Journal of the Macomb Dental Society • Summer 2018 Journal of the Macomb Dental Society • Summer 201811

Jeffrey S. Haddad D.D.S. received his Bachelor of Arts degree in Psychology from the University of Michigan in 1997. He completed his dental education at the University of Michigan in 2001. Dr. Haddad is a Fellow of the Las Vegas Institute for Advanced Dental Studies. He is also an independent consultant reviewing new products and technology for the Dental Advisor. He lectures nationally on cosmetic dentistry, TMJ and sleep disorders, and practice management and marketing. Dr. Haddad maintains two dental practices in Rochester and Troy, Michigan. His Troy office, The Michigan Center for TMJ and Sleep Wellness, is solely devoted to treating TMJ and Sleep Disorders.

Like I discussed in the spring journal, the majority of TMJ patients are not as “obvious” as one would think. We are taught in dental school to look for clicking or popping in the temporomandibular joints and usually only recommend treatment if pain is associated when chewing. Sometimes if we intervene early enough, a properly made occlusal guard to be worn at night can give a patient the relief to combat muscular head and neck tension and keep more severe symptoms at bay. But when is a bite guard not enough? The fact is that a lot of patients are suffering with many more severe symptoms like headaches, migraines, neck pain, tinnitus (ear ringing), and even vertigo (dizziness) without their dentists even being aware of it. These TMJ patients don’t think of these symptoms as “dentally” related or think they could possibly be caused by a poor jaw posture, so they never mention it to their dentists. My goal is to share a case with you that demonstrates that not all TMJ patients are created equal, and that we, as practitioners, can do to better identify these patients so that we can find them the help they are looking for.

This healthy 24 year old female patient presented to me for treatment of her potential TMJ disorder (Figure 1). Despite the patient’s healthy dentition, attractive facial appearance, and age, she was suffering daily with the following symptoms:

•DailyHeadaches•Migraines1-2timesperweek•Sinuspressureandaching•Severeneckpain•ClickingandpoppingofleftandrightTMJ•Continualvertigoepisodes

Our diagnostic workup included a comprehensive exam, full-mouthseriesofx-rays,3DConeBeamCT,diagnosticphotographs, diagnostic impressions, and very detailed neuromuscular questionnaire. Based on the patient’s symptoms, lower midline shift to the left, and depressed curve of spee, we were suspecting a torqued mandibular

Looks can be Deceiving with TMJ Patients A Case Study by Jeffrey S. Haddad DDS

Clinical

Figure 1. Healthy 24 year old with severe TMJ Symptoms

Figure 2. Pathologic Condylar Position in Centric Occlusion

Journal of the Macomb Dental Society • Summer 2018 Journal of the Macomb Dental Society • Summer 2018

position compressing the condyles and resulting in muscular distress. This posteriorized position of both condyles was confirmed and evident in the3DConeBeamviewasseenin(Figure 2).There is also significant beaking of the left condyle, which demonstrates the bony changes it has undergone due to its destructive position and dysfunction. Like I discussed in the last journal edition, another measurement that is very helpful determining the stability of a bite is called the Shimbashinumber.ThismeasurementfromCEJtoCEJofthemaxillaryandmandibularcentralincisors in stable dentitions should be between 17-21mm.TheShimbashinumberwasestablishedto indicate an ideal relationship between the upper and lower jaws. When there is an optimal position of the lower jaw relative to the upper jaw, the muscles which are connected to them will also be at their optimal length and can function ideally.Anymeasurementlessthan17mmisconsidereda deficient vertical dimension. And although our patient does not appear to have a severe overbite, her Shimbashi measurementwasonly14.7mm.

How to determine a comfortable jaw positionIn order to predictably support the patient in a comfortable and asymptomatic jaw posture, we utilized computerized instrumentation with surface electromyography(EMG).TheK7instrumentationfromMyotronics allowed us to establish baseline readings of her habitual bite and indicate where her new jaw position needed to be according to physiologic rest position, proper pathofclosure,andtheEMGsofherjawmusculature.

Afterestablishingthebaseline,aMyomonitorulf-TENSunit (Myotronics) was used to pulse her muscles into a more relaxed, untorqued position to establish the physiologic rest position of her mandible. At this point, theproperpathofclosurewasestablishedusingtheCMSjaw-trackingcapabilitiesoftheK7withsimultaneousmonitoringofthepatient’sEMGs.Oncethisjawpositionwasdetermined,thisidealmaxillary-mandibularrelationship was registered with Futar rigid bite material.

