A question: Does a 3a with vaulted palate + narrow airway (and sleep apnea) with debilitating symptoms (balance issue, diziness, chronique fatigue and pain) can recover with a neuromuscular orthotic ? I'm the one with this issue for 5 years now, in my 40s. Thank you.
Hello Jaz, as recommended by Dr. Dawson and Piper in their courses about a clinicar way to define if there is a piper stage IIIA (lateral pole click) or stage IvA (medial pole click) is the use of Doppler auscultation. So you check both rotation (medial pole) and translation (lateral pole) movements of both condyles . Again in combination with the history questions, muscle palpation, signs of inestability in teeth and tissues , CR load test . If you then have a click in rotation you would need to take a MRI to confirm this diagnosis and then give a prognosis of the case.
He keeps talking about medial and lateral, but that's not what he means, is it? He's actually talking about anterior and posterior. No? Medial and lateral disc displacements are rare, as are posterior ones. Most are anterior disc displacements. They can also be anteromedial or anterolateral, but in most cases it's an anterior disc displacement. So what he keeps calling medial, in fact, is anterior. Correct me if I'm wrong.
He definitely means medial and lateral - it's an area that is definitely overlooked at Dental school as we are used to seeing the anatomy of the TMJ in the sagittal view. Google for 'coronal view of TMJ' and it will become a lot clearer!
@JamesYoung24 sorry I only partially replied to the first few sentences of your comment (the email cuts it). Yes agreed that the most common displacement is anterior but if you look at the discal ligaments - they are only medial and lateral. When they elongate (damage, strain) the disc displacements can happen. For the disc to move purely anteriorly without any medial or lateral component can happen but its too simplistic. As the lateral pterygoid has a medial vector to it (origin of LP) more strain is placed on the distal ligaments hence many displacements are actually anterior with a medial component. Hope that helps!
@@protrusive The superior head of the lateral pterygoid is directly attached to the articular disc, via the (anterior) ligament. It's supposed to pull the disc forward when you open, and provide stability for the disc to return back when you close. When I was first learning TMJ anatomy, I would say that this muscle alone can give you a disc displacement. However, when I discovered the collateral (discal) ligaments, it ruined that thought. Because how can a disc displace anywhere in any significant way if the collateral ligaments are intact? It almost feels like the collateral ligaments keep the disc on the condyle and in place more so than the anterior and posterior ligaments. Though it's all connected, and if any piece of the puzzle goes, it can all go. What makes me sad is that the imaging we have is so, well, primitive. I wish I could image for the anterior, posterior, medial and lateral intracapsular ligaments, as well as the capsular (joint capsule) and lateral (extra capsular) ligaments, and get some definitive answers about their condition. Because it's one thing for any of those ligaments to stretch, and it's a whole different thing if any of those ligaments is torn. For a torn ligament I probably want surgery ASAP to reconnect or replace it. And for a stretched ligament I either want to give it time and pray it doesn't stretch further or gets torn up, or perhaps I want to try PRP/Prolotherapy/Stem cells, to cause some inflammation there and hope the ligaments tighten up. Yeah, I'm completely ignoring the teeth it seems. I think teeth matter a lot. I don't believe that the bite is responsible only for a tiny amount of TMJ problems. A lot of TMJ experts seem to think so, and I think it's nonsense. But once you cross the line of muscular TMJ to intracapsular TMJ (internal derangement, clicking), I just don't see how fixing the bite will restore things to normal. Unless we want to put our faith in the unknown, and fix the bite, and then hope that in due time the body readjsts the ligaments and the disc into an optimal place again. I also fear the bite adjustment after a disc displacement. What if you adjust the bite to chase the displacement, and in chasing the displacement you make it even worse. TMJ needs a lot more research. You can visit some Facebook groups for TMJ, and people are suffering. They're suffering for 20 and 30 and 40 years, with no relief. It's very sad. Lives are ruined. Jaw pain, jaw clicking, muscle pain, vertigo, eustachian tube dysfunction, ear pain, hearing loss, eye floaters, vertigo, dizziness, swollen lymph nodes, swollen tonsils, inability to eat normally, inability to speak normally, clicking necks, tense necks droppy eyes, uneven shoulders, and the list goes on. TMJ is hell. I'd rather have both of my legs and arms broken than to have an intracapsular TMJ problems. The arms and legs will heal, the TMJ won't :(
@JamesYoung24 some great reflections and I agree a lot especially that we need more research (easier said than done to get good quality research though). One minor point to add is part if the problem with the collateral ligaments is that they don't stretch and recoil, instead they elongate in response to stress. If the ligaments had more springback they would be more resilient and we would see less disc displacement. Thanks for the comment!
