OROFACIAL PAIN AND DISORDERS

Orofacial pain and disorders, sometimes called TMJ or TMD, are often associated with some of the following classical signs and symptoms:

• Headaches
• Clicking and/or popping noises in either one or both jaw joints
• Clenching
• Grinding - bruxing teeth at night-time, or even during the daytime
• Dizziness
• Fatigue
• Cramps and pains in the face and/or neck
• Limited mouth opening
• Inability to chew effectively
• Loss of back teeth
• Improper bites
• Loss of hearing
• Tinnitus
• Poor body posture
• Difficulty talking
• And, prior orthodontic treatment;

where any one or more may indicate a problem.

In order to properly diagnose these disorders many steps must be taken to ascertain a positive cause and effect relationship through signs and symptoms. The patient is a valuable source of information in this regard, as the symptoms - the information the patient gives - is solicited by questionnaires, and direct discussions. The signs come from many examinations of the patient to include:

Muscle exam

where muscles along with their origins and insertions on bones are palpated for: pain, tender points, tonicity, reflexes, and trigger points.

The temporalis muscle covers the side of the head, and is actually three muscles in one, as each portion of the muscles contracts at a different time dependant on the jaw movement. This muscle is attached to the lower jaw in front of the jaw joint, which acts like a hinge. When the temporalis contract the lower jaw is elevated until all the teeth touch. Where this muscle attaches to the lower jaw by many tendons pain is often solicited, much like tennis elbow. When the patient feels a headache coming on, massaging this area inside the mouth by the thumb and the outside by the middle finger, often make the headache goes away immediately. There are many reasons why this muscle induces headaches, which can be determined by the exams.

This image shows the big masseter [cheek] muscle used in chewing, by elevating the lower jaw. In humans this muscle does most of the work, it has two portions each with different functions, and its origin on the cheek bone can refer pain such as headache.

Like all bones being moved by muscles, the lower jaw bone is no exception regarding the two contrasting groups of muscles performing the movements. While there are many muscles that elevate the lower jaw for chewing, talking and augmenting breathing, there are many muscles acting in opposition to the elevating [closing] muscles that lower the lower jaw. These muscles can cause improper head posture, and they can also refer pain to the head. Some of these muscles attach to the voice-box, and are required in proper swallowing.

Posture exam

where the posture of the entire body is assessed for alignment, because often forward head posture caused by a lack of what is called - vertical dimension - which is the amount the lower jaw is postured away from the upper jaw when the patient bites on all teeth. An over-closed lower jaw causes the head to rotate forward, and because the eyes involuntarily always keep the head horizontal to the horizon, the head moves forward. This results in improper alignment of the cervical spine - the neck bones, and makes the muscles supporting the head do unnecessary work, often leading to pain in the neck muscles. The body's skeleton further compensates for the head and neck being out of position, by creating a lordosis - curve, of the lower back. This results with the pelvis rotating, and then further compensation is created by the locking of the knees. This is further compensated by rotating of the ankles

Sensory and Motor nerve exam

This exam is accomplished by palpation of the foramen - holes, in the head bones where these nerves exit from the brain case.

Tooth Status

The routine examination of the teeth directly with the aid of radiographs is also required to determine if there are any associations between the status of the teeth, the bone housing the teeth and the gingival tissues covering these bones and surrounding the teeth, with the pain the patient is experiencing. Anyone having a tooth ache knows that the pain associated with a diseased tooth effects the entire side of the face.

Occlusal Gram exam

During this examination the manner in which the teeth come together in the closed position as well as the various contacts of the teeth when the lower jaw is moved from side to side is charted. Sometimes teeth interfering with the normal functional movements of the lower jaw place undue pressure in the jaw joints causing pain in the joints and related muscles.

The completed occlusal gram gives indications of whether or not a few or many teeth actually touch, how many tooth surfaces actually participate in chewing, the presence of undesirable balancing contacts and whether or not the front teeth are functioning properly.

Diagnostic Casts exam

Impressions are made of the patient's teeth, and the casts of the teeth are related to each other by using a reference position bite relationship. The upper cast is mounted to an instrument called an articulator by either an anatomic or hinge axis face bow, which relates the casts of the patient's teeth to the jaw joints. The articulator can be set to reproduce the patient's lower jaw movements from the computerized Condylographic data. Because the patient's teeth are now represented in a dynamic movement fashion, determinations can be made on how the teeth actually function in the mouth, and especially how the teeth dominate the position of the jaw joints. The specialized casts shown here allow for the evaluation of individual teeth, as all the posterior [back] teeth can be removed from the cast, and replaced one at a time.

