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The temporomandibular joint (TMJ) is the area right in front of the ear on either side of the head where the upper jaw (maxilla) and lower jaw (mandible) meet. Muscles attached to and surrounding the jaw joint control the position and movement of the jaw. This joint is a unique sliding “ball and socket” that has a disc sandwiched between it, it is the only joint in the body which can move in all directions. The temporomandibular joint functions to move the jaw, especially in biting and chewing, talking, and yawning. It is one of the most used joints in the body.

The temporomandibular joints are very complex and are made up of muscles, tendons, a disc and bones.You have a temperomandibular joint on each side of your jaw (right and left side). Each part contributes to the smooth movement of the temperomandibular joint. When the muscles are relaxed and in balance and both jaw joints open and close comfortably, we are able to talk, chew, or yawn without discomfort or pain.

TMJ Syndromes

TMJ Symptoms

We can find the TMJ by placing a finger on the triangular area in front of the ear. The finger is moved just slightly forward and pressed firmly while opening the jaw. The motion felt is from the TMJ opening. We can also feel the joint motion if we put a little finger against the inside front part of the ear canal. If a patient is experiencing TMJ difficulty the simple act of opening and closing your mouth can cause considerable pain. Opening your mouth allows the rounded ends of the lower jaw (condyles) to glide along the joint socket of the temporal bone. The condyles are able to slide back to their original position when you close your mouth. The motion is kept smooth by a soft disc of cartilage that lies between the condyle and the temporal bone, creating a gliding cushion so that bone doesn’t rub across bone.  Chewing creates a very strong force. This disc is able to distribute the forces of chewing throughout the joint space.

TMJ disorders (also called TMJ Syndromes) are a complex set of problems of the jaw joint. The muscles and joints work as a team. A problem with either one can lead to stiffness, headaches, ear pain, bite problems ( also called a malocclusion), clicking sounds, or locked jaws. TMJ disorders can be caused by many different types of problems. These can include arthritis, trauma to the jaw, or muscle fatigue from clenching or grinding your teeth. TMJ disorders most commonly occur in women between the ages of 30 and 50, but can occur in teens after braces, and in both men and women at any age.

Behaviors that can Lead to TMJ Disorders

-Teeth grinding (bruxism) speeds up the wear and tear on the cartilage lining of the TMJ. People who grind or clench their teeth may be not even be aware they are doing it. Many patients wake in the morning with jaw pain, ear pain or even a headache. Teeth grinding as a habit can result in muscle spasm and inflammatory reactions, thus causing the initial pain. Changes in the normal stimuli or height of the teeth, misalignment of the teeth, and changes in the chewing muscles may cause temporomandibular joint changes. Generally, someone who has a teeth grinding habit usually does so during his or her sleep.

TMJ Syndrome

TMJ – Avoid Stress

-Teeth Clenching. People who clench continually bite on things while awake. This might be as simple as chewing gum, a pen or pencil, or even fingernails. The constant pounding on the joint causes the pain. Stress is often the leading cause of teeth clenching.

-Habitual gum chewing or fingernail biting

-Dental problems and misalignment of the teeth (malocclusion). Patients may complain that it is difficult to find a  comfortable bite or that the way their teeth fit together has changed.  Chewing on only one side of the jaw can lead to or be a result of TMJ  problems.

-Trauma to the jaws: Previous fractures in the jaw or facial bones can lead to TMJ disorders.

Trauma is split into 2 types: micro trauma and macro trauma.

Micro trauma is considered internal, such as grinding the teeth (bruxism) and clenching (jaw tightening). This continuous pounding on the temporomandibular joint can change the alignment of the teeth. The muscle involvement causes inflammation of the membranes surrounding the joint. Teeth grinding and clenching are habits that may be diagnosed in people who complain of pain in the temporomandibular joint or have facial pain that includes the muscles involved in chewing.

Macro trauma is from an external trauma like a punch to the face or a car accident. This trauma can fracture the jawbone, cause dislocation of the TMJ, or cause damage to the cartilage disc of the joint. Pain in the TMJ can also occur following dental treatment whereby the joint is stretched open for extended periods of time. Massage and heat application following your dental appointment can help relive the discomfort.

-Stress frequently leads to unreleased nervous energy. It is very common for people under stress to release this nervous energy by either consciously or unconsciously grinding  and clenching their teeth.

-Routine tasks or habits such as holding the telephone between the head and shoulder may contribute to TMJ disorders.

-Anatomy. You may have a malformed jawbone, joint, or disc, leading to poor function, wear and pain.

TMJ pain can usually occur because of unbalanced activity, spasm, or overuse of the jaw muscles. Symptoms tend to be chronic, and treatment is aimed at eliminating the cause. Many symptoms may not appear related to the TMJ itself.

 

Common TMJ Disorder Symptoms

-Headache. About 80% of patients with a TMJ disorder complain of headache and about 40% report facial pain, and ear pain. Pain is often worsened while opening and closing the jaw. Exposure to cold weather or air may increase muscle contraction and facial pain.

