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.