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image1The joint surgery corrects the damage to the joint structures, but it does not determine how the other structures can or should relate. An orthotic was used in Phase I treatment (as seen to the left). Physical therapy was also used during the initial treatment to help determine the functional bite position. In this patient’s case, the orthotic and physical therapy were used for 6 months following the joint surgery. The functional position needs to be maintained long-term in Phase II treatment.
image2This patient chose TMJ orthodontics for Phase II treatment. Arch dimensions were corrected to help maintain breathing and airway stability as the teeth are made to support the best functional mandibular / maxillary relationship as seen in the picture to the left. The orthotic was used at the beginning of treatment, and gradually reduced as treatment progressed.
image3The final mandibular / maxillary association was maintained (right) with an occlusion made to support the best functional bite position. The final bite position (below) maintains the optimal bite relationship now 14 years after the joint surgery and the patient has remained functional with minimal pain or limitations.
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We believe conservative treatment developed over the past 40 years is the best option and only refer patients to oral surgeons who provide optimal results, when surgery is necessary. We treat our patients as we would like to be treated. It is very common to hear, “Thank you for giving me my loved one back”, “I’ve been looking for you for 20 years”, and “I am so grateful for your office.” My office staff would be pleased to help your patients experiencing TMJ issues. Please let us know if we can help.

Insurance Consultants Are Referring Patients to Themselves

Within the last few years it has become more apparent that some dentists, serving as insurance consultants, are referring TMJ patients to themselves for examination and treatment. You might think it is either unethical, or violates some dental board ruling for this to occur. In a phone conversation, the Missouri Dental Board informed me that an insurance company may refer a patient anywhere they desire and to whomever they want, even to their own consultant. The following three patients had problems with this self-referral system.

Patient #1

image5This patient slipped on ice and was informed that she had to have surgery to repair the damage to her joints as she had a very restricted opening. She was referred by the insurance consultant to himself. The surgery was a bilateral condylectomy, eminectomy and discectomy. Her symptoms increased even though her treatments were completed and she had been dismissed from care.
Upon a second opinion refer to our office, our examination and diagnostic procedures demonstrated a significant mandibular / maxillary discrepancy with an inability to open or function. No conservative means were able to overcome the initial surgical results, so a surgical consultation and a subsequent second surgery were performed by a different oral surgeon who replaced both joints with TMJ Concepts joints. The second surgeon stated he has not performed a condylectomy, eminectomy and discectomy for over 30 years as it provides insufficient results.
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The above photo shows patient #1 after the second surgery where her joints were replaced with TMJ concepts joints and a maxillary Le Fort osteotomy for both an airway improvement and to reposition her maxilla. We completed here treatment with TMJ Orthodontic methods. She has been able to control her pain, can open 40mm, has returned to work and is maintaining an active lifestyle. The initial option to perform surgery alone was an inappropriate choice as it could not correct the multi-dimensional problems that existed.

Patient #2 – The Ball Missed the Socket

This next patient had a non-recapturable internal joint problem that required joint replacements. The patient was referred to an oral surgeon who helped develop the TMJ Concepts joint replacement therapy. The insurance consultant refused to allow the referral as he referred the patient to himself.
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The surgical results demonstrate the failure where the right condyle is positioned in the posterior aspect of the joint against external auditory meatus. The left condyle was positioned anterior to the implant against the base of the cranium. Unable to afford a second surgery, the patient remains in this position.

Patient #3

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As the patient completed the pre-surgical phase, he was referred to an oral surgeon who happened to be in our office the day of the consultation. This referral was not approved, as the insurance company consultant referred the patient to himself for surgery. However, the insurance consultant’s office was the provider of Patient #1’s surgery that had complications. The patient’s attorney forwarded the following:
Missouri law states “if it is shown that the requirements of care are being furnished in such a manner that there is reasonable grounds for believing that the health or recovery of the employee is endangered, thereby, the division may order a change of surgeon, hospital or other request.”

Managing Joint Replacement Patients

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A delicate balance exists between the upper quadrant structures. These structures either work in harmony or become compromised. When the anatomical parts fail to work in harmony, many patients feel one or all of the following: headaches, neck pain, ear aches, ear ringing, facial pain, muscle strain or tightness, joint pain, clicking/popping/noise upon opening or closing the mouth, dizziness, and occlusion mal-alignment. Harmony must be established and maintained before and after surgeries.
TMJ surgery corrects damage to the joint structures, but surgery does not address external causes related to compromise. In TM surgery case, a functional relationship is established post-surgery. We must find how the joints, muscles, head, neck, and occlusion best relate to each other. This functional association is established and maintained throughout the completion of treatment. The above patient had TMJ concept surgery to replace both of her degenerated joints in 2001.

About Keller Dental Group

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