tmj pain dentist charlotte north carolina nc bite occluso muscle disorder
Form follows function
Welcome to the most under diagnosed and under treated cause of dental disease,Occluso-Muscle Disorder (an unbalanced bite). Occluso-Muscle Disorder results in a group of symptoms we call Occlusal (Bite) Disease.
Click on the following to understand the four basic criteria for a balanced bite:
The following is from Functional Occlusion, From TMJ to Smile Design by Peter Dawson (As all Charlotte, NC dentists would agree, a world renowned dental clinician and authority on this stuff):
Occlusal disease is deformation or disturbance of function of any structure within the masticatory system that are in disequilibrium with the harmonious interrelationship between the TMJs, masticatory musculature and the occluding surfaces of the teeth.
The anatomical structures involved in the bite or occlusion are the teeth, the periodontium the jaw muscles and the jaw joints or TMJs.
These four components are anatomically and functionally connected and one directly affects the other. As a concerned Charlotte North Carolina dentist, I am continuously educating patients about the how the bite or occlusion affects these structures.
We spend a lot of time in our practice balancing the bite for our patients so the jaw muscles, the jaw joint and the teeth are working with each other instead of against each other. Deficient coordination between these components will lead to continued and new dental disease. Any knowledgeable dentist would agree with this statement.
According to Peter Dawson:
"Attention to occlusion would be elevated to a much higher priority if the following observations were more universally noticed and analyzed.
Occlusal disease is:
• The #1 most common destructive dental disorder.
• The #1 contributing factor to eventual loss of teeth.
• The #1 reason for needing extensive restorative dentistry.
• The #1 factor associated with discomfort within the masticatory system structures. This includes pain/discomfort in the musculature, the teeth, and the region of the temporomandibular joints (TMJs).
• The #1 factor in instability of orthodontic treatment.
• The #1 reason for soreness and hypersensitivity.
• The #1 most commonly missed diagnosis leading to unnecessary endodontics.
• The #1 most undiagnosed dental disorder until severe damage becomes too obvious to ignore."
In our Charlotte NC office we perform several important procedures as we diagnose and treat unbalanced bites (Occluso-Muscle Disorder). These include a TMJ and jaw muscle exam and an Occlusal (Bite) Analysis, Mounted Case (ADA procedure code: D9950). The Occlusal Analysis, Mounted Case is the most definitive analysis of the relationship of the jaw joint structures (TMJs), the jaw muscles and the occlusion or bite of the teeth. Along with this analysis we routinely perform an Occlusal (Bite) Adjustment, Complete (ADA code D9952). These procedures along with others will accomplish the following for my patients:
- Maximize proper function of the teeth, jaw joint and jaw muscles
- Maximize comfort in all the oral structures (teeth, joint and muscles)
- Minimize future dental disease (cavities, root canals, TMJ disease and periodontal disease)
- Maximize the life of completed dental treatment (fillings, crowns, bridges, implants, cosmetics procedures and periodontal (gum) procedures)
- Maximize esthetic or cosmetic appearance of dental treatments.
As a dentist who has been practicing for over 25 years, I find these procedures to be invaluable to achieve the best results for my patients. Many elite dental academiesand study centers support this concept.
Excessive grinding of the teeth or bruxism is another contributing factor to occlusal disease.
TMJ and Muscle exam.
A thorough examination of the TMJ (jaw joints) and jaw muscles (tmj and jaw muscle exam) is an integral part of our new patient examination at our Charlotte NC practice. An excellent dentist understands that the jaw muscles and TMJ are directly connected to the teeth and therefore the occlusion or bite. These structures cannot be ignored if we are treating our dental patients in a complete manner. It is important to get a base-line assessment of these structures to know if any damage has been and how these structures are presently functioning. If they are not functioning correctly then we can never achieve optimal dental or whole body health and our dental treatment cannot provide the best possible long term result for our Charlotte North Carolina area patients.
There are many jaw muscles involved in jaw movement and the
occlusion or bite can affect these positively or negatively.
Palpation to test for tenderness or pain in the jaw muscles.
TMJs (jaw joints):
palpation of jaw joint (TMJ) to check for tenderness or pain
loading of jaw joints (TMJs) to check for tenderness or pain
Doppler device is an ultrasound instrument that amplifies joint sounds during movement. A diagnosis of the health or derangement of the joint can then be made.
