I must agree with TMJDoc. Surgery and orthodontics are the last resorts you want to consider. As Dana821 mentioned if you you want to wear a splint for the rest of your life after those procedures and considering the possible nerve damages, maybe that would be a good solution. You have to understand that TMJ is just part of a triad system, muscles, joint and teeth. If those tree are not working in harmony it does not matter what technique you are using. Surgery only repositions the bone regardless of muscle fatigue and imbalance. Orthodontics (conventional that is) only moves teeth again regardless of muscles. Over the years I have encountered many post surgery/ortho patients who were worse off than before the procedure, some I could help with my technique the others unfortunately were beyond any help.
I know oral surgeons who used to perform these surgeries, but now they refer these patients to me because of the high failure rates.
You need to find a TMJ expert who knows how to handle the triads in consideration of the entire body posture. The key issue is to get the discs in a proper position and stabilize that position in a proper relationship of the lower jaw to the cranium and muscles at physiologic rest. Quite frankly those can not be achieved with orthodontics and orthognathic surgery!
Good luck, Dr. Mehregan
I would respectfully disagree with the concept that changing the bite, either with surgery or orthodontics will 'treat' the TMJ dysfunction. The bite is not the cause, therefore not the solution. Since I've practiced orthodontics as well for 30 yrs, you may understand that I have some experience in this area. The pathology that needs treatment is within the TMjoint itself. Orthotics create a new relationship within the joint. The key is a correct relationship of the disc, mandibular condyle, and the temporal fossa. I don't care what technique is used to accomplish this as long as the correct assessment and treatment goals are followed. This is why the experience of the clinician, not his/her treatment technique is important. Surgery of the TMjoint is only needed when all conservative treatment options have failed. Surgery is far less successful than the oral surgeons state--just look up the studies. I've treated numerous surgery failures successfully with conservative techniques because the initial clinicians lacked the expertise to accomplish it the first time. Obviously all of this is far to detailed to explain in this forum. No disrespect intendend, but Dana821's assessment of philosphies, orthognathic surgery and sequence of treatment are not completely accurate. Alignment of the teeth and the correct relationships of the TMjoint are two seperate, but related issues. Doing one of those only will not solve the issue in most cases--and knowing that is the key to long term stability for the patient. I'm never trying to insult anyone, but I think it would be unfortunate if you sought treatment as extensive as orthodontics and orthognathic surgery hoping to solve a TMjoint issue without treating the joint first.( I've seen that fail too many times). After treating the TMjoint pathology other treatment may not be necessary at that point--each patient is different and unique. TMJDoc
I'm also a TMJ sufferer, unfortunately there are many ways to treat your symptoms but from what I've read so far your physicians are treating only the symptoms and not the cause. You should consult with an Orthognathic surgeon and with this type of surgery they reposition the jaw(s) so that the teeth then come together, a cross bite can be fixed in this way. Typically this is done in conjuction with and Orthodontist and usually will take up to two years from beginning to end. The long term side affect of this surgery is that you could have permanent nerve damage, this is not too awful but for some it's a life style change. Please read more about Orthognathic surgery and find not only a OMFS who routinely performs these surgeries but also find out who the Orthodontist is so they can work together to reposition the jaw(s) properly. Once they reposition them and treatment is complete you may still need to wear an orthotic appliance at night, some people benefit from an daytime appliance as well. TMJ/D is a complicated issue to deal with, but remember there is always hope. Also take into account that there are several types of "philosophies" on how best to treat it. Ask your doctor what his/her philosophy is on treatment and research this carefully before choosing this provider. Two main philosophies are "Centric Relation" and Las Vegas Institute or LVI philosophies. They differ quite a bit so research and ask a lot of questions. One thing to avoid is multiple stages of treatment especially if the provider recommends orthotics, then orthodontics and then crowning all your teeth to compensate for the new bite pattern. This is a big red flag. Please consider ORTHOGNATHIC SURGERY this would end the cross bite issues and possibly your pain. Good luck! Dana from Florida
hi - I do think that your jaw is causing the problem but it puts pressure on the disks in your neck and causes the nerves to be sensitive. An xray doesnt show the nerves you should have an mri to see which nerves are being compressed by the disks or facet joints and then a pain mgt specialist can do a test where they numb particular joints in your neck and then you tell them if your pain subsides, if your pain eases with the numbing then you know which nerves and joints are the problem, then you can (burn) the nerve with an rf procedure ( painless) it stops the pain signal this does have to be repeated about a year later because the nerve grows back and then it should be permanent. AnywaY its just something to try, if the numbing doesnt releive any pain then you know your neck isnt the problem. i just think that if your in so much pain there has to be alot of nerves responsible. the chiropractor helped me a little too its just about maintenance. what is NM that the tmjdoc is refering. its all about getting the right doctor you should definitely try that doctor Liem good luck!
