Occlusal Adjustment at a TMJ Condylar Asymmetry?

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Asymmetry, Centric relation, condylar asymmetry recognition, Dental treatment, Dentistry, Occlusal adjustment, Occlusion, Preprosthetic occlusal adjustment, Retruded Position of the Mandible, TMJ rehabilitation, Treatment planning

Be careful! The tooth contacts which seem to be occlusal interferences at the first sight when the conventional retruded contact position of the mandible is being executed may not be disturbing tooth contacts at all. If they are located on the higher condyle side they may denote the vertical dimension of the inter maxillary relationship and should in my opinion not be removed. Only precontacts on the shorter condyle side are to be looked upon as true interferences and can be removed to such an extent that tooth contacts are established on the higher condyle side.

With the risk of repeating myself I  do want to advise the clinician to build up the occlusion on the shorter condyle side instead of adjusting the teeth through occlusal adjustment on the higher condyle side.In this way we will secure a correct vertical dimension between the two jaws in occlusion and thereby rescue the patient from a too low vertical dimension of the occlusion after completed dental work often jeopardising the function the temporomandibular joints.

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TMD 2015, Condylar Asymmetry?

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Arthrogeneous origin of TMJ pain, Asymmetry, Asymmetry Index, Bruxism, condylar asymmetry recognition, Dentistry, Occlusal device, Retruded Position of the Mandible, Temporomandibular joint diagnostics, Temporomandibular joint disorder, Temporomandibular joint pain, TMJ rehabilitation, Treatment planning

Reflecting back on the interesting information given by eighteen well known international speakers at the Quintessence International Symposium on TMD & FACIAL PAIN and HEADACHE, Bridging the Gap Between Current Research and Clinical Practice in Scottsdale Arizona ( February 6-7,2015, Co-Chaired by Drs Daniel M.Laskin and Charles S.Greene ) I once again would like to stress the importance to recognize a temporomandibular joint condylar asymmetry when present. Several speakers stressed the overloaded temporomandibular joint as the cause of TMD and advised to pay less attention  to the masticatory muscles initially at  the examination of TMD pain. Lack of synovial liquid and mini ruptures or even nano ruptures of the joint tissues are to be looked upon as causes for cartilage degeneration with osteoarthritis / osteoarthrosis as the end result.

It is my opinion that in combination with bruxism a temporomandibular joint condylar asymmetry needs to be acknowledged and addressed. The shorter condyle side joint is in its morphology unstable and easily develops internal derangement of its articulating parts.  The well known phenomenon of disk displacement is thereby a fact and the first step in joint break down with the diagnosis Arthritis microtraumatica art.temp.mand. In this perspective occlusion becomes extremely important . The shorter condyle side joint needs to be supported with the correct vertical dimension of occlusion. What is missing in vertical dimension inside that joint needs to be compensated for at the level of the teeth of the ipsilateral side. In my mind this is the only possibility to create a stable occlusion with the maintenance of improved joint function after the initially reversible approach with an orthotic device.

Finally a statement/question that might need some thoughts: How much longer are we as a profession going to talk about occlusion without considering the vertical dimension of the two temporomandibular joints!?

House of Gnathology?

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Arthrogeneous origin of TMJ pain, Asymmetry, Bruxism, Centric relation, condylar asymmetry recognition, Dentistry, Myogeneous origin of TMJ pain, Occlusal adjustment, Oral Stability, Retruded Position of the Mandible, Temporomandibular joint diagnostics, Temporomandibular joint disorder, Temporomandibular joint pain, TMJ rehabilitation, Treatment planning

A week ago I had the pleasure to attend the XXVII International AIG (Associazione Italiana di Gnatologia) Congress in Torino, Italy. Twentyseven speakers from six countries each had about 30 minutes to present their thoughts about the relationship between occlusion and temporomandibular joint disorders. In general it could be concluded that a stable occlusion would improve the function of the stomatognathic system and thereby reduce the risk for developing or aggravating a temporomandibular joint disorder. It was also underlined in several lectures that gnathology is a team work and that occlusion is one tool in the treatment of a temporomandibular joint disorder.
It was interesting to note that the speakers in general agreed in finding occlusion an important factor in the treatment of a temporomandibular joint disorder, i.e. a complete contradiction to the conclusion of several hundreds of articles and studies proclaiming that when RDC/TMD are used in the evaluation of treatment outcome occlusion is not important and should not get priority or most often not even be considered in the treatment of a temporomandibular joint disorder.

