This video shows a normal joint working in schematic form

The following video shows normal movement and all the soft tissues associated with this joint.

TMD are a family of problems related to the jaw joint. It can develop for many reasons. You might grind or clench you teeth at night, you may have received an injury. Whatever the cause the symptoms are some or all of the following. Pain and other symptoms affecting the head, jaw and face. Headache, tenderness of the jaw muscles, pain surrounding the ear area, dull aching facial pain with severe exacerbation in or around the ear, are common symptoms of TMD. Difficulty in opening the mouth “locking” of the jaw, clicking noises as the mouth is opened or closed, pain associated with opening the mouth very wide e.g. yawning or by chewing if persistent.

Causes of TMJ pain

There are a number of causes but principally it is felt that this pain and other symptoms are related to spasm of the muscles that are involved in chewing. {mastication }.This may be as a result of grinding or clenching the teeth due to stress\emotional tension\habit. Mal-alignment of the internal structures of the joint and therefore the muscles and ligaments which support this joint are not working together properly.
Damage to the meniscus, its attachments or other internal joint problems may also affect the muscles and supporting joint structures and lead to symptoms. Incorrect alignment of the teeth and\or jaws may place additional stress on the muscles and may be considered a factor.

TMJ problems may also be caused by displacement of the joint components as a result of jaw, head, and neck injuries. Osteoarthritis and other forms of arthritis are a rare cause of TMJ problems, but can occur and their management is not isolated to this joint but forms part of the overall care of that form of arthritis.

Treatment of TMJ disorders ( now known as TMD)

Treatment is NOT necessarily surgical. The American Society of Maxillofacial Surgeons recommends a conservative/ none surgical approach first. Only 20% of patients need to proceed to surgery.

( PLEASE NOTE The only registered specialists that treat this problem are Oral & Maxillofacial Surgeons. There is NO specialist category of TMJ specialists and any one purporting to be one is Not legitimate. )

There is no one specific treatment at present; treatment is either physiotherapy type, and is aimed at eliminating the muscle spasm and relieving the pain. The use of occusal appliances ( like mouth guards ) should really only be regarded as “oromandibular crutches”.

“They cannot unload the TMJ; they cannot retrain the muscles: they cannot relieve headache conditions that are neurovascular in origin: they CANNOT recapture discs or produce a ideal occlusion ” ( Klasser & Green Professors from College of Dentistry, University of Illinois.USA.

Do it yourself help for TMJ Pain

• Resting your jaw, this relaxes muscles and takes the pressure of the joint. The key to rest is keeping your teeth apart, eating soft foods and reducing stress.
• Using ice and heat in the combination of ice / cold for 20 minutes and then warmth / heat for 10 minutes. The use of ‘wheat bags’ or a ‘hottie’ both hot and cold are good ways to achieve this.
• Exercises of gentle opening and closing the mouth can be practiced on waking, before meals and at bedtime. Increase the movements gradually, eventually opening as widely as possible but not to the extent of causing any pain. To do this, hold your chin between your forefinger and thumb, and apply mild pressure backwards, slowly opening your mouth keeping the lower jaw pressed back as far as possible. After holding your mouth open for 2 to 5 seconds, slowly close it. Pause and then slowly repeat this exercise. Repeat this programme six times each session, two to four times daily.

Professional help for TMD

• First see and be correctly diagnosed by a registered specialist ,ensure that the professional you are seeing is appropriately speciality registered.
• ( Check using the Dental council or Medical council web sites ) As there are a considerable number of people currently claiming to be TMJ specialists and certainly appear to be legitimate and very plausible but in reality are little more self proclaimed experts.
• Formal physiotherapy and acupuncture. The use of muscle relaxing drugs, and/or non-steroidal anti-inflammatory medication.
• A bite raising appliance is often a very good method of reducing symptoms. This fits over the teeth and prevents grinding and or clenching, often at night. Because of the anatomy of the joint this type of appliance alters the functional relationship of the joint elements and hence helps in symptomatic relief. Its precise of action is not well understood.
• Surgical intervention such as arthroscopy with or without joint surgery and arthrocentesis may be indicated either for diagnosis or treatment.