Here is my big problem with all of this. There is not a single course on all this TMD stuff that doesn't focus 99% of its time trying to explain the etiology of TMD and now we have all this imaging that spend hours talking and I see slides and slides on the physiology of TMD etc. All nice, but in ALL these courses (Doesn't matter Dawson, spear, dental school classes etc.) no one spends any meaningful amount of time talking about TREATMENT. What are you going to do about it? you do all this imaging etc, but you as a general dentist what are you going to do to treat it? it has reached comical proportions the amount of time spent on diagnosis vs actual treatment. All too often we spend 95% of our time on etiology and physiology and when is the treatment you are going to provide as a GP? ultimately most of it boils down to 3 days of ibuprofen with warm compress or a splint. so you spend dozens of hours on it's physiology and then spend 30mins talking about doing a split, meanwhile, no one knows well how to do these splints and how to adjust them (i know Jaz has a course on it). A lot of these cases would have to go to OS for surgery etc. and as a GP you cannot do anything about it. It is sort of like pathology diagnosis. it cracks me up that i see GPs trying to write down "differential diagnosis" for a lesion in the jaw and argue with each other "i wonder what this could be" and at the end of the day you must refer to OS because guess what, if you are wrong about your diagnosis and don't refer and something happens you are responsible, and you cannot provide any treatment for 95% of these diagnoses anyway, so you can compile all the lists you want, but at the end of the day you have to refer to OS and they will do their own work-up and can actually do something about that lesion (which mostly involves resecting it out if they want to go that route). If i was on a panel listening to ANYONE about TMD, here is how that meeting will go........."please state your diagnosis in no more than 30 seconds, and devote the rest of your presentation to explaining your treatment step by step. If it involves a splint, please provide a screenshot of your prescription to the laboratory and a video of every single adjustment done on your appliance and go to the next case".
Excellent comment (that made me laugh, thank you!) I was frustrated for a long time about this. This is why I tried to learn as many philosophies as possible (and the literature on active TMD treatment is sparse and of poor quality ie. no concrete conclusions). As you mentioned, I created SplintCourse to share as GPs, exactly when (and how) I give stabilisation splints, B Splints and other AMPSAs, soft bite guards and Aqualisers. In practice I also use repositioning splints but I do think at that stage most GDPs should be referring if possible as thing (phase 2) can get very complicated. If ever you get such a panel and get to ask them the question....think of how a question about single tooth dentistry would vary among every Dentist - can you imagine how varied the management of TMD would actually be?
Long time sufferer who follows piper
This makes a LOT of sense!
Thank you for your videos!
kind of you to comment!
A question:
Does a 3a with vaulted palate + narrow airway (and sleep apnea) with debilitating symptoms (balance issue, diziness, chronique fatigue and pain) can recover with a neuromuscular orthotic ?
I'm the one with this issue for 5 years now, in my 40s.
Thank you.
Hello Jaz, as recommended by Dr. Dawson and Piper in their courses about a clinicar way to define if there is a piper stage IIIA (lateral pole click) or stage IvA (medial pole click) is the use of Doppler auscultation. So you check both rotation (medial pole) and translation (lateral pole) movements of both condyles . Again in combination with the history questions, muscle palpation, signs of inestability in teeth and tissues , CR load test . If you then have a click in rotation you would need to take a MRI to confirm this diagnosis and then give a prognosis of the case.
very well explained thanks!
He keeps talking about medial and lateral, but that's not what he means, is it? He's actually talking about anterior and posterior. No?
Medial and lateral disc displacements are rare, as are posterior ones. Most are anterior disc displacements. They can also be anteromedial or anterolateral, but in most cases it's an anterior disc displacement.
So what he keeps calling medial, in fact, is anterior. Correct me if I'm wrong.
He definitely means medial and lateral - it's an area that is definitely overlooked at Dental school as we are used to seeing the anatomy of the TMJ in the sagittal view. Google for 'coronal view of TMJ' and it will become a lot clearer!
@JamesYoung24 sorry I only partially replied to the first few sentences of your comment (the email cuts it).
Yes agreed that the most common displacement is anterior but if you look at the discal ligaments - they are only medial and lateral. When they elongate (damage, strain) the disc displacements can happen. For the disc to move purely anteriorly without any medial or lateral component can happen but its too simplistic. As the lateral pterygoid has a medial vector to it (origin of LP) more strain is placed on the distal ligaments hence many displacements are actually anterior with a medial component.
Hope that helps!
@@protrusive The superior head of the lateral pterygoid is directly attached to the articular disc, via the (anterior) ligament. It's supposed to pull the disc forward when you open, and provide stability for the disc to return back when you close. When I was first learning TMJ anatomy, I would say that this muscle alone can give you a disc displacement.
However, when I discovered the collateral (discal) ligaments, it ruined that thought. Because how can a disc displace anywhere in any significant way if the collateral ligaments are intact? It almost feels like the collateral ligaments keep the disc on the condyle and in place more so than the anterior and posterior ligaments. Though it's all connected, and if any piece of the puzzle goes, it can all go.
