From my days in dental school in the mid-1960s, the subject of TMJ has been cloaked in controversy, conjecture, dogma, and fear — and framed by some as beyond the diagnostic and treatment capabilities of mortal dentists. I call the 1980s the “TMJ Decade,” with notable gurus giving courses at least every month somewhere in the US. I spent thousands of dollars on airfare, hotels, and time away from my family with very young kids to attend many of those courses, because my dental school education about TMJ was abysmal.
In those courses there were some areas of agreement, but far more areas of disagreement. If causes were discussed, they were usually described as “a complex interplay of structural, functional, and behavioral issues” — or other word salad that merely signals the speaker doesn’t actually know the answer. It was the wild west, and treatment was very fragmented with different solutions depending on the guru. How could they all be right if they were so different, had no known cause, and had no unified approach to treatment that made sense?
Initially, all I really wanted was to not create TMJ problems. I was so confused that for several years I sat on the sidelines and didn’t treat any “TMJ patients,” even though I had spent significant money on TMJ courses. To me, doing nothing was better than doing something I did not understand and that could potentially cause patients to suffer.
That all changed in 1985 when I spent $2,700 (roughly $8,356 today) to observe an orthodontist, Dr. Ken Manning in Washington, North Carolina, for a day and a half. He had been trained exactly the way I had been, but rejected that training, took all the courses I had and then some, engaged his brain, tried many approaches, and found what worked and what didn’t. There is much more to what I learned than what I’m presenting here — but the critical part of the message is absolutely simple and doesn’t require a residency program to learn.
Don’t ever have the front teeth touch even a nanosecond before the back teeth touch.
There is a lot I cannot cover in a short article, but the essence is that simple. The problem is that most of what orthodontists are taught to do will often result in premature contact of the upper and lower incisor teeth. This distalizes the condyles, forces the meniscus forward, can cause displacement of the meniscus, and triggers a whole cascading series of symptoms we now describe as TMD (Temporomandibular Disorder). This type of problem can go in many different directions — from outcomes that may easily be resolved to those that require total joint replacement. A book would be required to cover it all.
All orthodontists try to do their best and are taught specific methods for finishing cases. Unfortunately, many of those methods produce premature contact of the front teeth. This is not to say that problems will always occur — but here are the common culprits:
How do you know when problems will occur? Do you know? Could you avoid them? If so, how? Do you care?
A chapter in the larger book on this topic would also need to address the “bio-psychosocial model” that has been put forth as the official position of the new ADA-authorized TMJ specialty. I, and many others, question whether TMD is something other than physical causes in most circumstances.
The take-home lesson is to not create premature contact of the anterior teeth in the first place. Simple? Not so simple — since much of what is done in standard orthodontic treatment can result in exactly that.
I was skeptical of Dr. Manning’s approach, but tried it because I felt it had no downside. That $2,700 was some of the best money I ever spent on continuing education. It literally changed my practice. I eliminated my wife’s migraine pattern completely using the concepts he promoted. I was able to help hundreds of people with the simple things he taught me about how to avoid the problem — and how to easily treat it when it arose.
A true portrayal of this problem is not easy to convey with words alone. Some graphics help make the discussion real and help practitioners open their eyes. I don’t want my students to believe me just because I say something. I want to motivate them to think, ask questions, and try treatment approaches that have no downside and can work. I want them to find out for themselves. That is the way we learn.
Doing so requires an open mind, a willingness to reject things we’ve been taught, and a decision to not dwell on the past — but to do something logical that might help others. Are you ready for change, or do all the things you learned 5, 10, or even 20 years ago still work for you?
