TMJ

Conservative (Palliative) TMJ/TMD Therapy

The basis of Dr. Rosenberg’s philosophy of treating TMD is:

Not to make permanent changes to a patient’s teeth, through dental procedures, or permanent changes to the jaws or joints, through surgery, until he is certain these permanent changes are going to benefit the patient.

In short: Conservative and reversible treatments should always precede permanent changes to a patient’s teeth or surgery.

What is Phase 1 Therapy?

Conservative TMD therapy does not change the patient permanently in any way. It should always be the first approach to TMJ pain unless there is an obvious surgical situation, such as a fractured jaw. Conservative therapy is also called Phase 1 therapy, and in the majority of TMD cases, no additional treatment is needed.

Conservative therapy utilizes the following approaches:

  • Bite splint or orthotics
  • Medication for pain control and muscle relaxation
  • Physical therapy
  • Alternative therapy, such as chiropractic and acupuncture, may also be beneficial

What are bite splints?

Bite splints are plastic appliances that fit over the upper or lower teeth and provide a surface for the dentist to control how the teeth opposite the splint will hit. By doing this, the dentist can control the positioning of the jaw and use the splint to reduce forces to the affected temporomandibular joints, relax muscles, and prevent further wear on natural teeth from grinding forces.

tmj1.jpgtmj2.gif

Other than certain technical considerations for each individual patient, it makes no difference whether the splint is worn on the upper or lower teeth. It is Dr. Rosenberg’s personal preference to use lower splints because many of his patients wear the splint all day and night. Lower splints tend to be more comfortable,  allow better speech and are much less noticeable.

Partial coverage splints cover only the back teeth or the front teeth. Because the teeth not covered do not touch with continuous wear of the splint, these teeth can now change position and erupt. The teeth that are covered by the splint can be compressed and unwanted major bite changes can occur. Dr. Rosenberg avoids using these splints whenever possible.

Full coverage splints cover all the upper or lower teeth. Because all of the teeth are covered, the teeth under the splint are “retained” and cannot shift. In this case, bite changes are minimized because all of the upper teeth are touching the splint. The patient can wear these splints safely for a long time. Dr. Rosenberg and many other practitioners prefer to use these types of splints. Most TMD patients who respond well to bite splints will continue to wear them when they sleep, even after TMJ pain as been relieved.

What is Phase 2 Therapy?

Conservative therapy may last for weeks or months, depending on the diagnosis. If conservative therapy is successful, but the patient is not comfortable with his or her bite and must continue wearing a bite splint during the day, the following approaches may be helpful. They may also be helpful if the patient keeps getting recurrent pain from time to time. Please note that these are permanent changes in your bite and cannot be easily reversed. None of these procedures should be attempted unless the patient has demonstrated significant pain relief in Phase 1 therapy. If a bite splint does not relieve pain, none of these procedures can be expected to work.

Many patients do not require Phase 2 treatment. They are comfortable after Phase 1 treatment and may continue to wear the bite splint and take medications occasionally. Other patients do not feel their bite is comfortable when they remove the bite splint. Some patients find they may be comfortable for a time but their pain returns. These patients are candidates for Phase 2 treatment, which will correct their bite problems (malocclusion).

The following are methods of changing bites:

  • Orthodontics (braces) – If the patient has healthy teeth that are sound (not many fillings or crowns), this is the best method for changing your bite.
  • Occlusal equilibration (tooth grinding) – The bite is changed by reshaping selected teeth with a dental drill. If small changes are needed, this may be the most desirable method. The dentist needs to practice on plaster models of your teeth first before touching your actual teeth, which will avoid unnecessary removal of tooth structure.
  • Crowns – If many teeth are broken down with large filling or old crowns, “capping” the teeth may be the best way to correct the bite.
  • Jaw surgery – Some people have a bad bite because of misalignment of the jaws. In these cases, the jaws are freed by sectioning (cutting the bone) and then placing them into proper position. These patients need to have orthodontic treatment before surgery. Even though this is the most radical approach, it may be the best and only approach for some patients. It must be emphasized that this involves surgery of the jaw bones not the TemporoMandibular Joints. Jaw surgery is not TemporoMandibular Joint surgery!

