| Oral and Maxillofacial Procedures » TMJ Treatment (Temporomandibular Joint Disorder Treatment) |
| TMJ (Temporomandibular Joint) Disorders and Treatment Dr. McBride is unusually qualified to evaluate and treat TMJ problems. He has extensive experience in the diagnosis and nonsurgical and surgical treatments of TMJ disorders. He wrote an exhaustive chapter on the management of TMJ disorders for a medical textbook, and has lectured around the world on this subject. He helped develop some of the earliest total joint replacement prostheses, and provided training programs for other surgeons on the management of all degrees of TMJ degeneration. He studied nonsurgical occlusal therapy, including occlusal equilibration and occlusal splint fabrication, at the Pankey Institute in Florida. He notes that he is able to treat over 95% of his TMJ patients without surgery. Because of the complexity of problems associated with TMJ disorders, there has been considerable confusion and disagreement about the management of TMJ disorders. Dr. McBride has been able to develop a thorough systematic approach to evaluation and diagnosis of these problems. He can prioritize the problems and identify the best treatment for each problem. There is almost always more than one factor contributing to the TMJ problem, so there is almost always two or more types of treatment that must be performed simultaneously in order obtain the best, long term relief. If only one problem is treated at a time, there will only be partial relief of symptoms. Temporomandibular disorders involve the jaw joints, the teeth and the muscles that move the lower jaw and head in many complex ways. Every patient is different with regard to their symptoms, the causes of their problems, the agrevating factors, and the treatment recommendations that may be appropriate for them. However, Dr. McBride has developed a very effective way to explain these issues to you. He has developed a very successful treatment sequence that can help to resolve your pain, restore function, and prevent progression of the disorder. At your first visit, Dr. McBride will diagnose your problem,
explain the problem to you so that it is easy to understand, and give you treatment suggestions to start resolving your pain right away. The temporomandibular joint is the jaw joint, the joint that connects the lower jaw (mandible) to the bottom of the skull (the temporal bone). TMJ (temporomandibular joint) disorders are a group of problems related to the jaw joint (TMJ) and/or the muscles that open and close the mouth and move the head. The symptoms include pain and/or clicking, popping and grinding noises in the jaw joint (TMJ), headaches, limited mouth opening, sore teeth, neck pain, and earaches. There may be tenderness and swelling around the temporomandibular joints, changes in how the teeth come together, and pain behind the eyes. All of the symptoms may be due to strained muscles, all of the symptoms may be due to joint strain or degeneration, or there may be a combination of joint and muscle symptoms. Dr. McBride focuses on nonsurgical treatment options including anti-inflammatory drugs, bite splint therapy, bite adjustment, muscle relaxants, stress reduction, cessation of gum chewing, soft diet, orthodontic treatment, heat and massage. He believes that surgery is indicated only in cases of relatively severe joint degeneration or dysfunction. If the cartilage gets displaced and is caught in the joint so that it severely limits the mobility of the joint, this is called locking of the joint, surgery is indicated. Dr. McBride has developed a simple surgical procedure to shave down the thickened cartilage disc so that it will move easily in the joint and permit a return to normal opening. Another problem that is treated surgically is a tear in the soft elastic tissue behind the cartilage. This tear causes the cartilage and bone to degenerate, producing a shrinkage of the joint which results in a change in the way the teeth fit together. If the tear is not repaired, the degeneration can progress to the point that total joint reconstruction is required. Dr. McBride has developed a retrodiscal repair surgery that very simply closes the tear and usually lets the joint repair itself. Dr. McBride has extensive experience in total joint reconstruction for those joints that have degenerated so far that repair is not possible. He uses excellent custom made total joint implants that fit the bony contours perfectly and restore function and stability to the joint. He teaches his technique to other surgeons so that more people can benefit from this approach. Symptoms of TMJ Disorders Headaches - on the sides of the head, back of the head, forehead, behind the eyes Pain or swelling in the jaw joints Popping, clicking or grinding noises in the jaw joints Temporary or permanent locking of the jaw joints so you can't open normally Pain in the chewing muscles on the sides of the jaw Pain when opening the mouth or when chewing Difficulty chewing a normal diet Difficulty or inability to open the mouth widely Bite changes, the teeth meet differently from day to day Neck pain Earaches, ringing in the ear, or stuffiness in the ears TMJ symptoms may result from clenching or grinding the teeth which can strain the jaw muscles and the TM joint. Trauma or arthritis may damage the jaw joint causing degeneration, swelling, pain, limited motion, and noises in the joint. Since some types of TMJ problems can lead to more serious conditions, early detection and treatment are important. Stress is a very common and important cause of TMJ muscle disorders. Stress causes many people to clench and grind their teeth. The clenching and grinding strain the chewing muscles, which then get tight and painful. There can be strain of the tissue in and around the TMJ, which can cause popping, clicking and grinding noises in the joints, as well as pain and swelling in the joints. Factors That Aggravate TMJ Symptoms Clenching or grinding the teeth
