TMD (TEMPOROMANDIBULAR JOINT DYSFUNCTION):

What is TMD (Temporomandibular Joint Dysfunction)

TMJ stands for the Temporomandibular Joint which is the joint which guides the movement of the jaw during opening, closing, talking and chewing.

TMD is the dysfunction or damage of the temporomandibular joint itself and/or its related muscles, nerves and occlusal structures (teeth) that support its movement resulting in a multitude of symptoms.

TMD or damage to these related TMJ structures can cause some or all of the symptoms listed below depending on the stage of progression:

• Pain in the joint
• Popping or Clicking in the joint
• Chronic Headaches
• Migraine Headaches
• Facial Pain
• Tooth Grinding
• Tooth Pain
• Facial Twitching
• Facial Neuralgia
• Ringing in the ears (tinnitus)
• Ear Pain
• Neck pain

Because of the complex interaction of the TMJ with the nerves and muscles of the head, neck and face, and the bite, proper diagnosis and treatment of a specific symptom can be complicated. Proper diagnosis and treatment requires a dentist with special training in the area of TMD and craniofacial pain.  Dr. Chomiak has undergone a mini-residency in TMD and Craniofacial Pain, completed extensive training in neuromuscular dentistry, JVA Interpretation, K-7 Interpretation, Therapeutic Botox Trigger Point Injections, and Roccobodo TMD manipulation and physical therapy.  Dr. Chomiak is a member of the American Academy of Craniofacial Pain.  His training places him as one of the leading specialists in Western Pennsylvania

What makes us unique in our ability to conservatively, painlessly, and successfully treat these TMD cases without surgery is our utilization of the latest diagnostic technology and our ability to offer a multitude of state of the art techniques including the combination of Neuromuscular and Occlusal (DTR) therapies.

Do I Have TMD?

Patients with TMJ problems can have one or many of the following symptoms as a result:

1. Clicking, popping or grating sounds when opening and closing the mouth
2. Locking of the jaw when opening
3. Limited jaw opening
4. Migraines, headaches, facial pain, or neck pain
5. Pain  or swelling around the joint near the front of the ear
6. Facial twitching, dizziness
7. Unexplained earaches (not related to infection), congestion, or ringing in the ears
8. Pain or tiredness in the jaw muscles
9. Difficulty swallowing
10. Poor forward posturing of the head
11. Grinding of the teeth, or sensitivity of the teeth
12. Blurring of the vision or pain behind the eyes
13. Problems with airway patency or sleep apnea
14. Neck or shoulder pain
15. Misdiagnosis of Fibromyalgia
16. Vertigo or dizziness

What Can Cause TMD?

The proper function of the temporomandibular joint requires a very complex balance of movement guided by the anatomy of the joint, disc position, chewing muscles, the head and neck muscles, and the teeth which guide the joint into its final position during closure.  Any disruption of this intricate system can cause pathologic changes in the joint, muscles, teeth, head and neck bringing about painful symptoms.  The dislocation of the disc with subsequent associated symptoms can be caused by:

1. Whiplash  from a car accident, a punch or blow to the jaw can cause rapid dislocation of the disc.
2. Poor alignment of the teeth causes micro trauma where the mandible is forced to move around malpositioned teeth in order to seat itself.  This causes a slow progressive dislocation of the disc.
3. Deep Dental Overbite the lower jaw is forced up and back compressing the nerves and blood vessels of the joint.
4. Lower Jaw Positioned too far back or Underdeveloped – posterior positioning of the mandible or underdevelopment of the mandible from birth can lead to a deep overbite trapping the mandible in a position too far back displacing the disc forward.
5. Neck injury to the cervical vertebrae or muscles of the neck, or bad posture can disrupt normal muscular function of the chewing muscles and the joint.
6. Airway problems as sleep apnea can cause anterior posturing of the head.  The head weighs 15lbs. For every inch your head is positioned forward, the weight to support it doubles, your shoulders roll forward and the jaw is pulled back changing the bite and the movement of the TMJ.
7. Missing teeth force the jaw to over close causing an upward and backward positioning of the jaw and loss of ligament stability and proper disc position.
8. Stress leads to clenching of the teeth which overloads the adaptive capabilities of the jaw creating strain and disruption of the joint

How Do We Correct TMJ Disorders?

The treatment is dependent on the specific nature of the disorder and the amount of time the patient has experienced the condition.  The neuromuscular dentist will perform a variety of tests to help understand the specific nature of each patient’s problems.  It is important to understand that this is an orthopedic correction that allows nerve decompression, healing and more normal function of the muscular and neurologic systems. This is not about a jaw or tooth problem alone, but rather a piece of a complex medical problem.  Dentists who use neuromuscular techniques are uniquely qualified to correct and work with both the craniomandibular disorders and the related medical issues.

There are two primary methods for treating TMJ disorders, Neuromuscular and DTR (Disclusion Time Reduction). Although both can be successful in treating TMD, both lack the ability to completely resolve symptoms in a percentage of their cases when applied alone. At Chomiak Dental we utilize a combination of both techniques based on the patient’s objective tests to eliminate or minimize symptoms in most all cases. Phase I Treatment usually involves the diagnosis and elimination of symptoms with neuromuscular and or DTR therapies. Phase II Treatment involves the permanent stabilization of the jaw with orthodontics, Invisalign or prosthetics to minimize any recurrence of symptoms throughout their life.

