A protocol for the Treatment of Temporomandibular Disorder James e metz, dds, Diplomate abdsm mickey c harrison, dds the Metz Center for Sleep Apnea



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A Key: Experience has shown that approximately 60% of patients initially reporting pain in the joint while chewing are not joint patients but are actually muscle patients41.





If there is ever a question of joint involvement with the anterior deprogrammer test the practitioner has two choices:

  1. Place cotton rolls on both the left and right sides between the first and second premolars, then tell the patient to bite hard42. The placement here is very important. Too far back on the molars and you will unload the joint; and too far forward on the anterior teeth, the lateral pterygoid, and temporalis are stimulated.

      • Joint patients will have pain

      • Muscle patients will not have pain

  2. Fabricate an anterior appliance and prescribe an anti-inflammatory medication. Seat appliance and wait two weeks. Sixty percent of the time, after 1 – 2 weeks the joint symptoms will disappear. If they do not resolve – make a pivotal appliance.

Special Situation for Disc Displaced Less than Four Weeks:

  1. Time is of the essence and all treatment must be completed in 4 weeks or the joint begins to fibrose, which will prevent the disc from repositioning.

  2. If the displacement is recent (less than 3 weeks), an anterior appliance is fabricated that day for the patient. The patient is then placed on a Medrol (methylprednisone, Upjohn) Dosepak six (6) day regimen (4 mg, 21 tablets), provided there are no contraindications.

  3. Patient should be seen after 3 days on Medrol and questioned about range of motion and symptoms.

  4. If range of motion is back to normal and the symptoms are in remission, then wait another three days and reexamine.

  5. If all normal – congratulations – if not proceed to step 6.pivotal

  6. If displacement has not reduced, consider having a capable specialist perform a TMJ arthrocentesis, a nonarthroscopic lavage and lysis, which is highly efficient in this particular type of TMJ problem.

  7. After the injection procedure, treat the patient with an anterior appliance to stabilize the disc.

  8. Time is of the essence. The surgeon must perform this

procedure immediately, within the 4 week deadline.

  1. The use of the anterior appliance for stabilization has been

very successful31. If joint symptoms

persist a pivotal appliance is necessary.

Treatment for a Painful Joint:

The pivotal appliance is generally effective for the displaced disc. It has the ability to alter the mechanics of the jaw at the joint level to an unloaded, uncompressed treatment position43 44. The appliance is perfectly flat, over the most distal tooth. Both left and right contact at the same time (refer to requirements of pivotal appliance handout). The pivotal appliance transfers the fulcrum from the TMJ to the teeth intentionally, until healing occurs.


The patient does not eat with the appliance in place, and the appliance is worn 24 hours each day. Generally, after 6 weeks the appliance is only worn at night. Treatment time is variable, but is generally at least 4 to as many as 18 months. Time must be given for healing to occur. Wear of the appliance continues until the loaded position is comfortable. One may test, as previously described, to assure healing of the TMJ has occurred. One of the true pleasures of dentistry is to see the positive change in the TMJ patient; sometimes, the personality change is dramatic.
How to determine if the loaded position is comfortable dsc00184

(Tests all previously described):



  1. Anterior Deprogrammer

  2. Cotton rolls in the premolar area

  3. Anterior Appliance


Variation of the Cotton Roll Test One Can Perform

To Validate the Idea of A Pivot:

The concept of changing the mechanics at the joint level requires a careful analysis of the mechanics involved. A skull helps in the understanding of the pivot mechanics. Here is a test which may be performed in one’s own office, when the clinician has diagnosed a probable TMJ problem:



  1. Place cotton rolls bilaterally in the first and second premolar area.

  2. Instruct the patient to bite hard – the joint will be painful (The placement is critical to ensure stimulation of the proper muscles; pressure on anterior teeth can cause contraction of the lateral pterygoid and temporalis muscles, which confuses the test due to referred pain).