What makes me sad is that the imaging we have is so, well, primitive. I wish I could image for the anterior, posterior, medial and lateral intracapsular ligaments, as well as the capsular (joint capsule) and lateral (extra capsular) ligaments, and get some definitive answers about their condition. Because it's one thing for any of those ligaments to stretch, and it's a whole different thing if any of those ligaments is torn.
For a torn ligament I probably want surgery ASAP to reconnect or replace it. And for a stretched ligament I either want to give it time and pray it doesn't stretch further or gets torn up, or perhaps I want to try PRP/Prolotherapy/Stem cells, to cause some inflammation there and hope the ligaments tighten up.
Yeah, I'm completely ignoring the teeth it seems. I think teeth matter a lot. I don't believe that the bite is responsible only for a tiny amount of TMJ problems. A lot of TMJ experts seem to think so, and I think it's nonsense. But once you cross the line of muscular TMJ to intracapsular TMJ (internal derangement, clicking), I just don't see how fixing the bite will restore things to normal. Unless we want to put our faith in the unknown, and fix the bite, and then hope that in due time the body readjsts the ligaments and the disc into an optimal place again. I also fear the bite adjustment after a disc displacement. What if you adjust the bite to chase the displacement, and in chasing the displacement you make it even worse.
TMJ needs a lot more research. You can visit some Facebook groups for TMJ, and people are suffering. They're suffering for 20 and 30 and 40 years, with no relief. It's very sad. Lives are ruined. Jaw pain, jaw clicking, muscle pain, vertigo, eustachian tube dysfunction, ear pain, hearing loss, eye floaters, vertigo, dizziness, swollen lymph nodes, swollen tonsils, inability to eat normally, inability to speak normally, clicking necks, tense necks droppy eyes, uneven shoulders, and the list goes on.
TMJ is hell. I'd rather have both of my legs and arms broken than to have an intracapsular TMJ problems. The arms and legs will heal, the TMJ won't :(
@JamesYoung24 some great reflections and I agree a lot especially that we need more research (easier said than done to get good quality research though).
One minor point to add is part if the problem with the collateral ligaments is that they don't stretch and recoil, instead they elongate in response to stress. If the ligaments had more springback they would be more resilient and we would see less disc displacement.
Thanks for the comment!
Here is my big problem with all of this. There is not a single course on all this TMD stuff that doesn't focus 99% of its time trying to explain the etiology of TMD and now we have all this imaging that spend hours talking and I see slides and slides on the physiology of TMD etc. All nice, but in ALL these courses (Doesn't matter Dawson, spear, dental school classes etc.) no one spends any meaningful amount of time talking about TREATMENT. What are you going to do about it? you do all this imaging etc, but you as a general dentist what are you going to do to treat it? it has reached comical proportions the amount of time spent on diagnosis vs actual treatment. All too often we spend 95% of our time on etiology and physiology and when is the treatment you are going to provide as a GP? ultimately most of it boils down to 3 days of ibuprofen with warm compress or a splint. so you spend dozens of hours on it's physiology and then spend 30mins talking about doing a split, meanwhile, no one knows well how to do these splints and how to adjust them (i know Jaz has a course on it). A lot of these cases would have to go to OS for surgery etc. and as a GP you cannot do anything about it. It is sort of like pathology diagnosis. it cracks me up that i see GPs trying to write down "differential diagnosis" for a lesion in the jaw and argue with each other "i wonder what this could be" and at the end of the day you must refer to OS because guess what, if you are wrong about your diagnosis and don't refer and something happens you are responsible, and you cannot provide any treatment for 95% of these diagnoses anyway, so you can compile all the lists you want, but at the end of the day you have to refer to OS and they will do their own work-up and can actually do something about that lesion (which mostly involves resecting it out if they want to go that route). If i was on a panel listening to ANYONE about TMD, here is how that meeting will go........."please state your diagnosis in no more than 30 seconds, and devote the rest of your presentation to explaining your treatment step by step. If it involves a splint, please provide a screenshot of your prescription to the laboratory and a video of every single adjustment done on your appliance and go to the next case".
Excellent comment (that made me laugh, thank you!) I was frustrated for a long time about this. This is why I tried to learn as many philosophies as possible (and the literature on active TMD treatment is sparse and of poor quality ie. no concrete conclusions). As you mentioned, I created SplintCourse to share as GPs, exactly when (and how) I give stabilisation splints, B Splints and other AMPSAs, soft bite guards and Aqualisers. In practice I also use repositioning splints but I do think at that stage most GDPs should be referring if possible as thing (phase 2) can get very complicated. If ever you get such a panel and get to ask them the question....think of how a question about single tooth dentistry would vary among every Dentist - can you imagine how varied the management of TMD would actually be?