Case 93: What Comes First? Treating TMJ Pain or Esthetics?

This 43-year-old woman presented for a consultation regarding pain in the temporomandibular joints (TMJs) and esthetic concerns about short anterior teeth. She had pain in the right and left TMJs, with the pain being greater in the left joint. She had regular headaches, neck pain, ear pain, and facial pain. She reports hearing crackling noises in her left TMJ for most of her life. Her jaw started to lock when she was 18 years old, and she has used multiple occlusal appliances since the age of 20. Her trauma history includes falling on her chin and receiving sutures to close the wound when she was 5 years old. She was very unhappy with the esthetic appearance of her teeth.

Medical History

The patient reported that she was allergic to sulfonamides, iodine, and possibly penicillin. She had a history of asthma and chronic anemia. She was not taking any medications.

Diagnostic Findings

Extraoral/Facial

Facial form: Symmetric and balanced.
Lower third and middle third facial proportions: Normal.
Lip length: Normal.
Lip mobility: Average.

Dental

Missing teeth nos. 1, 16, 17, 32.
Significant maxillary anterior tooth wear resulting in short clinical crowns.
Significant mandibular anterior tooth wear resulting in short clinical crowns.

TMJ/Mandibular Range of Motion/Muscles of Mastication and Facial Expression

Right TMJ: Average pain 2/10; worst pain 5/10.
Left TMJ: Average pain 6/10; worst pain 10/10.
Maximum opening with pain: 45 mm.
Maximum opening without pain: 25 mm.
Excursive movements: Normal.
Masticatory muscles tender to palpation.
Positive load test in right and left TMJs.
No clicking or popping in either TMJ.

Periodontal

Mobility: Normal for all teeth.
Sulcus depths: Normal for all teeth.
Root coverage: Normal for all teeth.
Tissue position relative to the cementoenamel junctions: Normal for all teeth.

Occlusal Notes

Initial point of contact in a fully seated condylar position: Tooth nos. 14 and 19, with a 1-mm shift from fully seated to maximum intercuspation.
Angle Class II malocclusion on right and left sides.

Pretreatment anterior view, teeth apart.

Radiographic Review: CBCT

Right condyle: Well developed.
Right ramus length: 65 mm.
Right compressed joint space at the lateral aspect of the TMJ.

Left vertical height development deficiency.
Left ramus length: 60 mm.
Facial skeletal asymmetry to the left.
Pharyngeal airway anatomy: Within normal limits.

Radiographic Review: MRI

Right TMJ: Complete anterior disc displacement with reduction (Piper 4A).
Left TMJ: Complete anterior disc displacement without reduction and with perforation (Piper 5A).
Left TMJ: Early edema in the condylar head.
Left TMJ: Microfractures at the lateral aspect of the left condyle.

FMX 2011

Diagnosis and Prognosis

Structurally altered TMJs at the lateral and medial poles.
Extensive anterior tooth wear.

Prognosis of the right TMJ: Guarded.
Prognosis of the left TMJ: Guarded.

Summary of Concerns

Can the TMJs be stabilized without surgical intervention to provide esthetic options for the maxillary and mandibular anterior teeth?
Do all the teeth require restorations to increase the length of the maxillary and mandibular anterior teeth?
Is there a way to restore the maxillary and mandibular anterior teeth without restoring the posterior teeth?

Proposed Treatment Plan

Phase I: Diagnostic Work-up and Consultation with Specialists

Perform initial examination and gather diagnostic records, including photographs, periodontal probings, radiographs, CBCT scans, MRI scans, and mounted study casts.
Consult with other specialists, including an oral and maxillofacial surgeon, orthodontist, and laboratory technician.

Phase II: Initial Treatment

In consultation with the oral and maxillofacial surgeon, the recommended treatment is occlusal appliance therapy to redistribute muscle forces in an attempt to change the loading of structurally altered TMJs. The patient was told the occlusal appliance may alleviate symptoms, exacerbate symptoms or may not change the symptoms.
Estimated treatment time is 6–12 months.

Phase III: Orthodontic Therapy

To address the esthetic problem resulting from the tooth wear, orthodontic appliance therapy will be scheduled following the occlusal appliance therapy assuming symptoms have resolved.
The maxillary and mandibular incisors will be intruded to align the CEJs in order to gain space to restore the worn tooth structure.
Estimated treatment time is 16-20 months.

Phase IV: Restorative Treatment

With the vertical space obtained through orthodontic intrusion, the plan is to rebuild the maxillary and mandibular anterior teeth.
A combination of lithium disilicate full-coverage restorations and composite to rebuild the incisal edges will be used.

Phase V: Maintenance

To protect the restorative treatment and to modify the loading on structurally altered TMJs, the use of long-term, dual-arch occlusal appliances will be recommended.

Active Clinical Treatment

Review of Treatment Goals

The patient, a 43-year-old woman, presented for a consultation regarding pain in the temporomandibular joints (TMJs) and esthetic concerns about short anterior teeth. She had pain in the right and left TMJs, with the pain being greater in the left joint. She had regular headaches, neck pain, ear pain, and facial pain. She reported hearing crackling noises in her left TMJ for most of her life. Her jaw started to lock when she was 18 years old, and she had used multiple occlusal appliances since the age of 20. Her trauma history included falling on her chin and receiving sutures to close the wound when she was 5 years old. She was very unhappy with the esthetic appearance of her teeth.

