"What A Long, Strange Trip It's Been" - Robert Hunter, Grateful Dead

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SinkFullOfDinner
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Re: "What A Long, Strange Trip It's Been" - Robert Hunter, Grateful Dead

#151 Post by SinkFullOfDinner »

I haven’t posted here in months, but it wasn’t because my ortho adventures had ended. I just thought most of the potential updates would be boring to anyone besides my ortho. However, I thought I’d take a shot at boiling all that time down to something that might be of interest to anyone who has TM joint pain that becomes aggravated during braces treatment or right after. By “boiling it down,” I don’t mean short, but I went with the ultra long version because I hadn’t found a lot of detail when I searched AW, and felt like TM issues are the “dark arts” of ortho.

Btw, special thanks to djspeece, Prometheus, Ali, and Nozzelnut for their helpful PM insights on the issue.

Before jumping in, I want to state the obvious that braces should be the domain of kids and only kids. I’m not a kid. Second, TMJ pain/disfunction/whatever mostly affects women, for whatever reason. I’m not one of those either. So, I’m currently 0-for-2. Those two issues should fall into the same categories as report cards and menopause, respectively, in terms of things that should be for others to worry about.

Nonetheless….

While I didn’t put it on this thread, my last post on the main forum asked for advice from anyone who had experienced TM joint pain toward the end of treatment and had it continue to get worse once they moved to retainers. That’s what was happening in my case during the last 6 mo before debonding (occasionally) and the first weeks after (more frequently). I initially assumed that the discomfort was caused by a move to heavier elastics, and maybe they were guiding or forcing my jaw into an unnatural position at night. It was only occasional, and I probably didn’t do a good enough job describing the issue, and I think I made the mistake of raising it with the assistant instead of my ortho. I don’t even remember at this point. I was told that your teeth undergo some natural settling after debonding, and those tiny, natural adjustments help the final occlusion. Ok, no worries then. It sounds like it might self-correct after settling.

Well, it didn’t. Instead, it continued to trend in the wrong direction starting a week or two after debonding. At the time, I thought it was likely caused by the Essix retainers and the two layers of plastic material adversely impacting my bite or jaw location. But the Essix were going to be temporary, so I thought I’d wait to see how the Hawleys went before getting nervous.

Everything else was great regarding the results. They did a nice job with straightening, rotating, crossbite, etc. :thumbsup: But one joint was feeling worse and worse. It wasn’t discomfort – it was pain. :ThumbsDown: We moved from the Essix retainers to Hawleys and did some enamel tweaking to help with the settling. (Here comes the first PSA: “Stuff I learned”) Hawleys are supposed to allow for more vertical settling than an Essix, and sometimes grinding off a bit of enamel that’s interfering with the bite can also make a difference. Made sense to me. Also, the TM joint has a decent bit of tolerance, and if you’re anywhere within that acceptable range (most people are), there’s no problem. Even if your condyle is off a little bit, if everything is otherwise aligned and it doesn’t hurt you’d never know that one or both of your condyles are not exactly centered. But once you cross the line too far out of center, ouch! Sometimes a little settling and that enamel tweaking is all it takes to bring things back within tolerance. Sometimes, that’s not enough. (End PSA) It still hurt like heck and was getting more intense and building up to an every-day issue. To say that I was getting extremely worried that I’d opened a P@ndora’s B0x (really? spam block on this?) and would be dealing with this pain indefinitely would be an understatement. So, off to the next step.

One of the fun diagnostics they do if you have the pleasure of getting to this stage is to take “facebow” measurements, (Part 2 of “Stuff I learned”) which involves this weird contraption that measures jaw angles and alignment. You’ll just have to google it because my description will never do justice. They use those angles and measurements to put your molds on an articulator (more new words for me) and draw whatever conclusions. What I can share with you is if you have a couple random kiddos in the chairs to either side when the ortho is using this facebow gizmo, you can feel the stares and mouths agape nearby and you couldn’t be more self-conscious if you were wearing a clown costume. :oops: My inner monologue consisted of repeating one phrase: “Please, please, please just hurry up and finish!” If your ortho has a private consultation room, you might want to insist on using it for this thrilling experience.

Anyway, it all led to having a splint made (I heard the terms “flat plane” and “occlusal” splint. Not sure if it’s the same thing). This was remarkably effective at temporarily reducing the pain, :thumbsup: but it’s really not practical during the workday. It’s a big hunk of acrylic and really impacts your speech. So, I’d wake up with some relief from the overnight use, but things would go downhill immediately from there. :ThumbsDown:

Besides helping with the pain, a flat splint is also intended to help the ortho diagnose whether there is a difference, and if so how much, between your condyles’ “centric relation” and “centric occlusion.” (You guessed it, more “Stuff I learned”). If I understand correctly, your centric relation is where your jaw lines up when the condyles are in the correct position in the joint (fossa), regardless of whether that’s your normal bite location. On the other hand, your centric occlusion is where your condyles are positioned in the joint when you bite down normally. Your brain memorizes this location as feeling like the best fit, regardless of whether it’s where the condyles should be. When your ortho asks you to bite together, what they see is your centric occlusion. Your centric relation can be a little hidden if they’re not specifically looking for it because your jaw muscles and any contact interference want to override it to go to your memorized centric occlusion position. Ideally, your condyles are in the same place in both centric relation and occlusion. If not, you get a shift when you bite. If the shift is too big, you have a problem.

