Temporomandibular joint (TMJ) disorders, commonly referred to as TMD, are a set of conditions affecting the jaw joint and surrounding muscles. With an estimated prevalence of 5-12% in the general population, TMD is a common issue that dentists encounter in their practices. 

Proper diagnosis and management of these disorders is crucial, as untreated TMD can lead to persistent pain, limited jaw function, and even permanent joint damage.

As dentists, we’ve been trained in the what behind TMD and TMJ. But what about the how? How can we effectively treat our patients’ TMD and improve their quality of life? Its when we start to consider the best practices for TMJ/TMD treatment that we can truly make a difference in our patients’ well-being.

The Piper Classification for TMJ Breakdown Stages 

The Piper Classification system is a widely used framework for categorizing the stages of TMJ breakdown. It ranges from Stage 1 (healthy joint) to Stage 5 (complete disc displacement and degenerative changes).

The Piper Classification system provides a comprehensive framework for categorizing the progressive stages of TMJ breakdown. Let’s revisit the classifications to see how they can inform treatment decisions and improve patient outcomes.

• Stage 1: Healthy TMJ with no structural defects or breakdown. The articular disc is centered, and the joint exhibits proper rotation and translation without ligament laxity.
• Stage 2: Early breakdown characterized by ligament laxity. The lateral pole of the articular disc begins to intermittently snap on and off the condyle head, leading to occasional clicking or popping sounds.
• Stage 3A: Reciprocal clicking during jaw opening and closing due to the disc being partially displaced. The lateral pole is displaced, but the medial pole remains intact, causing a loud “snap” as the condyle head transitions between rotation and translation.
• Stage 3B: Non-reducing anterior disc displacement of the lateral pole. The lateral pole remains displaced during rotation and translation, while the medial pole may remain partially intact.
• Stage 4A: Non-reducing anterior disc displacement of both lateral and medial poles. The entire disc is displaced, and the retrodiscal tissues begin to impinge into the joint space, leading to pain and discomfort.
• Stage 4B: Permanent disc displacement with degenerative changes. The retrodiscal tissues are perforated, and the condyle articulates directly against the glenoid fossa, resulting in a bone-on-bone situation.
• Stage 5: Advanced degenerative joint disease with significant condyle and glenoid fossa remodeling. While stability may improve, the joint’s function is permanently compromised.

Diagnostic Tools

So, what are the diagnostic tools used to determine the stage of TMJ disorder? The most common method is through clinical examination – where you, as the healthcare professional, will assess the patient’s range of motion, pain levels, and jaw clicking or popping. But going deeper, there are a few different elements to the diagnostic process:

Anterior Deprogrammers

Diagnostic tools like anterior deprogrammers (e.g., cotton rolls, Lucia jigs, NTI splints) can help differentiate extracapsular (muscle-related) issues from intracapsular (joint-related) problems. By temporarily disengaging the posterior teeth, these appliances can provide insight into the underlying cause of the patient’s symptoms.

Manual Manipulation

Another valuable technique is manual manipulation, also known as bilateral manipulation. By applying controlled pressure to the jaw joint, dentists can assess joint mobility, disc position, and the presence of inflammatory or degenerative changes. While this can sometimes be uncomfortable for the patient, it can provide key information for an accurate diagnosis.

Doppler Ultrasound

In some cases, Doppler ultrasound may detect joint sounds and assess disc position. This non-invasive imaging modality can complement clinical findings and aid in the differential diagnosis. The benefit of using Doppler ultrasound is that it allows for dynamic assessment of the joint, meaning that it can capture any changes in joint function with movement.

What Are The Typical TMJ/TMD Treatment Options?

Treating TMJ/TMD often requires a multifaceted approach that addresses the underlying cause and stage of the condition. As dentists, knowing which treatment option is best for each individual patient is key to giving them the best possible care and improving their quality of life.

Splint Therapy

One of the primary treatment modalities for TMJ/TMD is splint therapy. The type of splint prescribed depends on the underlying diagnosis and stage of joint breakdown. When placed in the mouth, the splint can help stabilize the joint and relieve pressure, tension, and pain. It can also reduce muscle spasms and protect against further damage.