What Procedures and Therapies might be used in TMD Treatment:

Neuromuscular Mandibular Repositioning is the repositioning of the lower jaw to provide smooth normal anatomical movement. The position is found by testing muscle function with EMG’s, relaxing the muscles with Low Frequency Tensing and then aligning the mandible (lower jaw) in a position where the joint can move more freely and minimize the stress and tension on the muscles. In phase I the position is maintained with a Neuromuscular Orthotic (splint) during treatment until healing occurs. It is similar to aligning the wheels of a car. In both cases the alignment assures smooth movement to eliminate symptoms and prevent more damage to the tires, or in this case the TMJoint.

DTR (Disclusion Time Reduction): DTR is particularly important in the early to middle stages of TMJ Disorders where the mandibular position has not yet been affected by chronic damage to the joint, wear of the teeth, or excessive loss of teeth . In these cases where the vertical position of the mandible has been lost, neuromuscular repositioning may also be required.  DTR  is the computerized adjustment of the position and timing of the bite as it moves through the chewing cycle to eliminate chewing interferences of the teeth which can cause microtrauma to the joint, muscles and nerves. It can be thought of as the balancing of tires which eliminates vibration in the tires and in this case, microtrauma and damage to the joint.  At Chomiak Dental DTR is performed at the end of every TMJ treatment to assure long term stability of the joint.

J-5 Low Frequency Tensing to relieve muscle engrams and spasms

Neuromuscular Splint Therapy to maintain the proper mandibular position.

EMG guided Botox Injections to relieve stubborn muscle engrams and spasms when necessary.

Corticosteroid Injections to help relieve acute articular pain.

Invisalign the appropriate neuromuscular position of the mandible can be permanently stabilized by repositioning the teeth through Invisalign to maintain a healthy TMJ

Conventional Orthodontics can be used to permanently reposition the Mandible similar to Invisalign.

Conventional Dental Prosthodontics: can be utilized to permanently stabilize the mandibular position in some cases.

TMD Physical Therapy under the guidelines of M Rocobaddo.

Iontophoresis an electronic device which painlessly delivers anesthetics and cortico-steroids directly into the joint through the skin by means of electrodes providing immediate joint pain relief in severe acute cases.

Ultrasound and Cold Tissue Laser  Two devices which when applied topically to the temporomandibular joint, help to increase joint mobility and relieve muscle and joint pain by increasing blood flow to the area and reducing inflammation.

How Long Does Treatment Take ?

Treatment time varies depending on the severity of the case and amount of dysfunction.  The average time for TMD correction and elimination of symptoms is 4-6 months in better than 90% of the cases.  Healing the joint is like healing a broken leg.  Cooperation and compliance by the patient is very important in reducing treatment time.  Severe or very advanced cases can take up to a year and may never get complete pathologic correction.  Our goal in these cases is to get the patients functioning and out of pain.

Will The Symptoms Come Back?

There is no guarantee that a relapse won’t recur over time, particularly without proper permanent stabilization. Once the dysfunction is treated and neck and TMD stabilization has been established, it is important to support the muscles and joint in the new position to prevent future problems.  This is usually done through conventional orthodontics (braces)or Invisalign to stabilize this new position. In patients who have compromised or missing teeth, fixed prosthodontics (the replacement of teeth with crowns and bridges) is an alternative for stabilization.  Patients whose budget does not allow permanent stabilization with orthodontics or fixed prosthodontics can provide the same correction with a removable appliance similar to the orthotic worn which overlays the teeth like a partial denture to provide the newly supported position.  If the patient chooses not to go into phase II stabilization, mild cases can many times slowly be weaned from the appliance so it is worn only at night. More severe cases may require the patient to wear the orthotic permanently if they choose not to proceed with phase II permanent stabilization. Permanent stabilization is very important for lifetime success.

What Type of Testing Will I Need?

Dr. Chomiak provides the latest in technology and techniques to make your diagnosis and treatment as precise, simple and comfortable as possible.  Objective testing eliminates guesswork and allows a good prognosis as to the extent the problem can be treated. Our goal in every case is for permanent relief of symptoms.

Depending on the severity of the case, some of the technology that may be used in testing and diagnosis includes:

1. On site CT-scan to aid in diagnosing joint pathologies. This enables the doctor to examine not only the shape and pathology of the  temporomandibular joint, but the cervical vertebrae  of the neck for any rotations, or compressions which may be contributing to craniofacial pain or TMD pathology

   

2. K-7 NEUROMUSCULAR DIAGNOSTICS:
   EMG: evaluates related activity of the involved muscles for the head, neck and chewing muscles for locating muscle dystonia and painful trigger points.  This is good for tracking progress as it allows the patient and doctor to follow the progression of the muscles returning to their normal healthy status during treatment.
   JAW TRACKING: computerized magnetic jaw tracking which allows the doctor to examine the movement of the jaw in 3 dimensions over time.
   SONOGRAPHY OF THE TMJ: provides a fingerprint of the joint pathology and progression.
   

   

3. JVA – Joint Vibration Analysis  A quick initial Sonographic (sound detecting) device which provides a general diagnosis of a healthy or damaged joint.

   

4. TekScan: Evaluates occlusal (teeth) discrepancies affecting the joint

   

5. Itero Scanning: computerized scanning to produce digital models necessary to Utilize with the TEKScan for proper occlusal diagnosis.
   

   

6. Doppler Analysis – allows the practitioner and patient to listen to the joint sounds to differentiate joint pathology.
7. Myoguide – a portable EMG which measures muscle activity at specific painful trigger points with a very small painless needle similar to those used in acupuncture. It allows for delivery of drugs such as Botox directly into the area of increased muscle activity to provide relief of persistent muscular pain to aide in the reconditioning of the muscles.