A bad bite
Chewing gum
Arthritis
Stress The TMJ is composed of a knob of bone on the lower jaw which fits into a cup in the bone on the bottom of the skull. The surfaces of these bones are covered with a slippery cartilage layer. In between these bones there is a pad of cartilage that moves around in the joint as the mouth opens and closes. The cartilage pad, which is called the disc, is also slippery and acts as a pad to protect the joint structures. Anything that reduces the lubricating ability of the fluid in the joint will contribute to arthritic degeneration of the cartilage in the joint. Arthritic degeneration in the TM joint can occur at a very early age. It is usually due to an hereditary weakness in the joint which causes the fluid in the joint to loose its lubricating abilities. Excessive friction develops in the joint, and the cartilage in the joint deteriorates. Dr. McBride is unusually qualified to evaluate and treat TMJ problems. He has extensive experience in the diagnosis and nonsurgical and surgical treatments of TMJ disorders. He wrote an exhaustive chapter on the management of TMJ disorders for a medical textbook, and has lectured around the world on this subject. He helped develop some of the earliest total joint replacement prostheses, and provided training programs for other surgeons on the management of all degrees of TMJ degeneration. He studied nonsurgical occlusal therapy, including occlusal equilibration and occlusal splint fabrication, at the Pankey Institute in Florida. He notes that he is able to treat over 95% of his TMJ patients without surgery. Because of the complexity of problems associated with TMJ disorders, there has been considerable confusion and disagreement about the management of TMJ disorders. Dr. McBride has been able to develop a thorough systematic approach to evaluation and diagnosis of these problems. He can prioritize the problems and identify the best treatment for each problem. There is almost always more than one factor contributing to the TMJ problem, so there is almost always two or more types of treatment that must be performed simultaneously in order obtain the best, long term relief. If only one problem is treated at a time, there will only be partial relief of symptoms. Dr. McBride focuses on nonsurgical treatment options including anti-inflammatory drugs, bite splint therapy, bite adjustment, muscle relaxants, stress reduction, cessation of gum chewing, soft diet, orthodontic treatment, heat and massage. He believes that surgery is indicated only in cases of relatively severe joint degeneration or dysfunction. If the cartilage gets displaced and is caught in the joint so that it severely limits the mobility of the joint, this is called locking of the joint, surgery is indicated. Dr. McBride has developed a simple surgical procedure to shave down the thickened cartilage disc so that it will move easily in the joint and permit a return to normal opening. Another problem that is treated surgically is a tear in the soft elastic tissue behind the cartilage. This tear causes the cartilage and bone to degenerate, producing a shrinkage of the joint which results in a change in the way the teeth fit together. If the tear is not repaired, the degeneration can progress to the point that total joint reconstruction is required. Dr. McBride has developed a retrodiscal repair surgery that very simply closes the tear and usually lets the joint repair itself. Dr. McBride has extensive experience in total joint reconstruction for those joints that have degenerated so far that repair is not possible. He uses excellent custom made total joint implants that fit the bony contours perfectly and restore function and stability to the joint. He teaches his technique to other surgeons so that more people can benefit from this approach. TMJ “Syndrome” Components A) Muscle Component - 90% of the complaints Clenching and Bruxism cause: • sore, swollen muscles • excessive wear of the teeth • fractured restorations
Muscle pain and swelling produce: • headaches in the temples, behind the eyes, in back of the head • facial soreness – in chewing muscles • reduced mouth opening ( caused by swollen, tight muscles) • referred pain to ears, shoulders, neck, teeth • bite instability • dental pain (referred pain) • bad bite (malocclusion)
B) Joint Component - 10% of the complaints; frequently the first symptom noticed
Early arthritic degeneration, such as disc displacement can cause: • popping and clicking in the joints • pain in the joints, referred pain in forehead • swelling around the jaw joints • limited motion, reduced opening and side to side movements
TMJ Treatment Several treatment modalities may need to be utilized simultaneously. Non-surgical treatment resolves symptoms in 99% of patients. TMJ surgery is only needed in cases of arthritis ( the cartilage disc is out of place) which fail to respond to comprehensive non-surgical therapy and have locked out disks with substantial reduction in mouth opening, torn tissue, or severe bony degeneration. Bite therapy • Splints (night guards) • Equilibration (reshaping teeth a little to make them fit together better) • Dental restorations (crowns, fillings, implants)• Orthodontic treatment (to align teeth) • Orthognathic surgery (to move one or both jaws so teeth fit together better) Stress management Insurance