Hi, Cervical spine and the mandible function together and become dysfunctional together as well. Your symptoms are not unusual, complex perhaps, but not unusual to an experienced TMJ specialist. That is what you need, not a technique, but a thourough diagnosis by a competent specialist. There are many ways to treat and all work in the right situation. Dr. Edmumd Liem is near Edmonton. He is experienced and quite competent, and yes, can do NM for those who are enamored with that technique. You can find him by going to American Academy of Craniofacial Pain website and use referral area.
For the record, top3dentists is a private organization that dentists are invited to join. It does not mean it's bad, just too self promoting for my comfort. American Academy of Orofacial Pain and American Academy of Craniofacial Pain are the two largest organizations that train and 'certify' dentists so the public can know that they have had the necessary training and examination to be called experts. They do not subscribe to any one treatment philosophy or technique, but rather encompass all evidence based treatment, of which NM is just one. I sincerely hope you can find the help you need. I've treated thousands like you, so I know it can be done--wish we could do this over the internet, but each individual has something unique that only experience can help diagnose and guide treatment for. Hope you can find that help. TMJDoc
I have received only an Xray of the head and neck last year, and it showed that my jaw is lying 2cm over to the right than it should be to be 'equal' on both sides (I'm not sure if perfection is a goal or not, right??) My Chiropractor ordered it and did manipulations try to equal things out. I forget the tecnique, and honestly, I'm not entirely sure what it did. All I know is tat noting else was working and I gave it a try because I trust my Chiropractor a great deal. The active release and this other technique was extremely painful to my head and neck and left me unable to drive home after quite a few visits. After 2.5 weeks of what I call willing torture, I had to ask not to do it anymore--and which he agreed as normally some form or progress will start after 2 weeks. Even HE believes I may need surgery and he is a man of natural means.
What is the technique that someone in a pain specialty can perform? and what is RF?
My neck pain didn't really exist until my jaw problems, but I wouldn't rule it out. I would be still highly surprised if it isn't my crossbite causing this, but since nothing has helped me, even with all the skepticism that is isnt the bite, it still remains plausible to me. *sigh*
Thanks for your reply!
Hi dana- you should have an mri of your neck to see if your cervical spine is a problem, sometimes facet joints can send pain signals up the back of the head and around the ear and add to the tmj problem. There are testing and rf procedures that a pain management specialist can do to facet joints that may stop some pain.
I just send you the name of few NM dentists in Canada. Hope you get them
It's well known that if a treatment modality causes more pain when managing chronic pain,the intervened treatment is probably causing more injury, the treatment should be discontinued. The traditional concept"no pain, no gain." is invalid now.
Your descriptions suggest presence of internal derangement of tmj and/or capulitis or synovitis.In your age, disc perforation is an unlikely occurence.In stead, disc displacement with or without reduction, or anchored disc phenomenon, or retrodiscitis may be present. If there is infammation pathology involving tmj, arthrocentesis generally yields promising result. When internal derangement is present, tmj is probably not stable, which results in unstable occlusion.However, occlusion is still within manageble condition. It probably needs more frequent adjustment of occlusal appliance. If an occlusal appliance is well fabricated, patients tend to respond with masseter relaxation almost immediately, no matter what class of malocclusion. In addtion, patients always report good quality restorative sleep. We have learnt that sleep is intimatety related to chronic pain. Finally, breathing or respiration contributes to chronic pain significantly. If you have faulty respiration,i.e, paradoxical respiration,it must be corrected.
In my experience, occlusal appliance therapy is highly effective for chronic craniocervicomandibular pain, but it's not panacea. Hope you can find a competent tmj specialist to help you relieve the suffering.
I appreciate your feedback.
As I'm in Canada, the top3dentists does not work for me as postal codes do not work, only zip. I'm not sure if I'd be willing to travel to the states quite yet for my mouth!
I'll look into neuromuscular dentistry and see if I can find anyone in the area that specializes in that.
Thanks again! I guess if it wasn't complex, less people would suffer from it, right?
My apologies to the forum, I was not aware of that. But you can find my and other TMD experts information by going to www.top3dentists.com and look under Neuromuscular Dentist or Orthodontist.
I read your post again. One of the biggest problems I have found treating patients with TMD issues is the type of "TMJ appliance" that was prescribed. The lower jaw is the movable jaw that should be related physiologically to the upper jaw and ultimately to the cranium and not vice verse. And I totally agree with Dr. scottma's comments. Treating TMJ issues does not stop at the jaw level it also should encompass the entire body as it is affecting it.
