TMJ and General health

The Clinical Management of Basic Maxillofacial Orthopedic Appliances
(BY JOHN W. WITZIG/TERRANCE J. SPAHL)

VOLUME Ⅲ TEMPOROMANDIBULAR JOINT

PATIENT: Age 50 years, 1 month

MAIN PROBLEM:
1. Frequent, reoccurring headaches, so severe that patient was going to stop working.
2. Pain in right TMJ.
3. Constant discomfort.

FINDINGS:
1. Right TMJ very painful to palpation.
2. Right and left TMJs locked.
3. Class Ⅱ/Div. Ⅱ malocclusion.
4. Incisal interference forcing the mandible posteriorly in occlusion.

RADIOGRAPHIC FINDINGS:
1. Right TMJ - Posterior superior displaced condyle.
- Flattening of condyle.
- Large bone spur on condyle.
2. Left TMJ - Posterior superior displaced condyle.
- Flattening of condyle.
3. Right TMJ arthrogram
a. Disc perforation.
b. Severe degenerative change.
c. Late stage internal derangement.

DIAGNOSIS: Internal derangement with degenerative arthritis, both left and right TMJs, advanced stage.
Right TMJ has a documented perforation.

TREATMENT:
1. Sagittal splint (Sagittal Ⅱ appliance) - 8 months.
2. Transverse splint (Transverse appliance) - 6 months.
3. Orthopedic Corrector I - 6 months.
4. Retainer splint - Wear at night indefinitely (to prevent upper anterior teeth to returning to former position.)

RESULTS:
1. Terrible headaches eliminated.
2. Patient said, " I don't have headaches anymore."
Patient said, "I feel good with my lower jaw biting forward."
3. No pain or problems.
4. Mary was examined and TMJs x-rayed, 6 1/2 year post treatment.
a. No headaches, pain or problems.
b. Wears retainer when sleeping.
c. Opening: 39ㅍmm.
Left lateral: 11ㅌmm.
Right lateral: 12ㅍmm.
d. TMJ x-rays showed condylar remodeling.
e. TMJ x-rays showed condyles are no longer posterior-superior displaced

Figure 1A-1P

(1 F) Note the Gothic arch appearance of the outline of the maxillary arch that forces the slightly wider mandibular arch to close further back to where upper and lower arch widths coincide, another form of the NRDM/SPDC phenomenon (neuromuscular reflexive displacement of the mandible causing superior posterior displacement of the condyles).

(1 G) Transcranial radiograph of the right TMJ before treatment. There is a 2.8-mm
posterior joint space at rest, but 0.8-mm posterior joint space at full
intercuspation.

(1 H) Tomogram of the right TMJ pretreatment at full intercuspal occlusion.

(1 I) Arthrogram with dye initially injected only into the lower compartment of the right TMJ.
Note how the day has gone through the perforation in the posterior attachment to fill
the upper compartment (white).

(1 J) Sagittal II appliance to (1) move the front teeth forward out of the way of the future
advanced mandibular arc of closure and (2) act as a TMJ splint by virtue of occlusal
coverings of acrylic over the upper back teeth.

(1 K) Next a transverse appliance (splint) was used to develop the upper arch laterally.
A wider upper arch would allow eventual advancement of the currently wider lower
arch and still permit proper dental interdigitation of the upper posterior teeth with the
newly advanced lowers. Wire (cut at midline) on the appliance helps prevent the
newly advanced upper anteriors from relapsing in lingually again during the
transverse appliance phase of treatment. Acrylic coverings of the transverse
appliance help prevent TMJ pain and headaches in a splintlike fashion similar to the
action of the acrylic occlusal coverings of the sagittal (splint) appliance.

(1 L) The patient is wearing a splint and is free of TMJ pains or headaches.

(1 M) Orthopedic Co2/1rrector I (OCI) appliance to increase the vertical permanently and reposition the mandible down and forward as per standard OCI technique.

(1 N) Mandatory HS (hour of sleep) bite guard and retainer worn at night only during sleep
indefinitely.

(1 O) Six and one-half years posttreatment, on a transcranial radiograph, note the large posterior joint spaces as compared with pretreatment films.

(1 P) At 6 1/2 years posttreatment there are no myofascial pains, headaches, or TMJ problems. (Courtesy of Dr. John Witzig.)