With temporomandibular disorders, pain is often what causes the patient to seek treatment and their first desire is usually to eliminate the symptoms. However, the symptoms are not the disorder, they are an expression of the disorder. In nearly all cases, other than acute trauma, dysfunction of the masticatory system precedes the pain. The word “dysfunction” simply means abnormal function and can occur in the muscles of mastication and/or in the temporomandibular joints.
Reducing or eliminating the patient’s subjective awareness of pain does not assure that the associated dysfunction is also resolved. There are a variety of methods for relieving symptoms on a short-term basis, but if the dysfunction that is the source of, and that accompanies, the pain is not addressed in a definitive manner, the patient will be left in a vulnerable condition, predisposed to having the symptoms return. Temporomandibular disorders have a reputation for recurring chronically and if the objective of treatment is only to treat the pain and does not include definitive treatment of the dysfunction, a chronic recurrence of the symptoms should not be surprising.
In our office, treatment of TMDs for most patients is based on a true “rehabilitation” model; i.e., to address not just the presenting symptoms, but to restore normal physiologic function (eliminate dysfunction), or as near to that as is feasible in the individual case. Our objective is to ultimately achieve a definitive level of stability within the masticatory system through the identification and elimination of probable predisposing and perpetuating factors. This approach has proven to be the most effective method of minimizing the likelihood of a return of the patient’s original symptom complex. To accomplish physiologic homeostasis and true rehabilitation within the masticatory system, a two-phase approach is usually employed.
• Phase I
The treatment objectives of Phase I ;
• Substantial reduction or elimination of the presenting symptoms.
• Re-establishment of normal physiologic function in the jaw mechanism (muscles and joints), or as near to that as is possible in the individual case.
•Achieving a stable and pain-free position of the temporomandibular joints within their fossae. This achieves an anatomic and functional physiologic relationship between the maxillary and mandibular arches.
• To instruct the patient regarding activities that may help in achieving and maintaining these goals and minimizing risks for further problems in the future.
In Phase I, every effort is made to achieve these objectives by non-invasive and largely reversible treatment protocols. However, if the temporomandibular joints had not previously been seated in their fossae and/or were painful to loading or to capsular palpation, treatment will often result in an appropriate change in condylar position as they become seated in their fossae. This change in condylar position will be reflected as a change in the dental occlusion.
Although such a change is entirely reversible, if the therapeutic change of joint position has lead to a reduction in pain from within the joints, this change must be seen as desirable and the dental occlusal issues may need to be addressed following Phase I to integrate the occlusion with the therapeutically-achieved new joint position. If the dental occlusion is not corrected, the likelihood that the patient will return to their original bite is quite high and this would likely lead to a return of the pain from the temporomandibular joints.
The objectives of Phase I are typically achieved by the use of a hard, full-arch coverage occlusal appliance. There are several types of these appliances and, although a standard “stabilization” appliance is used most frequently, there can be indications to select a different design. There is also an occasional need to use two appliances; one for day-time wear and another to be worn during sleep.
• Mantras for Dentistry
• The Jaw Always Closes Where the Teeth Fit Together Best
• This Closure Position Always Determines the Condylar Position
One of the primary purposes of an occlusal appliance is to mask any potentially detrimental factors in the patient’s own native bite and to create, temporarily on plastic, a new stable but “neutral” bite that will provide occlusal stability but will also permit changes in joint position if that should be necessary. With the dental occlusion “neutralized” as an influencing factor in the jaw closure position (condylar position), now the muscles of mastication are given permission to determine the optimum jaw position. The result is that the force vector of the elevator muscles will typically seat the condyles into the fossae. This will achieve the most stable joint position and, hopefully, a position that will allow the joints to be loaded without pain. This change in condylar position may also improve the intracapsular mechanics of joint function.
To facilitate a reduction of symptoms and the restoration of normal physiologic function, as an adjunct to appliance therapy, we frequently refer our patients for physical therapy. We work closely with excellent therapists who have demonstrated a high level of knowledge, skill, and experience in the management of problems within the jaw system. Often the cervical region and body posture can also be involved. When indicated, as determined by the physical therapist’s assessment, these other issues are also addressed in conjunction with the issues related to the jaw. The use of appropriate occlusal appliance therapy combined with skillful physical therapy is a potent combination for not only reducing symptoms, but improving function and to facilitate true rehabilitation.
