The TMJ is a complex joint that can be very difficult to treat when injured. This joint goes through motions of rotation and translation, which can influence pain, chewing, bite relationships and muscular spasm. Because the mechanism of the joint is complex, it stands to reason that the treatment is complex. In fact, there are different philosophies regarding the best way to treat this disorder.
There are two main ways to treat TMJ:
1. Neuromuscular treatment
2. Centric relation position
TMJ Treatment: First Steps
Regardless of the philosophy of the dentist, it is always best to be conservative in your treatment for TMJ problems. If you have TMJ pain, the first course of treatment is to eat soft foods and apply ice packs as needed for discomfort. As well, you should limit jaw opening by avoiding chewing gum, caramels and sticky foods, large sandwiches and yawning. To further decrease stress on your joint, you should cut up food into small pieces for a period of several weeks to decrease the trauma on your joint. If you are able to take non-steroidal anti-inflammatories such as ibuprofen, this can decrease joint pain and inflammation as well. If you need this for a prolonged period of time, however, you should see your physician or dentist. It is also helpful to practice relaxation exercises such as meditation and yoga to help relax your overall musculature.
Neuromuscular dentistry uses instruments to track jaw movement and muscle positions when you are at rest, as well as jaw relationships to the skull and path of jaw closure, to evaluate abnormalities. The dentist will often use sonography to record jaw sounds and x-rays to evaluate how your jaw may be deviating from the norm. The neuromuscular dentist will use TENS units, or ultra-low frequency transcutaneous electrical neural stimulation, to relax the muscles and increase blood flow. They also feel that endorphins released may decrease pain from this treatment modality.
The next step is to stabilize the bite by using mouth guards and other orthotics. After that, the dentist will try to affect permanent change by incorporating:
- Equilibration or tooth adjustment to change your bite and eliminate problem areas.
- Long term appliances that are worn on the teeth, called overlay partials.
- Full-mouth reconstruction or full-mouth rehabilitation, which builds crowns on all the teeth to permanently change the position of the jaws and location of the teeth. This is an irreversible change that may need to be done several times over the course of your life.
- Orthodontics, which may change the teeth to a more desirable position.
Centric Relation Treatment
Centric relation is considered the ideal orthopedic mandibular position of the mandibular condyle (ball) within the Glenoid Fossa (socket) of the skull. The C.R. dentist is taught that the muscles, tendons, ligaments and bony structures are all in harmony if the condyle is in (or can reach) the superior, most braced position in the skull or centric relation position during maximum intercuspation (all your teeth being together). To do this, they will evaluate the bite, perform splint therapy and then an equilibration to normalize the bite and ensure people can get into an ideal intercuspation position where all teeth fit together.
The centric position dentist will try to establish a canine guidance or mutually-protected centric occlusion position (MPO). This means that all teeth couple properly and that the canines will be built to glide left and right, allowing posterior teeth to separate during grinding. Any excessive lateral contacts are adjusted so that maximum intercuspation can be achieved. They believe that if there is not a protective coupling and guidance of the anterior teeth, then craniomandibular dysfuntion or TMJ can result.
Treatment may include an occlusal splint to build the ideal bite. This plastic orthotic can be built to idealize tooth contact and simulate a protected occlusion to relieve muscular soreness and allow the jaw joint to move in a normal, non-pathologic glide path. Once the bite is ideal and jaw symptoms have subsided, more permanent solutions can be undertaken.
Splint therapy is both diagnostic and therapeutic. This splint can be adjusted and the patient weaned off of it until it’s eliminated. The goal is to reposition the mandible into centric relation, rehabilitate the joint tissues, improve the path of closure and diagnose final treatment. Splint therapy should not be used long term or to create permanent changes in the bite. It is used to give the jaw and teeth a break and to allow proper healing to occur.
Sometimes the dentist will recommend orthodontics or crowns to affect permanent change for a person’s bite. It should be noted that irreversible procedures should always be avoided if possible.
In terms of which is the “right” method: it’s too controversial to pick a side. The truth may lie somewhere in between. The use of irreversible treatments such as crowns, full-mouth reconstruction and extensive grinding of teeth should be avoided if at all possible, as it may not work and can make your situation worse.
Anterior Repositioning Splints
The anterior repositioning splint is another treatment: moving the lower jaw forward with a splint takes pressure off of the vascular attachment that holds the TMJ cartilage in place. If this is torn, the dentist may try to position the lower jaw forward to try and recapture this disc. Then, by incremental adjustment they may try and walk the joint back and recapture the disc.
Using repositioning splints to try to recapture a disc that has been detached may work, or may help create a pseudo-disc or area where the disc can work with less pain. However, this is controversial. As long as this therapy is used for short periods of time it may be an effective modality to decrease pain. Using this treatment for long periods of time may change the anatomy of the joint and lead to altered positions of the teeth. This type of irreversible treatment has been found to be ineffective according to the National Institute of Health.
Surgery is the last treatment for TMJ and should only be used when no other treatment can be found that will give relief. There are surgical procedures as well (from arthroscopy to implants) but they are all of questionable success. The replacement of jaw joints with artificial implants may cause severe pain and permanent jaw problems.