Above Post Arthroscopic patient. Note very small and cosmetic scars

Whatever the type of treatment this will be organized to be appropriate to the individual patient and can be as simple as medication through to an artificial joint. A lateral x-ray showing a left artificial joint in place

The advent of dental implants has been able to totally solve this problem for most patients.

The implant-supported denture is stable, very retentive and enables most patients to eat and chew the kinds of food they haven’t eaten in years. In some patients biting into an apple is now the norm rather than a wish.

Some patients may require a bone graft to create sufficient bone to place the implants, this now uncommon. The procedure for implant-retained dentures is as follows and I have included some x-rays and photos from my casebook. All of my patients who have undergone this type of treatment wondered why they didn’t do it sooner and I have no patients who have not been more than happy with the end result.

The technique is similar for both the top and bottom jaws. The bottom jaw (mandible) is usually more straight forward than the upper jaw (maxilla). The maxilla requires a minimum of four implants.

The process starts with having the implants placed in the bone. This generally done either under deep sedation or general anesthesia and consists in having precision drilled holes into the bone. The implants are placed into these and the area allowed to heal. The implants may take up to 20 weeks to fully integrate – this is the time taken for the bone to join to the implants and lock them in.

The “locator tops” are placed on the implants instead of the healing caps. This completes the surgical side of the process.

The dentures then have to be adapted with a press stud like tops so they can clip to the locator tops. Whether you need new dentures or not needs to be discussed with the correctly qualified dental technician or your dentist. Once the dentures have been fitted, the dentures will stay in the mouth unless unclipped by you. Needless to say the usual denture hygiene needs to be undertaken. Remember this type of implant retained denture is like any other denture and is not a permanent fixtures. If you want permanent fixtures this is a different process but can be accomplished. The implants should last many years if not indefinitely.

Dental implants could be considered as a third set of teeth. They feel more natural and secure than the traditional removable dentures,especially if these are loose fitting due to bone loss. Implants can also be used to “anchor” dentures into the oral cavity thereby giving denture wearers much more confidence and biting ability than they had with just their plates.
Dental implants allow for the replacement of a single missing tooth [without having to modify adjacent teeth] through to a complete set of missing teeth. These pictures show only a single replacement but multiple teeth can be replaced.

Multiple Implants placed in the jaws for full mouth dental reconstruction

Full mouth reconstruction, crowns and bridges

Dental implants as a general rule are not complicated to place provided there is sufficient bone and gum to accept the implant. Where there has been a quantity of bone and /or gum loss, dental implants may still be used but the area may require pre-implant surgery with bone and gum augmentation.

The type of implant shown in the diagram is the type typical of those that are used to help secure dentures. The “ball head” clips into a special attachment on the inside of the denture, while the rest of the structure is integrated into the bone.
These two pictures show the basic type of implants that are currently available. One has its surface covered with spheres to increase surface area. The other is of a “self-tapping” screw type. There are now many different manufacturers but their products are only variations of these.

Stages

There are really three stages of placing implants although this depends upon the type of implant and what it’s specific function is.
Stage 1.
The implant root component is placed into the bone site. This is a surgical procedure involving opening the overlying gum to expose the alveolar bone. Making the implant socket in the bone and then either screwing the implant in on friction fitting it. The gum is then replaced and the wound closed with stitches. This procedure is done under sedation and local analgesia. After a week to ten days the stitches are removed and the buried implant is allowed to heal for about 20 weeks.
Stage 2.
This is usually a simple procedure and is done under local analgesia alone. The buried, secure implant is uncovered using a small incision in the gum tissue .A “healing coping” is attached to the implant and pokes up through the gum. The gum is allowed to heal around this coping for a period of about two weeks.
THIS COMPLETES THE SURGEONS PART OF THE PROCESS.
Stage 3.
The final post is screwed into the implant and the crown made and fitted.

