Braces & TMD

Guideline: Jaw joint stability comes before Braces-Invisalign

Guideline: Destructive grind/clench must be reduced to nondestructive level before braces

Guideline: Deficient Airway should be analyzed before braces

Guideline: Retainers are designed to protect alignment from destructive force grind

Guideline: Retainers cannot resist the destructive force grind-clench

Guideline: Practice preventive orthodontics by treating Destructive Grind-Clench

Moderate to severe damage TMJ must be treated before braces 1) TMJ dimensions affect alignment 2) Establish healing to joint before you challenge chewing system w/ braces 3) Need reduce destructive force that destroys alignment 4) Need protect alignment from destructive grind

Orthodontics refers to brackets, braces, Invisalgn, orthognathic surgery, to reposition teeth to be in harmony & function with all oral structures including deficient airway.

Retainers: 1) Redesigned & reinvented every year 2) Treating symptom not cause of problem 3) retainers try to maintain alignment in face of destructive forces from grind-clench 4) Braces can no longer ignore this destructive force by inventing new ways of retention 5) Best retainer for grind-clench is upper orthotic & lower lingual bar 6) Retainers are adequate for mild to moderate grind-clench

Position teeth

  1. Cosmetics 2. Arch 3. TMJ complex 4. Geometry 5. Airway 6. Tongue 7. Lips 8. Symmetry 9. Function 10. Neutral zone 11. Facial bone 12. Other

Braces position teeth to be in harmony with all oral structures.  Yes, braces was invented to be a cosmetic entity, but it is really to get teeth work in harmony with other oral structures.

WARNING: Braces are not a treatment for jaw joint pain, TMD dysfunction, chewing pain, jaw locking.

Misconceptions of braces? 1) Does orthodontics-braces-Invisalign cause jaw joint damage?   NO 2) Can braces set off hidden moderate damage TMJ? YES 3) Can braces work on mild jaw joint damage or muscle case?  YES 4) Can braces be used after mod jaw damage has healed? YES 5) Can braces be treatment for moderate TMD, restricted opening, complete displaced disc ? NO

WARNING: Moderate to severe TMJ damage must be treated first before braces. You must establish healing in damaged TMJ before the challenge of braces on chewing system.

Orthodontic exam should now include:

            Airway analysis Tongue size vs arch size

            Sleep apnea Jaw joint damage level

            Parafunctional level Anxiety level

Even when tooth position are grossly off, if moderate jaw joint damage present, one must treat damaged TMJ before braces. Jaw joint stability is a required before any dental treatment. TMJ affects position teeth !!!

Braces increase pain in moderate jaw joint damage cases.

Is orthodontics necessary after healing jaw joint damage? 1.Airway is deficient 2. Bite or Occlusion is not efficient 3. Aligned needs improving 4. Curves Spee & Wilson off 5. Bite plane is slanted. 6. Assymmetry

What kind cases need jaw joint stability before ortho? 1. Osteoarthritis 2. Complete displaced disc 3. Restricted opening 4. Destructive parafunction 5. Dual bites, multiple bites

What kind of case needs ortho after stabization of TMJ ? Facial asymmetry-bite plane tilted-sudden ant open bite-sudden post open bite

Why is sudden bite change referred to orofacial pain before ortho?

  1. Functions as  3-legged stool
  2. 2 back legs are jaw joints (condylar), the arch of teeth is front leg
  3. Change in back leg causes changes bite
  4. Two forms of condylar change
  5. Complete loss disc
  6. Bone loss

Moderate to severe jaw joint damage sets up variable dimensional changes in TMJ causing bite problems.

Dimensional changes in jaw joint must be stabilized before braces or Invisalign can be done.                  

  1. Bone loss in condylar head must be stopped
  2. Recapture disc in complete displaced disc

Guideline: Gaining control over destructive bruxism is critical to protecting position & integrity of chewing system structures before braces.

Destructive Parafunction (grinding/clenching) 1) Parafunction is destructive force behind orthodontic failures. 2. 3 catagories Parafunction: Mild Moderate Destructive

What is destructive parafunction ?

  1.  Movement disorder
  2.  Restless mouth syndrome
  3. Severe grind-clench

When does grinding & clenching become destructive

  1. Grinding power goes up 6 times chewing power
  2.  Power-duration-frequency elevated Anxiety

Retainers are adequate in mild & moderate parafunction, but they are woefully inadequate in destructive parafunction.

Guideline: Every single tool is inadequate to destructive bruxism.

Why is destructive grinding-clenching not diagnose before braces?

  1. Because we do not look at chewing system as whole
  2. The chewing system is divide in specialities
  3. No specialty looks at all damage in all areas
  4. Fragmented diagnosing misses point
  5. Must analayze all areas of damage looking for hints

Orthodontics must observe subtle hints in all 4 areas to be able to diagnose destructive parafunction. Must be additive-collection-summation of data:

         Teeth Bone support Muscles Joint

                                           Braces & Airway

The great orthodontist of today takes into account the airway needs of patient when planning the braces. 

Air pipe walls:

  1. Top wall: Palatial extension
  2. Side walls
  3. Bottom wall: Tongue vs arch size

Side wall made up of

  1. Medial Pterygoid
  2.  Tonsils
  3.  Pharyngeal wall-tissue-fat

Braces can cause decrease in air flow when tongue vs arch have size discrepancy

         Large tongue. Small arch Mandibular Tori

         Palatal width Palatal depth Buccal bone buttressing

         Palatal tori

Patient's should never have premolar extraction and braces without first analyzing the airway pipe size. If the airway is already compromised shrinking arch is not appropriate standard of care. Today’s orthodontist analyzes arch verses tongue size discrepancy. A small air way would not have premolar extraction, reduced arch size, and reduction in tongue space because it forces tongue into airway decreasing breathing at night.

The problem arises when we treat all patients with same approach and we do not take into account the other oral needs like breathing. Some of our past care, violate the needs of airway. A person with small pipe reducing size of arch pushing tongue into airway would set up snoring problem. I know, because I am one of those patients !!!

Complex Orthodontics should only be done by a well trained orthodontics. 1) Quote, "I can train you to do root canals in weekend, but it will take me 3 years to teach you exceptions" . 2) Yet, a specialist must know latest and greatest science. 3) Simple cases maybe managed by general dentist w/ adequate training 4) Practice economics gets ego maniac in over their head 5) Point: Giving patient the best care

The science of airway deficiency must be added to Orthodontic Treatment”;

  1. Reduce size Medial Pterygoid by anti- grind tx

2. Increase Tongue space by expand arch size with orthographic surgery & braces

3. Tongue size by TORS surgery & reduce size tongue

4. Stop Tongue falling into airway by sleep appliance in health TMJ

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