Management of TMD (Temporomandibular Dysfunction) is usually part of prosthodontic practice. TMD is often also managed by physiotherapists, oral surgeons, and general dentists. TMD is a term which encompasses several symptoms including jaw muscular pain, jaw joint pain, temporal headaches, teeth aches and pain, and any combination of these. It also includes jaw joint problems including clicking, locking, and grating or grinding noises. TMD is in most cases associated with excessive jaw clenching or grinding. Most people which attend our practice are unaware that they clench or grind teeth. Every person clenches or grinds their teeth a little or in some cases a lot. We call this jaw parafunction or excessive function. We do it while we concentrate, brace ourselves to carry out excessive physical activities, and while sleeping. For some reason, which is difficult to explain, clenching and grinding is more excessive when people are under stress. Stress can be as simple as lack of sleep and common illnesses. It can also be far more complex including emotional, medical, and drug related issues. Excessive clenching of the jaw muscles over long periods of time will result in inflammation buildup in the jaw muscles usually related to excessive lactic acid unable to escape the muscles. Excessive pressure on the jaw joints and teeth will also result in damage to these structures. The jaw joints, if placed under excessive forces, will result in inflammation and pain in the joint surfaces, the attached ligaments, and the internal disc within the joint. Excessive forces caused by clenching will also cause damage and pain to teeth and the surrounding bone. The jaw muscles are extremely powerful in relation to other muscles in the body. It is quite possible for jaw muscles to fracture and split teeth which is a problem we see.
What is the process for TMD?
Examination and Consultation
Treatment of TMD is commenced with an in-depth examination and consultation. Some people are more susceptible to these problems if they have excessive flexibility within the ligaments and joints. It is also commonly associated with stressful events such as student examinations, parenting, work stress, and other stressful episodes. In many cases the symptoms will resolve of their own accord. An assessment of the way the teeth fit together is made. Teeth move throughout life slightly and subtly. They can move into positions so that during normal clenching and grinding they can interrupted or obstructive the way teeth slide from side to side. These are called occlusal interferences. That is an interference in the normal and relaxed movement of the jaws. A normal assessment would also check the health of the temporomandibular joints, presence of tooth wear or signs of heavy jaw clenching, and a discussion of possible stressful situations. If the TMD symptoms have been in place for a significant amount of time, intervention is normally required. The most common treatment provided by a prosthodontist is construction of a maxillary occlusal splint. This appliance is usually a clear plastic appliance. It covers and attaches to the upper teeth. It provides an opening or contact for the lower teeth. A well-constructed occlusal splint usually needs to be as thin as possible. An excessively large occlusal splint will cause sleep problems. The smallest possible splint which is highly polished will be well tolerated by even light sleepers. A well-made occlusal splint needs to fit the upper teeth without rocking or moving at all. This is quite important. The other very important aspect of an occlusal splint, is that all the lower teeth need to close together at the same time or evenly.
The Procedure
The procedure itself is not difficult. Impressions are taken of the upper and lower jaws. The impression of the upper jaw on which the splint is to be constructed, is taken with a very accurate silicone impression material. The same material is used to construct crowns and veneers. We then recorded the way the teeth close together. These records are then used to construct the occlusal splint. The occlusal splint is constructed with heat cured acrylic resin. This resin is the hardest and longest wearing material available. Softer materials used for occlusal splints are ineffective. A soft occlusal splint will provide comfort for approximately 4 weeks. Following this the softness of the splint triggers further clenching and grinding within the jaws and will often exacerbate or make the condition worse. Approximately one week later an occlusal splint is ready for insertion. It is adjusted to fit the upper teeth. The manufacturing process for an occlusal splint will create slight changes within the splint. It needs to be adjusted a little to fit the upper teeth comfortably. Following this, the occlusion or bite needs to be adjusted and polished. At the end of the insertion appointment, the splint should fit the upper teeth comfortably and the lower teeth should close together evenly into the splint. As the splint starts to work, the jaw muscles relax and the pain starts to resolve. This causes slight changes in the bite position. This again will make the splint slightly inaccurate. The splint is adjusted 3 times over 6 months. The adjustments become less as time goes by. In most cases, the symptoms are completely resolved and no further adjustments are required at the 6-month visit.
Care
We give instructions in the care and cleanliness of the occlusal splint. The occlusal splint is usually for night-time use only. We will give you a hard case to store the splint so that it is not damaged when not in use. Most people adapt to sleeping with an occlusal splint without problems. In people who are very light sleepers, it may take several days or up to 1 week to sleep through the night with the splint. Occasionally splints are not successful. As TMD is multifactorial, which means caused by many different issues, it is not always possible to diagnose the most prominent cause for the jaw pain. TMD historically, has been difficult to manage because it is a condition which requires the expertise of a prosthodontist, a physiotherapist, and a psychologist. Unfortunately, there are very no clinicians who have expert specialist training in all these areas. Due to this situation, TMD management occasionally can be quite difficult.