They are called wisdom teeth because they appear in the mouth at the age one should be starting to be wise at about the age of 15 – 18 years. They may in fact not come through until much later. If they do not fit into the mouth, generally due to a disparity in tooth and jaw size or grow crookedly, they will fail to erupt properly and hence become “impacted”. The combination of pressure from the tooth and overlying irritation or infection of the gums can be very painful. Where the tooth is partially through the gum and becomes inflamed this can become a very troublesome problem and is called pericoronitis. Generally speaking this will often only be relieved by removal of the wisdom teeth.

The x-ray shown here is of a particularly badly impacted wisdom tooth and has the potential to cause major problems unless it is removed. These problems consist of infection surrounding the partially erupted crown.

The follicle ( biological bag )in which the tooth develops may become a cyst and this will leave to the resorption of tooth and bone surrounding the unerupted tooth. As seen in this following x-ray.

The older you are the worse the problem can develop. As the roots continue to grow, even if the tooth cannot go anywhere, this makes extraction more difficult. So most oral surgeons would consider removing your wisdom teeth at a younger age rather than a mature age, especially if they are causing inflammation or problems. Despite this I do “wizzies” on quite a number of older patients, the oldest to date was 84!

When removing wisdom teeth these can be done in a number of ways, even under a local anaesthetic, usually with sedation to make you nice and relaxed or in fact a full General Anaesthetic (GA) which makes you unconscious for the whole procedure. Sometimes the operation may appear to be very difficult and then I may suggest that you have a GA anyway!
I operative in a number of facilities all of which are appropriate operating theatres. These are at:
a) Shakespeare Surgical Suite, Suite 4, 181 Shakespeare Rd, Milford
b) Shore Surgery Ltd, Suite 5, 181 Shakespeare Rd, Milford
c) Mercy Ascot Hospital, 90 Greenlane East, Remuera. Auckland
d)The Northern Clinic, Wairau Road, Glenfield, North Shore

All of these facilities have fully equipped theatres and anaesthetic facilities which meet all the current recommendations of the ANZ College of Anaesthetists. You will normally come into the surgical facility on the morning of surgery, after having starved for at least six hours. The anaesthetist will see you and explain the procedure. I have a number of anaesthetists, all of whom are registered specialists with the medical council and very experienced.

Following surgery most patients are OK with oral pain killers, usually starting with paracetamol (or Panadol), or panadeine (if taken regularly every 4 hours in a decent dose of 15mg/kg., = 1 gram once every 4 hours for an average 70kg person). The Panadol capulets are much easier to swallow than the big round tablets, and they taste better too. Alternatively you might prefer the syrup (especially for kids) or the dissolvable ones, (but NOT disprin or asprin as they can start you bleeding again!)

If there is still some post operative pain then the addition of an anti-inflammatory medication should reduce it to a satisfactory level. Occasionally this is supplemented with a more potent analgesic prescribed by our anaesthetist or myself. The anaesthetist usually gives you some of this in operating theatre and occasionally a prescription for some tablets of this medication to take afterwards.

If you have another anti inflammatory drug such as Cataflam, Brufen or Nurofen at home this will be fine instead, but do NOT take these as well as the prescribed anti-inflammatory. These drugs are not a good idea if you have a history of stomach or duodenal ulcers, a bleeding disorder, kidney problems or if you are taking an ACE inhibitor such as Accupril, Capoten, Renitec, Plendil or Zestril for high blood pressure or heart problems.

You may also get an intravenous antibiotic. This is continued following surgery for approximately 5 – 7 days to minimize the chance of infection. Without this antibiotic the incidence of infection can be as high as 20%. Since the oral cavity is not a sterile environment, and many organisms live there normally, the prevention of these bacteria causing post operative infection is important. You may also get an intravenous dose of steroid called Dexamethasone which reduces inflammation and swelling after surgery.