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 as below - applies to the head and body, so balance and harmony in the cranium has to be reflected in the body and vice versa. s

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