After the bite registration was complete, the case was mounted to the new bite and an anatomically correct orthotic was fabricated to support this mandibular position (See Figure 3).Forphase1therapeutictreatmentin our TMJ cases, this mandibular repositioning orthotic

is fabricated for the patient to wear for a minimum of 4 months (a critical step to stabilize the patient and ensure theyaresymptom-freebeforemovingontoanyPhase2definitivetreatment).AlltreatmentperformedinPhase1orthotic therapy is completely reversible. The patient is given the opportunity to either continue with an orthotic as a nighttime device and limited daytime use as needed, or consider a permanent orthodontic or a restorative change in their dentition.

Letting the body guide orthotic adjustmentsOver the next four months, three coronoplasty adjustmentswereperformedwithTENSontheremovablemandibular orthotic. As the body unwinds, and the jaw musculature relaxes, the mandible is allowed to stabilize asinterferencesareremovedintheorthotic.TheK7instrumentation is used at all adjustment appointments to ensuretherewasnoincreaseinEMGswhenthepatientisinbitingintoherorthotic.Chewcyclerecordingswerealsomade to identify and remove any working or balancing interferences during function. Figure 4 shows the comparison of surface electromyography in the patient’s habitual occlusion versus occluding in her orthotic after adjustment 2. As can be seen, the patient’s musculature is significantly calmer in her orthotic position, resulting in continued reduction of her symptoms by 50% at month 2.

Final stabilization of the patientAt her fourth and final adjustment appointment, weutilizedTekScan(T-Scan)DigitalBiteAnalysisinstrumentation for micro adjustment of her orthotic.

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Figure 3. Anatomically Correct Mandibular Orthotic to Physiologic Jaw Posture

Journal of the Macomb Dental Society • Summer 2018 Journal of the Macomb Dental Society • Summer 2018

Studies show that a patient can detect occlusal interferences up to around 20 microns. Articulating paperislimitedtothe70-80micronlevelduetoitsthickness,butthe“T-Scan”showsprematuritiesthroughouttheocclusionuptothe3micronlevel.Thiscoronoplastyistrulyconsidered“micro-adjusting,”andmany times is essential for honing in a very difficult TMJ patient. See the series of scans in Figure 5 as the overall bite into the patient’s orthotic became more uniform and balanced.

After less than 5 months, the patient reports all symptoms reduced90-100%.HerTMJpoppingandclickingaregone while the orthotic is worn, she has no headaches or vertigo episodes, and she states that she “feels great.”

After resolution of symptoms to the patient’s satisfaction, verification of stability of path of closure (Figure 6) and calm facial musculature, the patient has completed this phase of treatment. At the end oforthotictherapy,wetakea3Dconebeamscanwith the patient in occlusion with her orthotic to compare final condylar position in the glenoid fossa to her habitual centric occlusion (Figure 7).With the orthotic in place, you can see how decompressed the condyles are allowing proper functional space for the articular disc and associated structures.

Knowing who we can helpProperidentificationofcandidatesforthistreatment and utilization of the latest dental technology and techniques, not only results in a successful outcome, it also minimizes patient time and maximizes patient results. This treatment is extremely predictable due to the objective datatheK7computerizedjawtrackingandsurface electromyography provides. It allows us to recognize patients that may not have the “standard” TMJ occlusal signs and head and neck characteristics we usually see in TMJ disorders. Although this patient appears to fall within the “normal limits” of a stable dentition and facial appearance, you can see the improvement in her profile, lower facial height, and head posture with her orthotic in. (Figure 8). Many patients do not realize what “healthy” is or what comfort feels like until we introduce them to a relaxed head

Clinical

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Figure 4. Calm Facial and Neck Musculature in Orthotic

Figure 5. Microadjusting of

orthotic with TekScan

Posteriorized path of closure in centric

occlusion

Physiologic path of closure in orthotic

Figure 6

Journal of the Macomb Dental Society • Summer 2018 Journal of the Macomb Dental Society • Summer 2018

and neck posture. They may be suffering from a myriad of symptoms that are a result of an undiagnosed TMJ disorder. Taking the time to ask the right questions, listen to our patients, and using diagnostic technologies available to us could help give these patients solutions for relief. ❖

Clinical

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Figure 8. Proper facial support and head posture with orthotic

With Orthotic Figure 7.

Centric Occlusion