manipulating patients into centric relation, making splints in that position

The early dentists who attempted to help TMD patients through occlusal therapy include the following:

Nathan A. Shore (1914-1984)  Spent 40 years focusing on “TMJ Syndrome”, NYC

Harold Gelb, NYC, did much to popularize “TMJ” from the 60’s thru the 80’s.  He had several controversial methods, including putting condyles in what he called the “4/7 position” and building a “Gelb splint” which did not follow the principles of occlusion.

In the early 70’s several dentists who had been trained in gnathology began eliminating the more esoteric methods (i.e., tripodized occlusion) and making it more user-friendly for clinicians.  I call it gnathology-lite.  They include:  Peter Dawson, Henry Tanner, Niles Guichet, Peter Neff, Bob Lee, and Terry Tanaka.  They perpetuated the concept of treating TMD through focusing on the occlusion, although Dr. Tanaka has done much to advance our understanding of the TMJ with excellent anatomical research via cadaver studies.

Barney Jankelson, a Seattle dentist, invented a jaw tracking device in the early 70’s.  He incorporated the use of TENS on the jaw muscles, and claimed that this method proved where the jaw “belongs.”  He then advocated rebuilding the occlusion to this “scientific” position, which almost always resulted in opening the bite.  His mantra was “If you can measure it, it’s a fact; if you can’t, it’s an opinion.”  He is considered the father of electrodiagnostics and neuromuscular dentistry.

Dr. George Goodheart, D.C., 1918-2008, Detroit, Michigan.  In 1964 Goodheart developed applied kinesiology—a method of “testing” the body in ways that “diagnosed” any physiologic or medical condition the patient may have.  For dentists, this technique was popularized by George Eversole, who had studied with Goodheart.  Many dentists interested in TMD took weekend courses from Eversole in the 1980’s.  Applied Kinesiology is widely used by chiropractors today.

Bill Farrar (pronounced “fair-ah”), Montgomery, AL, 1924-1985.  Bill Farrar, along with an oral surgeon, Bill McCarty, “discovered” the internal derangement of the jaw joint.  Prior to Farrar, the biomechanical function of the joint was poorly understood.  In 1979, Farrar began lecturing on his discoveries, which transformed our understanding of this condition.  He introduced (along with others) transcranial x-rays to study condylar position.  He introduced disc re-capturing and jaw unlocking techniques.  He used a pull-forward appliance on many of his patients to prevent their jaws from locking again.

o Review:  The underlying philosophy regarding appropriate condylar/mandibular position for TMD patients divides these experts into two basic camps:

Centric Relation/ Ideal occlusion

                      Gnathology,

Restorative occlusionists

Anterior Condylar Repositioning

                        Kinesiologists

                        Gelb

                        Jankelson

                        Farrar

We will revisit when and where to employ condylar repositioning later on.  Farrar was erroneously interpreted as saying that you had to hold the condyle forward forever.  He never said that.  However, he is the one most responsible for “phase II” dentistry on TMD patients.  More accurately, Farrar (along with Gelb, Jankelson, kinesiology) is used as an excuse by too many dentists to perform phase II dentistry  (orthodontics and/or extensive crownwork) on TMD patients.

The lite gnathologists, who I will now call the occlusionists, especially Dawson and Guichet, were adamant that Farrar was wrong about what caused jaw clicking and the need for provisional condylar repositioning.  They dismissed kinesiology, Gelb, and Jankelson out-of-hand as little more than quacks. 

#6  The claims of so-called experts in the field

By the early 1980’s, it became the battle of the gurus with egos, primarily between the occlusionists and Bill Farrar.  The occlusionists ganged up on Bill Farrar.  He was telling us that attempting to put TMD patients in centric relation was iatrogenic.  He was bringing their jaw forward to recapture their disc, or at least reduce joint capsulitis. The occlusionists regarded this as heresy.  However, Farrar was unflappable at conferences in which he was attacked.  I was privileged to be with him every year until he died in 1985 of emphysema.  He was only on the TMD national stage for 6 years, but he made a huge impact on TMD treatment throughout the world. 

Over 900 dentists traveled to Farrar’s small Montgomery AL office from 16 foreign countries and 46 states.  He taught 79 courses in Montgomery between 1980 and 1985.  He published numerous articles in American and European dental journals over a 25 year period.  He worked in his office until he died.

“My time is short, I will fight and I am not bitter. I have accomplished much of what I wanted to do. It has been exciting…Criticism on a professional level is actually beneficial, because it stimulates us to re-think and re-test our viewpoints and concepts.  We must not accept old ideas not based on scientific fact.”

