TMJ

It has been estimated that more than 50 million people in Canada and the U.S. suffer from severe headaches. These headaches can be so debilitating that they can adversely affect their ability to work and their relationships with family and friends. Although there can be many reasons for headaches, many headache patients suffer from temporomandibular joint disorders (TMJ disorders).

Have you been trying to find relief for your headaches and/or facial pain?

Your, "incurable" headache pain could be generated by an incorrect bite, jaw joints and/or spasms from the muscles surrounding the head and neck. Our office believes that it is necessary to treat the cause of the disorder in order to eliminate the symptoms rather than only giving temporary relief to the symptoms with drugs such as muscle relaxants and pain medications. Our focus is to address the jaw joint factors related to the pain by restoring proper function and improving overall health.

Because symptoms masquerade as many other conditions, people tend to go from doctor to doctor in search of answers.

Why Dentistry?

The jaw is literally one end of the postural (skeletal) chain. An imperfect bite can, over time, result in tension in the muscles of the face and jaw. Trauma or accidental injury can result in a state of sustained elevation of activity of the face and jaw muscles. (The delayed onset of muscle spasms following whiplash injury is a prime example.)

Prolonged spasm of facial muscles can lead to chronic muscle pain, often perceived in other areas (referred pain) and thus subject to misdiagnosis.

What is TMJ and TMD

TMJ means temporomandibular joint (jaw joint).

The temporomandibular joint (TMJ) is the joint connecting the lower jaw (mandible) to the skull (temporal bone). The lower jaw and the skull are connected by a number of muscles and ligaments, which function in harmony with each other if the lower jaw is in the correct position. The head of the jaw bone (lower jaw) is called the condyle and it fits into the concavity of the temporal bone called the glenoid fossa. The TM joint resembles a ball and socket with the round condyle being the ball and the glenoid fossa of the temporal bone being the socket. For normal joint function to occur, a piece of cartilage called an articular disc acts as a cushion or shock absorber between the two bones.

 

NORMAL JAW JOINT
 


When the lower jaw opens and closes, the disc stays between the condyle and the glenoid fossa of the temporal bone at all times. When this happens, this is a normal healthy TMJ and the patient can open wide without any discomfort and without any noise. With a normal opening, the patient should be able to get three fingers between the upper and lower front teeth when the mouth is open as wide as possible. In cases where the TM joint is functioning normally with the disc in the proper position, the muscles of the head, neck and shoulders function relatively pain-free.

What is TMD?

Temporomandibular disorder (TMD) is the condition referring to a joint that is not normal.

The position of your teeth can affect the position of your jaw joints. Each jaw joint is a ball and socket joint. When functioning properly, the ball and socket do not actually touch because a thin disc of cartilage rides between them. The disc acts as a cushion and allows the joint to move smoothly. Each disc is held in place and guided by muscles and ligaments. If your bite is not right, as in cases where the following may occur: deep overbite, lower jaw too far back, narrow upper jaw or upper front teeth crooked and tipped backwards, this can cause the jaw to become dislocated. Typically the disc is pulled forward. The lower jaw then has a tendency to go back too far and the top of the lower jaw, which resembles a ball (condyle), presses on the nerves and blood vessels at the back of the socket and causes pain.

Usually, the protective disc (cartilage) is displaced forward and no longer serves as a cushion between the condyle (lower jaw) and the bony socket (skull) and eventually this can lead to the condyle rubbing against the bony socket. This can cause a problem called osteoarthritis.

Mild displacements cause a clicking or popping sounds in the jaw joint.

When the disc becomes displaced, this is what causes the various noises within the jaw joints such as clicking and popping sounds. Patients must be aware that any noises or pain that occur during the opening and closing of the jaw is an indication that the jaw joints have become dislocated. Patients are advised to seek treatment as soon as possible to avoid allowing the problem to get worse.