Many patients do not have insurance coverage for treatment of temporomandibular joint disorders. We will assist our patients in determining if they have insurance coverage, the extent of the coverage, and we will help them to select the best treatment options. If we are not on your insurance plan, we can provide the service on an out-of-network basis. In this situation, the patient will pay our charges and be reimbursed by the insurance plan. Out of pocket expenses will vary depending on the insurance plan. Prior to a visit we will be happy to estimate the fees you may incur. Questions About TMJ Disorders and Treatment What is a bite splint or "night guard"? A bite splint is a thin, clear, hard plastic wafer that clips on your upper or lower teeth and makes it feel like your teeth fit together perfectly. What is the purpose of a bite splint? A bite splint is used to help reduce the chewing muscle strain that causes pain and headaches. Patients are not able to bite as hard on a splint as they can on their teeth, so they cannot clench as hard and cause the muscle irritation that produces muscle pain and stiffness. Patients usually experience excellent pain relief with a splint. How many hours a day should a bite splint be worn? When you first start wearing a splint, it should be worn 24 hours each day. You can take it out to eat, and to clean it. Usually the splint will begin reduce your muscle pain after a day or two. Your pain should continue to resolve over the next few weeks. During that time, the splint will help you to become aware of the times that you clench and grind your teeth. If you only clench during the night, you may only have to wear the splint at night. If you only clench during the day, or at certain times during the day, you may only need to wear the splint at those times. You will learn when it is important for you to wear the splint. Some people will want to wear their splint indefinitely because it provides such good pain relief. Others will want to solve their bite problem permanently, and reduce their clenching, so they will not need a splint. Does a splint need any adjustments? As you wear the splint during the first few weeks, your muscles will relax and your lower jaw may move into a slightly different position and change the bite on the splint. This change may irritate you muscles again and cause your pain to return. At this point you should have the plastic ground down so that the bite is perfect again, and your muscles will relax again. Several adjustments may be needed before your jaw muscles are completely relaxed and the bite stabilizes. After the bite on the splint has stabilized, you will need to consider a permanent correction of the bad bite between your teeth. This can be done with some very fine grinding of your teeth to get them to fit well, or orthodontic treatment to move your teeth into better positions. Rarely, if your bite is very bad, it may be necessary to surgically reposition one of your jaws so that the bite can be improved. What is equilibration? Equilibration is way to adjust your bite by doing a very little bit of grinding on your teeth to reshape them so they fit together well. It is a technique to "equalize" the bite. A dental drill with a polishing tip is used to make the adjustments. It does not hurt, so no anesthesia is required. Generally, immediately after the equilibration, there is dramatic relief of the muscle stress and pain caused by the bad bite. Some patients will need touch-up adjustments as their bite settles in. Why is stress management so important is the treatment of TMJ disorders? Stress is the primary cause of clenching and grinding of the teeth. And it is the clenching and grinding that cause the muscle irritation which results in headaches, jaw tightness and joint pain. Reducing the stress usually produces a similar reduction in pain. Some people have stress because they are perfectionists and try to make everything perfect in their lives. But they do not have control over every aspect of their lives, so they create their own stress by trying to solve their unsolvable problems. Other people have stress because of debt, unhappiness at work or at home, or their chronic pain. Managing the stress, regardless of the cause, is usually critical to reducing the pain. When is joint surgery indicated? Surgery is indicated when there is damaged tissue in the joint that is causing pain that cannot be resolved by other means (bite splint, stress reduction) , when the joint abnormality severely restricts mouth opening, or when there is severe degeneration of the joint. What changes occur in the TMJs as a result of arthritic degeneration? There are several types of arthritic degeneration, but, overall, they cause the bone and cartilage in the joint to deteriorate. By far, the most common type of arthritis in the jaw joint is osteoarthritis. It causes the fluid in the joint to loose its lubricating capacity. This causes friction on the cartilage and bone as the mouth is opened and closed, and results in degeneration of the tissue. There is a small disc of cartilage that fits between the bottom of the skull and the knob of bone (the condyle) of the lower jaw. This cartilage acts as a pad to protect the tissue as the joint moves. This cartilage can come out of place and move forward in the joint so that it is in front of the knob of bone (the condyle). As the condyle moves forward when the mouth opens, the disc is pulled back into place between the bones and makes a popping or clicking noise. This is a very common problem in TMJ disorders, and is responsible for much of the joint pain and degeneration. The abnormal