TMJ, TMD and Jaw Pain

The temporomandibular joints (TMJ) are the structures that attach the lower jaw to the rest of the skull.  The TMJ along with jaw muscles, tendons and ligaments allow the jaw to move during chewing, swallowing, speaking and sometimes breathing.  TMJ Dysfunction (TMD) is a group of different disorders with similar symptoms.  Of the many different symptoms that can occur, the most common are pain and difficult or limited jaw movement. These symptoms may be due to a problem with the joint itself or more commonly, hyperactivity and spasm of the jaw muscles. Grinding and clenching of the teeth and chewing gum are the most common habits that cause TMD.  You can reduce muscular hyperactivity and prevent pain by practicing some simple exercises and avoiding things that cause muscle tension.

TMD can be managed by exercise/stretching, behavior modification, diet modification, physiotherapy and massage therapy. In some patients, appliances such as biteplates and night guards can be helpful. Medication such as ibuprofen may be used as needed short term and prescription medication such as muscle relaxants may also be needed.

It is important to understand that the majority of TMD problems are muscular. As such, they are usually self-limiting and most would resolve without treatment. The therapies are intended to speed recovery, provide pain relief and prevent re-injury. For more serious conditions, treatment by a medical and/or dental specialist may be necessary.

Exercises to stretch jaw muscles

The purpose of jaw exercise is to stretch the jaw muscles, rest them and prevent them from going into spasm.  Jaw exercise is designed to stretch the jaw muscles similar to the way an athlete stretches muscles before and after physical activity.   

Behavior modification

People who have TMD often have habits that cause the muscles to become exhausted and lose their ability to elongate.

Common habits to avoid

Tooth contact - your teeth should only touch a total of 20-30 minutes per day and only during chewing and swallowing

Clenching your teeth

Leaning you chin into your hands

Biting on pens, pencils, straws or other objects

Biting on cheeks, lips or fingernails

Chewing on ice

Intentional clicking, popping or side to side shifting of the jaw

Wide yawns (limit opening by keeping your tongue against the roof of your mouth)

Work tendencies to avoid

Cradling the phone between you head and shoulder (use a headset)

Spending hours in front of a computer without a break (get up hourly and take a five minute break)

Using a laptop computer while sitting on a bed or laying on the floor

Carrying a heavy bag or knapsack

Diet Modification

During episodes of TMD, a soft diet allows sore muscles to rest.

Food to avoid

Hard foods - hard bread, bagels, pretzels, pizza crust, hard fruits and uncooked vegetables

Hard to chew foods - tough chewy meats and chewy candy

Foods that require wide opening - apples, large heroes and sandwiches

If you think you may have TMD, it is best to seek a consultation with a healthcare professional.

Dr. Frank R. Egan

www.TeethOnTheMove.com

Retainers

If it was up to me, nobody would have to wear retainers and their teeth would never move. Unfortunately, it’s not up to me and retainers are necessary to hold your teeth in their new positions after braces or Invisalign treatment. That’s because it may take the gums and bones around your teeth up to two years to adapt to the new positions of your teeth. Until they adapt, the gums and bones will tend to move the teeth back to their old positions. Fibers in the gums are like stretched and compressed springs that put pressure on the teeth. It can take 18-24 months for those fibers to be replaced with new fibers that fit the new positions of the teeth. Retainers also safeguard against new changes caused by pressure on the teeth due to jaw growth and developing third molars, aka wisdom teeth.

A special retention plan is made for each patient according to his or her needs and preferences. The most common protocol is to wear clear “invisible” retainers full-time for two months and then traditional wire and acrylic retainers at night-time only for at least two more years.

                  

We start with clear retainers because they are easy to speak with, easy to wear full-time and virtually “invisible”. The wire and acrylic retainers are very durable and can last may years or even decades! By making two sets of retainers, patients have a spare set for emergencies. Some patients require specially designed retainers to accommodate unique challenges such as missing teeth. Others prefer a “fixed” retainer that is bonded directly to the teeth.

