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Orthodontics/Braces Affecting TMJ Joint

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Question
Hi Dr,

I have a TMJ Disorder and a bad bite. I am undergoing orthodontic treatment to correct my posterior open bite and underbite, and part of that treatment involves running elastics from the back top to the middle bottom teeth. It is pulling my teeth forward but I am concerned as almost overnight my bite changed dramatically by going from edge to edge at the front to my bottom being behind the front in a near normal occlusion (other than my open bite which is still being corrected).

I know teeth cannot move that fast and figured the change must be from by entire jaw moving backwards in the joint and have heard this can reduce jaw joint space and damage the TMJ disc further and cause more issues. Is this something I should be concerned about?

thankyou

Answer

Hi Tom,

I have been working on your question for a while and it has sort of slowly dawned on me that it really is sufficiently complex that I canít really answer it and do it justice without additional records. I am therefore going to sort of answer it but not really fully answer it.  I would encourage you to in fact resubmit your question with a lateral cephalometric radiograph and maybe some photos. I usually respond to questions with detailed answers. In your case I initially tried but can't. So as not to leave the impression that I am not willing to respond,  here is my "nonresponse"  response.

Even with a "non-response" response, let me officially note the normal legal mumbo-jumbo preamble, namely that what I write here are only my opinions based on very limited information. My comments should not be viewed as any form of diagnosis, definitive or otherwise, or any form of treatment recommendation.  Indeed, in the ultimate analysis all final decisions, particularly clinical ones, should only be made by qualified doctors who have had a chance to see you in person and who have had an opportunity to take and analyze proper diagnostic records.

Okay, now for my "non-response".

As an adult, your bone structure is more or less fixed, that is to say that the bones are no longer growing and all the growth sutures are basically fused. The poor architectural relationship between your upper and lower jaws may be so profoundly out of balance that mere tooth movements and minor jaw repositioning may be insufficient. In such cases surgical orthognathic approaches need to be considered.

Regarding your specific question about the TMJ joint.  You wrote:

I know teeth cannot move that fast and figured the change must be from by entire jaw moving backwards in the joint and have heard this can reduce jaw joint space and damage the TMJ disc further and cause more issues. Is this something I should be concerned about?  

My reply  is a resounding  yes  . You indeed should be concerned. If the head of the condyle is pressed too deeply into the glenoid fossa ( ie the ball and socket relationship is changed such that the " ball" is mashed too excessively into the "socket" )  there may be damage or displacement of the thin disk or meniscus which separates the ball from the socket. Perforations  and tears are possible, as is the case sometimes when there are traumatic injuries, such as in vehicular accidents.

I hesitate to give you too much of a diagnosis of your particular situation and can only speak in broad generalities because of the lack of records. This is a situation where modern imaging technologies may give your doctor some additional insights.  Cone beam 3D imaging of the jaw joint with your jaw first positioned in the regular pretreatment position and then in the "corrected" retro-positioned bite relationship will give a better idea of what is happening inside the temporo mandibular joint (TMJ) area. If the disk is being dramatically squeezed, or is experiencing lateral, medial, anterior, or posterior displacement, this needs to be carefully evaluated. Excessive displacements can lead to dysfunction and possible pain.

Cone Beam Information Link:

http://www.dolphinimaging.com/imagings/3d/3d_tmj1_lg.jpg

It is potentially dangerous to simply treat and skeletal upper/lower jaw imbalance by just looking at the aesthetics of the face and the dental occlusion (dental bite of how the teeth mesh together). You are very correct to be concerned about the jaw and disc dynamics when such dramatic changes are being proposed, particularly within such a short time frame.

Ask your doctor if a 3D imaging procedure could be done. I think it will provide some valuable insights to you the patient and to the treating clinician alike. Tom, I would very much welcome a follow up question with additional records in the event that 3D imaging analysis does not clear up the question completely.  All the best Tom !!!

Paul Supan, DDS, MA, MPH
Board Certified Orthodontist

Specialist in Orthodontics
Specialist in Dental Public Health
http://www.braces.com
http://www.leesburgbraces.com

Please allow a week for a reply. I am in full time Private Practice, lecture on occasion, and am involved in many volunteer activities. I am therefore not always able to respond to questions straight away. I also will sometimes consult with other doctors on complex questions. This of course takes time.  Your understanding is appreciated.  

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Paul Supan, DDS, MA, MPH

Expertise

First may I say please set your questions to Public so other readers can benefit from the response. Also, if you look at my comprehensive answers, they are not short 1 or 2 paragraph quickie replies that anyone can type out in < 5 minutes. Instead I often will ask other colleagues in other specialties for their advice in order to provide you the questioner with a more interdisciplinary perspective. This all takes time. I ask for readers to therefore allow 5-7 days. You will be rewarded with a very detailed response.

Because of the nature of Orthodontic questions, any pictures of the teeth and X-ray images would be very helpful. If you write to me and explain that you have crooked overlapping front teeth can be interpreted in many many ways, and my goal is to provide a specific response that meets your needs.

I hold double specialty credentials. I am Board Certified in Orthodontics and Board Eligible in Dental Public Health. I welcome questions regarding Braces, Invisible Braces, & Invisalign, as well as issues involving combination Cosmetic Dentistry and Orthodontic treatment. Orthodontics alone sometimes is not enough to achieve that perfect smile. Gingival (gum) re-contouring, tooth reshaping, bonding and other services are sometimes needed. I also have substantial experience in the areas of Infection Control and Sterilization in the Dental Environment. My personal websites braces.com and Leesburgbraces.com are non-commercial for information purposes only and may provide you with some background to more precisely frame your question for allexperts.com.

Please allow a week for a reply. I am in full time Private Practice, lecture on occasion, and am involved in many volunteer activities. I am therefore not always able to respond to questions straight away. Your understanding is appreciated.

Experience

Board Certified Orthodontist (ABO Diplomate) with over 25 years of Private Practice experience. Second Specialty Certificate in Dental Public Health with research experience at NIH, and Epidemiology Training & Research at Harvard, NIH, and the Centers for Disease Control (CDC) in Atlanta. Postgraduate Masters degree from the Harvard School of Public Health, as well as a Master of Arts Degree in Education.

Organizations
American Dental Association, American Association of Orthodontists, Academy of General Dentistry, College of Diplomates of the ABO, OSAP - Office Sterilization & Asepsis Procedures Organization, Others

Publications
Available upon Request.

Education/Credentials
BS College of William & Mary, DDS Medical College of Virginia, Masters of Public Health (MPH) Degree Harvard School of Public Health. Dental Public Health Specialty Certificate from NIH. Orthodontic Specialty Certificate from University of Rochester Eastman Dental Center. USPHS clinical research experience at NIH, and Epidemiology Training & Research at Harvard, NIH, and the Centers for Disease Control. Fellow of the Academy of General Dentistry (FAGD), and Fully Board Certified Diplomate of the American Board of Orthodontics. Board Eligible in Dental Public Health. Visiting Adjunct Associate Professor at the Meharry Medical College School of Dentistry, Nashville, Tennessee.

Awards and Honors
Available upon Request Please see my personal websites braces.com and Leesburgbraces.com for further personal background.

Past/Present Clients
Available upon Request

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