Article by Dr. Mike Pilar, practice restricted to TMJ/TMD & Migraine

All the initial talk about treatment for TMJ, in many cases at the patient’s initial exam centers around their previous treatment experiences or explanation of their needed treatment by doctors indicating the need for muscle treated with medicines, Botox or other liquid injections or have jaw muscle physical exercises recommended or possible surgery needed. None of these entities should be initiated at the start of treatment. We do not consider treatment of muscles and jaw joints first because they are the victims of dysfunction. We must treat the source of the issue, not the victim. We consider this as PHASE 1 treatment. The idea is to take the patient out of pain initially by re-claiming normal joint and muscle movement followed by phase 2 treatment where we actually treat and fix the inadequacies of the bite and joint relationship, hopefully in conjunction with the patient’s referring dentist…. further explained below.

PHASE 1 TREATMENT – ANTERIOR DEPROGRAMER INSERTED
I fabricate a custom-made one- piece orthotic over the upper four front anterior teeth and I only allow the lower four front teeth to contact the upper appliance at any given time on the pre-determined plane of contact I’ve created at the base of the upper appliance. We are now restricting anterior vertical pressures to 20 pounds when the lower anterior teeth (four front teeth) contacting this upper orthotic plane of contact created by me. Upon this happening, we have eliminated massive muscle pressures up to 50% on the masseter muscle and temporal muscle pressures up to 70% reduction; no drugs capable of doing that.

There is no longer posterior contact of molars, bi-cuspids or canines on all movements. We have adjusted the vertical dimension space between the upper and lower jaw on closure to between 2 to 3 mm of space to allow freedom of comfortable sliding movement of teeth without upper and lower back teeth touching, which condition is created by the build-up of the vertical thickness of the upper appliance so as not to allow pressure of both condyles against the right and left ear wall assembly; that would possibly cause a feeling of “fullness” in the ears, a Eustachian tube blockage. All resulting in dizziness, imbalance, lightheadedness and brainfog condition with potential developing tinnitus, ear pain and eventual hearing loss.

Our resulting deprograming orthotic’s positive effects are freedom from condylar joint negative pressures along with constant equal movements of both joints in all directions all the time on wearing the orthotic. This important freedom of movement cannot be duplicated by any other orthotic made and is a major factor in the healing process of the joints. No longer can the condyle disrupt the temporal nerve in the joint area eliminating development of migraine / headache, sinus involvement, throat issues, eye muscle pain and trigger point connection to cervical area involving neck, shoulder and upper back pain.

This appliance can also be made over the lower teeth. However, the lower teeth do not afford as much support as the upper four front teeth. Orthotic must be custom-made as we cannot afford to incur any laboratory error. The laboratory cannot replicate the actual movements of the jaw and is at a major disadvantage in creating proper angles and thicknesses of the orthotic. The orthotic is too small and too definitive in its purposes. It is the controlling entity of a centric relationship you’ve created and movement of condyles equally on both sides without any interference. It takes time for the TMJ doctor to create it to perfection having the patient in the dental chair for same day direct material impression over upper front teeth to direct finish of the material to orthotic completion in the one visit and not the product of laboratory design and indirect laboratory fabrication taking one to two weeks of lab time.

By the first or second night, sleep is 100% better, migraines if existing are dissipating; general feeling is extremely better over a period of months and the jaw Joint relationship changes as the muscles get better and the muscle opening and closing arc is changing that’s resulting in certain teeth now possible to touch prematurely that didn’t touch before all now caused by vertical changes in muscle movement causing different angles of tooth contact on jaw closure. That’s when we start indiscriminate tooth reduction based on patient complaint. There are occasions, where at the initial visit of the orthotic fabrication, tooth balancing is necessary. That’s the first lesson with use of the orthotic to give us a stable centric occlusion so as we could see the differentiation between both right and left side tooth positioning.

When the patient is close to normal muscle condition, we can start PHASE 2 treatment and if needed, with a full bite reduction treatment concluding PHASE 1 treatment, by having the patient insert the orthotic into their mouth at a subsequent office visit months later in the dental chair and gradually we reduce the vertical height of the orthotic in the mouth. As we reduce the vertical height of the orthotic all done in the patient’s mouth, the posterior teeth get closer together. Interestingly, the teeth do not know what we’re doing only the muscles know and the muscles at this point are in good shape …so the muscles will determining which teeth are touching first, as we continually reduce the vertical thickness of the orthotic in the mouth causing the space between the upper and lower posterior teeth to be reduced.

