tmj-ortho-1There is a relationship between the way the teeth fit together and how the joints and muscles function. This relationship will either be one of harmony or one of compromise. The bite relationship either helps promote a functional relationship or serves to compromise normal relationships. This includes the structures of the entire upper quadrant; front and back of the head/neck and upper back regions.

Here we observe the bite functioning in a harmonious relationship with the temporomandibular joint. This occurs when the joint is properly seated in the socket as the teeth come fully together. The ball of the joint will seat against the relatively avascular central region of the disc which is seated against the front wall of the socket. This is an anatomic and physiologic stable relationship.

tmj-ortho-2Here is an example of a patient that has undergone conventional orthodontics with braces, retainers, etc. The treatments had been completed some 5 years prior and the results have not remained stable. The bite has “shifted” and the lower jaw deviates to the patient’s right, causing the right joint to move up and back in the socket. This up and back position of the ball of the joint compressing the biomechanical posterior “locking mechanism” is a pathologic position. The problem with this initial type of treatment is it assumes that the jaw is in the proper functional relationship. This is not the case for this patient as she is suffering headaches, popping in her jaw and associated pains.

We can observe the difference in the bite position in the functional position (below) when we compare the bite position that resulted from the first orthodontic corrections to the bite position where the joints and muscles are in balance. A diagnostic orthotic or splint was used to help determine the position where the patient no longer suffers pain or dysfunction. This position no longer compromises the joints and the muscles no longer suffer spasms or pain. This also demonstrates how far off the bite position was from the original orthodontics as compared to where it should be if the bite was made to function in harmony with the joints and muscles.

Using the TMJ-Orthodontic method allows the practitioner to maintain the function mandibular / maxillary relationship (determined by the phase I diagnostic treatment) as the teeth are approximated to support this relationship. The following photographs demonstrate the diagnostic orthotic that was used to help determine the functional position of the joints and allowed the muscles to function without pain.

Once the functional mandibular / maxillary relationship is established it is necessary to begin to evaluate the arch and dental relationships at this association. In the view above, it is obvious that the teeth will not fit together as the upper arch is almost edge to edge with the lower arch, indicating an inadequately developed maxilla and a resultant crowded mandible. Treatment determinations are made to begin the arch development to allow the teeth to be approximated at the functional TMJ position and functional TMJ range of motion.

A combination of fixed appliance therapy and removable orthopedic device therapy (Universal Lingual Arch Wire, Ortho Organizers) were used to begin the arch development as the diagnostic orthotic was adapted to allow the dental movement, while maintaining the functional joint and muscle position. Here the Universal Lingual Arch Wire (ULAW) can be observed where it facilitates transverse (side to side) and sagittal (front to back) development. The anterior ramp of acrylic serves as an anchor for the posterior springs to move the posterior molars distal (back). The forward component of motion is countered by anchoring the anterior teeth using inter-arch elastics as viewed here. This serves to help maintain the integrity of the arch by maintaining the dental positions of the teeth that should not be moved while allowing movements of the teeth that are not properly positioned.

During or after the arch development is completed, the anterior tooth movements to the functional joint position are begun. The orthotic maintains the jaw position and the fixed appliances begin the dental movements.

Once the arch development is completed and the anterior teeth are approximated, the diagnostic orthotic continues to maintain the functional jaw position and the most posterior teeth are approximated into the desired occlusal relationship. Here we can see the anterior teeth are approximated and the posterior teeth are being brought into position. This serves to form a tripod of the dentition around the orthotic that is maintaining the functional joint position. Once this is completed, these teeth can help maintain the functional joint and mandibular / maxillary relationship and the guidance from the initial orthotic can be transferred to the ULAW system.

These slides demonstrate the older version of the ULAW. The lingual arch is inserted and acrylic is added around the arch as the patient bites into their initial mandibular splint. The lower teeth form indentations in the acrylic as it hardens. Then the appliance is removed, polished and reinserted to replace the original lower splint or orthotic. This removal of the splint between the posterior teeth allows the approximate of these teeth to the functional position maintained by the anterior and posterior teeth which were approximated previously.

These slides illustrate the removal of the orthotic and the placement of the inter-arch elastics that will begin the posterior dental approximations. The ULAW and the anterior and posterior teeth continue to maintain the functional joint relationship.

The posterior dentition is now being approximated using inter-arch elastics. This usually requires segmental treatments to ensure the anterior and posterior teeth continue to help support the functional joint position will using the ULAW system. Straight wire techniques normally CANNOT accomplish these type of treatments.

The dental alignments are completed and an ideal occlusal relationship is obtained at the functional joint position. In this relationship the teeth, joints and muscles are able to function in harmony and in balance.

The final dental occlusion is now able to function with the joints properly seated, with the least amount of muscle activity and in a way where the occlusion supports and protects the other associated structures.