disorders

A variety of symptoms may be linked to TMD. Pain, particularly in the chewing muscles or jaw joint, is the most common symptom.

Limited Movement or Locking Of The Jaw (Closed Lock), Decreased mouth opening (<20mm), Side to side jaw movements may be limited, Feeling of cramp or muscle tightness, Muscles rigid and painful to palpation
Disc Malposition “Open Lock”: Severe discomfort. Patient is unable to close jaw (open lock). Anterior teeth will not contact. Patient may report incident of dental visit with prolonged opening of mouth or patient may report this as a recurring problem.
Pain brought on by yawning, chewing or opening the mouth widely.
Radiating pain in the face, neck or shoulders.
Tenderness of the jaw muscles.
Painful clicking, popping, or grating sounds in the jaw joint when opening or closing the mouth.
A sudden, major change in the way the upper and lower teeth fit together.
Symptoms such as headaches, earaches, dizziness and hearing problems may sometimes be related to TMD.

Common Symptoms Of Back Pain Can Help Patients To Understand Common Symptoms Of TM Pain.
Back pain is one of the most common medical problems in the U.S. It affects most people at least once in their lifetime and can be a good case in point. The most common form of back pain is due to muscle spasm and is very similar to the most common form of TM pain, which is also from muscle cramping. An imbalance, strain of the joint, history of trauma, or even something as slight as an awkward movement of the back or jaw, can lead to a muscle spasm. The muscle spasm can cause the back or jaw to lock, and can cause severe pain. This spasm can become part of a cycle that results in tissue damage, pain, muscle tenderness and more spasm. Back pain can reoccur from strenuous activities or imbalances, like weight gain in the abdominal area, which will increase demand and fatigue on spinal and pelvic muscles. Likewise, muscle strain from tooth grinding/clenching or imbalances of the jaw joint from unbalanced premature tooth to tooth contact can trigger symptoms of TM pain.

Muscle spasm of the back and TM joint are similar but it’s important to note that the TM joint is one of the most complex joints in the body. The anatomy of the TM joint is unique, especially because there are two joints working together and the position of both of the TM joints is set by the location of your teeth. To better understand functionality of the lower jaw, try imagining the handling of a wheelbarrow. A wheelbarrow has one wheel (your teeth) and two handles (terminal ends of the lower jaw which rest at the base of your skull). If the wheel barrel is balanced, it’s easy to push and move heavy loads. If the load is slightly off center, your muscles will be strained to move even the smallest of loads. It’s important to note that over time an unbalanced load will wear at the jaw joint and muscles. Malaligned TM joints in patients who grind have excessive degenerative forces on the muscles and the bones of the skull where these muscles are attached. While some cases of TM disorder may be clear-cut, such as trauma, arthritis, jaw imbalances, or grinding/clenching, most are due to a combination of factors.

Causes of TMD

Depending On Your Signs And Symptoms, TM Diagnosis And Treatment Recommendations Can Vary From Person to Person. Many people may not experience TM symptoms to abnormal bites and other TM disorders for long periods of time. For this reason, TM diagnosis may be delayed and treatment recommendations can vary from patient to patient. In general, any one or a combination of the following known causes of TMD will increase your likelihood of, or can increase the severity of TM Symptoms:

Myofascial Pain, The most common form of TMD, which is discomfort or pain in the muscles that control jaw function. This is commonly a result of day or nighttime habits called parafunction. Examples daytime clinching and nighttime grinding.
A History Of Or Current Symptoms Of Dislocated Jaw Or Displaced Disc (usually from an injury)
Degenerative Joint Disease (Arthritis in the jaw joint itself) Arthritis may be a long-term result of an injury.
Post Dental Visit TM Pain: (See our section of post dental visit Emergencies)
- DENTAL INJECTION TRAUMA
- POST VISIT TRAUMA
  - Stress from surgical trauma to a muscle or ligament
  - Strain from over opening or prolonged opening of mouth
  - Jaw fracture
- New Dental Restoration high in the bite
Grinding Away Flattened Tooth Structure: It is very well documented that flattened tooth anatomy creates excessive lateral force on the TM joint. People who grind can and will eventually grind away nature’s protective biting surfaces. The loss of these natural tooth inclinations will result in excessive force on the TM joint and associated joints and muscles.
Grinding Imbalance: People who grind on one side more then another will quickly create an imbalanced biting surface. Remember, if the jaw is forced out of alignment by the teeth, the muscles will be strained to accomplish everyday activities.
Clenching or Grinding Related Muscle Strain: People with TMD often Clench or Grind their teeth during the day or at night, which can tire the jaw muscles and lead to pain.
Family History Of TMD Or Grinding/Clenching
Excessive Parafunctional Habits: Excessive cheek biting, excessive gum chewing, etc.
A Thought Or Awareness That Your Bite Is Uncomfortable Or Abnormal
Occurrence of Tension or Stress: Some experts suggest that Stress, either mental or physical, may cause or aggra¬vate TMD.
Sleeping Disorders Oral habits such as clenching or grinding the teeth (Bruxism) may develop as a response to stress or as part of a sleep disorder.
Sinus Pain (Treatment Without Long Term Relief)
Migraine Headaches (Treatment Without Long Term Relief)
Tension Head Aches (Treatment Without Long Term Relief)
Any Treatment Of Head, Neck, Facial Pain (Without Long Term Relief)
Jaw Clicking: There is no scientific proof that jaw clicking leads to serious TMJ problems. In fact, jaw clicking is fairly common in the general population. As long as the displaced disc causes no pain or problems with jaw movement, no treatment is needed.
Occlusal Imbalances: If the teeth pull the jaw out of the socket during swallowing or biting, it destabilizes the jaw joint.
An Abnormal Bite from Cracked, Chipped, Worn, Broken, Crooked or Missing Teeth.
Abnormal Bite from Old Worn Dental Work. Remember all dental materials and tooth structure wear at a different rates. As an example, if you have porcelain crowns on your left side and the right side is healthy natural tooth structure. Over time, the porcelain crowns on your right will not wear as fast as your left side. The Crowns will end up higher then your right side.
Abnormal Bite from Improperly Balanced Dental Work
Orthodontic Treatment, such as braces and the use of headgear, has also been blamed for some forms of TMD, but studies now show that this is unlikely unless the final tooth position and bite is abnormal. One type of abnormal bite that may result from orthodontics is known as CPC, or constricted path of closure. In CPC, the anterior teeth forcefully lock the jaw back in an abnormal position.
Abnormal Bite from Age Related Wear of natural tooth structure.

Treatment for TM Disorders

To the extent that the causes of your TM disorder can be identified, proper diagnosis is an important step before treatment. It can save time and money by ensuring that you receive the treatment appropriate for your particular problem.

There is no formal treatment sequence or “norm” for treatment of TM disorders. Treatments for TM disorders vary, based on your individual diagnosis. Dr. Landers may recommend a treatment involving a series of phases. This step-by-step plan is in your best interest because the initial treatment phases of only minor corrective treatment may be all that is needed. Dr Landers will, unless otherwise indicated, begin with the initial treatment of dental disease, which will include conservative reversible treatment. If pain and other symptoms persist, a more involved treatment will need to be considered.

Dr. Landers and our team of other health professionals (who provide treatment for TM disorders) care about your health and comfort. Please feel free to discuss your concerns openly with our team.

The Key Words To Keep In Mind About TMD Treatment Are:

Start out with “conservative” and “reversible.”
Pain is not a disease. It is a warning that something is wrong. No doctor would give you pain medicine as the only treatment for a broken bone. It’s our goal to find and treat the reason you have the pain. It’s important to understand that finding the cause of your TM Pain may take more than one visit.
It is important to note that while many of the above factors are believed to cause TM disorders, and most treatment is successful, in rare cases, the exact causes of the disorders may be unknown and it may not be possible to determine the causes of the symptoms. In these situations, the symptoms should still be addressed and treated regardless of cause.

