Temporomandibular joint disorder
Encyclopedia
Temporomandibular joint disorder (TMJD or TMD), or TMJ syndrome, is an umbrella term covering acute or chronic
inflammation
of the temporomandibular joint
, which connects the mandible to the skull
. The disorder and resultant dysfunction can result in significant pain
and impairment. Because the disorder transcends the boundaries between several health-care disciplines—in particular, dentistry
and neurology
—there are a variety of treatment approaches.
The temporomandibular joint is susceptible to many of the conditions that affect other joints in the body, including ankylosis
, arthritis
, trauma, dislocation
s, developmental anomalies, and neoplasia
.
An older name for the condition is "Costen's syndrome", after James B. Costen, who partially characterized it in 1934.
Signs and symptoms of temporomandibular joint disorder vary in their presentation and can be very complex, but are often simple. On average the symptoms will involve more than one of the numerous TMJ components: muscle
s, nerves, tendons, ligaments, bone
s, connective tissue
, and the teeth.
Ear pain associated with the swelling of proximal tissue is a symptom of temporomandibular joint disorder.
Symptoms associated with TMJ disorders may be:
The surfaces in contact with one another (bone and cartilage) do not have any receptors to transmit the feeling of pain. The pain therefore originates from one of the surrounding soft tissues, or from the trigeminal nerve
itself, which runs through the joint area. When receptors from one of these areas are triggered, the pain can cause a reflex to limit the mandible's movement. Furthermore, inflammation of the joints or damage to the trigeminal nerve can cause constant pain, even without movement of the jaw.
Due to the proximity of the ear to the temporomandibular joint, TMJ pain can often be confused with ear pain. The pain may be referred
in around half of all patients and experienced as otalgia
(earache). Conversely, TMD is an important possible cause of secondary otalgia. Treatment of TMD may then significantly reduce symptoms of otalgia and tinnitus
, as well as atypical facial pain. Despite some of these findings, some researchers question whether TMD therapy can reduce symptoms in the ear, and there is currently an ongoing debate to settle the controversy.
The dysfunction involved is most often in regards to the relationship between the condyle of the mandible and the disc. The sounds produced by this dysfunction are usually described as a "click" or a "pop" when a single sound is heard and as "crepitation" or "crepitus" when there are multiple, rough sounds.
can be caused by destruction of the supporting bone and by heavy forces being placed on teeth. The movement of the teeth affects how they contact one another when the mouth closes, and the overall relationship between the teeth, muscles, and joints can be altered. Pulpitis, inflammation of the dental pulp, is another symptom that may result from excessive surface erosion. Perhaps the most important factor is the way the teeth meet together: the equilibration of forces of mastication and therefore the displacements of the condyle. Many report TMJ dysfunction after having their wisdom teeth extracted.
Bruxism has been shown to be a contributory factor in the majority of TMD cases. Over-opening the jaw beyond its range for the individual or unusually aggressive or repetitive sliding of the jaw sideways (laterally
) or forward (protrusive). These movements may also be due to parafunctional habits or a malalignment of the jaw or dentition. This may be due to:
Patients with TMD often experience pain such as migraines or headaches, and consider this pain TMJ-related. There is some evidence that some people who use a biofeedback headband
to reduce nighttime clenching experience a reduction in TMD. The dentist must ensure a correct diagnosis does not mistake trigeminal neuralgia
as a temporomandibular disorder.
(also called night guards or mouth guards) reduce nighttime clenching in some patients, while increasing clenching activity in other patients. Thus, while occlusal splints do prevent loss of tooth enamel from grinding, use of a splint can worsen TMJ disorder symptoms for some people.
or biofeedback
device) can be used to reduce bruxism
and thus reduce or eliminate the ongoing nightly cycle of damage that contributes to the majority of TMJ disorder symptoms. This treatment is non-invasive. The Bruxism Association warns that such devices can disrupt sleep and it does not consider them to be a safe treatment.
pain killers such as paracetamol
(acetaminophen) or NSAIDs provide initial relief for some sufferers, the pain is often more neurologic in nature, which often does not respond well to these drugs.
An alternative approach is for pain modification, for which off-label use
of low-doses of Tricyclic antidepressant
that have anti-muscarinic properties (e.g. Amitriptyline
or the less sedative Nortriptyline
) generally prove more effective.
In TMJD the muscles are unbalanced. Biofeedback using EMG is successful in balancing these muscles. A mirror can be used as a biofeedback device: Draw a vertical line on mirror. Relax the jaw by relaxing as you exhale. See the jaw relax in the midline. Practice the breathing and relaxing daily using the mirror. When the jaw does open midline the symptoms should abate.
