Oral Beauty and Function

Appearance and function are closely related. Frank Lloyd Wright's aphorism, "Form Is Function", is also true of teeth and their related structures. A dentist who is trained in Bioesthetics* can readily differentiate between those persons who have healthy oral function and those who don't. For instance, wear of the front teeth is an indicator of dysfunction. The following will describe the relationship of the teeth, jaw joints and surrounding structures, and how we diagnose disharmonies between them.

The Temporomandibular (jaw) joints (TMJ's) connect the lower jaw to the skull. This connection is dictated by the way the teeth fit together - in other words, the positions of the condyles (balls) in their fossae (sockets) and surrounding structures (muscles, ligaments, disks) are dependent on how the teeth mesh. When a bite is "off" (uneven mesh of the upper and lower back teeth) and the teeth meet, the joints "stretch" to accommodate the "off bite". This causes trauma to the TMJ's which can involve pain, popping/clicking, and stress to the surrounding structures resulting in head and neck pain, migraines, ringing in the ears (tinnitus), vertigo, tooth wear (especially the front teeth), clenching and grinding (bruxism). This uneven stress can also contribute to tooth fractures and pain, need for root canals and possible tooth loss. We now know that most of the deep grooves on the sides of teeth at the gumline aren't just from the toothbrush. They're called "abfractions", and are caused by horizontal stress on teeth.

It has been demonstrated that up to one half-ton pressure per square inch can be exerted by the back teeth. The front teeth can exert very little pressure in comparison, as they are far away from the fulcrum point (back teeth). If there are uneven biting pressures on the back teeth inclines, the brain gets a message to move the jaw out of position automatically and engage the front teeth to contact during chewing and take the heavy load off these back teeth inclines to prevent their heavy, traumatic contacts. This results in pathologic wear on the front teeth - they "pay the price", molecule by molecule.

Some persons have jaw joints which are extremely adaptable and they go through life with "off bites" and stretched joints without any discomfort, but most all of these persons have pathologic tooth wear and possible supporting bone loss. Others may adapt for quite a while and then at some time experience either mild symptoms (slight clicking, muscle discomfort, headache, jaw starting to "lock"), or possibly severe symptoms (extreme joint, muscle and head pain, loud popping/clicking with the jaw actually locking). Sometimes these events are episodic and the symptoms go away, while there are times that it continues to worsen - a true case of acute TMD (Temporomandibular Dysfunction). It is interesting to note that more women than men develop TMD. Men will wear their teeth, but in general develop the symptoms of joint popping/clicking and head/neck pain to a lesser degree than women.

* Bioesthetics: "The study or theory of the beauty of living things in their natural forms and function" Dr. R.L. Lee

Our approach to this problem consists first of developing a complete diagnosis which includes collection of functional data such as models of your mouth, and inter-jaw records to allow for placement of these models on a jaw simulator (articulator). With this, it can be seen how the teeth and joints relate to each other and function without the heavy influence of the protective jaw muscles. Also performed is a muscle palpation examination, measurement of jaw movements, and slide photographs of the teeth in their functional relationships. State of the art jaw joint x-rays (corrected tomograms, or laminograms) are taken at a laboratory to show the "ball and socket" positions at various openings, and to see if there are any bony changes such as arthritis, due to trauma. The above records, together with your past history will allow for the development of a diagnosis and an appropriate treatment plan.

Recognized causes of TMD:

- Trauma to the TMJ's
- Genetic predisposition
- Stress
- General state of health
- Changes in the way the teeth fit together due to:
      - sleeping on the face
      - missing teeth with resultant tooth shifting
      - improperly placed fillings, crowns, etc.
      - improper orthodontics

TREATING THE PROBLEM

In all cases of TMJ dysfunction, it has been demonstrated that the fluid that occupies the jaw joint capsule is dispersed, the joint ligaments stretched and the muscles that connect to it, inflamed. After initial diagnosis, the first treatment step is the construction of a removable orthotic device (also known as a "splint") which covers the biting surfaces of the upper teeth. It is fabricated so that all the lower teeth touch it evenly, which starts taking pressure off the jaw joints. This device is worn full time (excepting for removal during oral hygiene) and only soft foods are eaten - a major commitment for the patient. As the jaw joints become healthier, the lower teeth will begin to hit the orthotic differently, therefore it will need to be adjusted periodically to keep up with these healthy changes.

If a person is in severe discomfort, only joint x-rays are taken, and orthotic treatment is started immediately. The diagnostic process will begin once the person is free from pain.

The purpose of collecting data, orthotic therapy and developing a diagnosis is to let the dentist discover and the client know, before dental treatment of any kind is started, what type of treatment would be needed to maintain healthy, stable TMJ's after completion of orthotic care. Usually the health and certainly the new positioning of the joints will not be sustained without continuing orthotic wear, so it is important to know what type of dental treatment would allow a discontinuation of orthotic wear. Some people are comfortable enough wearing the orthotic part time, such as at night only, and elect not to have the dentistry needed to eliminate the need for the orthotic. Most often, after the joints become healthy through the orthotic therapy, the teeth will mesh much differently than before (without the orthotic in place), which will influence the treatment diagnosis. This is why it is important that orthotic therapy is completed before any definitive dental treatment recommendations, as the new, healthier jaw positions most always cause the teeth to come together much differently than before this therapy.

After orthotic therapy, dental treatment can consist of any one or a combination of four different types:

1. Equilibration (bite adjustment)
2. Restorative treatment such as crowns, bonding etc.
3. Orthodontics
4. In cases with extreme jaw discrepancy - orthognathic (jaw repositioning) surgery.

Orthotic wear and adjustment is the first treatment step in order to:

--eliminate pain, malfunction, and hopefully - popping/clicking.

--develop stable, healthy jaw joints before commencing any of the above dental treatment. In other words, since the joints and teeth have an influence on each other,
the final treatment of the biting surfaces of the teeth should be dictated by joints
having been treated to a healthy "end point".

--determine whether your symptoms are all or in part due to the bite discrepancy. It is important to understand that many times, along with a bite discrepancy as described above, other factors can contribute to the symptoms such as physical and emotional health, muscle tension caused by stress, general attitude and habits.

--have a reversible, non-invasive treatment to test our diagnosis. If orthotic treatment
alone is unsuccessful, other treatment modalities can be instituted such as Physical Therapy,
Biofeedback, Stress Management, Acupuncture, etc. At any stage during this phase
of treatment, discontinued wearing of the orthotic will result in the joints assuming
their original positions - it is a reversible process.

As indicated above, some people will find that after the resolution of their symptoms, night-time orthotic wear only will either eliminate the symptoms or lessen them enough to be adequate without further treatment.

TMJ dysfunction has come to light within the last 15-20 years, because more people are keeping their teeth for a lifetime and much more has been learned about it. It is important for the dentist to have a sound, tested and workable philosophy in dealing with these problems.

Our goal is to develop a comprehensive plan before we take the first step, so that our road can be paved with mutual understanding, improved health and function.

If there is any aspect of this information that you would like to have further explained, do not hesitate to ask for a consultation with me.