  3. Move back over the most posterior molar and bite hard – the joint will not hurt. What changed? The mechanics changed!

17cadaver-disc displacement of tmj2s
Lateral



Anterior

Superior head of Lateral Pterygoid

Extended disc


Posterior
Photo of disc is taken from the middle cranial fossa, the floor of which has been removed45. It should be noted that the disc has been displaced but the retrodiscal tissue has “extended the disc.” Collagen makes up much of the retrodiscal tissue and can be remodeled into disc tissue.


Deep Temporal Nerve

Conditions must be such that healing can happen. It is the goal that the pivotal appliance will create these conditions. If the patient’s pain is relieved, it is extremely likely that this healing has occurred.




Medial


TWO CONCERNS WITH THE PIVOTAL APPLIANCE EXPRESSED BY MANY PRACTITIONERS:

  1. Many practitioners have asked if this lack of anterior contact causes a problem. The answer is clear – it does not cause teeth to shift, when the appliance is used as described. The patient must understand they cannot eat with this or any appliance. Tooth movement can occur if this appliance is used for longer periods than described46.

  2. Since the appliance is two unilateral, unconnected appliances, will the patient swallow them and are they stable? If made correctly, stability will not be a problem. After fabrication, place the two appliances and ask the patient to try and “knock them loose” without using their hands. If the retention is not sufficient, reline or use the Biostar (pressure forming unit) from Great Lakes Orthodontics for fabrication.


Perfectly Flat

In this area

Second Molar First Molar Second Premolar
Second Molar First Molar Second

Premolar

pivotal



Requirements of Pivotal Appliance

  1. Appliance must be stable – Cover entire buccal and lingual surfaces of mandibular molars and second premolar. The appliance is two separate pieces. If the retention is not sufficient, reline or use the Biostar pressure forming unit from Great Lakes Orthodontics for fabrication.




  1. Add orthodontic acrylic to central fossa area of last mandibular molar, which has an opposing maxillary molar; make this addition as thin as possible and flat (If no molars exist, the dentist must supply them; this can be done with a removable partial denture or implants. If more retention is needed, grooves can be cut in the RPD for stabilization). At least 2mm of “slide area” is required from the centric point where the mesial lingual cusp of the last maxillary molar makes contact to edge of splint.




  1. Adjust the splints so they both touch at the same time when the patient closes with the tongue pressed against the roof of their mouth. No attempt is made to achieve centric relation.




  1. Teeth anterior to the last molar cannot touch – if they do, the appliance will not work! The patient must wear the appliance at all times, except when they eat, and return in approximately 2 weeks for a check. Examine, to be sure no teeth anterior to the contact point touch, and that the area where the posterior maxillary molar touches is perfectly flat. A relatively small depression in this area will prevent the appliance from functioning correctly.




  1. If appliance is adjusted properly the joint symptoms will be nearly nonexistent or much improved after 3 to 5 days. (A temporal headache indicates the pivotal appliance is too thick. High Angle Class ll patients have this problem, due to lack of freeway space. A solution is to make the appliance thinner or move the pivot to the first molar area.)




  1. Patient instructions – wear appliance except when eating and follow home care instructions (Page 19). After 6 weeks switch to nighttime wear only. Treatment time varies with age and magnitude of the problem. The normal length of time is from 6 to 18 months. The health of the joint can be determined by running a stress test with an anterior deprogramming device, anterior appliance or cotton rolls (described previously).




  1. After the loaded position is no longer painful, discontinue use of the pivot and treat as a muscle problem only. If the anterior appliance is not painful, treatment is successful.




  1. Patients should always be prescribed Colgate Prevident Fluoride Gel (not Colgate Prevident 5000 Paste), and they should place a “pea size” amount of the Gel in the splint before bed.