Patients may employ a nighttime biofeedback instrument such as a biofeedback headband or biofeedback
device to help them modify para-functional jaw habits which take place in sleep. In addition, there are various treatment modalities which a well-trained experienced dentist may employ to relieve symptoms and improve joint function. They include:
Treatment is oriented to eliminating oral habits, physical therapy to the masticatory muscles, and alleviating bad posture of the head and neck. A biofeedback headband or biofeedback
device may be worn at night to help patients train themselves out of the para-functional habit of nighttime clenching and grinding (bruxism
). A flat-plane full-coverage oral appliance
, e.g. a non-repositioning stabilization splint, reduces bruxism
in some patients, and can take stress off the temporomandibular joint, although some individuals may bite harder on it, resulting in a worsening of their conditions. The anterior splint, with contact at the front teeth only, may prove helpful to some patients, but for those patients who bite harder on this type of splint, even more damage may occur. Thus, different types of splint therapy may work for different patients.
Other interventions include:
s based on MRI and CAT scans now receive less attention. These techniques are reserved for the most recalcitrant cases where other therapeutic modalities have failed. Exercise protocols, habit control, and splinting should be the first line of approach, leaving oral surgery
as a last resort. Other possible causes of facial pain and jaw immobility and dysfunction should be the initial consideration of the examining professional.
One option for oral surgery is to manipulate the jaw under general anaesthetic and wash out the joint with a saline and anti-inflammatory solution in a procedure known as arthrocentesis
. In some cases, this will reduce the inflammatory process.
The jaw can also "slide out" as the person is sleeping on their side.
Chronic (medicine)
A chronic disease is a disease or other human health condition that is persistent or long-lasting in nature. The term chronic is usually applied when the course of the disease lasts for more than three months. Common chronic diseases include asthma, cancer, diabetes and HIV/AIDS.In medicine, the...
inflammation
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...
of the temporomandibular joint
Temporomandibular joint
The temporomandibular joint is the joint of the jaw and is frequently referred to as TMJ. There are two TMJs, one on either side, working in unison. The name is derived from the two bones which form the joint: the upper temporal bone which is part of the cranium , and the lower jaw bone called the...
, which connects the mandible to the skull
Human skull
The human skull is a bony structure, skeleton, that is in the human head and which supports the structures of the face and forms a cavity for the brain.In humans, the adult skull is normally made up of 22 bones...
. The disorder and resultant dysfunction can result in significant pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
and impairment. Because the disorder transcends the boundaries between several health-care disciplines—in particular, dentistry
Dentistry
Dentistry is the branch of medicine that is involved in the study, diagnosis, prevention, and treatment of diseases, disorders and conditions of the oral cavity, maxillofacial area and the adjacent and associated structures and their impact on the human body. Dentistry is widely considered...
and neurology
Neurology
Neurology is a medical specialty dealing with disorders of the nervous system. Specifically, it deals with the diagnosis and treatment of all categories of disease involving the central, peripheral, and autonomic nervous systems, including their coverings, blood vessels, and all effector tissue,...
—there are a variety of treatment approaches.
The temporomandibular joint is susceptible to many of the conditions that affect other joints in the body, including ankylosis
Ankylosis
Ankylosis or anchylosis is a stiffness of a joint due to abnormal adhesion and rigidity of the bones of the joint, which may be the result of injury or disease. The rigidity may be complete or partial and may be due to inflammation of the tendinous or muscular structures outside the joint or of...
, arthritis
Arthritis
Arthritis is a form of joint disorder that involves inflammation of one or more joints....
, trauma, dislocation
Dislocation (medicine)
Joint dislocation, or luxation , occurs when bones in a joint become displaced or misaligned. It is often caused by a sudden impact to the joint. The ligaments always become damaged as a result of a dislocation...
s, developmental anomalies, and neoplasia
Neoplasia
Neoplasm is an abnormal mass of tissue as a result of neoplasia. Neoplasia is the abnormal proliferation of cells. The growth of neoplastic cells exceeds and is not coordinated with that of the normal tissues around it. The growth persists in the same excessive manner even after cessation of the...
.
An older name for the condition is "Costen's syndrome", after James B. Costen, who partially characterized it in 1934.