RDC/TMD were discussed and by a great part of the participants even questioned in the final round table discussion of the congress. In my opinion and in agreement with many other clinicians RDC/TMD cannot and should not be used in the clinical situation in which a specific diagnosis is to be the sound base for the treatment. Reliable criteria like maximum mouth opening, mandibular movements, the difference between dynamic and static pain and even the difference between the vertical dimensions of the two temporomandibular joint condyles visible and measurable in a panoramic X-ray exist. Therefore my suggestion to the RDC/TMD supporters is: Next time you conduct a clinical study, why not incorporate the above mentioned criteria! I am pretty convinced that the results will be different regarding the eventual link between occlusion and the temporomandibular joint disorder.

Finally I would delete the ? from the title of this blog and agree with the suggestion from Dr.Eugenio Tanteri that a forum “House of Gnathology” might come to an agreement that a correctly designed and applied occlusion is important in providing  oral stability and thereby reduce the prevalence of temporomandibular joint disorders among our patients.

Tinnitus and TMD

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Asymmetry, condylar asymmetry recognition, Dentistry, Occlusal device, Occlusal splint, Oral Stability, Temporomandibular joint disorder, Tinnitus, TMJ rehabilitation, Treatment planning

Tinnitus in itself is not an indication for dental intervention. However,if tinnitus is mentioned at an examination of facial pain of either myogeneous or arthrogeneous origin there may be a chance to influence its existence. After reviewing some records of patients some years ago and present experience it is my opinion that it is about one third of the patients suffering tinnitus and TMD who will notice a reduction or even a total elimination of their tinnitus from oral stability initially from a stabilization splint compensating for a temporomandibular joint vertical condylar asymmetry, when present.

As it was just one third who reported a benefit regarding their tinnitus it must be up to the patient to decide if it is worth while to invest in an oral device fighting tinnitus. Objective information regarding a dubious result should precede the decision. It is also  important to tell the patient that very often the relief from tinnitus does not come immediately after the insertion of the device. It is reported by several patients that it could take a couple of months before they noticed a difference in their tinnitus. In conclusion: When a stabilization splint is being delivered  in trying to influence a tinnitus the patient might have to wear the splint several months before a change occurs  and before one actually knows if it was beneficial or not. 

Mounting casts

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Asymmetry, Asymmetry Index, Centric relation, condylar asymmetry recognition, Dental laboratory work, Dentistry, Mounting casts, Occlusal adjustment, Occlusal device, Occlusal splint, Occlusion, Oral rehabilitation, Oral Stability, TMJ rehabilitation, Treatment planning

The other day I had to check the mounting of the casts of the upper and lower jaws of a patient with a condylar asymmetry of about 6%. The reason for my visit to the dental laboratory was that the right side lower four units bridge had been redone and several times before that adjusted. And yet the patient found it too low i.e. her teeth of her right side did not contact in occlusion unless she  forced her mandible to the right.

During the visit at the laboratory it became once again obvious to me from the discussions with two well experienced dental technicians that very often the indices to be used in mounting the casts cannot be used. The indices are perforated and mostly show slides in the material used indicating that the mandible of the patient has not been stable at the time of index registration.  Therefore the technicians try to analyze different facets of the occlusal surfaces of the casts. They try to fake the movements of the patients mouth that have created them and thereafter, still manually, they fix the casts in the position which seems to  be the starting point for the suspected movement.This position usually is looked upon as the intercuspal position and will be used for the subsequent mounting of the casts.

At a condylar asymmetry it is therefore easy to understand that with the above described mounting of the casts the crowns or bridges of the ” shorter condyle ” side will be too low. Clinically oral stability will be lacking despite the insertion of the prosthodontic work. Very often tooth contacts of the ” higher condyle  ” side will be looked upon as occlusal interferences and removed in an ” adjustment “.This actually results in a decrease of the vertical dimension and a not one hundred percentage satisfied patient.

The problem and frustration can easily be avoided if the vertical condylar asymmetry is transferred into the Maaxloc instrument. A registration at the clinic or at the laboratory is made  and used in mounting the casts with the result that mostly the prosthodontic work can be inserted  without any adjustment at its delivery.