Patient Self-Care Practices for Active TMD Pain
Because most TMD problems are tem¬porary and do not get worse, simple treatment is all that is usually needed to relieve discomfort. For example,

Eating soft foods,
Applying heat or ice packs, i.e. warm wash cloth on the jaw area
And avoiding extreme jaw movements (such as wide yawning, loud singing, and gum chewing)
Learning special techniques for relaxing and reducing stress may also help patients deal with pain that often comes with TMD problems.
Watch how you are sleeping (with your hands near your face?).
THERAPEUTIC EXERCISES AND STRETCHES (only Once pain is reduced). This physical therapy which focuses on gentle muscle stretching and relaxing exercises, muscles should be stretched passively to full length while patient gently opens and closes.
Short-term use of muscle-relaxing and anti-inflammatory drugs such as Aspirin, Advil, Motrin or Naprosen.

Based On Dr. Landers’ Diagnosis, One or More Treatments May Be Recommended

Prescriptions: anti inflammatory and muscle relaxer
Behavioral management of subconscious daytime habits
Appliance that can be worn while sleeping for nighttime grinding
Appliance to be worn during the day to help with subconscious daytime habits
If an upper to lower jaw position interference is suspected *KD- Kois deprogrammer will be recommended.
Stress management suggestions as part of behavioral management
Rule out jaw or joint fracture with 3D dentistry
Attempt pain management (massage, Vapo-coolant spray, ice, local anesthetic)
Electrolytes or other lab work may be requested to rule out disorders (i.e. calcium/parathyroid disorders).
Occlusal Equilibration – Reshape the teeth to fit in harmony with your jaw joints
Even the bite or recon¬structing the biting surfaces with inlays, crowns, or bridges
Orthodontic Braces – Move the teeth with braces
Jaw Surgery – Rare internal damage may require surgery
Referral to other medical professional

* KD – Kois Deprogrammer looks like and is similar to an orthodontic. This retainer is commonly known as a Hawley in the dental world. This KD Hawley appliance slightly opens the bite (1mm) and allows for no tooth to tooth interferences, which will then allow the condyles to move freely. The relaxed condyles are free to move with no obstacles (i.e. teeth) to prevent them from achieving an equilibrium position. Tooth to tooth prematurely can trigger discoordination of masticatory muscles. The KD breaks this cycle by discluding the teeth and allows the muscles to return to normal function. As the patient wears the KD appliance the muscles find an equilibrium position. A dental record is made of this healthy stable position with the KD in place and the bite is balanced with the KD in place.

Treatment Options From Other Medical Professionals

Acupuncture to “trig¬ger points.”
Therapeutic Message Treatments soft tissue work – massage, trigger point work, soft tissue mobilization, etc.
Dietary And Nutritional Counseling: Pain relief diet
As a last resort refer to Oral Surgeon to consider surgical treatment

How Dr. Landers Determines if Your Pain Is From Muscle Spasms Due To Occlusal Interference

At our office we can determine if your pain is related to an abnormal bite in less than five minutes:

Clinically it’s a Four Step Process:

Evidence that you are clenching or grinding your teeth i.e. tooth wear.
A conflict between the centered position of your jaw joints and your teeth. CR vs. CO (MIP).
Pain and soreness in any jaw muscles.
Pain relief using the Bite Discluder.

If the Bite Discluder takes away your pain, you can expect substantial relief from bite treatment at our office. The combination of pain relief from a Bite Discluder and Dr. Landers’ diagnosis can indicate that a large percentage of your pain is due to muscle spasms that are caused by occlusal interference. If the Bite Discluder does not relieve your pain and your bite is still suspected to be the cause of your TMD, Dr Landers will likely suggest the use of a KD- Kois Deprogrammer for one week.

Only a trained dentist can fix your bite.

Grinding/Clenching vs TMJ

Bruxism can develop at any age. Many patients are unaware that they are grinding their teeth because it often happens while they sleep.