Signs and symptoms of temporomandibular joint disorder vary in their presentation and can be very complex, but are often simple. On average the symptoms will involve more than one of the numerous TMJ components: muscle
Muscle
Muscle is a contractile tissue of animals and is derived from the mesodermal layer of embryonic germ cells. Muscle cells contain contractile filaments that move past each other and change the size of the cell. They are classified as skeletal, cardiac, or smooth muscles. Their function is to...
s, nerves, tendons, ligaments, bone
Bone
Bones are rigid organs that constitute part of the endoskeleton of vertebrates. They support, and protect the various organs of the body, produce red and white blood cells and store minerals. Bone tissue is a type of dense connective tissue...
s, connective tissue
Connective tissue
"Connective tissue" is a fibrous tissue. It is one of the four traditional classes of tissues . Connective Tissue is found throughout the body.In fact the whole framework of the skeleton and the different specialized connective tissues from the crown of the head to the toes determine the form of...
, and the teeth.
Ear pain associated with the swelling of proximal tissue is a symptom of temporomandibular joint disorder.
Symptoms associated with TMJ disorders may be:
- Biting or chewing difficulty or discomfort it is painful
- Clicking, popping, or grating sound when opening or closing the mouth
- Dull, aching pain in the face
- Earache (particularly in the morning)
- Headache (particularly in the morning)
- Hearing loss
- Migraine (particularly in the morning)
- Jaw pain or tenderness of the jaw
- Reduced ability to open or close the mouth
- TinnitusTinnitusTinnitus |ringing]]") is the perception of sound within the human ear in the absence of corresponding external sound.Tinnitus is not a disease, but a symptom that can result from a wide range of underlying causes: abnormally loud sounds in the ear canal for even the briefest period , ear...
- Neck and shoulder pain
- Dizziness
Temporomandibular joints
Unlike a typical finger or vertebral junctions, each TMJ actually has two joints, which allows it to rotate and to translate (slide). With use, it is common to see wear of both the bone and cartilage components of the joint. Clicking is common, as are popping and deviations in the movements of the joint. Pain is the most conventional signifier of TMD.The surfaces in contact with one another (bone and cartilage) do not have any receptors to transmit the feeling of pain. The pain therefore originates from one of the surrounding soft tissues, or from the trigeminal nerve
Trigeminal nerve
The trigeminal nerve contains both sensory and motor fibres. It is responsible for sensation in the face and certain motor functions such as biting, chewing, and swallowing. Sensory information from the face and body is processed by parallel pathways in the central nervous system...
itself, which runs through the joint area. When receptors from one of these areas are triggered, the pain can cause a reflex to limit the mandible's movement. Furthermore, inflammation of the joints or damage to the trigeminal nerve can cause constant pain, even without movement of the jaw.
Due to the proximity of the ear to the temporomandibular joint, TMJ pain can often be confused with ear pain. The pain may be referred
Referred pain
Referred pain is pain perceived at a location other than the site of the painful stimulus. An example is the case of ischemia brought on by a myocardial infarction , where pain is often felt in the neck, shoulders, and back rather than in the chest, the site of the injury...
in around half of all patients and experienced as otalgia
Otalgia
Otalgia or an earache is ear pain. Primary otalgia is ear pain that originates inside the ear. Referred otalgia is ear pain that originates from outside the ear.Otalgia is not always associated with ear disease...
(earache). Conversely, TMD is an important possible cause of secondary otalgia. Treatment of TMD may then significantly reduce symptoms of otalgia and tinnitus
Tinnitus
Tinnitus |ringing]]") is the perception of sound within the human ear in the absence of corresponding external sound.Tinnitus is not a disease, but a symptom that can result from a wide range of underlying causes: abnormally loud sounds in the ear canal for even the briefest period , ear...
, as well as atypical facial pain. Despite some of these findings, some researchers question whether TMD therapy can reduce symptoms in the ear, and there is currently an ongoing debate to settle the controversy.
The dysfunction involved is most often in regards to the relationship between the condyle of the mandible and the disc. The sounds produced by this dysfunction are usually described as a "click" or a "pop" when a single sound is heard and as "crepitation" or "crepitus" when there are multiple, rough sounds.
Teeth
Disorders of the teeth can contribute to TMJ dysfunction. Impaired tooth mobility and tooth lossTooth loss
Tooth loss is when one or more teeth come loose and fall out. Tooth loss is normal for deciduous teeth , when they are replaced by a person's adult teeth. Otherwise, losing teeth is undesirable and is the result of injury or disease, such as mouth trauma, tooth injury, tooth decay, and gum disease...
can be caused by destruction of the supporting bone and by heavy forces being placed on teeth. The movement of the teeth affects how they contact one another when the mouth closes, and the overall relationship between the teeth, muscles, and joints can be altered. Pulpitis, inflammation of the dental pulp, is another symptom that may result from excessive surface erosion. Perhaps the most important factor is the way the teeth meet together: the equilibration of forces of mastication and therefore the displacements of the condyle. Many report TMJ dysfunction after having their wisdom teeth extracted.
