#164 The Correct Role for Orthodontists Treating TMD

Orthodontists have a role in treating patients, both adults and children, who suffer the disparate symptoms of Temporomandibular Joint Disorder, (TMD).  But it is not the role they have traditionally played.  It is widely accepted that moving teeth around can play a part in directing facial growth and development but not in all cases. Stated simply, 1. Timing is everything.  If you move teeth at a time that enhances normal growth you end up with a good outcome.  If you move teeth at a time and in a way that contradicts normal facial growth you end up with a bad outcome. And 2., knowing how and where the primary centers of facial growth are located and exactly how the facial skeleton grows is mandatory in achieving good results.  It has been my experience that almost all orthodontists completely ignore point #1 and have not been educated in point #2.   

The result is parents take Johnny or Jannie to the orthodontist because they see evidence that their child’s teeth do not fit together properly or are crooked in some form or fashion.  You don’t have to be a dentist to look at a child’s mouth and see if something is not right.  During the orthodontic appointment, the doctor is expected to know exactly what is wrong, why it happened, and what to do about it. Fortunately, facial growth is somewhat predictable based on the genes contributed by the parents and environmental factors, and majorly unpredictable based on the genes contributed by the parents and environmental factors.  During the growth years age 5 to 12, the way the face is going to grow is much more unpredictable than predictable. Without a good handle on facial growth prediction the orthodontist is rolling the dice when a decision is made about the correct treatment plan too early.   But this presents a problem for both parents and doctors.  The parent expects the doctor to take immediate action.  If he/she is not willing to do so, the parents think there is something wrong with the doctor and will easily find another orthodontist willing to take immediate action since the prior orthodontist declined.  Orthodontists quickly learn after entering practice that parents expect action and if they want the case, and not lose it to another orthodontist, they need to start treatment as the parents expect.  This scenario is the rule rather than the exception. The parents think they are getting good treatment when they are getting inappropriate care. Orthodontists who tell parents it is best to wait until the teeth, face, and jaws demonstrate conclusively how growth will develop is doing the correct thing but will lose a considerable portion of their business. 

More disturbing is the scenario of the orthodontist being confronted with a patient with malocclusion and symptoms of TMD. Knowing that functional malocclusion can cause TMD, the orthodontist tells the parent or patient that they need to get their teeth straightened without paying attention to Point #1 and #2.  Treatment is performed but the TMD symptoms don’t resolve.  They are not expected to resolve if #1 and #2 are not factored into the treatment   

The ultimate conundrum occurs when the patient is young and between the ages of 5 and 12 with simultaneous TMD symptoms.  Since TMD can cause malocclusions, and malocclusions can cause TMD, great care needs to be taken in working out the best treatment sequence and timing.  The correct role of the orthodontist should be to wait for facial growth to commit itself and proceed with orthodontic care in conjunction with simplified non-surgical TMD care.  In those instances, when significant facial growth mal-adaptive patterns are present, the orthodontist should not hesitate to advise the patient or parent that surgical correction of the facial (jaw) growth problem should be done along with orthodontic support.   

I have witnessed hundreds of cases of adults who have shared their dismay and criticism of orthodontists who, with the misappropriated consent of their parents, proceeded with orthodontics too early and ended up with a significantly unnatural occlusion and facial deformity with the symptoms of TMD unresolved.   

This can be completely avoided when points #1 and #2 are followed.