Classic symptoms of night grinding are:

Waking Up With A Headache
Toothache On Opposing Top And Bottom Teeth
Earache
Sore Face (Tightness Of Muscles Of The Jaw)
Noticeable Tooth Wear

*Grinding sets the stage for TM pain

*Grinding can wear away or fracture tooth enamel and may eventually loosen teeth.

*The disorders appear to affect about twice as many women as men.

Grinding Away Flattened Tooth Structure: It is very well documented that flattened tooth anatomy creates excessive lateral force on the TM joint. People who grind can, and will, eventually grind away nature’s protective biting surfaces. The loss of these natural tooth inclinations will result in excessive force on the TM joint and associated joints and muscles.
Grinding Imbalance: People who grind on one side more than another will quickly create an imbalanced biting surface. Remember, if the jaw is forced out of alignment by the teeth, the muscles will be strained to accomplish everyday activities.
Clenching or Grinding Related Muscle Strain: People with TMD often Clench or Grind their teeth at night, which can tire the jaw muscles and lead to pain.

Grinding and/or Clenching verses Root Surface Sensitivity
Grinding and root surface sensitivity commonly occur together. This is due to the fact that the pressure of grinding or clenching will cause bone loss and gum tissue recession with subsequent root surface exposure. In fact, patients who grind their teeth and have gum disease will lose bone 50% faster than those patients with gum disease alone.

Treatment of Grinding Habit

Check for abnormal bite and if necessary make adjustments.
Help the patient to recognize and eliminate the parafunctional habit.
Fabricate a grinding appliance

Benefits of a grinding appliance:

Prevent Tooth To Tooth Wear that occurs during grinding contact (attrition).
Slightly hold mouth in an open position. This lengthens muscles and helps reduce muscle cramping.
Covers and eliminates trauma from any unbalanced abnormal pathologic bite. A properly designed and professionally adjusted bite appliance will help patients move their jaw freely. Adjustment of an oral bruxing appliance is complex, and should be handled by a dentist who understands occlusion. Dr. Landers has been trained to equilibrate occlusion and oral appliances.
The acrylic appliance relieves some of the pressure of grinding and clenching, which can otherwise damage delicate jaw joints.

Fidgeting – Oral Para-functional Habits Versus TMJ Pain

We All Have Habits
All of us have a constant and basic metabolic rate or level of energy. Some inherently have more, while others have less. There is scientific research that suggests that we evolved with this energy because our ancestors needed energy for grooming. In our modern day society there is less need for grooming and our lives are more sedentary, i.e. desk work. As a result, we have extra energy. This energy manifests itself in one form or other. One such way to express this energy is fidgeting habits like: gum chewing, feet tapping, hair twirling, nail & cheek biting, and clenching/grinding, just to mention a few. Additionally, we know that some people allow their self-corrective attention to be sidetracked due to an over focus on work or other interests (=stress!).

Did you know that our mouth hygiene is unique in that most of oral cleansing is maintained from the movement of your cheeks and tongue over our teeth? Observe this behavior next time you have finished a meal. This is an example of a self-grooming habit.

Can an Oral Trigger Lead To Parafunctional Habit?
There is no scientific evidence to support the theory that increased oral awareness from an oral trigger is linked to the establishment of an oral parafunctional habit. On the other hand, an abnormal bite from a dental restoration can be just enough to cause tremendous problems. Some patients will test & retest their new bite over and over. If the bite interference is not eliminated, this behavior could initiate a repeated action and theoretically may result in a parafunctional habit. Long term, and not in all patients, this habit can become excessive and ultimately create strain and wear on muscles, ligaments and the TM joint itself.

It’s important to note, it is most often difficult to “pin- point” the origin of many parafunctional habits including tooth grinding or clenching. Additionally, grinding is often familial in occurrence (i.e. runs in families). Because the occurrence is familial, this suggests that there may be genetic factors involved. Additionally, grinding and clenching occur more commonly with an undiscovered oral trigger or tooth to tooth interference. Finally, it should be noted that tooth pain could lead to oral triggers.

