TMJ and General health

1.	Clicking in both TMJs.
2.	Class II/Division 1 malocclusion, with crowding and anterior open bite. First bicuspids and all anterior, upper and lower, are in open bite.
3.	Maximum openings = 39 1/2 mm.

RADIOGRAPHIC FINDINGS:
1. Posterior-superior displaced condyles.

DIAGNOSIS:
Internal derangement both left and right TMJs, with degenerative arthritis.

TREATMENT:

1.	Upper second molar removal, third molar replacement.
2.	Seven months-upper transverse splint
3.	Lower second molar removal, third molar replacement.
4.	Nine months-Orthopedic Corrector II appliance to change Class II to Class I occlusion and bring condyles down and forward. Averaged 13 hours of wear daily.

RESULTS:

1.	Headaches stopped.
2.	No pain in either TMJ. Left TMJ ?clicks? occasionally.
3.	Opening of 50 mm.
4.	Patient has been seen posttreatment once a year for 4 consecutive years. No recurring headaches and no TMJ pain.
5.	Condyles are no longer posteriorly-superiorly displaced.

Figure 14 A-14 T Anterior open-bite/TMJ case. Sometimes it is not anterior incisal interference that initiates the NRDM/SPDC phenomenon, but rather posterior bicuspid and/or molar interference that prevents the mandible from biting as far forward as the condyle-disc units would like. Posterior maxillary crossbites are hard on TMJs. So is maxillary posterior arch narrowing. Also it must be remembered that when the condyles start melting down due to functional abuse-inititated regressive remodeling the anterior bite tends to open.

(14 A and 14 B) Pretreatment facial views of a 20-year-old female with severe TMJ problems.

(14 C) Pretreatment anterior open-bite malocclusion.

(14 D) Pretreatment transcranial radiograph. Note the extremely tight joint spaces and condylar resorption and deformity (a narrow upper arch forces the lower arch, hence the condyle, back too far upon full occlusion).

(14 E) Panograph showing all third molars present. Removal of all second molars prior to lateral development allows for better stability and less chance of recrowding. Since the upper thirds can easily eplace the seconds at this age (although it would be almost too late for the lowers to do so) and since lateral development of the maxillary arch will be the initial phase of treatment in this case, all four second molars were removed.

(14 F) Upper Transverse appliance with occlusal pads of acrylic to give a splint effect and relieve TMJ abuses. Activation
of screws gradually widens the arch so that it will be compatible with a wider lower arch once the lower arch is advanced.

(14 G) (14 H) Since not only mandibular retrusion but also an anterior open bite exists in this patient, an Orthopedic Corrector II (OCII) is the next appliance used. After 7 months (active and passive) of treatment with the Transverse (splint) appliance the OCII is used to steadily advance the mandible and close down the anterior open bite (which becomes progressively more difficult as the patient passes from childhood to adolescence on through to young adulthood.

(14 I, 14 J) Facial view and transcranial radiographs 1 month after completion of the OCII phase of treatment and closing down of he anterior open bite.

(14 K and 14 L) Appearance of the patient and occlusion 1 year after completion of treatment.

(14 M - 14 O) Posttreatment study casts.

(14 P) Postreatment panograph 2 years after appliances. Note how the third molars replaced the second ones nicely, even on the lower arch, quite a task for the lowers considering the patient's age!

(14 Q and 14 R) Pretreatment cephalometric analysis (Sassouni Plus)

(14 S and 14 T) Posttreatment cephalometric analysis (Sassouni Plus) (Courtesy of Dr. John Witzig.)