Asymmetry Index ( AI ) for temporomandibular joint Condylar Asymmetry

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Arthrogeneous origin of TMJ pain, Asymmetry, Asymmetry Index, Centric relation, condylar asymmetry recognition, Dentistry, Myogeneous origin of TMJ pain, Occlusal adjustment, Oral rehabilitation, Oral Stability, Retruded Position of the Mandible, Reversible treatment, Temporomandibular joint, Temporomandibular joint diagnostics, Tension headache, TMJ rehabilitation

For more than twenty years I have been working on a regular basis with Dr Ugo Gambardella, Medical Space in Seriate, Italy. In 1993 we founded the T.A.C. Seriate clinic, ( Team Approach to Craniomandibular disorders ) in order to optimize the diagnostics and treatment of patients suffering facial pain due to dysfunction of the stomatognathic system. Dr Gambardella was already then experienced in prosthodontics as well as in implantology.
Already at the start it became obvious to us that a large portion of the mostly referred patients showed a condylar asymmetry and a lack of oral stability. Initially our treatment aimed at a normalization of the stomatognathic system via a stabilization splint in its design compensating for the condylar asymmetry, when present, and providing at least a temporary oral stability. After 6 – 12 months several patients wanted to have permanent oral stability, which then was achieved through mostly prosthodontics , sometimes in combination with preprosthetic orthodontics.
Some years ago and then more than 5 years after completed treatment the patients were invited to have their situation evaluated and to tell how they felt and how they were functioning after treatment. The equivalent clinical examination of their stomatognathic system was executed by an Italian speaking colleague, who did not know what kind of treatment the patients had got or been exposed to. The teeth depicted in the panoramic overview X-rays were covered i.e. made not visible to the examiner while the two temporomandibular joints were shown.
The condylar asymmetry was analyzed and for each patient an Asymmetry Index ( AI ) was calculated according to the following formula: ( R – L : R + L ) x 100 i.e. the right side condylar height minus the left side condylar height divided by the sum of the right and left side condylar heights multiplied by 100. Thus an asymmetry index was expressed in percentage for each patient.
The results of the subsequent analysis showed that after more than five years with permanent oral stability no patient any longer was found with a mainly arthrogeneous origin of pain. Myogeneous origin of pain was also frequently eliminated or markedly reduced. All patients showed an increase of maximum mouth opening.
The patients were grouped and analyzed according to the asymmetry index ( AI ) . It can be concluded from the results that patients with an AI > 3 % in general benefit from reversible treatment. Patients with an AI in the range between 3 % and 10 % may do well with just a temporary oral stability in form of a stabilization splint i.e. the splint can be worn part time, which for most patients means during sleep. As the participating patients with an AI > 10 % definitely benefitted the most and also felt subjectively completely different, mostly totally pain free after the treatment it is our opinion, that when you find a condylar asymmetry > 10 % in a patient with a diagnosed facial pain, you can comfortably suggest permanent occlusal treatment after the initially reversible period in the correct mandibular position guided by the higher temporomandibular joint condyle. The permanent treatment then executed in the same mandibular position will provide oral stability.

Cutting Temporomandibular Joints

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Asymmetry, condylar asymmetry recognition, Dentistry, Implantology, Occlusion, Orthodontics, Preprosthetic occlusal adjustment, Prosthodontics, Radiography, Temporomandibular joint, Temporomandibular joint disorder, Temporomandibular joint pain, Treatment planning

occurs in surgery. Thank God it does not happen too often, as responsible, well trained and experienced oral / maxillofacial surgeons are utmost cautious. They know it is involved with major draw backs. However, under certain circumstances and with the correct indications it is  necessary. I do not mind that at all, but what I do mind is all the cutting of temporomandibular joints in the panoramic x-rays we are exposed to in the literature and thus unconsciously gives us the message that the joints are not so very important.

It does not matter whether it is in a professional journal of prosthodontics, orthodontics, implantology, periodontics or even in a presentation at a congress it could be estimated that 8-9 out of 10 panoramic x-ray photos presented do not show the entire picture of the two temporomandibular joint condyles. The majority of condyles are cut totally  or at least partially while all the teeth are nicely depicted and aligned in the perfect occlusal plane  often before as well as always after treatment.  Is a vertical condylar asymmetry present in such a patient most likely the teeth are not aligned in the shown or anticipated correct occlusal plane. With a high probability the smile of that patient is tilted which is observed in the clinical situation and which often also might be the reason for the complaint of  the not satisfied patient.