More severe displacement can be very painful and eventually can cause permanent damage to the joint. An unstable bite can cause both jaw joint displacement and muscle strain and pain. Many seemingly unrelated symptoms results, which are collectively known as craniomandibular dysfunction. These symptoms include headaches, neck aches, ringing in the ears, stuffiness in the ears, pain behind the eyes, ear pain, shoulder and lower back pain, dizziness and fainting, difficulty swallowing, and tingling of the fingers and hands. These symptoms include:

  • Headaches
  • Neck aches
  • Ringing in the ears
  • Stuffiness in the ears
  • Pain behind the eyes
  • Ear pain
  • Shoulder and lower back pain
  • Dizziness and fainting
  • Difficulty swallowing
  • Tingling of the fingers and hands


Photo of Degenerative Joint Disease and Degenerative Joint

APPOINTMENTS NEEDED

  • Medical and Dental History as well as an examination of the teeth and the dental arches

  • TMJ Health Questionnaire
    Patients are asked questions regarding possible TM dysfunction symptoms. If the patient answers "yes" to any of the symptoms and "yes" to clenching and bruxing, then further tests are required to confirm the presence of a jaw joint problem (TM disorder).

  • Range of Motion
    Patients are checked for how wide they can open, slide left and right, move the jaw forward, and whether or not there is a deviation or deflection of the jaw upon opening. If there is a problem achieving normal range of motion, there is usually a structural problem within the joint.

  • Muscle Palpation
    Excessive muscle contractions and trigger points indicate a problem with the chewing muscles of mastication. This causes the muscles of the head and neck to be sore when pressed by the dentist. This usually means that the lower jaw is not in the correct position.

  • 3D-cone beam scan
    TMJ x-rays are important to see if the condyles (top of the lower jaw bone) are too far back where they would be impinging on the nerves and blood vessels at the back of the socket where the jaw bone fits into the skull. In cases where the lower jaw is too far back, dentists find a significant reduction in the signs and symptoms of TM disorders when the jaw is repositioned forward with a splint or a functional orthopedic appliance.

  • Computerized Joint Vibration Analysis
    This is specialized equipment used to take readings of the noises or vibrations occurring within the jaw joints upon opening and closing movements. The JVA is simply a 3-minute, non-invasive test where headphones are placed on both jaw joints and the patient is instructed to open and close six times. An abnormal or dislocated joint has distinctive vibrations which can be analyzed to help diagnose the seriousness of the problem.

    There are basically 5 stages of disc displacement. Ideally, if there is a jaw problem you would hope that the patient is in Stage 1 or Stage 2 where the disc can be recaptured. If the JVA reveals that the patient is in Stage 3, 4 or 5, this is a much more serious problem and the prognosis is not as good for resolution of all the symptoms.


Dr. Wall has the knowledge and experience needed for proper, thorough diagnosis and treatment of temporomandibular joint dysfunction.

TREATMENT

Since the teeth, jaw joints and muscles can all be involved, treatment for this condition varies. Typically, treatment will involve several phases. The first goal is to relieve the muscle spasm and pain as well as establish normal range of motion of the lower jaw. Then, your dentist must correct the way the teeth fit together. Often a temporary device known as an orthotic or splint is worn over the teeth until the bite is stabilized. Permanent correction may involve selective reshaping of the teeth, building crowns on the teeth, orthodontics or a permanent appliance to cover the teeth. If the jaw joint itself is damaged, it must be specifically treated. Although infrequent, surgery is sometimes required to correct a damaged joint. Ultimately, your dentist will stabilize your bite so that the teeth, muscles and joints all work together without strain.

Once a thorough diagnosis has been made, Dr. Wall will begin a personalized treatment program. Patients benefit from the non-surgical, conservative treatment our office provides. Individualized therapy will include muscle spasm reduction treatments in conjunction with an easy to wear, comfortable dental orthotic, referred to as a splint. The orthotic covers the lower teeth holding the jaw in proper alignment, reducing tension in the muscles of the jaw joint, allowing healing to take place. Once pain is controlled and the jaw joint is stabilized, the bite is balanced so the teeth, muscles and joints all work together in harmony.

It is important to assess the posture of each patient to determine whether or not the shoulders, pelvis and hips are level. Photos are taken of each patient to check for the above as well as to check for forward head posture. If there is a problem with the shoulders, hips or pelvis or if one leg is longer than the other, then a referral to a chiropractor would be necessary.

To solve the problem of forward head posture which can cause cervical (neck) problems, referral to a dentist or orthodontist who uses functional jaw orthopedic appliances should be made. These appliances such as the Twin Block, MARA or Herbst Appliance successfully reposition the lower jaw forward and eliminate the forward head posture.

For most patients, treatment is divided into two stages:

1. Phase I Diagnostic - Temporary Solution

2. Phase II Stabilization - Permanent Solution - four options:

    a. Orthodontic correction,

    b. Prosthetic correction,

    c. Weaning from the orthotic, or

    d. Continuing orthotic wear as needed.