TMD and Malocclusion

By Joseph Gronka Unpublished

Malocclusion is the misalignment of teeth between the upper and lower. Two teeth or more. The contact between these teeth causes the maximum intercuspal position to bring about the displacement of the mandible to a position that is muscle guided (learned? in some cases, habitual). In order to be able to achieve this acquired position on swallowing, the muscles must work "overtime"  24/7. This leads to hypertonicity and at times hypertonicity results in spasm with resultant pain that we term TMD. At times this pain is reflected in the TMJ. This is the result of a latero-posterior displacement of one or both condyles.
TMD/TMJ is, in my opinion, the most troublesome for all who have their first 28 teeth. At times it can affect children with mixed dentition and primary teeth. In youngsters occlusal problems manifest themselves in grinding. Lets start there. We all recognize that grinding the teeth, especially in a very young child, is abnormal. In every instance you will find malocclusion at the source. BUT, they're are so young, best to wait until they get their permanent teeth or wait until the 6s come in, or wait... The best time to treat a malocclusion is at the time of recognition. My youngest patient was almost 4. The longer we wait the worse the side affects. Habits become ingrained, discomfort in the form of "hurt" are not recognized by the child as relating to the teeth. They seldom complain about there teeth let alone their occlusion. Parents are completely unaware that a problem exists. By waiting, the problem only gets worse. It was worth repeating. Because you do not see the problem does not mean it does not exist. It would be the best of all possible worlds (for me) if we as dentists become so aware of malocclusion and the consequences of non recognition and no treatment, that it becomes our priority. The earlier the treatment is begun, the easier it is and we get a chance to prevent many undesirable sequelae. We can even get interested to the point we can practice interceptive orthodontics. That is the path that I chose. What if we sent these cases to the specialists, very early, so that the pedodontist or orthodontist has an opportunity to intercede and follow the growth and development of a child and introduce therapy in a timely fashion, maybe the resulting ortho case could be treated far more easily and in less time. So many FJO appliances are available. A simple thing as correcting a class II to class I makes equilibration so much easier. At times this is enough to complete a case. Correcting a x-bite is relatively easy with either fixed or removable appliances (my choice). There are some compliance problems at times. I place this responsibility on parents in young children and on the patients in those old enough to understand the importance of such therapy. Adults must take responsibility for their own health and comfort. I never "worry" about compliance. In most cases I simply tell the patient/family. "the problem is not mine". I can only help by correcting the situation caused by the problem. If you wish to get specific about cases, email the particulars and I will reply.
Children ought not to snore. A snoring child is a red flag. There is a problem with upper airway obstruction. Please encourage the parents to find a Pediatric ENT. It is likely that the adenoid tissue is closing the nasal passage. This creates a "mouth breather. Mouth breathers have cross bites and a host of other related problems with growth and development. WE are almost always the first ones to see this. Try to develop a good working relationship with one of these Pediatric ENTs. More details? write with particulars.

TMD in ages 12 through adult is no different in the recognition and treatment (early/timely). Keeping in mind what constitutes a malocclusion you have to recognize, diagnose the problem. After evaluation, prescribe a course of treatment. This is not easy at first. There are variations in what may appear to be the obvious, at first. Quite often, the cervical vertebrae are involved due to misalignment. Maybe they are simply elevating a shoulder so that the "shoulder bag" won't slip off. Sometimes it may be affected by posture, especially during sleep. You have to learn to ask the right questions. There may be spasm in the trapezius m/mm. Maybe includes a shoulder problem. This is where my friendly DC came in. I would have him evaluate those things that I considered problematic and make the necessary corrections. Sometimes the TMD problem disappeared with the DC treatment. Wonderful. Makes you look like a hero for seeing "something" that maybe others overlooked.
Case: Young male 15 yo. Mom brought him to my office because her relative, a C&B tech heard about me. Referred her. I was doing an exam on another pt. She and son stood behind me at a distance 5-6'. She was telling me about their experience. He had to quit football because he would fall down while running. This caught my attention because I had the same problem in college and forced me to take arly retirement. Sorry. Memories. Anyway, they were on their way home from a Dr appointment at a very prestigious hospital. The verdict was "nothing is wrong with him" Ha, I know better. Kids his age don't fall down while running. I turned to look at him and asked him to "stand up straight". As expected, he said "I am". With that, I asked Mom to step behind me. She hollard at him to "stand up straight". She began to get flustered because he would not comply with our commands. So I said to her, there is the problem. He has a spinal problem and needs to see a good chiropractor. I referred him to my friend's son. The following week he was back at practice and fortunately for him, and me, we naver saw each other again. Wonderful.
Another case: 14 yo female: Mother is with her. She "has a TMJ". Of course I cannot resist this. I looked at her and said she has two. Only dentists understand. Anyway, after a brief intra oral exam. I had her stand. She had already been seated. First thing that was very noticeable was that her left shoulder was about 3" below the imaginary horizontal plane consistent with the notch and the right shoulder. She was tilted. This always means a spinal problem, mostly subluxation of a vertebra or two. Referred to DC. Fine by the following week. Yes, she carried her book bag? other heavy objects on one side habitually. The resultant muscle spasms distorted the spine. My take, judging from experience.
I do not want to get involved with case studies here. Just know that not all "TMJ" cases  really involve the joints. Internal derangements are the result of neglected external forces operating over a prolonged time period. You and I of course know now that if we treat the malocclusion successfully, they also resolve. The body is marvelous. We just have to create conditions in which healing can take place. That is where appliance like the MORA are useful.  Very important. Do not attempt any irreversible "adjustments" in the presence of poor muscle tone. Take this further, every restoration we place should also be placed with muscles in good tone. So the question is why do we get away with our ignorance. Very simple.
Centric Relation is an area, not a point. If we restore teeth so that the restoration does not interfere with that area relationship, we will, most likely, restore to a place within the physiologically acceptable position. No consequences. The body is marvelous.
We all see disease and we all see what we perceive to be health. But of the two, health is much more difficult to asecess Between the two extremes there lies a grey area. Which implies How. To what degree, health/disease. Most of us are in that grey area. Placing restorations with disregard of muscle health may prove to be the the path toward bruxism, poor muscle tone in the head and neck etc. But we will recognize the problem eventually as "disease" or at least  a TMD problem.