Cause
There are many external factors that place undue strain on the TMJ. These include but are not limited to the following:Bruxism has been shown to be a contributory factor in the majority of TMD cases. Over-opening the jaw beyond its range for the individual or unusually aggressive or repetitive sliding of the jaw sideways (laterally
Anatomical terms of location
Standard anatomical terms of location are designations employed in science that deal with the anatomy of animals to avoid ambiguities that might otherwise arise. They are not language-specific, and thus require no translation...
) or forward (protrusive). These movements may also be due to parafunctional habits or a malalignment of the jaw or dentition. This may be due to:
- BruxismBruxismBruxism is characterized by the grinding of the teeth and typically includes the clenching of the jaw. It is an oral parafunctional activity that occurs in most humans at some time in their lives. In most people, bruxism is mild enough not to be a health problem...
(repetitive unconscious clenching or grinding of teeth, often at night). - Trauma
- Malalignment of the occlusal surfaces of the teeth due to defective crowns or other restorative procedures.
- Jaw thrusting (causing unusual speech and chewing habits).
- Excessive gum chewing or nail biting.
- Size of food bites eaten.
- Degenerative joint disease, such as osteoarthritis or organic degeneration of the articular surfaces, recurrent fibrous and/or bony ankylosis, developmental abnormality, or pathologic lesions within the TMJ
- Myofascial pain dysfunction syndrome
- Lack of overbite
Patients with TMD often experience pain such as migraines or headaches, and consider this pain TMJ-related. There is some evidence that some people who use a biofeedback headband
Biofeedback headband
A biofeedback headband is a self-contained biofeedback unit which is worn on the head and held in place by an elastic strap. Biofeedback headbands are most often used for controlling bruxism during sleep, but can also be used during the day...
to reduce nighttime clenching experience a reduction in TMD. The dentist must ensure a correct diagnosis does not mistake trigeminal neuralgia
Trigeminal neuralgia
Trigeminal neuralgia , tic douloureux is a neuropathic disorder characterized by episodes of intense pain in the face, originating from the trigeminal nerve. It has been described as among the most painful conditions known...
as a temporomandibular disorder.
Restoration of the occlusal surfaces of the teeth
If the occlusal surfaces of the teeth or the supporting structures have been altered due to inappropriate dental treatment, periodontal disease, or trauma, the proper occlusion may need to be restored. Patients with bridges, crowns, or onlays should be checked for bite discrepancies. These discrepancies, if present, may cause a person to make contact with posterior teeth during sideways chewing motions. These inappropriate contacts are called interferences, and if present, they can cause a patient to subconsciously avoid those motions, as they will provoke a painful response. The result can be excessive strain or even spasms of the chewing muscles. Treatment could include adjusting the restorations or replacing them. (Christensen 1997, A Consumer's Guide to Dentistry).Splint
Occlusal splintsOcclusal splint
Occlusal splints are removable dental appliances carefully molded to fit the upper or lower arches of teeth....
(also called night guards or mouth guards) reduce nighttime clenching in some patients, while increasing clenching activity in other patients. Thus, while occlusal splints do prevent loss of tooth enamel from grinding, use of a splint can worsen TMJ disorder symptoms for some people.
Nighttime biofeedback
Nighttime EMG biofeedback (for instance by using a biofeedback headbandBiofeedback headband
A biofeedback headband is a self-contained biofeedback unit which is worn on the head and held in place by an elastic strap. Biofeedback headbands are most often used for controlling bruxism during sleep, but can also be used during the day...
or biofeedback
Biofeedback
Biofeedback is the process of becoming aware of various physiological functions using instruments that provide information on the activity of those same systems, with a goal of being able to manipulate them at will...
device) can be used to reduce bruxism
Bruxism
Bruxism is characterized by the grinding of the teeth and typically includes the clenching of the jaw. It is an oral parafunctional activity that occurs in most humans at some time in their lives. In most people, bruxism is mild enough not to be a health problem...
and thus reduce or eliminate the ongoing nightly cycle of damage that contributes to the majority of TMJ disorder symptoms. This treatment is non-invasive. The Bruxism Association warns that such devices can disrupt sleep and it does not consider them to be a safe treatment.