Our treatment goals were, first, to reestablish an occlusal scheme that was as comfortable and as stable as possible, and second, to restore normal alignment and contours to the maxillary and mandibular incisors to create a functional and esthetic dentition.

Phase I: Diagnostic Work-up and Consultation with Specialists

Following the initial examination, we gathered diagnostic records including photographs, periodontal probings, radiographs, CBCT scans, MRI scans, and mounted study casts. Based on our findings, we consulted with other specialists, including an oral and maxillofacial surgeon, an orthodontist, and a laboratory technician.

Phase II: Occlusal Appliance Therapy

Dr Mark Piper was the oral and maxillofacial surgeon on the interdisciplinary team who treated this patient. After consulting with the patient, Dr Piper recommended a dual-arch maxillary and mandibular full-arch occlusal appliance. The rationale for the dual-arch appliance was to increase the vertical dimension and decrease the patient’s ability to generate muscle forces. While the surgical approach of disc replacement was discussed in detail, after reviewing the MRI and CBCT scans, Dr Piper believed that occlusal appliance therapy would be more conservative and had good potential for success.

The dual-arch appliance resolved the TMJ symptoms after a period of about 12 months. There was a detailed discussion about possible future bite changes due to future breakdown of the TMJs. The patient continued using the occlusal appliance while preparing for the next phase of treatment.

Phase III: Orthodontics to Intrude Maxillary and Mandibular Incisors

Dr Adam Saylor was the orthodontist on the interdisciplinary team treating this patient. After consulting with the patient, Dr Saylor recommended conventional orthodontic treatment with brackets and wires to intrude the anterior teeth. There was discussion of the possible use of temporary anchorage devices in addition to conventional orthodontic treatment with brackets and wires if the anterior teeth required additional anchorage for intrusion.

Dr Saylor started orthodontic treatment in January 2013 and concluded in October 2015. The orthodontic treatment was completed when the cemento-enamel junctions (CEJs) of the maxillary and mandibular incisors were in correct alignment with the CEJs of the posterior teeth and the posterior teeth were positioned to maintain the TMJ symptom resolution.

Orthodontic intrusion brackets and wires.

Phase IV: Restorative Treatment to Rebuild Maxillary and Mandibular Anterior Teeth

After the orthodontic treatment was complete, newly mounted study casts and digital photographs were obtained to finalize the treatment plan for the restorative phase of care. Upon reviewing the mounted study models and photographs, we determined that the canines (teeth nos. 6, 11, 22, and 27) had not lost enough tooth structure to require full-coverage restorations. The option of using composite to restore the natural contours to the canines was discussed in detail. The advantage of preserving tooth structure was a key factor in our decision to opt for composite to restore the canines as opposed to using full-coverage lithium disilicate.

The definitive treatment plan to restore the anterior teeth was as follows:

Teeth nos. 7, 8, 9, and 10: Lithium disilicate full-coverage restorations
Teeth nos. 23, 24, 25, and 26: Lithium disilicate full-coverage restorations
Teeth nos. 6, 11, 22, and 27: Composite restorations to rebuild the incisal edges

Post-orthodontic treatment photos were obtained and sent to Mr Matt Roberts, CDT. A digital design was created and a digital wax-up was fabricated for the patient’s approval. Once the patient approved the design, teeth nos. 7–10 and 23–26 were prepared for full-coverage restorations. Bisacryl provisional restorations were fabricated and composite restorations were placed on the incisal edges of teeth nos. 6, 11, 22, and 27 to create ideal contours for esthetics and function. The lithium disilicate restorations were fabricated, tried in, and approved by the patient. The restorations were inserted, and postoperative instructions were provided.

Phase V: Long-Term Dual-Arch Occlusal Appliance Therapy

The dual-arch occlusal appliances were relined to ensure the fit of the new restorations with the existing occlusal appliances.

Provisional restoration of anterior maxilla.

Postoperative FMX, 2018.

Commentary

This case demonstrates a conservative method to treat extensive anterior tooth wear. The patient had received a treatment plan from another dentist that called for crowning all the teeth to open the vertical dimension so as to create room to lengthen the anterior incisors. Using orthodontics to intrude the anterior incisors resulted in a much more conservative treatment plan and preserved posterior tooth structure.

The patient had exemplary compliance during the treatment in terms of following instructions for the occlusal appliance as well as maintaining excellent oral hygiene during the orthodontics phase of treatment.

This case demonstrates that it is possible to do comprehensive restorative treatment on a patient with significant structural alterations to the TMJs. The TMJ imaging allowed for discussion of the realistic prognosis with the patient regarding the occlusal stability of the treatment.

Jim McKee, DDS, is in private practice in Downers Grove, Illinois. He is a visiting faculty member of the Piper Research and Education Center in St Petersburg, Florida, and a resident faculty member at Spear Education in Scottsdale, Arizona.

Adam Saylor, DMD, is an orthodontist and is in private practice in Glen Ellyn, Illinois.

Mark Piper, MD, DMD, is an oral and maxillofacial surgeon and is the founder and director of the Piper Research and Education Center in St Petersburg, Florida.

Matt Roberts, CDT, is the founder and owner of CMR Dental Laboratory in Idaho Falls, Idaho. He is an accredited ceramist in the American Academy of Cosmetic Dentistry.