Treatment Guidelines for Temporomandibular joint (TMJ) Pain & Dental Occlusion

Temporomandibular disorder (TMD) is one common problem nowadays. Statistics showed that about 70% of the adults over 20 years old more or less experiences signs of TMD, e.g. TMJ clicking, tinnitus or receiving earache. Among them, 85% of the patients have their signs alleviated by conservative treatment. Another 15% of the patients experience consistent pain and fear of malocclusion or difficulty mouth opening. Therefore patients who show poor response to conservative treatment for 3-6months without showing any improvement of pain or malocclusion shall consider other treatment options.

suggest this kind of patient should visit all-in-one orthognathic and TMJ specialist clinic that offers combined assessment and treatment covering orthodontics, TMD correction, OSA therapy and various surgical approaches. All-in-one orthognathic and TMJ specialist clinic is the latest trend of treating TMD and correcting malocclusion in US, which adopts interdisciplinary management that effectively differentiate the cause of the signs as disorders or defects of the bone, occlusion, joint, respiratory tract or others, so as to provide the most appropriate treatment.
 

Long-term unsolved TMJ pain recurred 10 years after the orthodontic treatment aiming to correct malocclusion

Qi (24 years old) was troubled by TMJ pain for many years even after following medical advices from orthodontic or TMD specialists. Only until Qi consulted second opinion from clinicians in all-in-one orthognathic and TMJ specialist clinic, She came to know that the cause of her long-term TMJ pain could be traced back to a bike accident at 9 years old that led to displacement of TMJ disc.

Qi experienced TMJ pain early since studying in junior high school. At 12 years old she began orthodontic treatment. Due to persistent TMJ pain and difficulty mouth opening, the scheduled to be 1-2 year of orthodontic treatment plan was suspended for several times and eventually got finished in 4 years.

However Qi kept experiencing TMJ pain and therefore the parents brought her to visit TMD specialist in a general clinic who prescribed Qi with basic conservative treatment including occlusal splint and NSAID medication. Clinical studies showed that 85% of patients with TMJ pain got improved of the sign with conservative treatment. Qi had the treatment for another few years, and her TMJ pain was suppressed but never resolved. The family began to worry about the adverse effects from using such medicine over a long time.

Ten years after termination of orthodontic treatment, Qi was upset to find the malocclusion recurred. The upper and lower teeth again couldn't align well and Qi was not able to bite and eat properly. She went back to the former orthodontic doctor and was informed that she should receive another orthodontic treatment to correct the recurrent malocclusion. Qi felt helpless and didn't want to go through the nightmare of endless orthodontic treatment again. Until then Qi was referred by the former orthodontic doctor to another all-in-one orthognathic and TMJ specialist clinic for second option.
 

All-in-one orthodontic and TMJ specialist clinic provides tailor-made and comprehensive treatment plan for individual patient

Based on the past history, Qi was scheduled to have TMJ arthroscopy in our clinic for accurate diagnosis and comprehensive assessment. The results showed that the TMJ disc was displaced and the joint cavity was filled with inflammatory substances, fibrous tissue and adhesions, which further compressed the intra-articular space. TMJ arthroscopic lavage was performed to remove the inflammatory substance in order to create more intra-articular space and relieve the pain. Articular disc reduction was also performed to relocate the disc back to a normal anatomical position. It was very important to reestablish sound joint stability to prevent recurrence of TMJ pain.

Six months after surgery, the sign of difficulty mouth opening got improved and the TMJ pain relieved. There was no need to take pain pills any more. Unfortunately due to the long time under improper treatment, Qi exhibited condylar resorption leading to retrognathia and malocclusion. Qi could undergo orthodontic treatment to align the teeth, which however cannot improve the retrognathia condition and the possible consequence of obstructive sleep apnea and snoring problems. Alternatively Qi could choose to have orthognathic surgery to correct the malocclusion and retrognathia and prevent obstructive sleep apnea and snoring.

The biggest difference between orthodontic treatment and orthognathic surgery is the aesthetic outcome. Orthodontic treatment simply moves the teeth into better position without taking face shape into consideration. Comparatively orthognathic surgery repositions the facial bones to improve the appearance, correct the malocclusion and create more space in respiratory tract with the benefits to prevent obstructive sleep apnea and snoring. Afterwards orthodontic treatment is applicable for patients who require further needs to get better bite and finer appearance. The duration of afterwards orthodontic treatment can be greatly shortened as the joint stability is reestablished and the bones are repositioned to better position.

These are the unique advantages of all-in-one orthognathic and TMJ specialist clinic. The interdisciplinary team composed of a group of health professionals to give comprehensive assessment and custom made treatment plan and medical advices so as to improve the outcome and patient satisfaction.
 