The flat splint allows your jaw to slide around where it wants without any interference, guidance, or feedback from your teeth touching and, over time, find where your jaw naturally lines up best when it’s most relaxed and the condyles are allowed to properly center (centric relation) and the brain’s muscle memory isn’t overriding it. My ortho referred to it as allowing the jaw/bite to “reprogram” to it’s centered positioned. If there’s too much of a discrepancy between those two positions, you have the problem I described earlier about exceeding the joint’s tolerance when your condyle if forced too far out of its centered position when you bite. I’m sure my description and understanding isn’t perfect, but close enough. (End of PSAs. Fascinated yet? I didn’t think so.)

That exercise showed that when I’m centered my lower arch is built a little to the left overall and rotated a minute or two (the way I think of it) to the left of 12 o’clock relative to the maxilla. It was always there, but I guess when my bite was wonky and things didn’t fit correctly anyway, it was easy for my bite/brain to cheat one way or the other and stay within range and undetected (or at least unmentioned) by any of my four consultations. So, I really don’t fault my ortho. If you don’t have joint pain at a consultation, why would they go looking for the causes of joint pain? But it can screw up the best treatment plan if (when) it rears its head and starts causing problems. So, if it's not initially obvious there's a discrepancy, your ortho can ask you to bite together as many times as they want, but if your jaw automatically goes right to that pre-memorized location and there’s no pain, there’d be no reason to suspect an issue with condyle orientation. It’s the old “it’s not a problem until it’s a problem.” However, once the arches were coordinated toward the end of treatment, they fit perfectly in one – and only one – best position, as you’d expect. At that point there's was no way to subconsciously cheat on the bite position, and unfortunately that great fit forced a slight shift and rotation of my lower jaw I wasn’t even aware of. It didn’t become symptomatic until the shift to “best fit” started forcing the condyle too far to the back of the joint. Apparently there are nerves there (“Yeah, I already figured that out, Doc.”). Shockingly, you’re not supposed to press on those repeatedly. They don’t like it.

So, next came a choice: A) we try an interim step of using a few brackets (nothing obvious) and elastics at night to see if it would provide enough of a nudge to calm things down without requiring full braces to get the job done, or B) we assume that the amount of arch movement needed to prevent the condyle from being forced too far back will ultimately require braces anyway, and in that case just use braces from the start (also referred to as “the easiest solution” if you’re the ortho or, alternatively, “worse case scenario” if you’re the recipient). I jumped on A since I’d just been debonded and wasn’t keen on going right back into braces. My ortho estimated, however, that there was ~25% chance that going the A route would be enough without braces. Not great odds, but if he’s willing to try it, so am I if there’s any chance to avoid option B. At least he wasn’t trying to build false expectations.

We got to the point where the pain peaks weren’t as high – so that’s good – but it was still consistently painful and distracting, and then progress really slowed down. At the next few appointments, he’d gently suggest that braces would be more effective and try to gauge whether I was ready to throw in the towel. I wasn’t. After a few of those appointments, he said that things weren’t moving as much as he’d hoped and more discussion about braces being a better approach. I finally waved the white surrender flag. I think he was just patiently waiting me out until I capitulated so that I wouldn’t think he was rushing or pushing the braces option so soon after wrapping up the first round, which I guess I should start calling part one of a two-part treatment.

So, I’m back in the club for a while and just hoping that this works. He’s not charging anything extra, which I guess is his holiday gift to me, but I don’t ever want a Secret Santa like that again.

If you made it to the end of this post, you deserve some sort of prize! Hopefully this is helpful to someone out there. Happy holidays to everyone! No biting on candy canes this year I guess. Bah, humbug.

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Speck
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Re: "What A Long, Strange Trip It's Been" - Robert Hunter, Grateful Dead

#152 Post by Speck »

I read your post--very informative! Sincere thanks for taking the time to write up your experience, and best of luck to you!

Time to search "facebow".
-Andy


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Ali
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Re: "What A Long, Strange Trip It's Been" - Robert Hunter, Grateful Dead

#153 Post by Ali »

You've been through the wringer. I really hope that this round of braces "works" and brings everything where it needs to be.

