Pain

Without a diagnosis, treatment is symptomatic and as long as the underlying cause remains untreated, the patient’s general ability to cope and function becomes further undermined. In order to understand the underlying structural problems with the mouth and jaw, it is first necessary to understand normal function. With knowledge of ideal balance and function (the correct condyle/fossa/disc relationships, optimal muscle function and balanced occlusion), the forms of dysfunction can be better understood. Essentially, the chewing mechanism involves the interplay between jaws, joints, muscles and teeth. Change in one factor affects the rest. The body’s adaptive capacity is affected by numerous general health and lifestyle factors, stress in the form of muscle tension causing grinding and clenching being the most common. Stress is normal but it is the body’s failure to adapt that leads to dysfunction, together with stress levels. Many aggravating factors can be eliminated and reduced to enable compromised adaptation and hence, symptoms of pain and discomfort. Symptoms can range from low-grade nagging pain in the jaws, temples, neck, shoulders and low back to excruciating and debilitating agony. However, once the adaptive capacity is exceeded, the condition of the patient deteriorates. There is a place for multidisciplinary treatment, particularly in the acute phases.

Large-scale research from Japan suggests that more than 70% of children requiring orthodontic treatment had pre-existing internal derangements within their temporomandibular joints. Heated debates have been ongoing for many years as to whether malocclusion causes internal derangements or vice versa. The extent of the problem of TMD is becoming more generally realised within the profession, especially with the established importance of the imaging of internal derangements with MRI. Guidelines for orthodontists now require an examination of the functioning of the joints and recognition of the early signs of dysfunction. Treating malocclusion without correcting the underlying dysfunction within the joints will mean that the dental occlusion will ‘lock in’ the deranged joints, which may condemn the patient to TMD later in life. It is, of course, something of a lottery, as some patients can go through life having adapted to the dysfunction and never suffer any symptoms.

Dental surgeons who work with whole body physical therapists such as osteopaths can appreciate the complexity of the compensation patterns the skull, neck and rest of the body have to make, in order to adapt to the underlying structural malfunction of the jaw joints.

Diagnosis and treatment of chronic internal derangements of the joints frequently requires the combined efforts of several practitioners in order to stabilise the joints, reduce muscle hypertension and enable the rest of the body to ‘decompensate’. Since many chronic patients have neck, shoulder and low back problems, supportive treatment is required to help achieve stable results. In the case of our patient, the history of pain and clicking of the joints, a feeling of a tight band like headache, neck, shoulder pain and stiffness, loss of energy, depression and inability to work effectively was bringing on a mental and physical breakdown.

The dentition is a class I, post-orthodontic case, four 1st premolar extractions, with range of motion 50mm, excursions 7mm to the right and 12mm to the left. On opening slowly, there was a palpable click on the left and the midline shifted to the right before passing the midline to straighten up; beyond 20mm opening, the path was straight and smooth.

On protrusion to an edge-to-edge incisor relationship, the path of opening was straight and smooth without palpable disc displacement.
From this observation alone and prior to the physical examination, a clinical impression is made of reducing bilateral disc displacement; the first palpable click on the left indicating an earlier and hence possibly less severe displacement? than the right side. The fact that the displacements do not occur on protrusion would indicate that the condition is amenable to anterior jaw repositioning. The clinical impression should be supported by the findings of the physical examination. MRIs and Electromyographic muscle activity measurements (EMG) should support the diagnosis and any necessary second opinion received prior to commencing treatment. The diagnosis was confirmed following successful jaw stabilisation and disappearance of all symptoms.

Knowing the well-documented effects of disc displacement, the question arises – What caused it in the first place? The orthodontic treatment cannot be blamed, as it was the standard of care at the time and practitioners were not required to carry out a full TMJ examination prior to treatment. This patient may well have been in the 70% group with internal derangements prior to orthodontic treatment. It is necessary for the dental orthopaedic practitioner to work with whole body physical therapists to ensure the body posture is strain free, balanced and fully functional. Whole body osteopaths, chiropractors and physical therapists with an understanding of the importance of jaw stability form an increasingly important role dependent on the severity of the case.

It is clear that internal derangements are more common than formerly realised and can create symptoms later in life.
The chicken and egg situation as to whether the malocclusion causes the internal derangement or vice versa could be more clearly clarified if the early signs of dysfunction are recognised prior to treating the malocclusion. In this way, the lower jaw position can be first established in its most fully functional relationship with the maxilla, prior to starting treatment. By establishing healthy function first, the teeth can be moved into the best positions in order to support the joints and muscles.
Since the early signs of dysfunction can usually be readily recognised and treated, establishing normal healthy function should be the first requirement of any treatment plan.
1) Establish correct condyle/disc/fossa relationship.
2) Establish optimal relationship of maxilla/mandible.
3) Move teeth and alveolar bone, in order to stimulate development of arches to accommodate teeth.
4) Rearrange the teeth to support the maxilla/mandibular relationship – Orthodontics.

Orthodontics is a finishing procedure involving realignment of the teeth within the presenting arch and jaw relationships. By conforming the teeth to a compromised skeletal relationship, the underlying cause for the malocclusion remains undiagnosed, unrecognised and ignored by the majority. In truth, the underlying skeletal relationship of the skull bones affects jaw relationships. The occiput and sphenoid, forming a large part of the cranial base, are liable to distortion, particularly during the birthing process and from knocks and falls during development.

The position and relationship of the sphenoid bone, in particular, affects the maxilla, whilst the occiput via the temporal bones relate to the mandible at the temporomandibular joint. The close association between cranial bone imbalance and compromised jaw relationships means that dental orthopaedics needs to be carried out with cranial work. The old maxim – as above so below applies to the head and body, so balance and harmony in the cranium has to be reflected in the body and vice versa.