Condylographic exam

there are two computerized devices which give representations of how the jaw joints are working, and their specific pathways are related mathematically by two graphs for the right and left forward - backward movements, and two graphs for the sideways movements. The more simplified computerized system enables this information to be obtained in eight minutes. From the graphs of the patient's jaw joint movements, determinations of health status of each jaw joint can be deduced. When observations are made which don't appear normal, a more extensive computerized system is used to make more finite observations of not only each jaw joint but also the relationships of the jaw movements to all the teeth.

This diagram from Condylography shows the pathways of the right and left jaw joints. Data is also given in hundredths of a millimeter and seconds at each point along this pathway. In this case, the patient's left jaw joint is restricted, making the right jaw joint compensated for this lack of mobility in the left jaw joint.

In this 50 year old patient, the left joint shows a remarkable shift when the jaw is moved along with highly restricted movement, indicating a problem within the jaw joint itself.

In this case the patient favors the left side and the patient has atypical jaw movements when chewing and speaking.

This case shows the disc is out of place The spike in the time of movements on the left side when the teeth are shown the extreme velocity of the jaw touching and then the disc goes to where movement when disc goes to place is should be on the condyle when the mouth is opened and is termed a reciprocical click.

Cephalometric exam

This exam uses an X-ray of the head, where the center of rotation of each jaw joint [shown as red dots] and a third point are used to relate the dynamic jaw movements of the lower teeth to all the head bones and upper teeth. This program is designed for the placing of many digitized points from the head bones, the teeth and soft facial tissues into a program for analyses. These analyses allow for the determination of how the patient's spatial relationships of the head structures relate in terms of standard deviations from norms. A big factor is the plane of occlusion, which is the orientation of all the teeth to the head. Deviations here cause many dysfunctional problems. All this information can be related to the casts of the patients teeth mounted on the articulator.

The above two pictures show the lateral view of the patient, and the lower picture is of a lateral head film- X-ray of the head. The computer program allows for the digitizing into a program all the bones of the head and teeth for analyses

The illustration on the left shows the computerized data from the cephalometirc program overlaid on a photo of the patient. The numbers represent the relationships of the bones and teeth to each other in degrees, and in further analyses these numbers are compared to statistical norms.

TREATMENT:

After all the exams are accomplished the results are related to the patient's symptoms in a cause and effect process. In this context, there is too much information to be express here due to the many factors that represent orofacial pain and disorders, the diagnoses and proposed treatments. However, a few examples can be given in two cases.

CASE 1

This patient complains of headaches every morning, often during the day, and especially at times of stress. The patient also complains of pains in the sides of the face, difficulty opening their mouth wide, problems chewing, and some difficulty hearing although hearing tests are near normal. The patient's symptoms also include some dizziness, feeling tired, and a hard time concentrating without specific effort. The patient's history reveals that the headaches started when she reached twenty years of age, orthodontic treatment with teeth extracted was done during the teen years, along with academic problems in schools. The patient points to the areas above and below the eyes and sides of the head to show where the headaches appear.

The muscle exam shows painful temporal tendon insertions, the muscles on the side of the head that insert on the lower jaw used to elevate and retrude the lower jaw. There is also a lot of pain when pressing on the area of the lateral pterygoid muscles that move the lower jaw forward and side to side. In this case even the insertions of the medial pterygoid muscles is tender at the lower border of the lower jaw.

The posture exam shows a forward head position, and the muscles supporting the head are painful. There is also pressure on the examiners finger placed into the ear canal when the patient closes the jaw. This indicates that the jaw joint is driven backward, partially closing the ear canal, and putting pressure on the nerves supplying the inner ear.

The occlusal gram exam shows that the patient hits very hard on their front teeth first, before making contact on the back teeth. This test also shows teeth hitting on the side opposite from the side the patient is moving their jaw. These are called balancing side interferences, and have been known to create hyper-activity of the medial pterygoid muscles.

In relating the diagnostic casts of the patient's teeth to each other from a reference position bite registration, it appears that the lower teeth are ahead of their respective positions relative to the upper teeth, and upon placing all the teeth together, the lower jaw is forced backwards.

The analyses from the cephalometric exam show that the X-rayed position of the teeth are further back than normal positions of patient's teeth with the same boney types and relationships of the head bones. This indicates that the teeth are too far back in the head, creating the problem with moving the lower jaw too far backwards when all the teeth are together during a full bite.

The Condylographic exam illustrates a limited mouth opening, with otherwise normal tracings of the lower jaw's movements. There is also a “tail” at the beginning of the tracing from the position when the patient had their teeth together, indicating that the jaw joint was too far back in this starting position.

The clinical impression from the patient's symptoms and the findings during the exams indicated that this is what is termed a “compression case”, due to excessive pressure in the jaw joints.