Pain relief
While conventional analgesicAnalgesic
An analgesic is any member of the group of drugs used to relieve pain . The word analgesic derives from Greek an- and algos ....
pain killers such as paracetamol
Paracetamol
Paracetamol INN , or acetaminophen USAN , is a widely used over-the-counter analgesic and antipyretic . It is commonly used for the relief of headaches and other minor aches and pains and is a major ingredient in numerous cold and flu remedies...
(acetaminophen) or NSAIDs provide initial relief for some sufferers, the pain is often more neurologic in nature, which often does not respond well to these drugs.
An alternative approach is for pain modification, for which off-label use
Off-label use
Off-label use is the practice of prescribing pharmaceuticals for an unapproved indication or in an unapproved age group, unapproved dose or unapproved form of administration...
of low-doses of Tricyclic antidepressant
Tricyclic antidepressant
Tricyclic antidepressants are heterocyclic chemical compounds used primarily as antidepressants. The TCAs were first discovered in the early 1950s and were subsequently introduced later in the decade; they are named after their chemical structure, which contains three rings of atoms...
that have anti-muscarinic properties (e.g. Amitriptyline
Amitriptyline
Amitriptyline is a tricyclic antidepressant . It is the most widely used TCA and has at least equal efficacy against depression as the newer class of SSRIs...
or the less sedative Nortriptyline
Nortriptyline
Nortriptyline is a second-generation tricyclic antidepressant marketed as the hydrochloride salt under the trade names Sensoval, Aventyl, Pamelor, Norpress, Allegron, Noritren and Nortrilen. It is used in the treatment of major depression and childhood nocturnal enuresis...
) generally prove more effective.
In TMJD the muscles are unbalanced. Biofeedback using EMG is successful in balancing these muscles. A mirror can be used as a biofeedback device: Draw a vertical line on mirror. Relax the jaw by relaxing as you exhale. See the jaw relax in the midline. Practice the breathing and relaxing daily using the mirror. When the jaw does open midline the symptoms should abate.
Long-term approach
It is suggested that before the attending dentist commences any plan or approach using medications or surgery, a thorough search for inciting para-functional jaw habits must be performed. Correction of any discrepancies from normal can then be the primary goal.Patients may employ a nighttime biofeedback instrument such as a biofeedback headband or biofeedback
Biofeedback
Biofeedback is the process of becoming aware of various physiological functions using instruments that provide information on the activity of those same systems, with a goal of being able to manipulate them at will...
device to help them modify para-functional jaw habits which take place in sleep. In addition, there are various treatment modalities which a well-trained experienced dentist may employ to relieve symptoms and improve joint function. They include:
- Manual adjustment of the bite by grinding the teeth (occlusal adjustment). This, too, is not a widely accepted practice and should be avoided as it is irreversible.
- Nighttime biofeedback for para-functional habit modification
- Mandibular repositioning splints which move the jaw, ligaments and muscles into a new position and myofunctional therapy
- Reconstructive dentistry
- Orthodontics
- ArthrocentesisArthrocentesisArthrocentesis is the clinical procedure of using a syringe to collect synovial fluid from a joint capsule. It is also known as joint aspiration. Arthrocentesis is used in the diagnosis of gout, arthritis, and synovial infections....
(joint irrigation) - Surgical repositoning of jaws to correct congenital jaw malformations such as prognathismPrognathismPrognathism is a term used to describe the positional relationship of the mandible and/or maxilla to the skeletal base where either of the jaws protrudes beyond a predetermined imaginary line in the coronal plane of the skull. In general dentistry, oral and maxillofacial surgery and orthodontics...
and retrognathiaRetrognathismRetrognathia is a type of malocclusion which refers to an abnormal posterior positioning of the maxilla or mandible, particularly the mandible, relative to the facial skeleton and soft tissues.... - Replacement of the jaw joint(s) or disc(s) with TMJ implants (This should be considered only as a treatment of last resort.)
