When a TMJ TMD diagnosis and decision to treat is made, the first step in therapy is to relax the masticatory muscles, which are in a state of hyperactivity, fatigue or in spasm. This is done with TENS or Transcutaneous Electrical Neural Stimulation. This procedure uses a minute electrical current generated by a 9-volt battery. It relaxes the facial muscles.
Usually TENS is used for one hour, sometimes longer. Feeling a series of rhythmic taps on the cheeks, patients can read or nap during TENS therapy. It is like an electronic massage of the facial muscles. This is preferable to medication, which can also relax muscles throughout the body resulting in unwanted side effects. This procedure comfortably and effectively relaxes the facial and jaw muscles with minimal electrical stimulation.
Before and After TENS
Establishing the new occlusion (bite) position
Following the TENS procedure, the resting jaw position is recorded, as are changes in the resting activity of the muscles with EMG. The arc of jaw movement during the TENS is recorded on the computer to help the doctor in selecting a new treatment occlusal position (bite) near the rest position of the mandible. This information constitutes the "road map to health" for the entire temporomandibular system including muscles, nerves, joints and teeth.
Using the information obtained from the computerized recordings of jaw movement and muscle function, and the registration of the new bite position, the doctor constructs a tooth-colored orthotic appliance (orthosis). It is prepared with detailed tooth anatomy to provide a stable biting position. The orthosis, commonly called a "splint," comfortably fits over the lower back teeth and passes behind the front teeth, where it can remain invisibly for several months. Worn 24 hours a day, this precise appliance is removed only for cleaning the teeth and the splint. The orthosis permits the jaws to come together in a muscularly healthy position, retraining the muscles to move along a more natural, muscularly oriented pathway into the new occlusion. Patients often report experiencing a significant symptom improvement within a month, while wearing this comfortable appliance.
Following three months of full-time use of the splint, patients are asked to return for a second computerized study of their jaw and associated muscle function. Based on test data, together with the patient's symptom improvement, the outcome of the initial treatment is evaluated and options for additional therapy discussed.
After three to six months wearing the splint, a patient may elect to perpetuate the new healthy biting position either through restoration, shaping of certain teeth, or the use of a removable, durable long-term appliance. Another way to insure the new bite is through a process called passive eruption. The splint's plastic covering over the rearmost tooth on each side is removed, permitting the last teeth on the top and bottom to erupt naturally as they did when they first entered the mouth. This process, when successful, is repeated by uncovering the next pair of teeth when the rear-most teeth reach the new bite position.
Some patients chose not to wear the orthosis full time, and not to change their natural occlusion. Instead, they may use the orthosis part-time or discontinue usage of the appliance completely unless symptoms reappear. If symptoms reappear, the orthosis can again be used.
A very small percentage of patients with TMJ / TMD require evaluation and possible surgical intervention to treat their illness. Except in cases involving severe traumatic injury, which prohibits mandibular function, surgical intervention is usually not indicated as an initial treatment. If conservative treatment, such as splint therapy, has not promoted comfort and proper jaw function, surgical evaluation may be appropriate.
With the complex interconnection of the temporomandibular joints and the joints of the upper cervical spine and skull, when necessary the neuromuscular dentist may seek collaborative efforts with upper cervical chiropractors, physical therapists, massage therapists and myofunctional therapists who may dramatically increase the positive outcome in the treatment of TMJ TMD disorders. When indicated, the dentist will refer a patient for medical evaluation which could include the specialties of neurology, otolaryngology (ENT), ophthalmology, internal medicine, rehabilitation medicine and pain management.
Dental occlusion refers to the coming together of the upper and lower teeth. Neuromuscular occlusion occurs when the dental occlusion is synchronized (coordinated) with healthy relaxed masticatory (chewing) muscles. The concept of neuromuscular occlusion has applications in the treatment of dental patients as well as in the treatment of patients suffering from TMD.
Dental patients, as well as TMJ / TMD patients, may not have a comfortable, stable, neuromuscular occlusion. Their muscles can be overactive when they are supposed to be rested, and can be weak or uncoordinated when chewing foods or even in swallowing saliva. This muscle-system condition can predispose a healthy person without symptoms to future TMD.
Patients whose dental occlusion requires major alteration, such as in the fabrication of dentures or extensive dental reconstruction, may benefit from improved muscle function. The creation of a muscularly healthy neuromuscular occlusion, using the computerized measurement instrumentation described here, can be a valuable aid in accomplishing improved dental occlusion with comfort, function and health.
Rest position of the jaw exists most of the time when the upper and lower teeth are not in contact. At true rest, which is the position at which a person should ideally keep the jaw, except during eating and swallowing, the mandible is suspended in space, anchored at the two temporomandibular joints. The jaw is positioned in place by a set of both opening and closing muscles on both sides of the head, all of which are at full resting length. This is like the strings, which attach a hammock to two trees. In this rest position of the jaw, the upper and lower teeth are usually apart with about one to two millimeters of space between them.
At true rest position, all the muscles, which support and move the jaw, are at rest. That should be the status most of the time. This is like the two sets of muscles attached to your arm, one set pulls the arm upward and the other set pulls it downward. When your arm is truly at rest, hanging at your side, both sets of muscles are rested and at their resting length. Returning to the description of the jaw muscles, only during function, such as speaking or eating, is the jaw moved from rest position. When eating or swallowing saliva the jaw moves upward and forward to bring the teeth together. That is called occlusion. Each time swallowing occurs, 2,000 times throughout the day and night, the jaw is normally braced against the skull through the teeth to permit the reflex of swallowing to occur.
However, if the distance between the upper and lower teeth when the mandibular muscles are completely at resting length is more than two millimeters, the distance and/or time necessary to travel into occlusion is too great. Because of the excessive space between the teeth, people develop an adaptive, accommodative, false resting (pseudo-resting) or partially resting accommodative position of the jaw, to maintain the one to two millimeter resting space between the teeth. This keeps the muscles in a constant state of work, not rest. If the muscles that posture (hold the jaw up) and move the jaw are not allowed to fully rest, tension, resulting in muscle fatigue, dysfunction and sometimes spasm can result. That is a key to understanding one of the ways in which Temporomandibular Disorders (TMD) can occur. It is one of the common hidden causes of TMJ TMD or a predisposition to developing TMD.
There is far more in the makeup of a good, healthy, comfortable bite than just the manner in which upper and lower teeth fit together and the esthetics of the teeth. When the dental occlusion is synchronized with healthy balanced muscle function, muscles can fully rest at the rest position of the mandible and work effectively with balanced strength when called upon during chewing. The creation of a neuromuscular occlusion is a key element in the treatment of those Temporomandibular Disorders, which are caused by an unhealthy dental occlusion. The comfortable bite is a healthy, neuromuscular occlusion.