Doppler auscultation performed on TMJ.
Jaw muscles in more detail:
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Damage and dysfunction in the joint itself can cause pain in the joint. Some of the common causes for pain in the TMJs are listed here.
- Occlusal-Muscle Disorder
- Acute trauma/injury (e.g. car accident, punch in the jaw, a fall
- Joint disease (infection, autoimmune)
More general info:
The temporomandibular joint is the joint of the jaw and is frequently referred to as TMJ. There are two TMJs, one on either side, working in unison. The name is derived from the two bones which form the joint: the upper temporal bone which is part of the cranium (skull), and the lower jaw bone called the mandible. The unique feature of the TMJs is the articular disc. The disc is composed of fibrocartilagenous tissue (like the firm and flexible elastic cartilage of the ear) which is positioned between the two bones that form the joint. The TMJs are one of the only synovial joints in the human body with an articular disc, another being the sternoclavicular joint. The disc divides each joint into two. The lower joint compartment formed by the mandible and the articular disc is involved in rotational movement—this is the initial movement of the jaw when the mouth opens. The upper joint compartment formed by the articular disk and the temporal bone is involved in translational movement—this is the secondary gliding motion of the jaw as it is opened widely. The part of the mandible which mates to the under-surface of the disc is the condyle and the part of the temporal bone which mates to the upper surface of the disk is the glenoid (or mandibular) fossa.
Pain or dysfunction of the temporomandibular joint is commonly referred to as "TMJ", when in fact, TMJ is really the name of the joint, and Temporomandibular joint disorder (or dysfunction) is abbreviated TMD. This term is used to refer to a group of problems involving the TMJs and the muscles, tendons, ligaments, blood vessels, and other tissues associated with them. Some practitioners might include the neck, the back and even the whole body in describing problems with the TMJs.
The TMJ is a ginglymoarthrodial joint, referring to its dual compartment structure and function (ginglymo- and arthrodial).
The condyle articulates with the temporal bone in the mandibular fossa. The mandibular fossa is a concave depression in the squamous portion of the temporal bone.
These two bones are actually separated by an articular disc, which divides the TMJ into two distinct compartments. The inferior compartment allows for rotation of the condylar head around an instantaneous axis of rotation, corresponding to the first 20 mm or so of the opening of the mouth. After the mouth is open to this extent, the mouth can no longer open without the superior compartment of the TMJ becoming active.
At this point, if the mouth continues to open, not only is the condylar head rotating within the lower compartment of the TMJ, but the entire apparatus (condylar head and articular disc) translates. Although this had traditionally been explained as a forward and downward sliding motion, on the anterior concave surface of the glenoid fossa and the posterior convex surface of the articular eminence, this translation actually amounts to a rotation around another axis. This effectively produces an evolute which can be termed the resultant axis of mandibular rotation, which lies in the vicinity of the mandibular foramen, allowing for a low-tension environment for the vasculature and innervation of the mandible.
The necessity of translation to produce further opening past that which can be accomplished with sole rotation of the condyle can be demonstrated by placing a resistant fist against the chin and trying to open the mouth more than 20 or so mm.
There are six main components of the TMJ.
Mandibular condyles Articular surface of the temporal bone Capsule Articular disc Ligaments Lateral pterygoid
Capsule and articular disc
The capsule is a fibrous membrane that surrounds the joint and incorporates the articular eminence. It attaches to the articular eminence, the articular disc and the neck of the mandibular condyle.
The articular disc is a fibrous extension of the capsule in between the two bones of the joint. The disc functions as articular surfaces against both the temporal bone and the condyles and divides the joint into two sections, as described in more detail below. It is biconcave in structure and attaches to the condyle medially and laterally. The anterior portion of the disc splits in the vertical dimension, coincident with the insertion of the superior head of the lateral pterygoid. The posterior portion also splits in the vertical dimension, and the area between the split continues posteriorly and is referred to as the retrodiscal tissue. Unlike the disc itself, this piece of connective tissue is vascular and innervated, and in some cases of anterior disc displacement, the pain felt during movement of the mandible is due to the condyle compressing this area against the articular surface of the temporal bone.
There are three ligaments associated with the TMJ: one major and two minor ligaments.