What is TMJ surgery?

A bite splint and conservative therapy should always precede permanent bite changes. If a patient does not get relief of their symptoms in Phase 1 therapy, and there is a mechanical problem in the jaw joint demonstrated by MRI findings, then jaw joint surgery may be indicated. In major facial pain centers around the country, only 5-10% of TMD patients need surgery and only 6% of the patients in Dr. Rosenberg’s practice have required surgery.

Patients with intractable pain that is not relieved, or with a sudden severe locked jaw, should only wait a few weeks before surgery is recommended. Younger patients, especially teenagers, have better results with surgeries than adults.

Most TMJ surgery is performed to treat patients with limited jaw opening (closed lock), where conservative therapy has failed. The jaw is blocked from opening because the disc or cartilage over the joint has loosened and is blocking opening. The most accurate diagnosis for this disorder is MRI imaging of both joints, and disc repositioning should not be attempted without this study.

The following procedures are available for disc repositioning:

  • Arthrocentesis – This is a relatively simple procedure where needles are placed so that liquid can flow through the joint (saline solution and steroid to reduce inflammation). This “unsticks” the cartilage, and the patient can now open the jaw. The cartilage is still loose, however, and clicking of the jaw may remain. The downside of this procedure is that the cartilage is not replaced. It is also a blind procedure where the surgeon cannot see where the needles are and depend on experience and skill for good results.
  • Athroscopic centesis and repair – An arthroscope is a needle with a television camera. Many surgeons prefer this procedure because they can see what they are doing. They free the cartilage and replace it on the jaw joint. There is no clicking after this procedure.
  • TMJ microsurgery – In this procedure, the surgeon makes a small incision in front of the ear, and using microscopic magnification, replaces the disc and repairs the joint.
  • Open surgery – In this procedure, the incision is larger so that the surgeon can see the entire joint while operating. If the cartilage is badly torn, or misshapen, it may be removed in the open procedure and sometimes it is not replaced. Various substances can be used, both natural and synthetic, to replace the disc. In the 1980s, synthetic Proplast was used to replace joint cartilages, which led to serious complications and the product was removed from the market by the FDA. Patients who had Proplast replacements required second surgeries to remove them.

There are more complex surgical procedures, even artificial joint replacements, available today. Surgery is necessary in a minority of TMD cases, and the surgery is similar to other orthopedic joint procedures (e.g., knee, hip, shoulder, etc.).

What results can I expect from surgery?

One of the primary problems of TMJ surgery is the recovery phase. While a knee or a shoulder can be rested after surgical procedures, because of eating, chewing, talking and swallowing (plus habits such as nighttime tooth grinding), it is virtually impossible to “rest” the TMJs. Dr. Rosenberg believes this is why these surgeries are less successful statistically than other joint surgeries and why many patients still continue to have problems after surgical procedures. It is also the reason that conservative management should always precede surgery.

Is TMJ/TMD covered by insurance?

Because of confusion in the medical and dental profession in this area, many insurance companies have “TMJ (or TMD) exclusions” in their coverage contracts. We will provide any patient in our office with an insurance statement you can send to your insurance company. Most TMD claims will be filed with your medical insurance, not dental insurance. Because of the wide range of coverage, we ask that you pay for your treatments and submit a claim for reimbursement to your insurance company. Our office Financial Coordinator (lyndagriff@rosenbergorthodontics.com) will be pleased to make financial arrangements with you.

If you are experiencing or have any questions regarding the symptoms mentioned above, please call our office in Burke at (703) 250-2208 or our Gainesville Office at (571) 248-4355. We would be happy to discuss your concerns. It has been very rewarding for our team to help correct these problems for many of our dental family, giving them vast improvement in their quality of life.