                    

Retainers sometimes meet their end prematurely. Dogs are attracted to retainers because of the smell of saliva and it only takes one bite to destroy a retainer. Retainers that are wrapped in a tissue or napkin often end up in the dumpster! The hard plastic case that came with the retainer is the best place to store it.

By the time 2 years have passed and growth is complete and any third molars have either grown in or been removed, an orthodontic patient is just like someone who was lucky enough to have their teeth grow in straight and aligned in the first place. Unfortunately, even those people may experience tooth movement over their lifetimes. Our bodies can change over time and our teeth are no exception. These changes typically occur very slowly, but may become noticeable over many years. For this reason, I generally recommend wearing retainers indefinitely one or twice a week. When a revision is necessary to undo changes of any kind, Invisalign is usually the treatment of choice.

Dr. Frank Egan

www.TeethOnTheMove.com

Two Stage Orthodontic Treatment

For most of the last century, orthodontic treatment was not initiated until all of the “baby teeth” had fallen out. For most patients, this worked out fine with excellent final results. For some patients, however, results were less than satisfactory. These were patients with certain jaw problems, functional problems or problems that damaged or otherwise adversely affected the jaws or the permanent teeth.

We now know that these patients can be treated with the same excellent final results if treatment is done in two phases or stages. Generally, the first stage of treatment addresses the jaw problem, functional problem or problem adversely affecting the jaws or the permanent teeth. The second stage addresses the alignment and spacing of the teeth and the coordination of the upper and lower teeth.

Sometimes phase I treatment is initiated for elective, esthetic or cosmetic reasons. In these patients, the final results are the same, but some of the benefits of treatment can be enjoyed much sooner. The decision to start elective two phase treatment is often motivated by social factors. 

Compared to single stage treatment, the total treatment time may be more or the same and the cost is usually greater. This is more than made up for by the superior results of the orthodontic treatment.

For patients receiving phase I treatment, future treatment requirements are hard to predict, because they depend on growth and development that has yet to occur. Some patients will require no additional treatment. Most will require a second phase of treatment. Typically this involves full or partial braces and can last from as little as 6 to as many as 24 months or more. The specific treatment needs for your child can be determined by an orthodontic evaluation.

Dr. Frank R. Egan

www.TeethOnTheMove.com

Deep Bite

In orthodontics, the most eye-catching “before and after” photos are the severely crowded malocclusions (bad bite) with blocked out cuspids looking more like vampire fangs than human teeth. Most parents will notice the Class II malocclusion with the classic “buck teeth”. Crossbites are routinely diagnosed during dental checkups by dentists and hygienists. Often overlooked, however, is the deep overbite malocclusion. In the absence of crowding, the deep overbite maybe ignored. 

In a deep overbite malocclusion, the upper incisors cover the lower incisors excessively, sometimes completely, when the teeth are brought together to bite.

Unfortunately, deep overbite can be extremely destructive over time.  Typically by middle age, patients with untreated deep over bites have severely worn mandibular incisors (lower front teeth).  Many of these patients are bruxers (teeth grinders), but even in the absence of bruxing, the tooth wear can be devastating. Attempts at restoring the lost tooth structure end in frustration for the dentist and the patient because the restorations are subject to the same forces that ruined the natural teeth. TMJ dysfunction (jaw pain) is also statistically more likely in patients with deep overbites.

Prevention is the best treatment. In growing children, orthodontic treatment with braces or Invisalign can result in a stable occlusion with ideal overbite. One of the keys to a long–lasting result is correction of the angulation of the incisors. Typically, the upper incisors are tipped in with a deep overbite. Treatment may be initiated in younger patients if incisor impingement on the palate is causing pain. When achieved at an early age, however, overbite correction may be difficult to maintain during the loss of the remaining “baby” teeth. In these cases, retreatment may be necessary. Stable overbite correction can usually be achieved in adults as well. 

Each patient must be evaluated individually to consider any other orthodontic problems and to determine the best treatment. As with most orthodontic treatment, a timely evaluation can insure optimal treatment timing and the best possible result. 