And I bet you could eat candy cane-flavored ice cream. :)

SinkFullOfDinner
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Re: "What A Long, Strange Trip It's Been" - Robert Hunter, Grateful Dead

#154 Post by SinkFullOfDinner »

Thanks, Ali and Speck!
Ali wrote: Wed Dec 12, 2018 7:40 pm ...And I bet you could eat candy cane-flavored ice cream. :)
Hmmm, I might have to try that, or perhaps something with a slightly higher proof! Although I might get carded now. :lol:

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djspeece
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Re: "What A Long, Strange Trip It's Been" - Robert Hunter, Grateful Dead

#155 Post by djspeece »

Nicely told -- and what an interesting connection between muscle memory, the brain, and the TMJ. It's a wonder that all of us don't have some sort of pain considering the complexity of that joint and surrounding anatomy. Best of luck to you!
Dan

Pain is inevitable. Suffering is optional. -- Buddist saying

SinkFullOfDinner
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Re: "What A Long, Strange Trip It's Been" - Robert Hunter, Grateful Dead

#156 Post by SinkFullOfDinner »

Thanks again, Dan. And isn't it great to know that even if your long-term and short-term memory get crappier over time, your brain will still have its "A" game going with your jaw's muscle memory? Evolution dropped the ball on that one, right?

Jethro
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Re: "What A Long, Strange Trip It's Been" - Robert Hunter, Grateful Dead

#157 Post by Jethro »

Wow Sink, that's very unfortunate to hear. Hopefully, you will get some relief soon and get things resolved (permanently). Kudos to your ortho for stepping up. And by all means up the proof...it's the holidays, right? :jokerlaugh:

All the Best,

Jethro

SinkFullOfDinner
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Re: "What A Long, Strange Trip It's Been" - Robert Hunter, Grateful Dead

#158 Post by SinkFullOfDinner »

Jethro wrote: Tue Dec 18, 2018 11:45 am Wow Sink, that's very unfortunate to hear. Hopefully, you will get some relief soon and get things resolved (permanently). Kudos to your ortho for stepping up. And by all means up the proof...it's the holidays, right? :jokerlaugh:
As if we need a holiday excuse! :lol:

Thanks, and you're right, kudos to my ortho for stepping up. I'll take a "glass half full" approach with this. Sure, I'd prefer to have it caught earlier so we could have killed two birds with one round of braces, but if it showed up in a year or two instead of immediately, I have to assume it would have been a new case and associated cost. Some orthos might have considered it a new case regardless, or might not have been as committed to owning the result. My guy's approach was just "o.k., that's really not good, we need to take care of it." Of course, there's also the little part about "you might not like what it involves." :cry: So, overall, I'm probably more lucky than unlucky with this. Also, I've seen so many posts that talk about not being able to ask questions or getting much information when they do. My guy makes time and seems to enjoy explaining what's going on. The only downside to that is I get all of this detail that becomes a "mother of all posts" assault on your attention span, like the one above.

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Nozzelnut
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Re: "What A Long, Strange Trip It's Been" - Robert Hunter, Grateful Dead

#159 Post by Nozzelnut »

I know it isn't that great getting back into braces; one of the reasons I wanted things as good as they could be before they came off; after 4 years...

But; if it allows your TMJ's to heal and eventually feel better all the time instead of just when being treated with splints; all the better. Jaw pain is right up there with a bum thumb; you don't realize how often you use it until it hurts every time you do.

As for the candy canes; smack them on the table a couple times and eat the pieces...
Round 3 (lifetime) Damon stainless applied 3/16/20 (after 4 weeks attempting invisalign) On for about 18 months
Night time elastics with invisalign retainers; still...
Double jaw surgery was 6/18/15...
Orthodontics never really ends...
I'm emphatically against extraction orthodontics!

SinkFullOfDinner
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Re: "What A Long, Strange Trip It's Been" - Robert Hunter, Grateful Dead

#160 Post by SinkFullOfDinner »

Nozzelnut wrote: Wed Dec 19, 2018 4:22 pmJaw pain is right up there with a bum thumb; you don't realize how often you use it until it hurts every time you do.
Truth
Nozzelnut wrote: Wed Dec 19, 2018 4:22 pm As for the candy canes; smack them on the table a couple times and eat the pieces...
Brilliant! How about a combo deal in which I break it on the table, put the pieces in the freezer, and then use them as ice cubes in my high proof elixir?

SinkFullOfDinner
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Re: "What A Long, Strange Trip It's Been" - Robert Hunter, Grateful Dead

#161 Post by SinkFullOfDinner »

I really should have realized that when you move from a splint to braces, all of the relief that came from the splint settling your TM joint goes out the window too. Obvious, right? Not to me. Holy moly (and some other four-letter words) my jaw has not been happy these last few weeks. It has definitely felt like taking zero steps forward and a bunch of steps back, though I'm sure that's not the case. I'll ask at the next appointment, but I don't imagine there's a quick and easy way to address it, if for no other reason than "quick" and "easy" don't seem to be part of an orthodontist's vernacular.