pressure in the joint caused by the cartilage returning to the normal position, and the loss of the normal cushioning provided by the disc, can cause the condlye to degererate and shrink. When the condyle shrinks, the bite changes, causing more muscle pain. The disc can become permanently out of position (locked) and severely limit the joint motion. Surgery to reduce the thickness of the disc will usually let the disc move freely and improve the joint motion dramatically. When the disc remains out of place for an extended period of time, the condyle can wear a hole in the stretchy tissue behind the disc. The hole lets the condyle rub along the bone at the bottom of the skull, causing additional bone degeneration and shrinkage. A relatively simple surgical procedure can repair the tear in the tissue to reduce pain and the potential for further degeneration. The torn tissue, if not repaired, can permit severe degeneration to progress and scar tissue to develop which can severely limit joint motion. The degeneration may become so advanced that a total joint replacement implant is required to reduce pain and restore function. Fortunately, the total joint replacement implants available today are very effective and durable. What should I know about joint surgery? Joint surgery is generally not considered until non-surgical treatments have failed to produce the desired result. However, in certain cases of severe joint degeneration, locked out discs with limited mouth opening, and cases of torn tissue behind the disc, surgery may be considered early in treatment. Other than total joint replacement procedures, temporomandibular joint surgery has relatively little down time and simple recovery. For Dr. McBride, most surgery involves repairing the soft tissue in the joint. The bone is not operated upon. There are two procedures that Dr. McBride feels are effective for restoring function and comfort. Both procedures are done on a day surgery basis. Disc Contouring. The first procedure is called "disc contouring" and is used when the disc is very thick and is locked out of place in such a way as to severely restrict mouth opening. A small incision is made in front of the ear and the joint is entered through a small opening. The top of the cartilage disc is shaved down to restore the more normal thin contour. It is rarely possible to put the disc back into its normal position, so it is left in front of the condyle. The incision is closed and the suture line heals extremely well. The patient can usually return to work within a few days. A soft diet is required for about one month. Perforation Repair. The second procedure is called "perforation repair". It is used to repair the torn tissue behind the displaced disc. A small incision is made in front of the ear and the joint is entered through a small opening. The tear in the tissue behind the disc is sutured closed with a soft permanent suture material. The torn edges heal together and form a tough layer that resists further tearing. As with the first procedure, it is rarely possible to put the disc back into its normal position, so it is left in front of the condyle. The incision is closed and the suture line heals extremely well. The patient can usually return to work within a few days. To permit the tissue to heal properly, a very soft diet is necessary for the first four to six weeks. Total Joint Replacement. As with other joints, such as hips and knees, it may be necessary to replace a severely degenerated joint with a total joint implant. Dr. McBride uses custom made total joint implants from TMJ Concepts, Inc. He has used these implants for over ten years with excellent success. They are made from the same materials used in total joints for hips and knees: ultrahigh molecular weight polyethylene, titanium, and chrome-cobalt stainless steel. The implants are made on models that replicate the exact contours of the patient's skull and jaw. The model is made from the data obtained from a very accurate CT scan of the patient. Dr. McBride trims the model to the exact contours that he will trim the bone to at surgery. The model is returned to the manufacturer with specific prescription for how the implant is to be fabricated. A wax model is then made of the implants. The model is returned to Dr. McBride for his approval before the implants are fabricated. When the implants are ready, surgery may be performed. It is ususlly done in the hospital and the patient spends the night in the hospital after surgery. An incision is made infront of the ear along the line of a facelift incision. Another short incision is made below the angle of the jaw in front of the ear. The joint is exposed through the incision in front of the ear, and the lower jaw bone is exposed through the incision below the jaw. The degenerated portion of the joint is removed, the teeth are wired together into the best bite, and the implants are secured to the bone of the skull and the lower jaw with titanium screws. The wires holding the teeth together are removed at surgery. The incisions are closed meticulously to provide the best healing. The patient usually goes home the next day. Patients are able to open their mouths right after surgery, but the amount of opening is restricted by swelling and muscle soreness. This limits the diet to soft foods for several weeks. The recovery with total joint surgery is substantially longer than with disc contouring or perforation repair. The muscles will need to heal to the lower jaw, and the patient will need to exercise the muscles to return to a normal opening. Dr. McBride will guide you through the process and help you obtain the best result. |