Dr. Frank Egan

www.TeethOnTheMove.com

Open Bite

An open bite is usually described as vertical gap between the biting edges of the front teeth or the chewing surfaces of the back teeth. Open bites are often associated with jaw growth problems, but they are always associated with forward tongue position. Sometimes they are associated with thumb and finger habits.

It is normal for babies and very young children to suck fingers and pacifiers. It provides comfort and security. Most children stop sucking on fingers or pacifiers between two and four years of age and no harm is done to their teeth or jaws. If a child continues sucking beyond this age it may cause the upper front teeth to tip forward, the lower front teeth to tip back and the upper jaw to narrow. These changes in the teeth and jaws will cause abnormal tongue and lip function and development.

If sucking persists beyond four years of age, the child should be encouraged to stop the habit. A visit to the dentist or orthodontist can be a helpful way to explain why sucking is bad for the teeth and jaws. Once the child is interested in stopping, a stepwise approach is used until the habit is stopped. For very persistent habits, a special appliance may be needed. Soon after the sucking stops, the problems caused by it may begin to correct themselves. Depending on the child’s age and other conditions present, additional orthodontic treatment may be needed.

Forward tongue posture or “tongue thrust” is seen in open bite patients with or without thumb/finger habits. This too is normal in infants and is usually outgrown. Beyond this time, it can cause undesirable changes in the bite similar to those seen in thumbsuckers. In young children (8-10), forward tongue posture can be predictably corrected with appliance therapy. Myofunctional therapy, a behavioral approach to retraining the tongue, can be an extremely valuable adjunct to appliance therapy.

Posterior open bites are less common. When they do occur, they are often associated with baby molars that are ankylosed or fused to the bone. This becomes an even bigger issue when the permanent second premolars are missing. Posterior open bites are also associated with lateral tongue thrusts.

In patients with severe anterior “skeletal” open bite, orthodontics combined with jaw surgery may be the best treatment. A complete four dimensional evaluation is critical, since growth changes must be considered.

For patients with an open bite, early evaluation is critical in order to achieve the best results with the most conservative treatment.

Dr. Frank R. Egan

www.TeethOnTheMove.com

Expansion

Rapid Maxillary Expansion (RME) is the widening of the maxilla(upper jaw) by controlled stretching of the midpalatal suture (the soft connection between the two halves of the upper jaw), which is then returned to normal through the formation of new bone.

RME is needed when the maxilla is narrow compared to the mandible (lower jaw). Usually this presents as a posterior crossbite. Teeth are in crossbite when the lower teeth overlap the upper teeth. There are two important exceptions caused by tipping of the teeth: 1)  there is no crossbite present even though a RME is needed.  2) a crossbite is present even though RME is not indicated.

Tipping of the teeth can be evaluated clinically, but it is more precisely evaluated with digital study models that allow viewing and measuring in infinite ways. Once tipping has been taken into account, the amount of expansion needed can also be calculated by measuring the virtual study models.

Rapid Maxillary Expansion (RME) is the widening of the maxilla(upper jaw) by controlled stretching of the midpalatal suture (the soft connection between the two halves of the upper jaw), which is then returned to normal through the formation of new bone.

RME is needed when the maxilla is narrow compared to the mandible (lower jaw). Usually this presents as a posterior crossbite. Teeth are in crossbite when the lower teeth overlap the upper teeth. There are two important exceptions. 1) When the maxillary posteriors are tipped buccally and/or the mandibular posteriors are tipped lingually, a crossbite may not be present even though a TMMI exists and RME is indicated.  2) When the maxillary posteriors are tipped palatally and/or the mandibular posteriors are tipped buccally a crossbite may be present even though a TMMI does not exist and RME is not indicated.

Tipping of the teeth can be evaluated clinically, but it is more precisely evaluated with digital study models that allow viewing and measuring in infinite ways. Once tipping has been taken into account, the amount of expansion needed can also be calculated by measuring the virtual study models.