Patient with TMD underwent osteopathic Manipulation in Kung Fu Institute resulted in acute TMJ inflammation

Qi is just one of the many patients who spent lots of time and efforts ended in vain. Some patients even searched help from psychologists or Kung Fu Institute.

One I had a patient Hai who was in his early 20s. He began to show the sign of earache and therefore went to visit ENT specialist. The ENT doctor told it might be caused by middle ear effusion so prescribed antibiotics and pain pills. The medication didn't help and the earache remained. Then he started to feel pain even while eating or opening the mouth. The parents were worried and brought Hai to Kung Fu Institute, hoping the signs could be improved by osteopathic manipulation.

Unexpectedly the osteopathic manipulation didn't make any improvements; instead, Hai could not even open his mouth. The parents got recommendation from friend and brought him to our clinic. After examination and assessment, Hai was diagnosed with TMD. The osteopathic manipulation have caused acute TMJ arthritis and deteriorated the displacement of TMJ disc, resulting in inability to open the mouth.

Based on the results of MRI imaging examination, the main diagnostic tool for disc displacement nowadays, we suggested Hai have TMJ arthroscopic lavage to remove intra-articular inflammatory substances and create more intra-articular spaces so Hai would open the mouth normally. Then with 3 months following the basic TMD treatment including occlusal splint, rest and soft diet, Hai was fully recovered.
 

Most parents easily overlook the malocclusion of the children may be resulted from TMD

It is worthy mentioned that Qi and Hai represents the population with high risk of developing TMDin adolescence and adult, respectively. In particular, Qi's case shows that TMD occurred during bone growth stage in childhood or adolescence without proper treatment will cause abnormal facial bone growth, e.g. facial asymmetry, mandibular prognathism, malocclusion, mandibular deviation and buckteeth. This is because TMJ is the growth center of facial bones. Any injury on TMJ could affect the growth of upper and lower jaws and result in facial bone and dental abnormality.

Unfortunately most parents do not know about the great impact of TMD on the facial aesthetics and its potential to induce pain. Prents care more about occlusal problems, unaligned teeth, protruding or receding chin, and hope that orthodontic treatment could solve all these problems. They never realized that the root of these problems lies in TMD. Without careful diagnosis and assessment, undesired result may occur 5-10 years after finishing the orthondontic treatment, just like in Qi's case.

Luckily nowadays most of the medical centers or orthodontic specialist clinics perform TMJ assessment before giving orthodontic treatment. It has become consensus among the clinicians that the top priority is to reestablish the joint stability before dealing with bite and bone problems. In another words, no matter the displacement of TMJ disc is caused by trauma, crash, pressure or malocclusion, the first thing to do is relieving the pain and correcting the dislocated TMJ disc, then consider orthodontic treatment or orthognathic surgery.

It should be noted that the assessment of TMD in general clinics is mostly based on the presence of clinical signs, especially joint pain. However clinical statistic data showed that 25% of the patients with severe TMD exhibited no obvious signs. Therefore people should not overlook malocclusion, even in those cases not coupled with TMD signs such as joint pain, earache and joint clicking. Because ¼ of the malocclusion cases are caused by TMD. I have seen many patients came to our clinic due to pain caused from deterioration of TMD during orthodontic treatment.

This also explains why all-in-one orthognathic and TMJ specialist clinic has become major trend in USA, as patients can get comprehensive assessment and treatment for occlusal, joint or bone problems and avoid delays in treatment
 

Ten self-assessment questions for the screening of TMD

All in all, while facing patients with TMD, orthognathic and TMJ specialists shall put focus on the effect of TMD on facial bone growth in young patients, while treating directly the signs and underlying causes in adult patients, e.g. TMJ replacement surgery with autogenous rib graft or alloplastic joint system.

Do you wonder if you have TMD? Here listed 10 self-assessment questions for the general public to make judgment whether it is necessary to consult the orthognathic and TMJ specialists

Signs of clenching or bruxism?
Experience of head and neck pain or stiffness when waking up?
Experience of TMJ pain getting worse from a hard bite?
Experience of TMJ pain getting worse from a hard bite?
Experience of pain when opening the mouth, eating or yawning?
Experience of joint pain or history of arthritis in other joints
The upper and lower teeth do not align completely
Front teeth cannot get direct touch or tear the food while eating.
Signs of facial deviation, asymmetry or severe retrognathia.
Teeth abrasion or severely sensitive to cold or heat

A higher proportion of "yes" answers to the above-mentioned questions indicate a higher risk of having TMD. We highly suggest the readers who have many yes answers should visit the all-in-one orthognathic and TMJ specialist clinic that covers interdisciplinary treatment options including orthodontics, orthognathic surgery, treatment for TMD and OSA to have a comprehensive assessment and proper treatment plan. That is the unique advantage of all-in-one orthognathic and TMJ specialist clinics.