Where Do We Go From Here?
With the background discussed in Chapter 1, let me share my own experience, as I have had to transform my philosophy and my practices over the past 32+ years. I don’t do this to claim that my way is the right way or the only way. It is simply a way to view these problems, and treat them conservatively. For me, it is the way I would want a member of my family treated.
Before starting, let me state that today I rarely recommend “phase II” dentistry to my patients. I hung up my high speed over 20 years ago, and have performed no restorative dentistry since then. The reasons for this are discussed below.
I went through five different CE courses on gnathological occlusion before I graduated from dental school (I finished my graduation requirements a year early). The first thing I bought after graduating was a pantograph (for recording condylar movements) and a fully adjustable articulator (programmed by the pantographic tracings). While I do not use either of these devices today, the education I obtained about the stomatognathic system was invaluable, and continues to serve me today.
I first heard Bill Farrar in 1979. In two days he shook me to the core intellectually, and challenged everything I had learned about jaw function, anatomy, physiology, and TMJ pathology. I was a member of the American Equilibration Society, as well as the Society for Occlusal Studies. Everyone in these organizations was similarly rattled by what Farrar was showing us (as stated in chapter 1, some of the guru occlusionists attacked him and fought him on every point). I immediately took additional courses from Jack Haden, Bernie Williams, and others. Bernie was kind enough to let me observe in his office. By 1980 I was treating patients much differently than I was originally trained in gnathological occlusion, and getting more predictable results. My success was also much improved by working with some outstanding physical therapists. I have learned it frequently requires a team-approach to successfully manage these patients.
Following the Farrar model, I did condylar repositioning on the patients that were locking or had painful clicks. To be clear, I let the closing click tell me where to position them—just anterior to the closing click. However, I never repositioned them more than 2 mm forward from their relaxed jaw position.
At that time, if I had to do condylar repositioning this meant that I had to recommend phase II dentistry (to correct the resulting posterior open bite). This included:
- Fixed prosthodontics
- Orthodontics (by an orthodontist)
- Functional ortho (by an orthodontist)
- Selected eruption of posterior teeth while cutting off the back of the splint
- A cast metal orthotic the patient could wear full time (in rare cases)
All work was performed only after obtaining mounted study models, using a facebow, along with pre and post-treatment transcranial x-rays to verify condylar position. The fixed prosthodontics had a highly specialized occlusion, including ramps on the distal marginal ridges of the upper 2nd molars, to resist retrusion of the mandible. This restorative work was performed utilizing a special anterior jig that locked the mandible into the final therapeutic condylar position. In addition, all patients continued to sleep in a disc appliance at night after all phase II dentistry was completed. Patients were recalled every 4 months for a year, then every 6 months.
After 7 years of treating patients in this manner, I decided to recall all the patients I had treated with phase II dentistry at least 5 years earlier. I wanted to verify that they were continuing to be asymptomatic, and that they were maintaining the proper condylar position. By this time I had over 100 cases that had been treated in the manner described above, and that were at least 5 years post-treatment.
I soon learned the first lesson in the difficulty of doing a prospective/longitudinal trials—getting the patients to come back. After begging and pleading, we were able to get 26 of the 100 patients back. All of the ones we contacted said they were doing well, but some said they just didn’t want to take time off work to come in, even though we were not charging them. Each of these 5-year recalls underwent a full exam, along with follow-up joint x-rays. The results were both encouraging and discouraging.
The encouraging part was that all of these patients were asymptomatic, while some of them continued to have clicking in their jaws.
The discouraging part was what I saw on the films. Without exception, every patient had regressed to his or her pre-treatment condylar position. This shocked me. I had done my very best to hold them in their final therapeutic condylar position. Most of these patients were still wearing disc appliances every night.
By this time, I had been an instructor for the Society For Occlusal Studies for several years, teaching the TMJ course with Bernie Williams. I had been throughout the US, Canada, Hawaii, and Alaska, teaching dentists how to perform phase II dentistry after Bernie had taught them how to conduct phase I diagnosis and treatment.
In 1987 there was a retreat for the SOS staff in Banff, Alberta, where we were to share nuggets we had learned. I sheepishly got up before this group, and disclosed to them the findings of my 5-year follow-up study. I fully expected to be ridiculed and expelled as inept. Instead, the response I got was “We are seeing the same thing. Condylar repositioning is not stable.” This caused me to re-examine everything I was doing for these patients.
Since condylar positioning is not stable, that means we should be re-evaluating why we had the idea that patients must be maintained in a certain mandibular posture indefinitely. I began converting “pull-forward” appliances to stabilization appliances after the patient had been in treatment for 3-4 months. I also began experimenting with having them wear the splint just part-time during the day plus at night. Very few of them relapsed. This was very reassuring.