As a Neuromuscular dentist I do too use a splint but it is made by physiologically relating the mandible to the upper jaw and skull. It is a long procedure that unfortunately this forum does not suffice for me to explain this complex treatment.
There are a lot of philosophies out there how to treat TMJ disorders and all have their positives and negatives. I believe it comes down to the doctors ability to recognize the multidisciplinary issues associated with a TMD patients and be able to address all of those and not just the joints and jaw.
Thanks for you reply,
I've already had a multidisciplinary approach through both my TMJ specialist and through his TMD clinic at a different time this fall. The only new suggestions the clinic had for me was to get an audiologist (which after I asked how that would help, they said it wouldn't), and pushing an anti-depressant. I would be willing to see a third specialist, though, but I know in an actual clinic setting, I've been to the only one of its kind in my city (I'm in Edmonton, Canada)
The splint they made me was upper, and the last time they adjusted it, they said it was nearly shaved down to nothing. I would be willing to try it again, but it was so painful I can't imagine how unproductive I will be during that time-- and not to be a pessimist; I just didn't sleep with it in, with 10+/10 pain. I was basically told by a couple of people (one a dentist, one a TMJ specialist) that because my bite is not in its proper spot to begin with, an occlusal splint won't help.--- is this totally inaccurate?
I'm having a really bad week. Thanks again for your feedback,
Chronic pain is a complexed issue. It's not always caused or associated with structural deformity. However, your descriptions appear to suggest disc diplacement and perforation. Hyperacusis and sensation of fullness generally respond to occlusal appliance therapy very well in my practice. If your pain symptom gets worse after splint insertion, the splint is probably not fabricated properly.Hope Dr.Mehregan can help you find a competent tmj specialist. In addition to tmj therapy,multidiscipline management is probably needed.
Hi Dr. Mehregan, thank you for your quick response.
The forum starred out your email address, and I was unable to locate your email address from your personal page. Is there another way I can contact you?
For now, these are the treatments I've had:
- Upper splint which was adjusted by two different TMD specialists-- only causing more pain than any relief (my pain is more at night, and better in the morning on most days) and I've never had markings on my splint
-Seen three different physiotherapists: heat, light touch, craniosacral therapy and acupuncture, as well as exercise therapy
-Monthly massage therapy of the entire body
-Chiropractic treatment- to adjust the atlas and active release to head/neck/shoulders (after other treatment was not responding)
-Psychologist: for cognitive therapy, sleep aid
-Chronic pain specialist
-TMD multidisciplinary clinic
I've been told that if I'm not willing to use a splint there is not much help for me, but after using the splint twice for 3-5 months each time, and the pain being excruciating, I cannot let myself be in that much pain and continue on with my life going to work (I was off work both times and unable to function well). I cannot have my teeth cleaned without excruciating pain for the next week, which frequently happens with massage therapy to the neck as well. People seem to want to throw antidepressants at me, when I feel that frustration is a valid feeling through all of this, and as a nurse, I feel is not an issue at this time. I am so young and I feel that I'm wasting my glory days in pain and isolating myself from things that aggrivate my issues. My left ear easily gets sensory overload to touch and sound, I'm tired all the time, and my life is run around when I take my medications and things that will bother my ear. Even a movie in theater is generally too loud for my ear. Its just really frustrating, and I would rather take a change to have an increase in pain and have a small change of decreasing it, and having a better bite, which I know is VERY off from where it should be. My mandible is not stable, and night it falls back in my head and feels more comfortable, whereas motions pushing it forward (such as kissing) becomes very painful. My boyfriend is extremely patient with me, but I know its testing our relationship.
The only other therapy that I've heard of that I haven't tried is (I think) called hydrotherapy, where a dextrose/saline solution is injected into the sore sites and encourages movement of inflammatory markers, etc, but there are not a lot of people that perform this in my city (2, actually) and I cannot find a lot of research on it, leaving me skeptical. I do not take lightly to injecting needles into my sore areas, knowing how I react to touch.
I have had a CT tomograph, and an MRI, which shows that I do not have any degenerative bone disease, but my capsules are crumpled and perforated (I do believe those are the words they used), with capsulitis, and something with the ant.translation, which I can't remember at the moment.
Thank you for your help. Even if you are unable to comment, it feels good to rant about it either way :)
PS: if you could type out what was bleeped out in the last message from your email, and write it consecutively without any dots or at signs, I'll privately message you. Hopefully that can break the system!
I have treated several patients with cross bite and TMD issues. As far as there is no correlation between cross bite and TMJ is far from truth. I would not suggest surgery at this point. I need to know more about the TMJ treatments you had so far. If you would like e-mail me privately at drramin.***@****. Maybe I can help you or find someone who is qualified to do so.