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 treatmment 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, and 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.

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