I Don’t Grind My Teeth… Do I?
Quite often, patients are not aware of their oral fidgeting type or parafunctional habits. Clinically, patients will present with obvious tooth to tooth wear that clearly suggests some current or past history of an oral habit. Most of the time, on the patients subsequent visit, they will surprisingly inform me that they have discovered their parafunctional habit.

Treatment of Grinding Habit

Check for abnormal bite and if necessary make adjustments.
Help the patient to recognize and eliminate the parafunctional habit.
If habit is still present after bite is balanced, conservative treatment of a grinding-bruxing appliance is properly equilibrated.
Benefits of a grinding appliance\
- Prevent tooth to tooth wear that occurs during grinding contact (attrition).
- Opens mouth which lengthens muscles and helps reduce muscle cramping.
- Covers and eliminates trauma from any unbalanced abnormal pathologic bite. A properly designed and professionally adjusted bite appliance will help patients to move their jaw freely. This is a complex type of adjustment and should be handled by a dentist who understands occlusion. Dr. Landers has been trained to equilibrate occlusion and oral appliances.
- The appliance relieves some of the pressure of grinding and clenching, which can damage delicate jaw joints.

TMJ & Migraine Pain Diagnosed In 10 Minutes

How Dr. Landers Determines if Your Pain Is From Muscle Spasms Due To Occlusal Interference

At our office, we can determine if your pain is related to an abnormal bite in less than five minutes:

Clinically it’s A Four Step Process:

Evidence that you are clenching or grinding your teeth
A conflict between the centered position of your jaw joints and your teeth
Pain and soreness in any jaw muscles
Pain relief using the Bite Discluder

If the Bite Discluder takes away your pain, you can expect substantial relief from bite treatment. The combination of pain relief from a Bite Discluder and Dr. Landers’ diagnosis can indicate that a large percentage of your pain is due to muscle spasms that are caused by occlusal interference. Only a trained dentist can fix your bite.

Please review Video + our section of TMJ under “Emergency Self Help” Section

Tension Headaches, Migraine headaches Vs. Temporomandibular Disorders-TMD

Pain is not a disease. It is a warning that something is wrong. No doctor would give you pain medicine as the only treatment for a broken bone. Our treatment goal is to help you cure the reason for your pain. The cause of headache pain must also be discovered and treated. However, treatment often only includes pain relievers, trapping the patient in an unending cycle of drugs and pain.

Tension headaches are one of the most common forms of headache and are often confused with migraine headaches. They may occur at any age, but are most common in adults and adolescents. If a headache occurs 2 or more times weekly for several months or longer, the condition is considered chronic.

Tension headaches result from the contraction of neck and scalp muscles. One cause of this muscle contraction is a response to stress, depression, or anxiety. Some experts suggest that Stress, either mental or physical, may cause or aggra¬vate TMD. People with TMD often tense muscles in the Jaw joint and Clench or Grind their teeth at night, which can tire the jaw muscles and lead to pain.

Is Jaw Pain Or TMJ Pain A Possible Reason For My Head Pain?

Occlusal interference is a conflict between the teeth and jaw joints which is the cause of over 40 million people’s head, neck, or facial pain and dental damage
A disease with symptoms that are commonly confused with migraine, tension, cluster and stress headaches
A problem that can easily be treated by your dentist

In a landmark study, Dr. Jannet Travell, MD found that the pain from occlusal interference could radiate and refer to other areas of the head, neck and face with varying intensity and frequency.

How Dr. Landers Determines if Your Pain Is From Muscle Spasms Due To Occlusal Interference

At our office we can determine if your pain is related to an abnormal bite in less than five minutes:

Clinically it’s A Four Step Process:

Evidence that you are clenching or grinding your teeth
A conflict between the centered position of your jaw joints and your teeth
Pain and soreness in any jaw muscles
Pain relief using the Bite Discluder

*Tension headaches are not associated with structural lesions in the brain as in Migraine headache pain.