In rehabilitation priority is supposed to be given to the whole stomatognathic system and not only to one third of it. As the other two thirds of the system ( the masticatory muscles and the two temporomandibular joints ) are dependent on the teeth it is my advice that the teeth must be aligned in such a way that they vertically compensate for what is missing in the vertical dimension of the shorter condyle when present. Addressing the vertical condylar asymmetry, when present, is of utmost importance and  in my opinion it should be done already at the time of treatment planning regardless specialty of the therapist. To incorporate an index, preferably via Maaxloc, between the models already at the initial analysis of the ” study ” models instead of just manually having the models to occlude will definitely contribute to a bigger certainty in reaching the goal of treatment. It makes the whole planning easier and it decreases the risk of unnecessary difficulties during treatment. In not accepting cut temporomandibular joint condyles in the panoramic x-ray and instead  only accepting  the picture when it is  complete i.e. picturing  both the temporomandibular joint condyles we most probably will be  expanding our clinical success and consequently patient satisfaction.

Uneven Front Teeth Wear

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Asymmetry, Bruxism, Centric relation, condylar asymmetry recognition, Dentistry, Occlusal device, Occlusal splint, Occlusion, Orthodontics, Preprosthetic occlusal adjustment, Retruded Position of the Mandible, Reversible treatment, Temporomandibular joint, Temporomandibular joint disorder, Temporomandibular joint pain, Treatment planning

may very well denote a temporomandibular joint condylar asymmetry and may therefore indicate the necessity of a panoramic x-ray in order to avoid negative consequences of a dental treatment. It is my experience that very often the front teeth ( the central and the lateral incisors ) of the quadrant of the ” higher condyle ” side are more worn than the equivalent teeth of the contra lateral side. The ” higher condyle ” side seems with a far more higher prevalence be used as the laterotrusive side ( working side ). The contra lateral side of the face then also looks bigger or thicker, most probably due to the unilateral hyperactivity of the superficial masseter muscle of that side. When this kind of an observation is made there is an absolute indication to proceed with a clinical examination in order to rule out whether pain or discomfort are involved.

If pain is present the stomatognathic system needs to get normalized. This is easily accomplished with the insertion of a correctly designed stabilization splint. The splint preferably already at the dental laboratory is  fabricated in the correct relation between the models i.e. the models have been mounted in an articulator according to the index ( registration ) made in the Maaxloc and thereby based upon the difference between the two condylar heights. Within a couple of weeks, not to say surprisingly often within a couple of days, the patient returns with markedly reduced pain or completely without pain. Also without any difficulties the patient normally finds his / her natural way in getting his / her teeth together. However,on the ” shorter condyle ” side tooth contacts are missing. This most often results in a slide between the mandibular reference position, RPM, and the intercuspal position and therefore often indicates a need for extended dental treatment or at least a change of direction of your earlier planned treatment.  The empty space between the teeth of the ” shorter condyle ” therefore needs to be filled in or the teeth of the ” shorter condyle ” side need to be built up. After four to six months and with a reversible approach in form of a partial and casted metal splint cemented on the not occluding teeth of the ” shorter condyle ” side oral stability is achieved. Personally I always have that splint casted in gold and made for the lower premolars / molars. The earlier worn stabilization splint is being adjusted to the new and reversible occlusion and is used part time, during sleep for an individually determined length of time. Finally permanent treatment can be considered at the choice of you and your patient.

Uneven front teeth wear occurs and is also sometimes observed in young patients.In these individuals it may be even more important to analyze the vertical dimensions of the two temporomandibular joint condyles. At a condylar asymmetry an index via Maaxloc may serve as an adequate guide to relate the upper and lower models of the teeth, indicating the correct vertical dimensions of the jaws after completed treatment and thereby contribute to the best outcome of the orthodontic treatment. In not addressing the condylar asymmetry, when present, in the initial phase of treatment planning there is always the risk to deliver a yet perfect occlusion but in a not perfect occlusal plane, i. e. a perfect smile what concerns the teeth but less perfect what concerns the smiling mouth of the whole face.