Elimination of para-functional habits
An approach to eliminating para-functional habits involves the taking of a detailed history and careful physical examination. The medical history should be designed to reveal duration of illness and symptoms, previous treatment and effects, contributing medical findings, history of facial trauma, and a search for habits that may have produced or enhanced symptoms. Particular attention should be directed in identifying perverse jaw habits, such as clenching or teeth grinding, lip or cheek biting, or positioning of the lower jaw in an edge-to-edge bite. All of the above strain the muscles of mastication (chewing) and result in jaw pain. Palpation of these muscles will cause a painful response.Treatment is oriented to eliminating oral habits, physical therapy to the masticatory muscles, and alleviating bad posture of the head and neck. A biofeedback headband or biofeedback
Biofeedback
Biofeedback is the process of becoming aware of various physiological functions using instruments that provide information on the activity of those same systems, with a goal of being able to manipulate them at will...
device may be worn at night to help patients train themselves out of the para-functional habit of nighttime clenching and grinding (bruxism
Bruxism
Bruxism is characterized by the grinding of the teeth and typically includes the clenching of the jaw. It is an oral parafunctional activity that occurs in most humans at some time in their lives. In most people, bruxism is mild enough not to be a health problem...
). A flat-plane full-coverage oral appliance
Oral appliance
An oral appliance is a device that a patient will wear for a certain period of time to treat various orofacial disorders. Such appliances are commonly used to treat sleep apnea and TMJ disorders.-MORA:...
, e.g. a non-repositioning stabilization splint, reduces bruxism
Bruxism
Bruxism is characterized by the grinding of the teeth and typically includes the clenching of the jaw. It is an oral parafunctional activity that occurs in most humans at some time in their lives. In most people, bruxism is mild enough not to be a health problem...
in some patients, and can take stress off the temporomandibular joint, although some individuals may bite harder on it, resulting in a worsening of their conditions. The anterior splint, with contact at the front teeth only, may prove helpful to some patients, but for those patients who bite harder on this type of splint, even more damage may occur. Thus, different types of splint therapy may work for different patients.
Reversible treatments
In line with the recommendations of the National Institute of Dental and Craniofacial Research (NIDCR) of the National Institutes of Health (NIH), treatments for TMJD should not permanently alter the jaw or teeth, but need to be reversible. To avoid permanent change, over-the-counter or prescription pain medications may be prescribed. Some sufferers may also benefit from gentle stretching or relaxation exercises for the jaw, which may be recommended by their healthcare providers.Other interventions include:
- Stabilization splint (biteplate, nightguard) is a common but unproven treatment for TMJD. A splint should be properly fitted to avoid exacerbating the problem and used for brief periods of time. The use of the splint should be discontinued if it is painful or increases existing pain.
- FeldenkraisFeldenkraisFeldenkrais can refer to either:* the Feldenkrais method in movement education* Moshé Feldenkrais, physicist, judoka and inventor of this method....
TMJ Program, claims to retrain muscles to reduce chronic tension in the jaw, face, neck, and upper back, and to reverse long-standing movement habits responsible for the original TMJD symptoms. - Mandibular Repositioning (MORA) Devices can be worn for a short time to help alleviate symptoms related to painful clicking when opening the mouth wide, but 24-hour wear for the long term may lead to changes in the position of the teeth that can complicate treatment. A typical long-term permanent treatment (if the device is proven to work especially well for the situation) would be to convert the device to a flat-plane bite plate fully covering either the upper or lower teeth and to be used only at night. According to an article on Quackwatch.org, MORA devices are considered the most widely used option although their scientific validity has not been proven.
Surgery
Attempts in the last decade to develop surgical treatmentSurgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
s based on MRI and CAT scans now receive less attention. These techniques are reserved for the most recalcitrant cases where other therapeutic modalities have failed. Exercise protocols, habit control, and splinting should be the first line of approach, leaving oral surgery
Oral Surgery
Oral Surgery is a recognized international specialty in dentistry. It includes the diagnosis, surgical and related treatment of diseases, injuries and defects involving both the functional and esthetic aspects of the hard and soft tissues of the head, mouth, teeth, gums, jaws and neck.It involves,...
as a last resort. Other possible causes of facial pain and jaw immobility and dysfunction should be the initial consideration of the examining professional.
One option for oral surgery is to manipulate the jaw under general anaesthetic and wash out the joint with a saline and anti-inflammatory solution in a procedure known as arthrocentesis
Arthrocentesis
Arthrocentesis is the clinical procedure of using a syringe to collect synovial fluid from a joint capsule. It is also known as joint aspiration. Arthrocentesis is used in the diagnosis of gout, arthritis, and synovial infections....
. In some cases, this will reduce the inflammatory process.
Jaw dislocation
The jaw can dislocate if a person opens their mouth too wide, particularly when a person attempts to open the jaw widely in an effort to stretch the facial muscles i.e. to relieve tense facial muscles as the wisdom teeth develop and emerge.The jaw can also "slide out" as the person is sleeping on their side.