The Relationship Between TMJ and Orthodontics Three Patient Scenarios

When considering the question of whether there is a relationship between orthodontic treatment and TMJ symptoms (jaw pain, clicking, locking, limited opening, etc.) there are three scenarios to consider.

Scenario 1: A patient with a recent onset of TMJ symptoms and a history of orthodontic treatment many years prior.

Scenario 2: A patient with an onset of TMJ symptoms within several months of completing orthodontic treatment.

Scenario 3: A patient involved in fixed orthodontics and/or aligner-driven orthodontic?therapy who develops TMJ symptoms while in the midst of care.

Let’s examine each scenario closely:

Scenario 1: A patient with a recent onset of TMJ symptoms and a history of orthodontic treatment many years prior.

Though blanket statements are hard to make, it would be rather difficult to implicate orthodontic intervention as the primary or sole factor that leads to the onset of TMJ symptoms. The vast majority of research studies have shown that longstanding bite relationships (God-given or created by braces) play only a small role in the development of TMJ problems.

Therefore, while searching for meaningful clues as to why a problem has developed, I would not look primarily at tooth-to-tooth relationships in this patient population. Rather, my focus would be on other risk factors that commonly lead to jaw pain and orthopedic instability in the jaw. Four lines of questioning come to mind during an initial consultation:

1. Did You Have An Injury??

Since the TMJs and associated jaw muscles can be injured the same way as a knee or elbow, this line of questioning is vital. Was the patient injured on the athletic field or in a car accident? Did the patient have recent medical procedures that kept the mouth open for a long period of time or in an awkward way? Did the patient ever notice sudden jaw pain or popping while eating, yawning, playing a musical instrument, or even singing? Did he or she have dental work performed or a recent challenging wisdom tooth removal that could have compromised jaw structures? Has there been a change of diet to one that requires more consistent chewing of tougher foods? The possibilities are endless so the questions need to be asked.

2. Do You Over-Stress Your Jaw??

Since overuse behaviors and head postures can impact the structure and stability of the jaw muscles and temporomandibular joints,?these risk factors need to be assessed. Does the patient have a history of chewing?gum or nail biting, cuticle biting, or chewing on pens? Does the patient hold his or her eyeglass frames between the teeth? Does he or she grind or clench the teeth at night and/or during the day? Is there a work-related neck strain? Are there longstanding neck symptoms that include pain and muscle tightness (as this type of problem is often responsible for the onset of jaw symptoms)? The bottom line is that you need to determine if there are ongoing factors that fatigue the muscles and/or sprain the TM joints.

3. Has Your Health Changed?

Changes in a patient’s medical health can also be a potential source of challenge to the jaw. Is the patient taking new medication that may be stimulating muscle tension or nerve excitation? Has the patient stopped smoking? Are there any new neuromuscular, rheumatologic and/or autoimmune diseases? Is there profound depression or anxiety? Has he or she been diagnosed with a chronic illness? Does the patient have problematic insomnia, migraines or gastrointestinal issues? Beyond the specific features of a medical disease that can impact the jaw, even the stress of being concerned about one’s health is sufficient enough to initiate jaw muscle tension and pain.

4. Are You Stressed-Out?

A fatigued, conflicted and unhappy brain is a source of muscle tension and can negatively impact the nervous and immune system. This can lead to a lower threshold of pain. Does the patient have ongoing challenges at home and/or at work? Is he or she caring for a sick child or parent? Are there marital problems? Are there financial worries? An endless list of critical life matters can cause changes in the way a patient sleeps, breaths, and holds muscle tension throughout the body. All of these changes can bring on jaw-related symptoms .

Less commonly seen, but worth mentioning, is the patient who had traditional orthodontics many years in the past to correct a malocclusion. The origin of the malocclusion was due to skeletal imbalances in the jaw-to-jaw relationships. As a result, ideal tooth-to-tooth contacts were never realized and the jaw-to-jaw asymmetry issues remained. Some of these patients develop jaw symptoms over time that require a careful look at structure to see if this is where treatment is best directed.

