Treatment of Bilateral TMJ disorder

What was causing her pain? There were no typical indicators:

As a Prosthodontist, I have experience with complex dental problems, and with my TMJ specialization, I am able to diagnosis and treat difficult temporomandibular disorders. As a Prosthodontist, I have experience planning multistage treatments and can coordinate with a patient’s general dentist and other dental specialists.

I performed a full clinical examination, which included the following findings:

1. MRI images were taken on close and maximum opening and showed bilateral anterior displaced articulating discs with reduction.
2. Anne had a limited mandibular opening of 21 mm without pain and 28 mm with pain. With mandibular manipulation 40 mm with a slight increase of pain.
3. Bilateral opening clicks noted at 21-25 mm.
4. Lateral mandibular movement, left 9 mm and right 10 mm with some discomfort, but no TMJ noises.
5. Protrusion 6 mm, but no TMJ noises.
6. The muscle of mastication was sore to palpation. Both left and right lateral and medial Pterigoids were particularly painful to the touch, bilateral moderate capsulitis noted.
7. Clinical examination corroborated MRI findings of bilateral articulating disc anterior displacement with reduction. Bilateral opening and closing clicks with mandibular manipulation, Maximum Opening (MO) 40 mm.
8. An occlusal study noted that she had posterior bilateral interferences on lateral movement on 2/31 and 15/18. Centric relation was unstable by the lack or unstable tooth contact on 1st molars and premolars. Anterior guidance was missing bilateral cuspid rise.

My diagnoses for Anne were:

• Bilateral displaced discs with reduction
• Deficient mutually protected occlusion: Occlusal interferences, missing canine and anterior guidance.

Treatment Provided:

PHASE 1

• Impression taken and also delivered same-day maxillary full-coverage anterior reposition orthotic device (acetate + clear self polymerization acrylic) on a position where both articulating discs were reduced with only anterior contact for 1 week, used 24 hours a day. She was instructed to remove the device for eating / oral hygiene and given a prescription of 400mg
ibuprofen every 6 hours as needed for pain.

• Added posterior occlusal contacts on a flat plane to the same orthotic device, and Anne was still pain-free.
• Re-evaluation and adjusted as needed and she used this orthotic device for 1 more week.

PHASE 2

• Step back to tentative centric relation and capture the same position with a centric relation orthotic device that had anterior and lateral protections. Anne was still pain-free and had all mandibular movement with a max opening of 39 mm, protrusion 7 mm, and lateral movement of right 10 mm and left 11 mm.
• Anne was maintained with same centric relation orthotic device for 2 more months with 24-hour use. She was seen weekly and we adjusted to a final centric relation position.
• Study casts were mounted again on a Denar articulator with facebow and protrusion and lateral records for occlusal evaluation.

PHASE 3

• Anne was sent to an orthodontist to correct malocclusion. Mounted case on articulator provided to an orthodontist for an evaluation.
• Orthodontist treatment was done in 7 months and finished with a final minimal occlusal adjustment in our office. Thankfully we had a stable occlusion on centric with adequate anterior guidance.
• Lastly, a thermo-polymerization acrylic maxillary centric relation appliance was provided for night use.

We followed-up with Anne every 6 months for 2 years. She moved out of town for college and according to her father, she has been stable since completing our treatment.

This case had the following challenges:

1. Bilaterally affected joints.
2. Recapture both discs in centric relation and maintain them stable there.
3. History of being already treated by other colleagues.
4. She was the daughter of a friend!

If you have comments or questions about how I treated Anne from this Bilateral TMJ disorder, please email my office at smileagain@gaprostho.com