RESULT
Again, as you are reducing the vertical height of the orthotic in the mouth, the posterior teeth are getting closer together. At some point certain teeth may touch first Those are the teeth to be reduced in height. You must remove the contact points until there is no upper and lower back teeth touching and you continue to make the orthotic smaller until the patient indicates that other teeth are now touching first… at one point you will arrive at a condition where all the back teeth on both sides are closing and touching the same time…you are now finished…all accomplished by the controlled reduction of the vertical size of the orthotic in the mouth. In the meantime all the tissues are healing and symptoms significantly gone.

The muscles are now better with a balanced bite. This is not to preclude the need for any extensive dental work in Phase 2 that may be needed….and we’ve certainly helped in creating the perfect condition for the phase 2 treatment.

Note: this treatment modality has been accomplished on most of the 3500 cases seen over the past 25+ years you can read my Google reviews and see firsthand patient response.

 Online Journal of Dentistry & Oral Health 

 The Comment Below was Part of an Introduction for an Advanced Course in “Bite Equilabration Technique” Offered to Orthodontists 

“Important Connection Between TMD and Orthodontia” 

Conventional and even functional orthodontics share the same diagnostic dilemma as psychiatry, that is, they both do not have a diagnostic protocol to assess the baseline of patients before, during, and after treatment. The treatment objectives of orthodontics are admirable: straight teeth, a pretty smile, and functional temporo-mandibular joints. The one key component missing from the treatment objective equation is an occlusal cranial balance. The reason for this is that the orthodontic and dental profession does not know that they do not know that this component even exists. The only saving grace is the cranium’s ability to adapt to the distortions created by orthodontic treatment. Patients and dentists alike do not connect the dots between the occlusal cranial distortions they have created and the symptoms of trigeminal Neuralgia, atypical facial pain, migraine and tension headaches, cervical, low back pain, and more.” 

Pilar Views Follow…. 

1. Many Patients Share the Same Issue 

A) A surprising number of my female patients between the age of 17 and 32 have had one thing in common. 

B) All have had orthodontic treatment; and after treatment completed, some patients are still wearing their initial orthodontic retainer for years. 

C) As part of our initial exam most patients questioned never experienced their dentist asking them if they ever had headaches. 

D) Most migraine and headache patients have seen neurologist before coming to me. From my diagnostic experience, hardly ever does the neurologist examine the head and neck muscles, nor ask the patient about symptoms usually related to TMD. Their interest is strictly in having MRI of brain taken so as to rule out tumor or vascular involvement. When tumors are ruled out, only treatment given is muscle relaxant pills and hope for the best. 

E) Most TMJ/migraine patients I have examined have seen at least three to six medical professionals before coming to me. Those visited are Neurologist’s, ENT’s (ear, nose and throat), Primary Physicians, Pain Management doctors, Chiropractic, Physical Therapy, Cranial-Sacral, Acupuncture, and Massage Therapy. 

F) Physicians look at patient symptoms as a disease entity not singularly or collectively as part of a dysfunction entity. Medication is the choice of treatment; not investigation for source. Initially, health professionals treat the patient symptom as possible tissue, nerve or bone disease. These patient TMD symptoms range from tension/stress, to headaches & brain fog & dizziness condition, to sinusitis, to visual disturbances, to ear pain, to jaw joint noises to throat / eye muscle issues / to neck & shoulder muscle contracture / to sleep deprivation & resulting daily yawning. These symptoms gyrate up and down over months to years before patients respond medically. 

G) Jaw joint dysfunction can be the result of genetic inheritance or environmental mishap or combination of both. The discomfort usually afflicting one side of the head first before the other side. 

H) Constant Jaw joint complex dysfunctional abuse leads to inflammation of bone and tissue that lead to eventual degeneration of muscle tissue and bone. 