-Ear pain. About one half of patients with a TMJ disorder notice ear pain and do not have any signs of ear infection. The ear pain is usually described as being in front of or below the ear. Because ear pain occurs so commonly in TMJ patients. Ear specialists are routinely called on to make the definitive diagnosis of a TMJ disorder.

-Sounds. Grinding, crunching, clicking, or popping sounds (medical term = crepitus) are common for patients with a TMJ disorder. These sounds are not always associated with increased pain.

-Dizziness. Approximately 40% report a slight sense of dizziness or imbalance. The cause of this type of dizziness is not known.

-Fullness of the Ear. About one third of patients with a TMJ disorder describe muffled, clogged, or full ears. They may be aware of ear fullness and pain during airplane takeoffs and landings. These symptoms are usually caused by Eustachian-tube dysfunction (structure responsible for the regulation of pressure in the middle ear). It is believed that patients with TMJ syndromes have hyperactivity (muscle spasms) of the muscles responsible for regulating the opening and closing of the Eustachian tube.

-Tinnitus (ringing or noise in ear). For reasons unknown, 33% of patients with a TMJ disorder experience tinnitus. 50% of those patients will have resolution of their tinnitus after successful treatment of their TMJ disorder.

Diagnosis

Many  conditions can cause similar symptoms to TMD. These include a toothache, sinus problems, arthritis, ear infection, or gum disease. Your dentist will conduct a careful patient history, dental examination, and take necessary x-rays to determine the cause of your symptoms.  A CT scan can provide the doctor or dentist very detailed images of the bones involved in the joint and MRI’s can show issues with the joint’s disk.

Treatment

Patients TMJ issues can sometimes go away on their own. If your symptoms persist, your doctor may recommend medications or a night guard to help keep you from grinding your teeth at night. Surgery may be required (in very rare cases) to repair or replace the joint. Conventional treatment consists of a diet of soft foods along with warm compresses to settle down the tension of the muscles.

Medications for Treatment of TMJ Disorders

-Painkillers. Dentist or doctor will recommend over the counter medications (like Aleve or Motrin), or prescription medications such as Dolobid are a first option to relieve pain. If pain continues, they may prescribe something stronger to deal with pain.

-Tricyclic antidepressants (Amitriptyline or Nortriptyline). Antidepressants prescribed to be taken at bedtime have been successful in relieving TMJ pain in some patients.

-Muscle relaxants (Valium). These types of drugs are sometimes used for a few days or weeks to help relieve pain caused by TMJ disorders.

-Corticosteroid drugs. These drugs can be injected into the joint space to provide relief. This is only used in patients with sever pain and discomfort.

Aleve for TMJ Symptoms

Aleve for TMJ Symptoms

-Botulinum toxin. Injecting botulinum toxin (example Botox) into the jaw muscles may give relief to pain associated with TMJ disorders.

Therapies Available

-Night Guard. For patients who grind their teeth patients may gain from wearing a  firm custom made appliance. This night guard prevents your teeth from coming together in contact, and repositions teeth to decompress the jaw joint.

-Psychological Therapy. For patients whose main symptom is from stress or anxiety they may benefit from a visit to a psychotherapist. This would allow the patient to become self aware of stress triggers as well learning relaxation techniques to relieve stress.

Surgical Treatment

-Dental Adjustments. Your dentist may improve your bite by adjusting the biting surfaces of your teeth. This will allow for your bite to be in a more balanced state. Other options include replacing missing teeth, or replacing needed fillings or crowns. These actions sometimes worsen TMJ pain.

-Joint Aspiration (Arthrocentesis). This procedure allows for joint irrigation. The joint will be irrigated to remove debris and inflammatory by products.

-Surgery. This is considered to be a last resort. The surgery would be done to repair or replace the joint. This should be avoided when possible. Only about 1% of those with TMJ disorders requires surgery for joint replacement.

Most patients are quite successful with conventional conservative therapy (such as resting the jaw or night guard). The success of treatment depends on how severe the symptoms are and how well you comply with treatment. As always, it is best to maintain regular appointments to see your dentist and let them know if there any TMJ issues developing.

 

Dental Implants have changed the way we look at dentistry. Dental implants are not just for single tooth or multiple teeth replacement. They can also be used in support and stabilization

of removable dentures. Long time denture wearers will tell you that over time the bone remodels and resorbs resulting in loose and ill fitting dentures. When this happens patients used to be forced to grin and bear it using various denture adhesives. Now with the development of dental implant supported dentures those days can be a relic left in the past for many patients.

Dental Implant Overdenture – What is it?

A dental implant supported denture is also called an overdenture. A traditional removable denture rests directly on the gums, and is not supported by dental implants. This is because the denture sits over the dental implants. The dental implants give support and stability to the denture.

A dental implant supported denture is recommended when a person is missing all the teeth in the jaw. The patient needs to have enough bone in the jaw to support the dental implants. The denture is able to stay in place using special attachments that allow the denture to “snap” into place over the dental implants.

