Adults and the new orthodontics - Part 3

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PART THREE IN A SERIES Adults and the new orthodontics - Part 3 By Derek Mahony, BDS, MDS S.

The Nine Keys to Lower Facial Harmony written about in the book have been found to be essential goals in achieving that coveted Movie Star Smile while having a positive impact on total body health.

1 PART THREE IN A SERIES Adults and the new orthodontics - Part 3 By Derek Mahony, BDS, MDS S. Kent Lauson, DDS, MS T his is the third in a series of articles on adult orthodontics teaching a philosophy of orthodontics as presented in the book Straight Talk about Crooked Teeth (Figure 1). The Nine Keys to Lower Facial Harmony written about in the book have been found to be essential goals in achieving that coveted Movie Star Smile while having a positive impact on total body health. This breakthrough book has received many accolades by orthodontic leaders throughout the world. Jay W. Barnett, DDS, FACD (Orthodontist, Former Chairman, L.D. Pankey Institute Orthodontic Program, noted author and lecturer) stated: In all my years in dentistry, I have never seen a book like this; certainly nothing out there is comparable at this time. This book is a possibility book - showing that beautiful life changes are possible as a result of the treatment that Dr Lauson has to share. He has shown that even the most complicated of cases Figure 1. Straight Talk about Crooked Teeth. are treatable with predictability when the principles in the book are implemented. I would recommend this book to anyone. To give a brief review, the first two articles dealt with the first three keys to lower facial harmony: Key #1 - Fully Developed Upper Jaw; Key #2 - Unobstructed Nasal Breathing and Key #3 - Proper Forward Positioning of Lower Jaw. We emphasized how the keys build upon each other and if the first keys are not addressed then subsequent keys, many times, cannot be achieved. This is certainly true concerning Key #4 - Healthy TMJ Function. We wrote about the principle of the trapping of the lower jaw and how this can lead to TMJ Dysfunction. In each of the two cases presented in the previous articles, the patient had sought orthodontic treatment because they did not like their appearance because of skeletal imbalances. However, each patient also had significant TMJ Dysfunction needing correction. Traditional orthodontic 70 Australasian Dental Practice July/August 2013