I) TMD leads to muscle contracture of head and neck, which leads to disuse atrophy and major restrictive head and neck muscle movements 

J) The patient is usually not aware of the TMD teeth clenching of upper teeth to lower teeth during their restless sleep periods. 

K) The patient or the doctor is usually not aware of the connection of night time teeth clenching with dizziness, imbalance, ear congestion, ringing in the ears with potential hearing loss, and visual disruption. 

L) The patient and doctor many times fail to connect the migraine to erratic clenching of back teeth during sleep; in many cases the imbalance of upper to lower back teeth at 160 lbs to 300 lbs vertical/lateral abnormal movements being the causative agent…along with the accompanying condyle displacement / The elevator muscles of the head notably the Lateral pterygoids in spasm along with the Tensor veli palatini muscles in joint spasm closing off the eustachian tube and produce middle ear involvement, etc…. 

M) Imbalance of teeth (uppers to lowers) can originate via: 

1) Genetic inheritance of bone structure dictating erratic tooth position; or… 

2) Environmentally created impact of whiplash accidents; or… 

3) Faulty orthodontic intervention being a causative agent, when considering vertical and lateral movements of jaw are pre-determined during bone growth stage but now interfered with by orthodontic tooth movement to create a more esthetic alignment of teeth creating imbalanced tooth position, rather than normal jaw muscle control functioning with proper tooth position. This pre-determined re-positioning of teeth would be acceptable if a manual balancing of the teeth between uppers to lowers in all excursions under acceptable muscle condition were to be instituted prior to a full arch retainer being fitted. 

To emphasize, jaw joint movements are directed either by: 

1) Proper muscle control with normal bite, 

or… 

2) Poorly related teeth in faulty position to each other controlling jaw positioning and promoting night-time jaw clenching. 

3) Jaw-joint mal-development sometimes creating joint dysfunction, and muscle and bone inflammation leading to progressive degeneration. 

For Migraine Prevention… 

in my estimation, the only appliance that can effectively treat migraines and basic TMJ dysfunction is an anterior deprogramming orthotic device for the prophylactic treatment of medically diagnosed migraine pain and migraine associated tension headaches; and for the prevention of bruxism and TMJ syndrome by reducing trigeminally innervated muscular activity. Upper anterior orthotic is favored over lower orthotic based on greater surface area support. 

With this appliance in place we also reduce the muscle stress that normally occurs with posterior clenching from the aggressive 160 pounds up to 300 pounds of pressure on posterior occlusion to 20 lbs of acceptable pressure on anterior occlusion, resulting in 50% reduced masseter muscle stress and 70% reduced Temporal muscle stress. No pills can accomplish that. 

The Pilar orthotic is a deprograming stabilizing oral devise. It is fabricated chair-side with much detail resulting in a perfect fit controlling necessary joint movements in all directions. A laboratory processed orthotic will not have all the critical clinical refinements necessary for treatment success. For a dentist to refine a laboratory processed orthotic in “re-fitting and adjusting” is akin to you starting from scratch with border limitations that might not apply, it doesn’t work. 

The one-time belief that migraines are a primarily a vascular phenomenon is no longer viable. Today, most theories on the causes of migraines now include a trigeminal pathway, and cite the common peri-cranial muscular tenderness in migraine sufferers. There still exists a lack of objective evidence for a causative element for migraine pain, keeping the healthcare industry from isolating an acceptable means of prevention. I maintain along with my colleagues that Migraine/Tension Headache is not part of a disease entity as suggested by many of the health profession, unless we are dealing with a potential brain tumor or isolated vascular issue; it is a symptom of an underlying source. We address that source. Tension/stress & excess emotion is certainly part of the negative process along with the fact that 85% of the TMD affected population are woman. 

TOO BAD… THEY SHOULD ALL KNOW ABOUT THE ANTERIOR DEPROGRAMING ORTHOTIC. 

Acknowledgement 

None. 

Conflict of Interest 

No conflict of interest

Citation: Mike Pilar DDS*. What I’ve Seen in My TMJ/TMD Practice Personally Examined Over 3,500 TMD Patients Over the Last 25 Years and Treated Most of them. On J Dent & Oral Health. 6(2): 2022. OJDOH.MS.ID.000632. DOI: 10.33552/OJDOH.2022.06.000632.