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.