Raman Smiles Blog

Jaw bone connected to the head bone...head bone connected to the neck bone.....

Most people remember the children's song for teaching human skeletal bones that goes something like........

The foot bone connected to the leg bone, The leg bone connected to the knee bone, The knee bone connected to the thigh bone, The thigh bone connected to ...etc. Yet... dentists have traditionally looked at the manbible as though it operates in isolation.  Not much attention is paid to the posture of the neck or rest of the body.  In reality, the lower jaw and head works together as a 'functioning unit' when chewing and moving.  There have been a number of studies, especially in Physical Therapy literature, about the connection between jaw/ bite relation and neck posture. Poor neck posture has an important role in causation of headaches as well. Neuro Muscular dentists understand this connection and recognize the need for correcting neck posture along with jaw alignment for stability.  Hence the development of a new method for relaxing the neck muscles, discussed in an earlier post in this blog. The case study here is that of a physician who had suffered with headaches and jaw pain for many years.  Despite several therapy attempts including orthodontics twice, the problem was not solved.  Once we determined the NM bite position with the optimal jaw and neck position, a fixed orthotic was placed on his lower teeth. This is just 2 weeks later.  See the change for yourself.  The guest reports 90% improvement of the symptoms!  It is easy to see why! This image shows the "normal" alignment of the head.  The ear hole (External Auditory Meatus) should line up perpendicularly above the shoulder. This image is before and after orthotic on this guest. This improved jaw alignment is also conducive to improved Airway!  Sleep Breathing Disorders, including Sleep Apnea is a huge problem.  So correcting the jaw alignement often helps airway also. How about the change in profile?  Look at the lower third of the face.  It looks more proportionate...and younger! Correcting the jaw alignment has profound improving effects.  Jaw bone connected to the head bone....head bone connected to the neck bone...neck bone connected to the back bone......<G>.

Is it "Typical" TMJ? Progress (Continued)

K.H. is now wearing  a fixed orthotic to correctly align her lower jaw.

The progress report at 4 weeks of orthotic therapy showing 95% improvement and her comments are reproduced below.  This is a “Comfort Scale” instead of the usual “Pain Scale”.  So a 10 is perfect and 0 is worst.

Once the mandible is optimally aligned, the rest of the musculature adapt which it turn affects the mandibular position.  Fine tuning this over 3 months will get us ready of the Phase 2 Stabilization.  There are many options at that point.  Most likely in K.H.’s case, I will start with Neuromuscular Orthodontics and possibly finish with porcelain restorations.

This case illustrates three points. 

1.  Most TMD cases don’t present with “typical TMJ” symptoms. 

2.  Seemingly unrelated musculoskeletal symptoms and referred pain could be due to poor mandibular alignment

3.  With the Neuromuscular LVI protocol the “difficult” cases often resolve very quickly.

Is it "Typical" TMJ?

This is the story of K.H. who is a Kansas City, MO Police detective.  She was referred to us by her family dentist for evaluation.  K.H. is a very physically fit 30+ year old that had suffered with a variety of symptoms, none of which were “typical TMJ” symptoms.  Her primary complaint at her dentist’s office was ongoing tooth aches of unknown etiology.  The dentist had conscientiously checked the teeth repeatedly and found no cause for the pain.  To his credit, no treatment was provided to these teeth since he could not find an objective reason for the pain.  I have seen many cases where endodontic treatment and even extractions were done due to reported severe tooth pain.

Despite wearing the night guard that her dentist had made for her for 3 years, the symptoms were gradually worsening.  Our initial conversation brought to light many other symptoms such as ear pain, tinnitus, neck pain, shoulder pain, back pain, tingling down the arm, fatigue etc. that she has endured for many years.  K.H. had attributed much of this to her stressful job.  No one realized that there may be a connection to TMD.  Parts of her questionnaire are reproduced here.

  A battery of tests including detailed jaw computer scans, i-CAT CT scan imaging of the joints and other records revealed the discrepancy between the current occlusion and the optimal jaw alignment where the muscles would be unstrained.  K.H. now has a fixed LVI orthotic on her lower arch precisely made to align her mandible. 

Her progress will be reported on my next blog...entitled  "Is it "Typical" TMJ? Progress"

What is "typical TMJ"?

What is a typical “TMJ”?

It is common for a patient to come to our office who has had various pain or dysfunction symptoms for years.   Often, the patient has spent time and money unsuccessfully pursuing alternate therapies. At times, it is because the patient had been told that she does not have “TMJ” since it is not “typical”. 

So it begs the question what is a “typical TMJ”? 

What were we taught in dental school? 

1.  Clicking joints are fairly common and do not need any intervention.   

2.  “TMJ” is self limiting and “settles” down with time. 

3.  “TMJ” is primarily a “psycho social disorder” that is stress-induced. 

4.  Pain or discomfort in the TM joints or the joints locking open or closed constituted typical “TMJ” symptoms. 

The conservative therapy would be occlusal splints or bite guards along with soft diet and perhaps some muscle relaxing medications.  That would help many patients to get some symptom relief. If that does not help, then the next step is referral to a maxillo-facial surgeon for joint or jaw surgery.

If we look at this as a “joint” problem, then when joint symptoms (such as pain or strain in the TM Joints, clicking, popping or grinding of the TM joints) appear, it is “typical TMJ”.  Our dental education placed the emphasis on joint position when it comes to occlusion. 

Let me use an analogy to illustrate another way to look at this.

 

I am sure you can think of a door that does not quite shut right, where the door runs into the door jamb first.  How do you shut the door to keep the cold air out?  Some would answer, “slam it”, or “lift the door and push it” or some other answer.  If that is done thousands of times, what would happen to the door and jamb where they meet first?  Would there be damage to the paint or wood at this place?  What would happen to the hinges over time?  Would there be some strain at the hinges? They may creak, wear out or fall apart.  If that happens, would the solution be to just put a new hinge in?  If so, how long would it last, before the new hinges wear out as well?  Unless the underlying cause of the problem is addressed, it may not last.

The way the door swings freely before running into the jamb is analogous to the neuromuscular trajectory of the mandible.  The wear in the door (mandibular incisors) and door jamb (maxillary incisors) is something all of us commonly see.  Correcting the door and jamb so they align readily without straining the hinges, is analogous to a Neuromuscular bite correction. 

What are missing in this analogy are muscles and nerves.  The mandible (lower jaw) is much more complex than a hinged door.  It is controlled by the muscles of mastication which includes neck muscles. 

Nerves send the commands to the muscles and also sense their position or strain.  This could result in a number of symptoms including headaches, neck aches, tingling down the arms, ear pain, ear congestion, tinnitus, pain referred to teeth etc. 90% of ALL pain is muscular in origin.  But it still may not be “typical TMJ”.

One way to reduce the tension on the hinges is to put a door prop and not allow the door to close.  This is similar to a bite guard or an NTI device.  But doors are meant to close and teeth need to occlude- fit together - for chewing function. 

It is, of course, the patient that chooses whether to correct the jaw alignment or just lessen the strain on the masticatory system, or take medications to mask the syptoms or do nothing at all. 

As long as we have educated the patient about the consequences of each option including ‘doing nothing’, we can absolutely support any of the informed choices they make.  Ultimately the decison is theirs.