If you search for advice with TMJ problems, some sites suggest simple self-care is all you should do. And they say it’s a “self-limiting muscle tension problem” that will resolve. Decades ago that might have been believed. With improved imaging technology, there is understanding of the progressive damage to the TMJ (one study showed nearly 90% of adults have a misaligned TMJ) that is asymptomatic or episodically painful or showing signs of irreversible damage, such as clicking or limited opening.
Damage to the cartilage disk inside the jaw joint begins years before signs or symptoms and is easily recognized with 3D cone beam imaging and good clinical skills. If found, it can be monitored for damage or treated before irreversible damage has occurred, if patients choose to.
A few “TMJ Advice” sites are very adamant in “not doing anything that will change the bite (or occlusion)” for a TMJ disorder. Here is the dilemma. The study mentioned earlier showed (by MRI on about 100 adults seeking braces) that most had displaced discs in one of their jaw joints.
The TMJ joint is misaligned in most of us as we grow, due to functional habits, genetics and environmental growth interferences (allergies). If your teeth aren’t ideally aligned (without braces) then YOU are one of the 90%. You may or may not develop pain, but you will have intermittent damage to the joints as the years go by. Unequal growth of the upper and lower jaws is the instigating factor.
Unequal size of the upper and lower jaw is seen as crowded or crooked teeth (even mild). Bruxing and clenching of teeth is also a symptom of this misalignment (as well as other things – stress is only a minor contributor). Over time, the cartilage, bone, or muscles may develop symptoms as damage progresses. Over several years, it becomes an obvious problem. If you can’t fit your 4 fingers between your open mouth (like a salute) you have TMJ problems, regardless of pain, at any age. Three fingers width is typically chronic degenerative disease that may have burned out and is often without acute pain. It does flare up easily with dental care.
One of the common “warnings” is to “not change the bite” if you have TMJ. Since an underlying cause of TMJ IS the imbalance of the jaws/teeth/joint, it is also the solution, if you understand current orthopedic approaches to treatment. Let’s look at options:
- Do nothing. Because you have been told it is “self-limiting”. As the joints/cartilage degrade or become arthritic, the lower jaw will begin to shift and cause either a noticeable bite changes or, result in bruxing, broken molar teeth, painful teeth, etc. This is the early phase. More advance damage can cause the front teeth not to touch when biting, or contribute to more teeth breaking, etc. This is a pathologic result of TMJ damage and represents a bite change. Some are dramatic. So, doing nothing WILL result in a bite change. The TMJ Association is vocal with this approach. They advocate self-help, counseling for chronic pain, and a multitude of pharmaceuticals to suppress bone damage, muscle tension, anxiety and stress, depression, etc. They are also strong advocates of psychological counseling. Their board (last time I looked) has PhD’s from pharmaceutical and psychology backgrounds. A couple dentists have received grants from them and focus on the “psychosocial” approach with some doing tooth grinding as their method of treatment (…that changes the bite… what they say NOT to do). For some cases this is appropriate but based on studies, it should be less than 10% of sufferers).
- Adjust the “bite” or equilibration of the teeth. Sometimes it is a minor 1-2 tooth re-shaping (due to the underlying bigger problem mentioned above) or to try and relieve muscle symptoms or joint clicking (a dislocated disc). Grinding down the teeth (and using a “bite plate” in between sessions to “relax the muscles”) is, essentially allowing the joint to degrade and grind the enamel off the teeth until the joint is so badly damaged it stops degrading or “burns out”. Often at this point the recommendation is to “crown all the teeth” because the enamel has been ground off and the teeth are flattened. The “restoration” is to restore the grooves on the teeth. What happens if the joints start degrading again? A new round of grinding the crowns and later replacing them again. I don’t support this approach as it is simply following the self-destruction of the TMJ – similar to “do nothing”.
- Orthopedic approach. This is what I follow and have for 30+ years. It has strong support from orthopedic literature, and organizations including the American Academy of Craniofacial pain, International College of Craniofacial Pain. The American Academy of Orofacial Pain is also embracing the orthopedic approach in recent years.
- The use of orthopedic orthotics (just as an orthotic can correct a leg length problem and eliminate hip/back pain) to place the damaged joint under traction, allow disc repair and re-alignment. The reflex-driven muscle tension/pain is almost always resolved. Once improved, a long-term use of a stabilizing orthotic supports the joint in a proper, comfortable position without damaging the teeth. This does result in a slight “gap” between the back teeth (due to re-alignment of the jaw from the distorted growth – the 90% of us). I recommend use of this device indefinitely or for 1-2 years to insure the condition is stable and comfortable. Some patients elect to undergo carefully guided orthodontics or crowns (if dentally indicated) that maintain the exact alignment the orthotic had, but this is the minority.
- Surgery. All websites and groups support that this is a “last resort” in cases when damage is so widespread from trauma, misdiagnosis, systemic disease or craniofacial syndromes. Surgical entry into the TMJ does considerable damage and always require post-surgical orthopedic therapy (# 4 above) due to the significant, post-surgical bone damage and joint destruction.
The bottom line is: You acquire a TMJ disorder because of unequal growth of the jaws. Genetics, large tonsils and/or adenoids, having a “tongue tie”, or other environmental influences on growth in the first few years of life. Correction of a TMJ disorder, will always change the alignment of the jaws and, “the bite”. If you use an orthopedic approach the “bite change”, is really a correction of abnormal jaw growth. If caught early we can use orthopedic orthodontic principles to guide growth and lessen the chance of developing a TMJ problem later.