Mary’s Jaw

Dr. Halligan
Dr. Halligan

Mary is a woman who long before I saw her in my office had a small kitchen mishap: she forgot that her dishwasher’s door was wide open and she tripped over it breaking her right foot. Once she got over having to wear a cast on her foot for a couple of months, and the injury was healed, the story was worth a chuckle or two but went largely forgotten. And yet there were further repercussions that would unravel more than a year later.

Mary is actually a personal friend and didn’t start out as a patient in my office; in fact she was reluctant to bring up her TMJ symptoms with my wife and me as she didn’t want to impose. And yet, after she’d seen everybody else in town, her physician, a couple of neurologists and dentists, another friend said to her, “Mary, you should just have Bill check you. He takes care of problems like this, you know.”

Mary put if off longer than she should have but finally saw me in the summer. Her complaint? Jaw pain on the right side that was aggravating at first but getting steadily worse. Chewing was painful. She found it painful to sleep on her right side. Simply opening her mouth was becoming more and more difficult. She also had constant right ear pain.

No dentist could see anything wrong. Brain MRI results were negative. Teeth, gums, and bite all looked ok. In short, she was told repeatedly that there seemed to be no structural or organic explanation.

Mary isn’t a complainer and even though my wife and I got together with her and her husband occasionally, she never let on that she was having these problems. She finally told us that she wanted an evaluation. I ordered CBCTs of the TMJs. I had the scans before her first appointment.

Mary’s CT scan. Notice marked posterior displacement of the left mandibular condyle with cratering on the superior surface of the condyle. There is slight displacement of the right condyle as well. The questionable bridge is on the lower right.

When I met with Mary I told her, “I know your pain is on the right side, but the problem is actually on the left.” That obviously surprised her, but I showed her the image of the displaced mandibular condyle on the left side.

The look on her face told me that she was thinking about that and coming to some conclusion of her own. “Remember when I broke my foot?” I told her of course I did. “Well, I didn’t tell you at the time, but I when I fell I also hit the left side of my head and face. Knocked myself out as a matter of fact. But my foot was the big concern. I forgot about my head. Could this have happened then?”

“Sure.”

“I have had jaw pain ever since, but I didn’t put it together with the fall because the pain has always been on the right.”

Palpation exam elicited pain to the right masseter, right medial pterygoid, right temporal tendon, and right intra-auricualar area—the right ear. She also had right side neck pain and right side occipital pain.

I evaluated Mary’s occlusion with T-scan.

Here is a graphic of Mary’s occlusion. Notice essentially zero right side contact and bite instability.

Here is Mary’s T-scan result. Interesting that there is almost no right side occlusion. A careful and observant dentist should have spotted that with good old articulation paper. But perhaps it is just as well that it wasn’t seen because someone may have concluded that doing restorative dentistry on the right side would solve the problem. Doing so would not have addressed the source of the trouble.

My treatment consisted of daytime and nighttime intra-oral orthotics to correct the left side joint architecture. At the same time I did tell Mary that after TMJ therapy she might need to replace her lower right bridge that appeared to be completely out of occlusion. But, I would only recommend that after the joints were stable.

In a fairly short time, Mary’s right side jaw and neck pain were gone; she could sleep on her right side, and she could open wide without pain. And one more thing, and a pleasant surprise at that: after eight weeks of appliance wear, her occlusion without the appliances was markedly improved. That right side bridge is in occlusion and looks like it will not have to be replaced after all.

Correcting the left TMJ resulted in her right side teeth coming back together.

Who woulda thunk it?

The Dawson Academy, an excellent place for any dentist who wants to improve his level of knowledge and skill, states that “good esthetic and complete dentistry must begin with a thorough understanding of dental occlusion and the functions of the masticatory system.” But often overlooked is the fact that the foundation of the occlusion is position and health of the jaw joints.

For Mary, that displacement of the left TMJ changed everything.

It is surprising to me that numerous doctors, including neurologists, general practice physicians, and several dentists all said they found nothing wrong. Mary suffered more than a year of pain, and she is certainly not alone. It is not unusual for patients referred to my office to report that their symptoms had been present and undiagnosed for a decade or more.

Listen: I’m just a guy with a dental degree. I’m not any smarter than most of you. I’ve just found that there’s an additional place to look. That’s what I want from our profession: look a little closer and maybe look in one more place.

 

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2 thoughts on “Mary’s Jaw

  1. Hi Bill,

    That’s a great story! Unfortunately, not a rare one. I think your idea of the hands-on workshop is a great way to move into another phase before complete retirement! Since you have documented so many cases you have plenty of teaching aids. You could have a few dentists bring in patients for analysis. I hope something like this works out.

    Jim

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