If anyone has had the same situation, any words of wisdom? Was it a short term issue, or did it take awhile to get back to the "moderate relief" level that the splint provided? I'd love to hear that it only lasted for a couple months and then all was good. Even if it's not true, I was gullible enough as a kid to believe in Santa, the Easter Bunny, and Tooth Fairy, so I'd probably believe you, too, and feel wildly encouraged.

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djspeece
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Re: "What A Long, Strange Trip It's Been" - Robert Hunter, Grateful Dead

#162 Post by djspeece »

SinkFullOfDinner wrote: Sun Jan 20, 2019 9:33 am .... I'll ask at the next appointment, but I don't imagine there's a quick and easy way to address it, if for no other reason than "quick" and "easy" don't seem to be part of an orthodontist's vernacular.

If anyone has had the same situation, any words of wisdom? Was it a short term issue, or did it take awhile to get back to the "moderate relief" level that the splint provided? I'd love to hear that it only lasted for a couple months and then all was good. Even if it's not true, I was gullible enough as a kid to believe in Santa, the Easter Bunny, and Tooth Fairy, so I'd probably believe you, too, and feel wildly encouraged.
Amen to the observation about the limitations of an orthodontist's vocabulary!

I don't have any words of wisdom concerning the timeline for your TMJ pain, but I am good at making things up and providing SWAGs on demand.
So, I'd say you'll be fine when your TMJ surrenders to the righteousness of proper anatomical alignment any day now.

Seriously, best wishes for a return to some manageable level of discomfort/pain.
Dan

Pain is inevitable. Suffering is optional. -- Buddist saying

SinkFullOfDinner
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Re: "What A Long, Strange Trip It's Been" - Robert Hunter, Grateful Dead

#163 Post by SinkFullOfDinner »

djspeece wrote: Tue Feb 05, 2019 10:08 am ...but I am good at making things up and providing SWAGs on demand.
It sounds like you and my ortho have a lot in common!
djspeece wrote: Tue Feb 05, 2019 10:08 am So, I'd say you'll be fine when your TMJ surrenders to the righteousness of proper anatomical alignment any day now.
That would be nice, but unfortunately, I don't think my ortho uses the top secret "Six Day Smiles" system. I'll try to speak your forecast into existence, but won't be holding my breath.

SinkFullOfDinner
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Making progress (yay!)...and a molar tube question

#164 Post by SinkFullOfDinner »

I'm happy to say that it feels like we're making progress! After taking what felt like a few steps backwards initially, I'm finally getting a few more back-to-back-to-back days where the TM joint pain is somewhere between "not too bad" and great. In fact, earlier this month the Joint Fairy (the temperamental alter ego of the Tooth Fairy) granted me a whole week's reprieve. If you've never dealt with jaw pain, you have no idea what a gift that feels like! Of course, that's been followed by a week+ of crappy discomfort, but the more frequent days off has me feeling that we're on the right path. So, for anyone that's trying to address TMJ pain but hasn't seen much progress or seen it actually get worse initially, hang in there!

Now for the question about the molar tubes (and other "stuff" that's welded onto the molar bands). The molar bands that are on my upper first and second molars seem to have "the works" on the outside and inside surfaces. The outside hardware look like this: https://www.ghorthodontics.com/images_c ... allery.jpg, while the lingual side looks like this: https://www.orthotechnology.com/wp-cont ... 00x600.jpg.

I've mostly figured out what everything is for, either because it's been used already or it's obvious (posts or hooks on both the inside and outside for elastics; rectangular lingual tube to insert TPA; middle rectangular tube on the outside to insert archwire...). The big, round tube is completely unnecessary since it's only for headgear, so why have it? But I have no idea why there would be that third rectangular tube above and to the outside of the archwire tube. It hasn't been used, and I can't for the life of me think of what it's for. And I forget to ask my ortho. Any ideas? I'm hoping that – like the unnecessary headgear tube – it's just a standard add-on for other treatment plans that will go unused. But that also begs the question of why use a molar band with unnecessary additional hardware? It all just gets in the way and adds one more thing to rub up against your cheek or tongue. Maybe it's just simpler for orthos to keep track of less inventory and have one do-all band, even if a lot of the features go unused most of the time.

Jethro
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Re: "What A Long, Strange Trip It's Been" - Robert Hunter, Grateful Dead

#165 Post by Jethro »

Hey Sink, great to hear you're finally getting some relief from the tmj pain...hopefully it will fully resolve. I had tmj issues during my previous round and I know firsthand it is no joke.

I think you're correct about the one-size-fits-all molar bands, but can't speak from experience since my ortho uses all brackets on adult patients.

All the Best,

Jethro

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