I took my first course from Jeff Okeson at about the same time. Jeff said something that I found intriguing. He said patients do better if you do not have them wear their splint full time. “Growing up” in the world of gnathological occlusion, I had believed that what the (stabilization) splint was doing is providing an (artificial) ideal occlusion. The splint uncoupled them from their malocclusion, thus allowing the muscles of mastication to relax (or so I thought). Jeff explained that actually what splints do is alter muscle engrams temporarily, to reduce muscle activity. However, if they wear the splint full-time, their muscle engrams permanently change, making the splint less effective over time (look up “muscle engrams” in Okeson’s text). This made sense, because I had some patients who told me their splint helped tremendously the first 2 or 3 weeks, but became ineffective after that.
I was reminded of John Rugh’s study in which he had a dental student intentionally place a high crown on another student, and then performed over-night EMG studies on the “patient”. He found that for the first few days, the EMG readings were dramatically lower, then gradually returned to normal or increased above baseline.
I started having patients wear their splint no more than 2 or 3 hours during the day, plus during sleeping hours. This included the patients I was holding forward in disc appliances at night. They did better as well. Since I was not permanently holding them forward, I found less of a need for phase II dentistry.
Because condylar repositioning is not stable long-term, by 1990 I stopped performing restorative treatment on TMD patients (I stopped seeing general dental patients in 1981). Another amazing thing happened after I did this. I saw fewer and fewer patients who needed permanent alterations in their occlusions, even those who had been previously locked. I did (and still do) perform an occasional occlusal adjustment. However, I have performed no formal equilibrations (with mandibular manipulation) on TMD patients since 1987. Now, I simply free up their occlusion, by removing inclined-plane contacts, especially non-working interferences, or premature anterior tooth contacts.
I now have to say that I was “diagnosing” the need for follow-up restorative work on TMD patients partly because I still used a high speed drill. Since I hung up my high speed I have never looked back. I now refer less than 5% of my patients back to their dentist for restorative work. Most of the patients I now refer have the need for restorative work because of failed restorations (they needed crowns anyway). Some are referred because of unilateral condylar erosion, resulting in a posterior open bite on the contra-lateral side. In short, it is amazing how much less you see the need for phase II dentistry if you don’t perform phase II dentistry yourself.
Today, I rarely make a “pull-forward” disc appliance. If I do, it is only to 1) prevent morning locking in their jaw, or 2) to be inserted after the oral surgeon unlocks them under I.V. sedation. I have found that if you effectively relax the lateral pterygoid muscle, so that it is not constantly pulling the disc forward, that a stabilization splint is adequate for most patients with morning locking. Without permanent condylar repositioning, the need for phase II dentistry is greatly diminished.
Today, thanks to extensive marketing and “sponsored” lectures by experts, more and more dentists are buying into the concept of mandibular repositioning and/or bite opening, followed by extensive dentistry.
For those of you who continue to believe that mandibular repositioning/bite opening is justified, my challenge to you is this: Do your own 5-year follow-ups on patients you have held forward with splints and phase II dentistry (or patients you have performed neuromuscular dentistry on). If you based your altered jaw position on a neuromuscular approach, retest them with the electrodiagnostic instrumentation. You may be surprised at what you find 5 years (or even 1 year) later. If you think you recaptured their disc, do an MRI on them at this 5-year follow-up. Just because they can open over 40mm without clicking, pain, or restriction does not mean their disc is on the head of the condyle. I treat approximately 500 patients a year who come in with a displaced disc. Most of them leave with a displaced disc, but they leave comfortable and without jaw impairment. Given the fact that 1/3 of the general population has a disc dislocation (most of whom are not even aware of it), why do we think it is imperative for us to get the disc back in place on our patients?
In summary, I spend approximately 90 min with a new patient, reviewing their 8-page history, reviewing their CT scan, which was previously obtained by my staff, interviewing them, examining them, formulating a treatment plan, consulting with them, and dictating a 3 or 4 page report. This process involves deciding which of the three categories of contributing factors and which individual factors within each category are playing the most significant role for that particular patient. I then make a recommended treatment for each of these etiological factors. I will often be recommending 4 to 7 specific treatment modalities to the patient, along with a list of things they can do to reduce stress on their jaw. For approximately 1/4 of the patients we see, I recommend that all of the treatment be performed outside our office, because what they thought was a jaw problem is really caused by something else.
Our patient’s treatment is typically completed within 4 months, unless we have to wait longer to take a follow-up CT to check for bone loss. Once we have competed the active phase of treatment, for about 70% of them I recommend that they continue wearing their splint at night only—nothing else. On 20%, I recommend a conservative “hands-off” (without mandibular manipulation) occlusal adjustment. 5% will need full or partial ortho, and they are referred to an orthodontist. No more than 2% will need some restorative work. Usually this is only 1 quadrant. None of my patients have needed full-mouth rehab for many years, because I don’t open bites and I don’t try to maintain the condyle in an advanced position.