109-0943_img109-0945_img109-0942_img


Anterior Appliance



The Pivotal Appliance


Perfectly Flat

In this area


Second Molar First Molar Second Premolar

Premolar

pivotal



Advanced Understanding

Mechanics of the Pivotal Appliance
Possible Axis:


Condyle—Condyle

Condyle-Fulcrum


Home Care Disciplines for Muscle and Joint Soreness

James E. Metz, DDS, 1271 East Broad Street, Columbus, Ohio, 43205



614-252-4444, metzdds@yahoo.com

The time it will take to gain comfort will depend, in part, upon you following these instructions.

  1. MOST IMPORTANT DISCIPLINE – Preferred position of sleep

  • Sleep on your side with the pillow high on your head, and with no pressure on the jaw. Speak with Dr. Metz if you have a question, especially if you are abnormally tired during the day with a sufficient amount of sleep.

  • Use a rolled up towel or pillow against the back to keep from changing to flat on the back. It is very hard to change sleep habits, so do not give up! As long as 6 months is sometimes needed to change sleeping positions.

  1. Avoid caffeine and sugar as much as possible, both are stimulants to the nervous system.

  • Intake of coffee, Mountain Dew, cola, diet cola, tea, chocolate, etc. should be very carefully monitored and curtailed.

  • The caffeine contained in one cup of coffee is the maximum amount a person should consume per day.

  • Caffeine can get rid of a headache and can cause headache.

  • Reducing your intake of caffeine “cold turkey” will bring on headaches in many people.

  • You may need to take ibuprofen (400 mg. four times a day, read the warnings on the packaging) to control a withdrawal headache from caffeine.

  1. Eat a soft diet and avoid chewing as much as possible.

  • Absolutely no gum chewing.

  • Avoid clenching your teeth.

  • No bagels, hard carrots, tough meats, or anything that requires “hard chewing.”

  1. Avoid clenching your teeth during the day. Many people think they do not clench but most do at times.

  • A good technique for catching yourself clenching is to program your brain to think, “Am I clenching my teeth?” You can use every day events to “jog” your memory. Think! Every time you look at your watch (before you even think of the time) or walk through a door, try to catch yourself clenching. After practice, this technique is very effective in preventing TMD headache during your waking hours.

  • Small “sticky dots” from a stationary store can remind you not to clench. Put one wherever it will be a good reminder. If you see one, think “am I clenching my teeth?” (Technique from Dr. Gordon Douglass, San Francisco, CA)

  • If you catch yourself, place your tongue in the roof of your mouth and push hard while you move your jaw up and down.

  1. Avoid over opening and stretching your jaw. A two and one-half finger width of opening is maximum distance allowed, especially when yawning; push up with a fist under your jaw when yawning to limit opening.

  2. Take your medications.

  • Medication helps to gain control of symptoms more rapidly by decreasing inflammation.

  • Call the office or emergency (911) if you feel an allergic reaction is occurring, and discontinue medication use immediately.

  1. Wear your appliance!

  • You can decrease the wear time of the anterior appliance as soon as you start to feel better.

  • The pivotal appliance needs a 6 to 18-month period to accomplish its goals and the wear time is variable. Never wear the appliance after the initial 2 week period during the day.

  • After the pivotal appliance healing period, the anterior appliance will follow.

  • Never wear either appliance when eating.

  1. It is your responsibility to maintain contact with the office.

  • If you start to have pain, call the office.

  • A regular check appointment is essential, especially for the pivotal. Initially the appointment time is every two weeks. After control is gained, every three to six months is essential.

  • Never wear the pivotal appliance singly because the appliance will cause harm.

  • Never wear a broken appliance.

  • Call if you have a problem or if your appliance is making the symptoms worse.

  • Call immediately if the pain starts to center in or around your ear.




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21 ©James E Metz, DDS, 1271 East Broad Street, Columbus, Ohio, 43205, 614-252-4444, www.ColumbusDentistry.com; Flowchart developed with Dr. William McHorris, Memphis, Tennessee

22 McHorris WH, American Academy of Restorative Dentistry, 1995

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