Only when a satisfactory outcome has been achieved in Phase I, based on the previously-stated objectives, are Phase II treatment objectives consideration appropriate. The broad objective of Phase II treatment, when indicated, is to create and environment where the fit of the teeth supports the therapeutically-achieved functional joint position.
• Phase II
When appropriate, Phase II will involve some form of occlusal treatment. Not every patient requires Phase II therapy and it is not considered unless the objectives of Phase I have been achieved to a substantial degree. The rationale for doing Phase II definitive correction of the dental occlusion is to minimize the likelihood that the patient will have further problems in the future as a result of an unstable and/or malfunctional dental occlusion. The objectives of Phase II therapy, when indicated, are;
• To identify and eliminate, where possible, factors that may have contributed to and/or may have the potential to perpetuate or contribute to the return of masticatory dysfunction and symptoms.
• To definitively stabilize the therapeutically-determined functional relationship between the upper and lower jaws as determined by the condylar position.
• To instruct the patient regarding activities that may help in avoiding future problems.
• The Diagnostic Value of Mounted Dental Models
To determine what, if any, occlusal correction may be appropriate following Phase I therapy, our standard procedure is to do mounted diagnostic dental models of the patient’s teeth. These models are mounted to the corrected joint position and allows us to accurately determine the nature and extent of any needed occlusal correction.
If Phase I therapy has resulted in a dental occlusal change, my preference is to correct the dental occlusion by the simplest means possible. If an equilibration and some occlusal bonding will achieve a stable and functional result, that is what we would elect to do. If the patient requires orthodontic treatment, I work closely with a very short list of selected orthodontists to assure that the desired occlusal outcome is achieved. On rare occasions restorative dentistry may be indicated, sometimes in conjunction with equilibration and/or orthodontic treatment.
In an older patient, even when occlusal correction might otherwise be justified, we may elect to work with the patient, using their occlusal appliance as a “crutch” to help them remain symptom-free and functional. This may not always be a viable option but is certainly considered when contemplating possible Phase II options in olders patients.
• The Role of Dental Occlusion — Is There a Causative Relationship?
When Phase I therapy has resulted in a change in the dental occlusal relationships, the question sometimes arises as to whether the dental occlusion was the cause or a major contributor to the onset of the dysfunction and pain. This question has been the source of a decades-long debate within the dental profession and there are strong opinions on both sides of the question. An honest, unbiased consideration of the available scientific literature does not provide a clear answer to this question, regardless of which side of the debate one is on. However, at the end of Phase I, having achieved the goals that were defined previously, my concern is not nearly so much what caused the problem. Causation is a complicated issue with regard to TMDs. There is frequently no single cause and often multiple contributors may have played a role in an insidious onset.
My interest, following successful Phase I treatment, is more focused on what may be necessary to minimize the likelihood that the problem will return. It is difficult to ignore the fact that, with the use of the occlusal appliance, by improving occlusal stability and allowing a change in the condylar position, a stable, symptom-free, beneficial outcome has been produced. Once such a change has been achieved, when necessary, it is possible to maintain a patient on an appliance for prolonged periods of time without a return of symptoms, with only occasional minor maintenance of the appliance. This has been borne out in numerous patients over a long career when, for various reasons, definitive stabilization of the dental occlusion was not feasible. This fact, alone, speaks as graphic testimony to the importance of dental occlusion in achieving and maintaining physiologic integration of the masticatory triad, the joints, the muscles, and the teeth.
To reiterate what was stated at the beginning, TMDs are not simply a group of symptoms. The symptoms are not the disorder — they are an expression of the disorder. The disorder is the dysfunction within the masticatory system that has resulted in the symptoms. If the dysfunction can be definitively addressed in Phase I, if the symptoms can be significantly reduced or eliminated, and if something close to normal function can be achieved, it seems only logical to stabilize the outcome of Phase I therapy by occlusal treatment in Phase II, to minimize the likelihood of further dysfunction in the future.