2 Figure 2. Functional TMJ: A - Temporal Bone; B - Articular Disc (or just Disc); C - Condyle; D - Posterior Ligament (containing nerves and blood vessels); E - Lateral Pterygoid Muscle; and F - Ear Canal. Figure 3. Dysfunctional TMJ: A - Temporal Bone; B - Disk (showing degeneration); C - Condyle; D - Posterior Ligament (showing pinched nerves and blood vessels); E - Lateral Pterygoid Muscle in Spasm; and F - Ear Canal. treatment would have likely prescribed premolar extractions and/or surgery to correct the skeletal problem. This traditional treatment may have not addressed the TMJ dysfunction, since TMJ evaluations (including x-rays) are not routinely performed. When doing a comprehensive orthodontic evaluation, it is necessary to take radiographs of the TMJs along with the customary diagnostic records. The complete protocol for an orthodontic evaluation is discussed in the book. Of note is that each of these cases was successfully treated without the extraction of permanent teeth or surgery. The final results show substantial skeletal changes, achieving improved lower facial harmony. Because TMJ function is so important, especially when considering adult orthodontic treatment, we are focusing this entire article on TMJ function. Key #4: Healthy TMJ function Early in a person s dental career, a new dentist will likely hear some disturbing things about treating TMJ Dysfunction. It may be said that people who have TMJ problems are a little crazy and should be politely dismissed from the office, the sooner the better. You may have been told that these people either can t be successfully treated, or that the problem will eventually go away if you do nothing. Neither of these long-held beliefs is true. These problems can be successfully treated and if left untreated, the problem may be slow to progress, but will likely get much worse over the years. Many subtle things can occur that affect the health of the entire human body, 80 of which are centered in the TMJ s. The problems can range from just annoying jaw clicks to excruciating pain and dysfunction in many areas of the body. Unfortunately (or fortunately depending on how you look at it), there is growing realization that the problems associated with the TMJ need to be dealt with within the dental profession, because the well-trained dentist is uniquely qualified to handle them. This article can be a wakeup call, challenging you with information that will help you to understand how dentistry can address joint dysfunctions and help people who suffer from TMD. Although it is beyond the scope of this article, and even the book, there are many fine courses that teach about the treatment of TMD. A direct quote from Straight Talk about Crooked Teeth begins to shed some light on this often-misunderstood topic: In recent years, the TMJ has become a familiar part of our language. People who suffer from jaw pain commonly say, I have TMJ. Everybody has a Temporomandibular joint, or TMJ - actually two of them, located in front of each ear - which are responsible for allowing the lower jaw to move. The TMJ is also responsible for all the wide-ranging motions that are performed effortlessly upon chewing, talking, yawning, laughing or swallowing. When people have problems with their jaw joint, what they actually mean is that they have TMJ dysfunction, or TMD. The TMJ is especially worthy of attention due to its versatility and functionality. It is important to know that the TMJ is the most complex and active joint in the human body. Composed of only a few ounces of cartilage, bones, ligaments, and muscles, it springs into action as many as 100,000 times a day, completing more repetitions than any other similar body part. When functioning properly, it is capable of performing a myriad of intricate maneuvers, within seconds, even shifting (when needed) from one-dimensional plane to another. But, when it s out of place, it causes considerable pain and discomfort, oftentimes affecting the entire body - causing headaches, ear or vision problems and even backaches, just to name a few. Because of the TMJ s crucial role in the human body and its intimate connection to the teeth, it is one of the signature components that must be dealt with in respect to any corrections of the mouth, teeth, or jaws. Figure 2 shows the anatomy of an ideally functioning TMJ in centric relation occlusion. July/August 2013 Australasian Dental Practice 71

3 The TMJ under stress So, how did the TMJs get out of alignment in the first place? It s important to understand that when a person bites down, to chew his or her food, the TMJs and surrounding muscles always seek a position to accommodate the best fit of the teeth. The rule is this: Teeth dominate, muscles and joints accommodate, so it stands to reason that the TMJs will accommodate as well as they can. If the TMJs and teeth work together in harmony, then their actions will operate smoothly and without incident for years, even a lifetime. Conversely, when the act of chewing forces the jaws out of a healthy position, repeated stress occurs within the joint. This stress affects the surrounding muscles and nerves. The typical scenario is this: Every time a person bites down in an unhealthy position, the condyle is forced back, too far, and pushes into the posterior ligament containing nerves and blood vessels. These nerves and blood vessels are constantly under assault and go to areas like the ears, eyes, and even the brain - areas that The TMJ is the most complex and active joint in the human body. Composed of only a few ounces of cartilage, bones, ligaments, and muscles, it springs into action as many as 100,000 times a day, completing more repetitions than any other similar body part... there is growing realization that the problems associated with the TMJ need to be dealt with within the dental profession, because the well-trained dentist is uniquely qualified to handle them... are vitally important to a person s overall health and happiness. Figure 3 shows the pinching of the nerves and blood vessels that have to pass through the area at the posterior of the jaw joint. There literally is no other area for them to pass through that wouldn t be very vulnerable to other outside pressures or injuries. Unfortunately, they are subject to damage internally from improper condyle placement. No wonder the symptoms of TMD are so widespread. Similar to having a pinched nerve in your neck, the nerves and blood vessels affected in the TMJ can also be painful. Topping the list of the most common problems are headaches, facial pain, problems with the eyes and ears and even neck problems. The list of maladies affected by TMD is very widespread and includes recent discoveries that many neurological disorders, such as Parkinson s disease and Tourette s syndrome, can have a direct relationship with TMJ dysfunction. It seems that TMD is both a liability and a huge opportunity for the dental community Australasian Dental Practice July/August 2013

Figure 4. Pre-treatment. Treatment was formulated over a number of phases.