Implant supported removable dentures usually are fabricated for the lower jaw. This is because regular dentures tend to be less stable on the lower arch due to tongue and musculature present. Usually, a regular denture made to fit an upper jaw is much more stable and tolerable on its own and doesn’t need the extra support offered by implants. If the patient chooses they can receive a dental implant supported denture in either the upper or lower jaw.

Dental implant supported denture should be removed daily to clean the denture and gum area just like traditional dentures. Also, you should not sleep with the dental implant supported dentures at night. Some people prefer to have fixed (permanent) crown and bridgework in their mouths that can’t be removed but this is not always possible in every patient’s case. Your dentist will consider your particular needs and preferences when suggesting fixed or removable options.

Dental Implants with bar supporting denture

Dental Implants with Bar Supporting Denture

Types of Dental Implant Supported Dentures

 

There are two types of dental implant supported dentures:

1) Bar-retained dentures. Your dentist will have a thin metal bar custom fabricated for your mouth. This bar will follow the curve of your jaw and is attached to 2-5 dental implants that have been placed directly into your jawbone. Clips or other types of attachments are fitted to the bar, the denture or both. The denture is then designed to fit directly over the bar stabilized by the attachments. The dental implants along with the bar and attachments gives the denture support and stability.

2) Ball-retained dentures. The dental implants in the jawbone hold a metal attachment(ball) that fits into another attachment(socket) on the

Dental implant supported denture - Ball retained

Dental Implants – Ball Retained Denture

denture. In most cases, the attachments on the implants are ball-shaped (“male” attachments), and they fit into sockets (“female” attachments)

on the denture. In some cases, the situation is reversed and the male attachment is in the denture and female attachment is on the dental implant. This also gives the denture wearer increased stability and retention over the traditional removable denture without dental implants.

In both scenarios, the removable denture will be made of a custom fabricated acrylic base that will look like gingival tissue. The teeth can be made of porcelain or acrylic. These teeth will look very natural. Either type of denture needs a minimum of 2 dental implants to work properly over the long term.

Placement of Dental Implants

The prime location for placement of the dental implants is in the front of the mouth. The reason for this is due to the fact that there is

supporting denture with dental implants

Visualization of dental implants supporting dentures

generally more bone present in this area for the dental implants. This is the case even if the teeth have been missing for a long period of time. When teeth are lost, bone is lost in that surrounding area.  Anatomy plays a role as well. In the front of the mouth there are less nerves orother important structures that could interfere with he placement of the dental implants.

The time schedule to complete the dental implants can be complicated. The general time frame is approximately 5 months for the lower jaw and approximately 7 months in the upper jaw. The process can take much longer if the case is more complicated. Complications can include the need for bone grafting or even sinus lifts.

The procedure generally requires two surgeries. The first surgery is for placement of the dental implants in the jawbone under your gingival tissue. The second surgery is to remove the gingival tissue that has now covered the dental implants. The second procedure comes 3-6 after the first.

There has been increased use of a one stage procedure.

A one-stage procedure is now used sometimes. In this procedure, your dentist places the implants and the supporting bar all at same visit.  The success rate of this procedure is high. if properly treatment planned.

Dental Implant Supported Denture Care

The dentures need to be removed at at night and to clean them. The attachments and/or bar need to be cleaned as well. Your dentist will give you instructions on how to clean these as they can be delicate.

Your dentist will periodically check the parts of your new denture to ensure they are secure and in proper place. Your denture may seem stable but over time these attachments can loosen. If they loosen even slightly it will cause the denture to move when chewing. This movement of the denture can cause sore spots as the denture rubs against your gums. Your dentist will also check to make sure your bite is correct and make any adjustments as needed.

The clip or other attachments on the bar retained denture usually will need to be replaced every 6-12 months. They are made of a plastic material (nylon) and will wear after continued use.

Complications that may Arise

The actual dental implant surgery carries its own risks but so does a bar retained denture. The fabrication of a bar retained denture needs extra space inside the denture to allow for the bar to fit inside. This means there is less support for the teeth in the denture. Due to this, the teeth sometimes come loose. This is an easy fix but an inconvenience for the patient.

Another important item is that the denture fits on the bar passively. This means that the bar is evenly balanced across all implants. If the fit is not passive, the extra strain can cause the screws holding the bar down to loosen. A special note for teeth grinders or clenchers is that their parts are more likely to break due to the excessive force they are placing on the components and dental implants.

Dental Implant Overdenture Expectations

A denture supported by dental implants will be far more stable than a traditional removable denture. Patients will find everyday tasks easier. They will find speaking easier. They will also not be concerned that their denture may fall out or become loose. Patients report being able to eat foods they have not been able to eat in years. A word of caution is to avoid sticky or very hard foods as you can damage the denture with these types of food.

A big advantage to having dental implants support the upper denture is the dentist can make your denture much less bulky. A traditional denture covers your entire palate whereas a dental implant supported denture does not need that extra material for support.

A whole new world has opened up with dental implants for both patient and dentist. The old compromise and limitations are slowly being worn away. We are entering a new world of dentistry and dental implants are leading the way!

 

Benefits of Dental Implants with Removable Dentures
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