The major ligament, the temporomandibular ligament, is actually the thickened lateral portion of the capsule, and it has two parts: an outer oblique portion (OOP) and an inner horizontal portion (IHP).
The two minor ligaments, the stylomandibular and sphenomandibular ligaments are accessory and are not directly attached to any part of the joint.
The stylomandibular ligament separates the infratemporal region (anterior) from the parotid region (posterior), and runs from the styloid process to the angle of the mandible.
The sphenomandibular ligament runs from the spine of the sphenoid bone to the lingula of mandible.
These ligaments are important in that they define the border movements, or in other words, the farthest extents of movements, of the mandible. Movements of the mandible made past the extents functionally allowed by the muscular attachments will result in painful stimuli, and thus, movements past these more limited borders are rarely achieved in normal function.
Other ligaments, called "oto-mandibular ligaments", connect middle ear (malleus) with temporomandibular joint:
discomallear (or disco-malleolar) ligament, malleomandibular (or malleolar-mandibular) ligament.
Innervation and vascularization
Sensory innervation of the temporomandibular joint is derived from the auriculotemporal and masseteric branches of V3 (otherwise known as the mandibular branch of the trigeminal nerve). These are only sensory innervation. Recall that motor is to the muscles.
Its arterial blood supply is provided by branches of the external carotid artery, predominately the superficial temporal branch. Other branches of the external carotid artery namely: the deep auricular artery, anterior tympanic artery, ascending pharyngeal artery, and maxillary artery- may also contribute to the arterial blood supply of the joint.
The specific mechanics of proprioception in the temporomandibular joint involve four receptors. Ruffini endings function as static mechanoreceptors which position the mandible. Pacinian corpuscles are dynamic mechanoreceptors which accelerate movement during reflexes. Golgi tendon organs function as static mechanoreceptors for protection of ligaments around the temporomandibular joint. Free nerve endings are the pain receptors for protection of the temporomandibular joint itself.
In order to work properly, there is neither innervation nor vascularization within the central portion of the articular disc. Had there been any nerve fibers or blood vessels, people would bleed whenever they moved their jaws, and movement itself would be too painful.
TMJ, Jaw Joint Damage
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Instability hurts and causes damage.
TMJ Jaw Joint Damage:
How the teeth hit each other affects the jaw joint structures. I am constantly educating my Charlotte NC are patients on this fact. The bite or occlusion can benefit the jaw joints (TMJs) or it can damage them. Ideally, all Charlotte NC dentist/dentists should know how to diagnose the condition of the TMJs before commencing treatment. When the occlusion or bite is working against the jaw muscles it is called Occlusal-Muscle Disorder
A dissected healthy jaw joint showing the slippery disc between the bones:
The following diagrams show how a healthy mandible and disk moves in a coordinated manner during opening:
In a healthy joint and balanced bite, the disk is between
the upper and lower bones in the TMJ (red lines line up).
For approximately the first 1/3 of opening the condyle
only rotate in the joint and stays in the same position:
As the jaw continues to open the condyle translates
forward and down and the disk remains between the bones.
At full opening the condyle moves forward and down more
while the disk stays between the bones. The opposite
movements of the condyle and disk occur during closing.
A healthy and undamaged disc.
A disk damaged from occluso-muscle disorder or unbalanced bite.
The amazing thing is that highly inflamed, infected and damaged tissue like the above damaged disc, does not usually cause pain. Like periodontitis, atherosclerosis, autoimmune disease and other disease that cause chronically inflamed tissue, it does not hurt until major damage is done. In the mean time, the painless chronic inflammation is slowly "killing" you.
One common outcome of joint damage is osteoarthritis or degenerative joint disease:
The following is from the U.S. National Library of Medicine:
"Osteoarthritis is caused by 'wear and tear' on a joint.
- Cartilage is the firm, rubbery tissue that cushions your bones at the joints, and allows bones to glide over one another.
- Cartilage can break down and wear away. As a result, the bones rub together, causing pain, swelling, and stiffness.
- Bony spurs or extra bone may form around the joint, and the ligaments and muscles around the hip become weaker and stiffer."
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Damaged TMJs (jaw joints) are chronically inflamed. All chronically inflamed tissue in the body eventually becomes infected with microbes:
Microbes and inflammatory chemicals from damaged oral structures leach into the blood stream to cause inflammation and damage to the rest of the body: