TMJD treatment with splint therapy

[Aspiring]

Looks like I'm in this for real, so it's time to start my own thread.

I've had occasional popping in my TMJs for ... well, as long as I can remember. At least I could make it happen intentionally. A couple of times over the years, my jaw got stuck, which was excruciating, but I got it to pop back into place on my own, and went on about my life. About a year ago, suddenly my right TMJ made a crunching sound, exactly like someone was crumpling a sheet of aluminum foil up into a ball. It was over before I could react and stop it. From that point on, every time I open my jaw wide, the right side pops. It was sore for a while. I decided to see if it got better or worse with time instead of seeking immediate treatment. After a month or two, the constant soreness went away, but it continued popping every time I opened wide. I adapted by mostly avoiding wide opening.

Over the course of the past year, the right hasn't really changed any, but the left is hurting and it gets stuck. It has gotten worse over the year, so now it always gets stuck closed. I have to slide my jaw forward, then right, then the right TMJ will pop, then I can open to my maximum. If I don't do the sliding just right, or my muscles are too tight, it just won't go. Usually I can work the joints enough to get the muscles to loosen up, try and try again, lots of pain, and finally get it to open. This may take up to 15 minutes.

My daughter has reached the age where she needs the services of an orthodontist. Making the calls for her was the trigger that pushed me over the edge to finally take care of myself instead of "yeah, I need to take care of that. Maybe next week."

I went to see one orthodontist last week who saw how restricted my opening is, and they referred me to a dentist who does a lot of TMJD work. That particular dentist also practices woo, so I wasn't thrilled about going there. Willing, but not thrilled. The first ortho was not willing to touch me until my joint issues were fixed. I had already scheduled an appointment with another orthodontist this week (who happens to also be my daughter's ortho). This one took a quick look at my teeth (which I would like some orthodontic cosmetic work on, but that's low priority compared to my TMJD) and then gave my TMJs a thorough exam. I agreed to go ahead with treatment, so I had to have records done. X-rays were fine but the impressions. Oh, the impressions! Getting the trays fitted was fine, but when they brought them over full of the goop to do the actual impressions, my left side felt like it moved out of position. Oh, it was excruciating! I closed my eyes and breathed slowly and deeply, trying to relax my whole body, and thought about it being over soon. I know that the material sets up in 3.5 minutes from when they start mixing it, so I only had to tolerate it that long. Then the impressions were stuck and they couldn't get them out, and every time they pulled, it put pressure on my already very hurting TMJ. They finally got it out, but my jaw was still out of place. They were very kind about it, giving me space and they told me to let them know when I was ready to do the lowers. That took all the psychological pressure off, I was able to relax, and work it back into place. The bottom was pretty much a repeat of the top, it popped out when they brought the trays over, and then trying to remove it put pressure on the joint which hurt more. Thankfully it wasn't quite as bad as the upper impression.

After that trauma, my jaw muscles spasmed and I couldn't close my mouth fully. The doctor came right over and examined me more, but the muscles relaxed in a minute or two and I was back to "normal." Very sore, but normal. Doctor said he wanted to see me back ASAP for the consult, my condition is serious and urgent. I made an appointment for my consultation for the next day. My left side joint was very painful for the rest of the day. I considered taking medication for it, but I don't like taking medication unless it's necessary. I was busy enough that I wasn't thinking about it, and over time it did feel a bit better. I had a milkshake for dinner because I was not willing to try to open my jaw. Still in pain when I went to bed, but the next day it just felt tired, as though I had spent the previous day chewing on very tough gum all day.

At my consult, he explained that every day that my disc stays out of place, every time it pops out, it reduces the chances that they will be able to fix it. There is a surgical option, but that is only after trying everything else first. My treatment plan is splint therapy, to place my lower jaw in a position where the disc stays between the bones where it belongs, for up to 10 months. Either it will work within 10 months, or it will not ever work, so there is no point in continuing splint therapy beyond that time. If the splint therapy is successful, then I will have braces to move my teeth so that my bite lines up with the new jaw position.

I agreed with the treatment plan, went to the desk and worked out financials and a contract, then back to the chair for a bite register. He found the proper jaw position for my joints to be in, then took an impression of the bite. That will be used, along with the upper and lower impressions, to make the splints. Initially they said they had to repeat the impressions, but then they said they could just use the ones they already had.

I will have two splints, one for daytime use and one for night time. The day one just goes over my lower teeth, and makes my upper and lower teeth meet in the new jaw position. The night time one goes over my upper teeth, and includes a sort of ramp to guide my lower jaw forward to the new position.

Now I just have to wait a month for my splints to come in from the lab. In the meantime, I am trying to hold my jaw forward in the new position as much as possible.

[Prometheus]

Aspiring, nice to hear your story. Mine is similar, I was told my whole life not to worry about the popping in and out and an uncomfortable bite unless it was painful. By the time it began to really hurt I was 58 years old and had bone grinding against bone in my TMJ, the disk had been completely crushed out. The pain went from nothing to unbearable over the course of only a few months. I ended up wearing a bite splint for 7 months and then braces. The pain has pretty much disappeared and now my jaw seems OK, but my bite is now worse than ever. It is a journey, I have a long time to go, but I think its going to be worth it in the end.

[Aspiring]

I got my splint a couple days ago. Only a lower for now, and if there are signs of success, then maybe NSAID therapy and/or an upper (sleep) splint later. Ortho told me it's fine to ease myself into wearing it, but work up to full time (always except eating and brushing) wear.

Day 1 was wonderful. My discs almost immediately popped in to correct position, both sides, and stayed there until bed time. I chose a mush dinner so that I did not have to pop them back out in order to chew, as the new position of my jaw does not have any teeth meeting for chewing.

Day 2 was not so good. I woke up with both sides out, and they stayed out until mid-afternoon, when something shifted in my left and suddenly I had extreme pain. I took the splint out, which relieved the pain, and called the ortho. He said that the disc is almost but not quite going back in, which is causing the pain, and likely I'm wearing the splint too much right now. My soft tissues such as the muscles need more time to adapt. Switch to sleep wear only and check in with him in two days.

He was quite surprised when I told him that both sides popped in on day 1. In fact, he was surprised that one disc was trying to go in on day 2. Apparently it's very early in treatment for them to be moving like that, especially considering the length of time I have been having problems with my TMJs and that I have been in near-continuous close lock for much of that. It's good news, because it means that treatment is more likely to be successful. Unfortunately, I have to slow down treatment in order to let the whole system adjust.

Now it is day 3. Once again, I don't feel like the splint was able to do anything last night, since the splint requires my jaws to be closed in order to do its thing, and I sleep with my mouth open more often than not. I might pop it in for an hour or so today and see if my joints pop back in. It feels so good when that happens.

[Aspiring]

I got the go-ahead to gradually increase my hours of wear, heading toward full time, with instructions to take the splint out if it starts hurting again. I've been averaging 16 hours/day (including sleep hours) but the last few days especially, the hours have been decreasing. Left feels really off. When I wake in the morning, everything feels fine except I'm in closed lock. By noon, my jaw wants to shift to the right. Left joint aches, hurts to close fully, hurts to open (and this is different than my normal close lock sensation), hurts to try to slide forward or back. This is different than the excruciating pain I had on day 2. I can not make my teeth line up in my old bite without the splint, due to what feels like a lot of pressure in the left joint. So I take the splint out, and by bedtime it's not so bad, though not pain-free. A call to the ortho is in order.

Neither joint has popped back in since day 1. Left has made some noises the last couple of days, but it's not relief like when the disc goes back in, it's even more painful. I'm feeling frustrated with the lack of improvement of symptoms, but reassured by the total lack of pain when I wake in the morning. I know that I can stop using the splint and go back to my original condition, I haven't caused significant additional permanent problems. And I know that things are changing in the joint, as evidenced by the changes in range of motion. The left side is also getting higher, as first thing in the morning all teeth meet on the splint evenly, but after several hours the left side is completely non-contact, and often the incisors rise out of contact as well. I end up with contact only on the right.

[Aspiring]

I called the ortho, but no answer 30 minutes before closing time. That evening, I actually looked at my log and added up the hours ... the days the left was really hurting, I had jumped up to 20+ hours of wear! Pain-free days were 14-15 hours wear, tops. I put myself on a schedule, at 14 hours wear for now, and the left pain has resolved. Gradually working up to full-time wear, hopefully within a week or so, but definitely giving myself permission to adjust the hours down as my joint tells me it is necessary.

In my old bite, my lower midline is shifted left by about 4 mm. Now, even with splint out, it's coincident or slightly to the right. Things are definitely changing in that left joint.

[Aspiring]

At three weeks into treatment, I was pretty miserable. Left hurt constantly, to the point I was ready to quit treatment. I went in to the ortho, who changed nothing, but told me not to push my hours of splint wear. Keep it to where I felt most comfortable, which was around 13 hours per 24 (including overnight). Suddenly, like the very next day, my pain just vanished. Well not 100%, but much, much better, and it's been like that for over a week now. I wear the splint any time I'm not eating or cleaning my mouth. I do not have constant pain. I have a tiny bit of tenderness over the joint when I press on it, it hurts a bit if I open maximally, occasionally it feels slightly unstable, but those are all relatively minor complaints. And, most exciting of all to me, I can open my mouth! I measured myself at 38 mm opening the other day. 40ish is normal, and before treatment I was stuck at 28 mm or less. For reference, that's less than two slices of bread without anything in the middle, meaning pretty much all of my food was either cut into itty bitty bites, or I had to mash it at my mouth.

Five more weeks until I go back to the ortho. At my initial consult he told me I would be getting one splint for day and a different one for night. That didn't materialize, and at my last visit (the one when I was ready to quit) he said I might get the night one eventually but his tone of voice said probably not. Combined with the deterioration in my joints from initial exam until now (disks used to reduce, since the trauma of impressions they no longer reduce) I was/am afraid he is giving up on my joints. Hopefully now that I am wearing the splint full time and virtually pain free, combined with increased opening, will show that my poor joints can be rehabilitated.

My biggest complaint right now is that I do not have a functional bite. My jaw stays in the new position for a while even when the splint is removed, which leaves a gap between my molars large enough to stick my tongue through to the other side. I've gotten very good at swallowing good-sized chunks of food.

[Aspiring]

Checkup earlier this week. I'm still wearing the splint comfortably and full time. No changes. "Probably" will get my upper splint next appointment, in seven weeks. It was gotten out of storage at this appointment but he didn't give it to me, I just saw its case on the counter.

I have a small hole that has formed where the acrylic is the thinnest, where two teeth nearly touched. Well now they actually do touch. I asked about it to see if it needed to be repaired, and the answer was no.

[Rocks58]

Hi there!
So sorry to hear about all that you've been through, it's a scary process and even scarier choosing to undergo treatment.

I'm curious as to what your dentist did in order to create your orthotic/splint?
It sounds like he just took molds and made them from that.
Did he take any measurements? Use an JVA, EMG, K7, TENS, iCAT scan, or tomography X-rays of your joints before and after splint placement?
Usually when making an appliance to alleviate joint inflammation and find the optimal jaw alignment, these tests are utilized.

I personally have not begun any treatment yet, I am still doing research on different doctors and techniques.

How is your treatment progressing? Are you getting better?

[Aspiring]

It's been a while since I've updated. I did get the upper splint at the end of August. That one has a ramp on it to move my lower jaw forward in my sleep. Since using that, my jaw never drops back into the old position. My vertical opening dimension is over 40 mm now, almost double what I started with. I am very happy with the results and I'm ready to move the teeth and make this permanent.

Last week they took new photographs and a new cephalogram. I go tomorrow morning to discuss the plan for phase 2.

Hi there!
So sorry to hear about all that you've been through, it's a scary process and even scarier choosing to undergo treatment.

I'm curious as to what your dentist did in order to create your orthotic/splint?
It sounds like he just took molds and made them from that.
Did he take any measurements? Use an JVA, EMG, K7, TENS, iCAT scan, or tomography X-rays of your joints before and after splint placement?
Usually when making an appliance to alleviate joint inflammation and find the optimal jaw alignment, these tests are utilized.

I personally have not begun any treatment yet, I am still doing research on different doctors and techniques.

How is your treatment progressing? Are you getting better?

No fancy imaging was used. It was based on my symptoms and the doctor used a stethoscope to listen to my joints. I moved my jaw forward bit by bit until no more clicking was heard or felt. Then they took a bite register at that location. That, combined with my traditional upper and lower impressions, was used to make the splints.

[Aspiring]

Eight spacers are in. Ow. My teeth were so tight the doc broke a spacer trying to insert it. The smidgen of a space I had between each tooth, just enough for me to get floss in (often shredding it), is gone. All of my teeth on top are moving, even the incisors. On the bottom, it's just the molars that are sore.

I'm still wearing my splints with the spacers. Once I have brackets, I'll use just the lower splint all the time. For now, the spacers are in the exact same spots where the ball clasps are on my splints. It works okay. The splints don't want to seat quite all the way down, but close enough that it works and there's no chance of a splint falling out.

Today I need to go shopping for braces supplies, starting with acetaminophen. I'm supposed to be using both acetaminophen and ibuprofen throughout my time in braces but especially right now that the spacers are in.

Next week I'll get bracketed. He mentioned some differences in how he treats adults vs kids, because adult bones are denser. I'll have elastics in the back and in the front, sometimes days sometimes nights, throughout treatment. Estimated time 24 months.

Before splint therapy: class 2 subdivision, overjet, deep bite, slight posterior and moderate lateral open bite, midline off by about half a tooth width, maximum vertical opening 24 mm.

After splint therapy, before braces: class 3, huge open bite laterally and posterior, midlines coincident, maximum vertical opening greater than 40 mm.

[Aspiring]

Had my first adjustment yesterday. Same wire on bottom, moved to 16 on top. No more daytime splint, down to only night use of the lower splint.

It's amazing how much they have moved in just three weeks. I am glad that I took before/after pictures so I can see the movement.

There is one space that I haven't been able to get floss in since getting bracketed. I guess yesterday's adjustment (just re-ligating with the same wire) was enough to open up the space, because this morning the floss went in with no problem.

Everything feels tight this morning. Nothing really hurts except when I'm trying to chew, I have to chew gingerly.

[Aspiring]

Appointment today. Before: 0.016 round upper, 0.012 round lower, splint during sleep, no accessories.

Now: 0.016 round upper, 0.018 round lower, power pushers added to lower 3s, class 3 elastic lower 3 to upper 6, 1/4" x 4 oz, splint every other night.