Case study The following patient case illustrates how proper TMJ treatment

When Pamela arrived for an evaluation, she was 70 years old and had been

She had received many of the routine medication treatments and physical

She was in such intense pain that she didn t even want us to touch her face

She later shared with us that her constant pain, at that first appointment,

told that the only way to cure this problem was to have injections to

Of course that meant that she would never have feeling in that side of her

This was not an appealing option for Pamela so she was continuing to seek

A partial list of her presenting complaints was as follows: Excruciating

neck and upper back pain; Fatigue and loss of sleep; Difficulty opening and

Pain while eating; and Clenching of teeth.

cuspid right with mutilated dentition; Bilateral posterior open bite; No

4 Figure 4. Pre-treatment. Treatment was formulated over a number of phases. Figure 5. Post-treatment. Case study The following patient case illustrates how proper TMJ treatment can profoundly change a person s life, for the better. When Pamela arrived for an evaluation, she was 70 years old and had been involved in an automobile accident, a year before. She had received many of the routine medication treatments and physical therapy, but to no avail. She was in such intense pain that she didn t even want us to touch her face during the initial evaluation. She later shared with us that her constant pain, at that first appointment, was so extreme and because she was not getting the help she needed, was considering suicide. She had been diagnosed with Trigeminal Neuralgia by other doctors and was told that the only way to cure this problem was to have injections to cauterize and destroy the facial nerves. Of course that meant that she would never have feeling in that side of her face and may have a drooping, drooling lip for the rest of her life. This was not an appealing option for Pamela so she was continuing to seek help to see if any other possibility existed. A partial list of her presenting complaints was as follows: Excruciating facial pain on right side of the face; Jaw and jaw joint pain; Very severe neck and upper back pain; Fatigue and loss of sleep; Difficulty opening and closing the jaw; Clicking and grating of jaw joints; Fullness in the ears; Pain while eating; and Clenching of teeth. Our evaluation findings included: Class I cuspid left side and Class III cuspid right with mutilated dentition; Bilateral posterior open bite; No molar classification possible; Restricted mandibular range of motion with 25mm opening and 7mm right and left lateral exercusions; Partial anterior cross-bite; Maxillary and mandibular constriction; Right TMJ click Forward head posture; and Evidence of myofascial pain dysfunction, in both face and neck. Our diagnosis was trauma-induced Temporomandibular Dysfunction with significant craniofacial orthopedic imbalance. Figure 4 shows the patient pre-treatment. 74 Australasian Dental Practice July/August 2013