TREATMENT:

Phase 1

After all the data is taken into consideration, the first phase of treatment is to make a decompression splint. A splint is a removable plastic device which covers either the upper or lower teeth to reposition the lower jaw. Splints are divided into 5 classical categories based on the diagnostic needs of the patient. They are diagnostic devices, not intended for treatment; rather they are designed to resolve the patient's immediate problems, therefore acting as a pain management tool, and to give guidance for future treatment. The splint is made on the diagnostic casts of the patient's teeth to alleviate the problems found in the exams. This splint is made on the lower teeth so the patient can wear it all the time and still speak. Eating with the splint in is problematical for most patients however, shortly after wearing this splint the back teeth no longer will touch in normal closing of the jaw. All splints are not intended to be used for more than 6 weeks, as after six weeks if the pain resulting in symptoms is not relieved, one must question the diagnosis.

Phase 2

Phase 2 treatment is intended for a longer term of diagnostic evaluations, where the entire occlusion of all teeth comes to play in the original diagnosis, as in this case. The most suitable device to be employed is the use of overlays that are bonded to the existing teeth, to replace the splint. From the overlays, many treatment options are available, to include re-doing the orthodontic treatment, simple moving of the upper front teeth to allow the lower jaw to come forward to later move or crown all or some of the back teeth.

Phase 3

Phase 3 is referred to as the final or definitive stage of treatment. In the above case example, the patient experienced frequent headaches, and pains in and around the head and neck. The diagnostic splint relieved these symptoms, and the results of the many exams indicated a direct relationship between the posture of the lower jaw and the upper jaw whereby, moving the lower jaw forward relieved the symptoms. Definitive treatment is then directed towards moving the upper teeth forward, either by fixed or removable orthodontic appliances. Often in cases like this, full orthodontic treatment is done to replace the extracted premolars, and to advance the mandible. In cases where this is not an option due to the patient's desires overlays can be placed, with the understanding that this is not considered long term treatment, however the need to wear a splint is eliminated.

CASE 2

This patient presents with complaints of headaches, pain in and around the head and neck, problems chewing, loss of tooth structure due to bruxing all the time, and a lot of clicking and popping noises in both jaw joints. The patient also complains of sleep apnea, feeling tired all the time and listlessness.

The muscle exam reveals pain in all the muscles moving the lower jaw, as well as the head posture and upper back muscles.

The occlusal gram shows that the patient has worn down the teeth to the extent that they are in contact in all lower jaw movements. This clearly indicates the presence of balancing side contacts, which will prompt muscles normally intended to be relaxed to become in tension all the time.

The mounted casts of the patient show the amount of tooth loss from bruxing and the machine like precision the patient has worn down the teeth in all positions of the lower jaw.

The Condylographic exam shows the presence of the clicking late in the opening of the mouth at the level of each jaw joint and the presence of the second clicking noise when the mouth is almost fully closed. The clinical impression is that the disc that is supposed to be between the lower jaw's condyle and the depression, or fosse, in the head bone is displaced ahead of the head of the condyle. Then, after the patient opens the tissues attached between the head bone and disc are fully stretched, which moves the disc back on top of the condyle in its normal position. However, when the patient closes and the worn down teeth contact again, the condyle goes far back into the fosse and the disc is pushed off the top and ahead of the condyle. The terms for this disorder are: luxation with reduction of the temporomandibular joint.

The cephalometric analyses reveal that the patient's bite is closed, the occlussal plane is flattened, and the teeth are a lot shorter than normal.

TREATMENT

Phase 1

A lower splint was constructed to open the patient's bite and worn during the day time, at the position where the disc remained in its proper place on top of each condyle as determined from the Condylographic data as transferred to the articulator. A night time upper splint was also made to keep the patient's bite open and the lower jaw forward while sleeping.

Phase 2

The diagnostic splints worn during phase 1 eliminated the headaches, and much of the muscle pain. Physical and massage therapy was also introduced into the treatment plan. Upper and lower splints were then made in the ideal shapes of the patient's once existing teeth before they were worn down from bruxing, in the position of where the discs remained in their proper place.

Phase 3

After many months of wearing the Phase 2 upper and lower tooth-form splints, the patient had relief from pain and liked the appearance these splints restored to the natural appearance. The final or definitive treatment choice was to place crowns on all teeth to restore the missing tooth structure, and maintain a proper posture of the lower jaw enabling the discs to remain in their proper place. The patient also significantly reduced the use of a machine designed to assist breathing while sleeping. After several years of follow-up exams, the patient remained headache and pain free.

Further information about the approach taken in the office is available by viewing the web-site of the Institute of Advanced Definitive Dentistry at: www.iadd.net. Click on: Theses/Publications, to view the many research projects already completed and published. The Curriculum Vitae of each dentist on the faculty at IADD is also available.

Information about the computerized data gathering diagnostic and research instruments employed in this dental practice is available at: www.gammadental.com.