Anterior Deprogrammers

Anterior deprogrammers, such as cotton rolls, Lucia jigs, or NTI splints, are permissive splints that disengage the posterior teeth and allow the condyle to sit in the glenoid fossa. These are often used for diagnostic purposes or as initial therapy for extracapsular (muscle-related) issues.

Full Arch Splints

For intracapsular (joint-related) problems, full arch splints that cover all occlusal surfaces are recommended. These can be either upper or lower splints, such as the classic stabilization splint with a perfected occlusal scheme.

The key to successful splint therapy is sequential adjustments and monitoring. Gradual adjustments are made to the splint over several months, allowing the condyle to reposition and the joint to adapt. This process aims to achieve a stable, loadable joint position.

Occlusal Therapy

Once the joint has been stabilized through splint therapy, occlusal therapy may be necessary to establish a permanent, tooth-supported occlusion. This can involve orthodontic treatment (e.g., Invisalign) to align the arches, followed by conservative restorative procedures like additive composite bonding or equilibration.

The goal is to reproduce the idealized occlusal scheme from the splint onto the natural dentition, minimizing future joint loading and breakdown.

Other Considerations

Acute Disc Displacements: In cases of acute disc displacement with significant pain and limited opening, a temporary anterior repositioning splint may be used briefly to reduce joint pressure and allow for initial healing.

Sleep Apnea Appliances: Although mandibular advancement devices (MADs) are often used for sleep apnea, they can cause permanent joint changes if the condyle is held in a protruded position for long periods. Proper morning aligner use is important to allow the joint to return to its normal seated position.

Diagnosis & Treatment Case Study: Dana

During our recent webinar, we discussed the case of “Dana,” a patient who presented with severe TMJ discomfort and dysfunction. This case showed just how important it was to combine both diagnostic and treatment methods to achieve the best outcomes.

Dana was referred by another general dentist due to her inability to undergo routine dental procedures due to jaw pain. Upon examination, it was determined that Dana had a Stage 3B TMJ condition, with the lateral pole of her articular disc displaced and the medial pole beginning to displace as well.

The initial course of treatment involved splint therapy using a full-arch stabilization splint. Over a period of 6 to 12 months, the splint was sequentially adjusted to gradually reposition Dana’s condyles and allow for joint adaptation. This critical step helped achieve loadable, stable joint positions.

Once the joints were stabilized, Dana underwent orthodontic treatment with Invisalign to align her arches and create an ideal arch form. This was followed by conservative composite bonding and equilibration to reproduce the optimized occlusal scheme from the splint onto her natural dentition.

Although Dana’s joint health and function were restored with comprehensive treatment, it’s important to remember that altered TMJs need ongoing monitoring. Dana received a nighttime splint and was advised that periodic adjustments may be needed to stabilize the joint.

Remember – Proper TMJ/TMD Education Can Help Boost Patient Success

Managing TMJ/TMD conditions is a complex and multifaceted process that requires a comprehensive understanding of diagnosis, treatment modalities, and long-term monitoring strategies. 

Mastering these best practices is crucial for dentists and oral health professionals to achieve optimal treatment outcomes and ensure patient comfort and well-being.

Patients suffering from TMJ/TMD disorders often experience significant pain, limited jaw function, and a diminished quality of life – conditions that may lead to permanent joint damage and further complications. Dental professionals are responsible for being well-versed in the latest TMJ/TMD management protocols to provide their patients with the highest standard of care.

Accurate differential diagnosis is the foundation of successful treatment plans. Dentists must be skilled in interpreting diagnostic findings, such as those from anterior deprogrammers, manual manipulation, and imaging modalities like Doppler ultrasound. Knowing these options enables them to distinguish between extracapsular and intracapsular issues, guiding the appropriate selection of splint therapy, occlusal therapy, or other interventions.

By investing in continuing education and staying abreast of the latest advancements in TMJ/TMD management, dentists can position themselves as leaders in this field, providing their patients with the highest care and comfort. 

Remember your call to care for the whole life of the patient – a deep understanding of TMJ/TMD best practices is not only a professional obligation but also a testament to the commitment to improving patients’ overall well-being.

To expand on this topic, join us at Core 1: Occlusion & Smile Design