Several appliances are available for expansion.  The Rapid Palatal Expander (RPE) or “Hyrax” appliance is the most precise with the fewest potential complications. The RPE, when used correctly, is one of the most effective and predictable orthodontic appliances available. When fabricated properly it is also the appliance most easily tolerated by patients.

Once the first molars have grown in, distance between them doesn’t change.  Failure to expand where indicated will prevent correct occlusion and cause uneven jaw growth that can only be corrected with surgery as an adult. 

While expansion has the “bonus” effect of improving “crowding”, it should not be used as a treatment for crowding in the absence of a narrow upper jaw. This would result in the creation of a malocclusion.

Recently two other “bonus” benefits of RME have been identified.  In patients with conductive hearing loss, RME was 100% effective in improving hearing.  More puzzling was the effect on patients with nocturnal enuresis or “bedwetting”.  Patients who had RME were 50% more likely to exhibit improvement as compared to a control group.

While all patients with crossbite should have an orthodontic consultation, it is more prudent to for all children to have an orthodontic evaluation by 7 or 8 years of age.Several appliances are available for expansion.  The Rapid Palatal Expander (RPE) or “Hyrax” appliance is the appliance taht I prefer. It is the most precise with the fewest potential complications. The RPE, when used correctly, is one of the most effective and predictable orthodontic appliances available. When fabricated properly it is also the appliance most easily tolerated by patients.

Once the first molars have grown in, the distance between them doesn’t change.  Failure to expand where indicated will prevent correct occlusion and cause uneven jaw growth that can only be corrected with surgery as an adult. 

While expansion has the “bonus” effect of improving “crowding”, it should not be used as a treatment for crowding in the absence of a narrow upper jaw. This would result in the creation of a malocclusion.

Recently two other “bonus” benefits of RME have been identified.  In patients with conductive hearing loss, RME was 100% effective in improving hearing.  More puzzling was the effect on patients with nocturnal enuresis or “bedwetting”.  Patients who had RME were 50% more likely to exhibit improvement as compared to a control group.

While all patients with crossbite should have an orthodontic consultation, it is more prudent to for all children to have an orthodontic evaluation by 7 or 8 years of age.

Dr Frank R. Egan

www.TeethOnTheMove.com

First Orthodontic Checkup

I agree with the American Association of Orthodontists recommendation that all children have an orthodontic checkup no later than age 7. At this age, the permanent incisors(front teeth) have begun to erupt along with the first molars. Also, important facial features are beginning to take form. For a select few patients, treatment at this age will prevent the need for more invasive or unpredictable treatment in the future.

This is the best time to correct certain jaw growth problems including narrow maxilla or “upper jaw” (usually presenting as a posterior crossbite) and short maxilla (usually presenting as an anterior crossbite). It is also an excellent time to address open bites caused by habits such as thumbsucking and functional problems such as tongue-thrusting. Impaction (inability to erupt) of the permanent incisors and first molars should also be addressed at this time.

Other problems such as mandibular (lower jaw) deficiency and excess are usually not best addressed early. The same is true with spacing and crowding, except when social reasons are in play. Frequently incisor irregularity and incisor protrusion are disfiguring to the point that it would be cruel not to correct it early even though a good result could be achieved by starting later. This is determined in consultation with the child and parent.

It is important to remember that the first orthodontic examination usually does not result in immediate treatment. However, it does give parents greater peace of mind.  It also gives me information to use in the future when the patient is ready for treatment. I much prefer to have a record of three or four annual observations prior to evaluating a 12 year old for treatment rather than observations at one single point in time.

After the initial evaluation, I will monitor facial growth and development with periodic checkups while the permanent teeth erupt and the face and jaws continue to grow. During this period of “watchful waiting”, small problems in growth or development can be noticed and corrected before they become bigger problems.

For some patients, it is best to delay orthodontic treatment until all of the primary teeth are lost. With severe mandibular prognathism, it may even be best to wait until the jaws are finished growing.

By beginning treatment at the ideal time, the best results can be achieved in the least amount of time. 

Dr. Frank R. Egan

www.TeethOnTheMove.com