Scenario 2: A patient with an onset of TMJ symptoms within months of completing orthodontic treatment.

This patient population has already made the assumption that their just-completed orthodontic treatment is the culprit. It would be hard to argue to the contrary unless other independent factors or events have been identified.

With an understanding that TMJ problems are orthopedic in nature, one must appreciate that as teeth are moved and then settle into new positions in the upper and lower jaw bones, the jaw muscles, tendons, joint ligaments, cartilage, bones, lubricating systems, and shock absorbing disc must all adapt to the new environment. Fortunately this adaptive response is most common, but not guaranteed.

When the finalized tooth positions, however, don’t support a consistent, balanced, or symmetric jaw-to-jaw relationship while the teeth are together or involved in chewing, there is the potential for trouble.

With some people the end orthodontic result is, unfortunately, less than ideal and leads to asymmetric tooth contacts or tooth contact patterns that force the lower jaw into an awkward position when the teeth are brought together. Therefore, during chewing, the jaw can be consistently forced into postural positions that lead to jaw sprains and strains. In addition, if this scenario occurs in a person who has daytime behaviors that prompt tooth contact or who has a history of night clenching or grinding, these awkward bite postures will have an even greater impact leading to more TMJ symptoms.

It would certainly be shortsighted in this scenario to look beyond the teeth, although a broad evaluation process is always encouraged. If the tooth-to-tooth contacts appear to adversely impact the relationship between the upper and lower jaw and related chewing mechanics, then intervention may well be required. If there is a need to “shore up the foundation”, hopefully this can be done simply with a short course of orthodontics being reintroduced or at times with dental procedures on specific teeth to provide more tooth contact symmetry (i.e. bonding of tooth-colored resin directly to the surface of the teeth). This restorative process could be all that is required or it can be used to create a blueprint to guide additional orthodontics at a later time.

The main message here is that orthopedic stability was lost as the teeth were moved and settled-in. This created an opportunity for orthopedic problems to arise.

Scenario 3: A patient involved in fixed orthodontics and/or aligner-driven orthodontic therapy who develops TMJ symptoms while in the midst of care.

This is clearly a most challenging scenario as patients actively involved in any form of orthodontics become concerned when their jaws begin to hurt or their joints make noises and/or lock.

Regardless of whether tooth movement is being performed with fixed wires or removable aligners, the first question usually posed by patients of any age is this: “What is happening? Why is it happening? Should I bail out of treatment?”

To fully answer these questions is beyond the scope of this newsletter, but it is sufficient to say that in this scenario orthopedic stability is certainly being challenged.

The emergence of joint noise, locking, and/or pain (beyond the teeth) is not an expected consequence of orthodontics. Therefore, the presence any of these symptoms should be a red flag and prompt quick reassessment and a possible change in the course of treatment (such as abandoning the use of elastics).

In addition, with the advent of aligner-directed orthodontics I have seen many patients who persistently bite down on the aligner trays, which promotes muscle fatigue and joint loading. These types of issues must be taken into consideration if problems begin to surface.

As the orthodontic process evolves, beyond reassessing the type of mechanics being used to move the teeth, there must also be some scrutiny of the patient’s behavioral tendencies. Is he or she a new or a longstanding nail biter and/or cuticle biter, for example? Does the patient chew gum or clench his or her teeth during the day? Have nighttime clenching or grinding patterns increased as a result of poor sleep prompted by medical problems, worry, anxiety, or the demands of school or the workplace? Are new medications being taken that may be disrupting sleep or stimulating an individual’s fight-or-flight tendencies, therefore driving muscle tension?

These and other factors must at least be considered before all blame goes to the orthodontic process.

Conclusion

Orthodontics is by no means a universal cause of TMJ problems. But at times it is responsible for the emergence of muscle and joint problems. Each patient scenario is different. Careful assessment of the history and clinical characteristics of every patient must be considered before pointing fingers and/or determining how to proceed to achieve the best long-term outcomes.

I welcome your thoughts.