Establish Stable Joint Relations By Brock Rondeau, DDS, IBO

The American Dental Association made the statement in 1990 that dentists have the prime responsibility in diagnosing and treating TMD (temporomandibular dysfunction) to the limit of their ability. I totally agree that it is the dental profession’s responsibility to help our patients who suffer from this disorder but I am frustrated with the lack of knowledge we received in dental school. Most of us were taught that the correct position of the condyle in the fossa was up and back and that flat plane maxillary splints and occlusal adjustments would solve most problems. This information is totally misleading and indeed false.

The key to any successful treatment is diagnosis. One of the most important roles a dentist can play is to determine if the patient is suffering from extra capsular problems or intra capsular problems. Patients with extra capsular or muscle related problems usually have the condyle in a physiologically correct position in the glenoid fossa (downward and forward). If the condyle-disc relationship is normal, then there is no clicking or crepitus. Extra capsular problems are mainly caused by occlusal interferences in lateral or protrusive movements or parafunctional habits such as clenching or grinding. To solve this problem, an upper appliance should be worn at night with an anterior biteplate with the only contact during swallowing being the lower central and lateral incisors. When the posterior teeth do not touch, the temporalis and masseter muscles are unable to contract excessively and this eliminates the parafunctional habits such as clenching and grinding as well as the resultant headaches.

With intra capsular problems, the disc is usually anteriorly or antero-medially displaced in relation to the condyle which is usually posteriorly displaced. There are five stages of internal derangement (intra capsular) ranging from clicking, jaw locking and eventually to advanced degenerative osteoarthritis. Since internal derangements can worsen over time, it is essential that treatment be initiated as early as possible. The treatment of choice would be to use some form of functional jaw orthopedic appliance or an anterior repositioning splint to try and recapture the displaced disc.

I believe it is time for the dental profession to get serious about treating patients with TMJ problems. Patients with unstable temporomandibular relationships can suffer from many symptoms including headaches, neck aches, pain behind the eyes, stuffiness or ringing in the ears, difficulty swallowing, ear pain, fainting and dizziness. If the patient’s symptoms are being caused by parafunctional habits such as clenching and grinding or has an anteriorly displaced disc, only the members of the dental profession who have been trained to use the various splints and functional jaw orthopedic appliances can treat these patients successfully.

I firmly believe the dental schools have got to change the curriculum so graduating dentists will be competent to treat these patients. The other problem is that if the dentist does not properly diagnose and treat extra capsular and intra capsular problems, the patient suffers needlessly for many years or, in fact, could get worse if the restorative or prosthetic procedures performed actually aggravate an existing TM dysfunction.

The dental profession has made significant strides in the last several years at making patients more attractive by helping to create beautiful smiles with veneers, crowns and implants. Teeth whitening has also helped give patients a whiter smile and improved self-esteem. Now the time has come to make our patients healthier by diagnosing and treating existing TMJ problems prior to any form of dental treatment.

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“I firmly believe dental schools must change
the curriculum so graduating dentists will be
competent to treat these patients.”

Brock Rondeau, DDS, IBO

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Most dentists are taught in dental school that the correct position of the condyle in the fossa is upwards and backwards. A careful review of the anatomy of the TM Joint reveals that this could not possibly be the correct position since nerves and blood vessels occupy the area posterior to the head of the condyle. The fact is that most patients suffering from internal derangements have the condyle posteriorly displaced. The treatment of choice for these patients is to reposition the condyle downward and forward utilizing appliances such as anterior repositioning splints and functional orthopedic appliances (Twin Block, Rick-A-Nator or MARA Appliances). Following the use of these appliances, most patients experience a significant reduction in the signs and symptoms of TM Dysfunction. Only a medical doctor can fix a dislocated shoulder but only a dentist can fix a dislocated jaw.

Dentists who utilize their knowledge and these appliances and splints, experience a great deal of personal satisfaction from significantly improving the quality of life of their patients.

During the past 25 years, I have interviewed many patients whose TMJ dysfunction worsened with orthodontic, restorative and prosthetic procedures. Clinicians cannot continue to ignore this problem, especially when you see the number of lawyers in the U.S. who are anxious to sue anyone with assets including dentists.

My clinical experience has convinced me that to eliminate internal derangements, the mandible must be properly related to the maxilla in three dimensions: transversely, antero-posteriorly and vertically in order to achieve a normal disc-condyle-fossa relationship. The best way to accomplish this is to learn to be proficient in removable and fixed functional jaw orthopedic appliances and anterior repositioning splints. Patients who demonstrate signs and symptoms of TM dysfunction must have the TMJ stabilized before proceeding with any type of treatment. How can the dental profession continue to treat the teeth and the gums and continue to ignore patients who complain of clicking, inability to open their mouths and have an abundance of muscle spasms and trigger points in the head and neck area. My experience has been that the medical profession is similarly not well equipped to treat these problems. Most medical doctors treat the symptoms with medications such as muscle relaxants, anti-inflammatories, pain medication and even anti-depressants. To solve the problem, clinicians must treat the cause of the problem, not just the symptoms. In my opinion, the dental profession must make a concerted effort to try and help the thousands of patients who are suffering from this disorder.

The dental profession must become aware of the fact that most patients who suffer from TM Dysfunction present with a skeletal or dental malocclusion. Some of these patients have also had their TM Joints further traumatized by whiplash injuries, trauma, or during intubation procedures in hospitals. The most common malocclusions that affect the TMJ negatively are constricted maxillary arches, deep overbites and retrognathic mandibles. I would advise all clinicians prior to restorative or prosthetic treatment to correct the malocclusions and TM Dysfunction first.

Contractors would never consider constructing a new roof on a house unless it first had a stable foundation. I think the dental profession should treat similarly. Dentistry can no longer deny the importance of a stable joint relationship prior to any restorative, orthodontic, prosthetic or cosmetic procedure. The dental profession is aware of the importance of the diagnosis and the treatment of periodontal disease. Failure to either diagnose or treat this disease can indeed put the patient as well as the dentist at risk. I feel that a similar situation will develop soon with regard to TM dysfunction. If dental procedures cause the patient’s problems to worsen, as I have seen many times, resulting in decreased range of motion, increased clicking and jaw locking and increased muscle spasms and pain, then it could well be the lawyers who are going to be the main beneficiaries of the treatment.

One wonders how the dental profession which holds the key to the elimination of so many “medical symptoms” could fail to properly diagnose and treat a condition that is so prevalent in our society. This is indeed a sad commentary on our profession!

It is time for all of us to continue our education in the diagnosis and treatment of TM dysfunction and to “step up to the plate” and take responsibility for the temporomandibular joints. The dental profession must work with other health care professionals in helping to eliminate TM dysfunction and craniofacial pain which affects thousands of patients.

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Dr. Rondeau is a general dentist whose practice is limited to the treatment of patients with orthodontic, orthopedic and TMJ problems.

Dr. Rondeau is a diplomat of the International Board of Orthodontics, is a Senior Certified Instructor for the International Association for Orthodontics, lectures over 100 days per year, and has approximately 1,000 active patients. Dr. Rondeau was awarded the IAO’s highest honor - the Leon Pinker Award and Duane Stanford Award and was the AAFO Clinician of the Year in 1993.

For further information on his seminars call: 519-455-4110 or 800-522-0595 Ext 200 or 214. FAX: 519-455-1589 Email: brondeau@rondeauseminars.com or visit his website at: www.rondeauseminars.com.