The Cause, Pathology, Diagnosis and of Temporomandibular Joint Disorders by Dr. Clayton Chan

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“The relatively small joint can become relatively incurable”.  THIS IS NOT TRUE.
(Some clinicians give’s their perspective from an orthodontist/orthotropic perspective, which is his opinion).

We Can Agree on Temporomandibular Joint Anatomy and Abnormal Positioning

We all agree on how the anatomy and function of the temporomandibular joints work. He references Lund’s scandanavian study regarding children whose joints were supposedly fractured joints and that 95% of these cases all reformed back to normal. The question is what part of the masticatory system is NORMAL. How does one define NORMAL? Observation awareness of normal or by objective physiologic measurements to define normal?

Many dentist agree that condyles can change and alter on the surface morphology, but the notion that fractured joints can reform back to normal 95% of the cases is far beyond the norm and clinical reality of what many TMD clinicians are observing when treating adult TMD and imaging these temporomandibular joints routinely.

We agree that habitual occlusion often may show condyles up and back in the fossa, while teeth apart may show condyles down and forward. His “orthotropic” theory is not unique to the dental community, but in fact the community of dentistry have recognized these issues for many years prior to his proposed theory as recognized by Costen (Costen’s Syndrome) from the early 1934. Otorhinolaryngologists and members of the dental profession have recognized varying degrees of differential diagnosis of recurring facial pain. Literature acknowledges these TMD muscular occlusal issues, occipital pain, sensitive teeth, abnormal tongue habits and posturing along with airway breathing issues and more that can contribute to the disturbance of temporomandibular joint function. Even more a disturbance of the musculature that drives the joints and upper and lower jaws.

90% of TMD Pain Comes from Hyperactive Muscles

Remember it is the muscles that are 90% of the TMJ patients complaint and problem of TMD disorder. Our profession for some odd reason tends to focus on the TM joints themselves as if they are the source of the problem, (it is NOT). The fact of the matter is the hyperactive muscles is the problem to which many pain patients seem to realize, but the dentists as a whole tend to overlook. This is where we differ in our emphasis to TMD diagnosis and treatment.

The pathology observed as either malocclusion from any cause or destructive changes of one or both mandibular joints is a result of a driving force (MUSCLES). Pain comes from ABNORMAL MUSCLE ACTIVITY, and to lesser degree from the TM joints themselves. The resultant abnormal pressure to the glenoid fossa contributes to condylar changes as well as partial or complete closure of the internal auditory canal, accounting for the “stuffy deaf” ear congestion sensation so common to TMD are from muscles. The diverse and seemingly unconnected neuralgic pains are due to either direct nerve compression within the abnormal joint all stemming from abnormal muscle activities that are a driving force that contributes to abnormal tooth wear, tooth fracture, tooth loss, gum recession, condylar changes within the fossa as well as tension/migrainous type pains to the head, neck, occipital regions, shoulders and neck regions.

Why Do Specialist Focus on the Temporomandibular Joints

Why do specialists focus on these small joints when the bigger and larger issues is technical the musculature to which most of those who are on these forums are complaining about (their pains). It is what is if not partially impairing them and or disabling them because of the abnormal muscles not functioning in harmony with good occlusion. The abnormal muscle functioning that is going on causes the underlying boney structures to strain, distort, bend, flex and alter….thus leading to an out of balanced structural, occlusal and masticatory system.

As a reminder to all, the masticatory system is not comprised of 80% joints, and 5-10% teeth/occlusion and only 10% muscles and nerves, but rather a different percentage to these areas of anatomy when we study them and convey are theories should be altered to reflect clinical and TMJ form realities. If we asked our forum members what entities of their TMD are giving the ill feelings I believe a greater majority would say 80-90% of their TMD pain is related to muscles. Lesser degree to joints, etc.

RELAX THE MUSCLES, support the calm muscles with proper occlusion that fits calm muscles and you have happy joints and resolution of TMD. You ignore the muscles, focus on joints, ignore teeth teeth and or try to build splints to unhappy joints without recognizing muscles and you have confusion and opinions.

OBJECTIVE MEASUREMENTS lead to Different Conclusions and TMD Understanding

Objective measurement test studies of swallowing movements have proven that aberrant tongue posture between the teeth contributes to intrusion of the posterior teeth (mal alignment of teeth and jaws), stunted vertical growth patterns of the teeth and jaws. As a result the condyles will compress themselves furthering joint and disc derangement problems. Swallowing with teeth a part is not a normal thing, but rather a pathologic force (different than Dr. J. Mew’s “orthotropic” belief). Abnormal tongue swallowing habits only perpetuates abnormal joint positioning with clicking and popping joints. A truly centered joint doesn’t function with clicks and pops during opening and closing jaw movements. If it does it only further contributes to a war between muscles, joints and teeth. Hyper active muscles will try to close the jaw to some over closed bite/occlusion thus intruding or compressing the disc and condyles in the fossa.

Certainly I believe in a PHYSIOLOGIC RESTING FREEWAY SPACE should exist when the muscles are at their resting length, comfortable and no pain. Teeth should brace together when the patient normally swallows. The tongue should not be inserted between the teeth during the swallowing act. If it does this is abnormal. But patients with TMD problems as noted above do not have normal inter occlusal freeway space, neither normal swallowing patterns, rather the freeway space is usually infringed upon and muscles are hyperactive due to the lack of proper VDO support and or the mandible is functioning and closing posterior to where their lower jaw wants to optimally function and close…this is what contributes to TMD. Joints do not remodel to a centered position with the fossa when pathologic muscles strains and over closed biting forces exist. Condyles remodel in a pathologic manner exhibiting on radiographic imaging as bend condylar necks, flatten anterior and super surfaces of condyles, and anti gonial notching (extra bone growth at the corner of the lower posterior part of the mandible). These are all clear clinical signs and indicators of pathology and dysfunction.

I believe CLENCHERS can be resolved and the over closed bite cases can be resolved.

The reason why some says what they say, I believe is because they have never measured swallowing patterns to compare normal from abnormal using the K7 to see where the occlusion goes during the swallowing act. I don’t believe these professors and TMD advocates fully are familiar with EMG measurement technology that measures and compares physiologic rest position vs. habitual resting freeway space between teeth.

Because these doctors (orthodontic professors) don’t measure their TMD patients their understanding of resting modes of muscles vs functioning modes will be different than mine. Their views are just their opinion and not what I clinically observe in my 100% TMD pain TMD, orthodontics/orthopedic and restorative practice. I measure using my K7 and I see TMD differently based on objective data. That is the difference.

To Read more: What does the K7 Techonology Measure?

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The Cause, Pathology, Diagnosis and of Temporomandibular Joint Disorders by Dr. Clayton Chan