My wife and I did some fairly extensive mountain (and road) biking in the Eastern Sierra last week.
While we were staying in Mammoth Lakes, I received a call on my cell phone from our friend Melissa. She said she and her family were staying at nearby Convict Lake and invited us down for lunch.
“Oh, by the way”, Melissa said. “One of my sons is in ortho and I have some concerns. He has clicking in his jaw joints now. He has a constant earache in the right ear, and he just doesn’t feel good. His jaw hurts. His orthodontist doesn’t seem worried about it. What do you think?”
I call Christopher, a somewhat reluctant high school aged boy, up from the banks of the lake. Step one, I wonder if there’s a frontal occlusal cant (see my article, TMJ Pain: Whose Fault Is It for a discussion of this subject with sample photos). I find a fairly straight stick, about eight inches long and a quarter inch in diameter—just the thing.
I ask Christopher to hold the stick left to right between his premolars (“Don’t worry; it’s a clean stick.” He seems a bit dubious, but goes along with the game). And what’s the result? The frontal plane is canted up on the right side about 4 mm.
So what do I know at this point? First, there’s a good chance of an internal derangement of one or both temporomandibular joints. In fact, published studies state that if there’s an obvious canted frontal occlusal plane, there is a 76% chance of a disc displacement.
And, if he’s one of the 24% who does not have a joint problem, there is still a good chance that the occlusion is compromised with the low side (his left posterior teeth) hitting first and hard. There is also likely to be an esthetic compromise.
Range of motion looks normal to me. The mandibular midline appears to be off a couple of mm to the right. There is deviation to the right on opening. On palpation there is masseter muscle tenderness on both sides and pain just in front of the right ear.
Next, what about clicking? Well, I don’t have a computer and JVA down here at the lake, but on palpation there is an obvious click on the right side and a less obvious one on the left. With my left little finger in his right ear, I can feel the impact of the condyle on the tympanic plate of bone as he closes.
Not a good sign.
So, I explain, with some rough diagrams, that Christopher likely has posterior displacement of the right condyle, and possibly both condyles, and also anterior displacement of the right articular disc.
“So, what should we do?” Melissa wants to know.
“The first thing to do is to obtain good joint images. If there’s an x-ray lab near you, I’d request 3D cone beam images. Get the results on a disc and send the disc to me. If the joints are actually displaced as I believe they are, then I’m probably going to irritate (I used a different, slightly less PG, term for ‘irritate’) your orthodontist. If there is a displacement, he should stop orthodontics until the joint is stable and then finish ortho.” It appears to me, that Christopher is over-closed and finishing ortho will entail adding at least 2 mm of vertical for the finished result. Some orthodontists love that, as you can imagine.
I then try another test. With Christoper standing I find that he is quite unstable and loses his balance easily. Based on visual clues, I find a flat rock—think of something you might use for skipping stones across the water—and place it under his left heel. I push him from side to side again. The result? Instant and remarkably strong stability.
“I don’t know if that means an actual leg length discrepancy,” I tell Melissa, “or if the problem is in his low back and hips. But the fact is foot orthotics made by a good podiatrist will be helpful. His balance is obviously off. Correcting the jaw joints will be helpful. So will chiropractic. But I’d have a podiatrist check the feet. Getting proper balance of the feet could make a world of difference.”
Mom is relieved to know that there is an explanation for what her son is experiencing. She has complained to the orthodontist, but he does not seem to think there is a problem worthy of concern. She has also taken him to an ENT because of the constant ear pain. He cannot offer any explanation. I think the ear pain is directly related to condylar position.
With some basic screening steps, I believe I know exactly what’s going on and what will be required to fix it. Without intervention, I think the orthodontic result will be poor—possibly even a failure with a need to do orthodontics again in the future. However, I tell Melissa that these screening steps are not sufficient by themselves. A 3D tomogram and in-office computerized joint vibration analysis along with a full exam should fill in the missing puzzle pieces.
Back at my office in San Diego (God, I miss Mammoth Lakes) I’m waiting for the digitized images on a disc. I expect them to arrive in the mail any day. This should prove to be an interesting case, from TMJ therapy through the finish of orthodontics. Stay tuned to future articles featuring Christopher.