5 The treatment plan Phase I The objective of this initial phase of treatment was to normalize the TMJ function. Full time wear of a neuromuscularly balanced mandibular orthotic was used to reposition the mandible to a better balance. This mandibular position was achieved with the use of a Myotronics K-7 Computerized Mandibular Scan. At the same time the associated dysfunctional muscles were treated with electrotherapeutic (TENS) stimulation and neuromuscular massage therapy concentrating on the head, neck and upper back. This TENS and massage was used liberally to achieve a more normalized muscular function. The 24/7 wearing of the orthotic allowed us to achieve a stable condylar position. In 5 months time, this phase was completed and symptom levels had been reduced by over 90%, including the facial pain thought to be associated with Trigeminal Neuralgia. Phase II The objective of the second phase of treatment was to create a skeletal balance, in the lower facial structures, with the use of functional facial orthopedics. Because of the substantial constriction of the upper jaw and a lack of AP development on her right side, an upper 2-way sagittal appliance was used to develop the maxilla. We also added an expansion screw to the lower orthotic in order to upright the lower teeth so they could be in balance with the upper arch development. All symptoms were now listed as absent except for mild neck discomfort. Note: It is believed by many of our colleagues that this type of expansion on a person past age 70 is not possible. In fact, many still believe that an adult, at any age, requires surgery to accomplish this development. This case was selected to show that bone development can be accomplished at any age and non-extraction treatment is also a viable treatment option at any age provided slow expansion with light forces is employed. If we hold onto old limiting beliefs that extractions and surgery are necessary in a case like this, then we are selling our treatment short and doing our patients a disservice. Phase III The objective of this final phase of treatment is, as with any case, to optim ally align the teeth for function, beauty and stability. This is listed as Key #9 in the Nine Keys to Lower Facial Harmony, written about in the book, and is always the final objective for dentists practising orthodontics. This alignment is much easier to accomplish because of the first two phases of treatment. Braces were able to do their job of individualized tooth movement to achieve optimal occlusion. With the lower jaw functioning in its corrected position for almost a year, the TMJ was considerably more stable and much more able to withstand some adverse pressures such as the wearing of elastics to bring the bite together. With Pamela, this last phase was completed in 24 months during which time she remained symptom free. Even though the aesthetics of this phase are important to doctor and patient alike, the foundational importance of a good occlusion is critical to solidify the overall result, so that the patient can have an ideally functioning, pain-free outcome. Discussion When beginning treatment with us, Pamela was attempting to recover her expenses through a well-known insurance company that she was insured with. We sent off a report clearly connecting the cause and effect of the automobile collision and the resultant pain and dysfunction. The insurance company months later asked for an Independent Medical Evaluation (IME) to be completed. An orthodontist was hired by the insurance company who clearly did not have a background in treating TMJ dysfunctions and completed a brief exam. Neither our initial examination findings, nor the substantial progress of Pamela s treatment was considered. However, the conclusion of their report indicated that any pain Pamela experienced was not due to the motor vehicle accident. This conclusion was made even though the patient had no history of pain prior to the accident. The success of our treatment had been clearly defined in our communication with them and the patient s symptom levels were already significantly reduced when the IME evaluation was done. Having received a rejection letter from the insurance company, we resubmitted with further explanations, but the insurance company held their ground; they had their IME dentist report supporting them and therefore were not budging. It is decisions like these that give the impression that many insurance companies are more interested in protecting their profits than taking care of their insured customers. It is also notable that a few medical and dental professionals working with insurance companies may be willing to facilitate this denial of coverage. Although this was a challenging case for a number of reasons, by systematically following a logical sequence of priorities, we were able to achieve a great result that left the patient in a much better state of health than she was before her automobile accident. For more information regarding The Lauson System: Nine Keys to Lower Facial Harmony please read the book Straight Talk about Crooked Teeth, which is available from EODO via Brenda@eodo.com About the authors Dr Derek Mahony is a Sydney-based specialist orthodontist who has been actively involved in research that links constricted maxillary archforms to nasal breathing problems, adverse facial growth and systemic health problems such as nocturnal enuresis. He has presented over 400 lectures on orthodontic topics in more than 50 countries. As a practising clinician, Dr Mahony s research interests are in the aetiology of malocclusion and the guidance of facial growth. Please contact info@derekmahony.com for further information or clinical questions. Dr Kent Lauson s distinguished career as a specialist in orthodontics, dentofacial orthopedics and temporomandibular dysfunction (TMJ) has spanned over 30 years. He graduated from the University of Iowa with his Doctorate of Dental Surgery Degree in 1971 and spent two years in the USAF Dental Corps where he studied Periodontics and was the Preventive Dentistry officer of his base. He then completed his orthodontic residency in 1975 at St. Louis University Medical Center and has been in private practice in Metro Denver ever since. During this time he helped develop the techniques for completing orthodontic treatment resulting in full beautiful smiles without the removal of any permanent teeth. 76 Australasian Dental Practice July/August 2013

STRAIGHT TALK about CROOKED TEETH: Key #4, Healthy TMJ Function

STRAIGHT TALK about CROOKED TEETH: Key #4, Healthy TMJ Function This is fourth in a series of articles by Derek Mahony, BDS, MDSc and S. Kent Lauson, DDS, MS (Orthodontists) Their book was written with