--Bill Farrar

“Dr. Farrar considered his patients his primary teachers. His clinical findings encouraged him, even drove him, to scientific contributions. He possessed a mind that did not allow intermissions and a heart that reached out to his patients.”  

--Dr. Jack Haden

In his final days, Farrar was heard to say, “Medical science has not yet been able to attach a prognosis of doom on man’s spirit nor to predict the physical strength it can harness. I ask only to contribute to life as long as I live it.”

Bottom Line:  Bill Farrar caused a huge paradigm shift in the world of TMD.  More than any other before or since.  Those who profess expertise in this field are standing on the shoulders of Bill Farrar, whether they know it or not.  For more on Dr. Farrar, see Jack Haden’s guest editorial in the Journal of Craniomandibular Practice, Oct, 2008, found here:  FarrarHadenCranioArticle.pdf

For those of us who grew up in the world of gnathological occlusion, we could see the writing on the wall.  We realized within a year of Farrar’s 1979 revelations that the days of manipulating patients into centric relation, making splints in that position and subsequently equilibrating them into this position was not the answer for TMD patients.  If the disc is dislocated, as it is in the majority of TMD patients, there is no such thing as “centric relation.”  The most you can hope to accomplish is identify an “adapted centric position” (Dawson’s term).

Also, by the late 1970’s we had some excellent clinicians who were leading the way in looking at more than just occlusion in evaluating and treating these patients.  They include:

All three organizations support the use of splints, although they use them for different purposes and have different beliefs about the mechanism of how a splint works.

create a false dental open bite thereby creating the need for unnecessary dental treatment.

1. Isn't this just anterior repositioning of the Mandible? It is very important to distinguish between the position of the condyle in the healthy patient and unhealthy patient. In a healthy joint complex with asymptomatic patient we usually find the condyle to be sitting the ideal centered position in the glenoid fossa. There is usually 3mm of space behind and above the head of the condyle. This allows the retrodiscal tissue to nourish the joint complex and room for the articular disc to sit on the head of the condyle and provide the important function of guiding the condyle through its movements. This position is commonly referred to as the "Gelb 4/7" position as described by Dr. Harold Gelb, New York, widely acclaimed leading authority on TMD. The common finding in symptomatic patients is that the condyle is superiorly and distally retruded, sometimes resting against the back wall of the glenoid fossa. In these situations, the retrodiscal tissues are crushed and the articular disc is pushed forward off the head, which accounts for the clicking and popping during opening. So, treatment for retruded condyles does reposition the mandible in a three dimensional direction towards its normal position of health that must have existed before the patient became symptomatic. The mandible is brought down, forward and laterally as required to position it where Mother Nature can heal the injured tissues.  2. Does TMD Treatment pull the jaw out of its socket? IT IS IMPORTANT TO UNDERSTAND THAT TMD ORTHOTICS ARE MOVING MANDIBLES TO A POSITION OF HEALTH .... NOT AWAY FROM A HEALTHY POSITION TO A MORE ADVANCED POSITION. There is great confusion about this repositioning concept. Some TMD detractors will try to convince you that the jaw is being pulled out of its socket to create a false dental open bite thereby creating the need for unnecessary dental treatment. Nothing could be further from the truth.

http://www.tmjorthocentre.com/index.php/what-are-tmj-and-tmd/faqs-tmj-disorders-tmd

Gelb 4/7 position in non-extraction expansive orthodontics

A little history – the Fathers of Gnathology, Drs. Stallard, Stuart and McCollum followed Bonwill’s mechanical occlusion theory and translated the movement of the jaw to an articulator in 1930. They developed a jaw position called Centric Relation, which was the most retruded superior postion of the jaw joint.

These men were revered at the time and are still in the USC Dental Hall of Fame. Around the same time, Tweed had just graduated from Angie’s School of Orthodontics and rejected non-extraction theory as producing faces that were too protrusive. He began extracting permanent bicuspids to “flatten” profiles and supposedly give more stable results (Figure 3). Ron Roth and Robert Williams took the CR concept to orthodontics in ensuing years. Over the next 25 years, the Gnathologists and Tweed orthodontists each contributed to a more retruded jaw position with fewer teeth (Figure 3). This jaw position was taught and utilized in American dentistry from 1930-1995.

To dentists like Bill Farrar, Barney Jankelson, and Harold Gelb, this made no sense. The condyle wars in the 1970s pitted gnathologists from Pankey, Dawson, and SOS against Gelb, Farrar, Jankelson, and Witzig. Witzig taught the European school of functional orthodontics popularized by Schwartz and Frankel which used the Gelb 4/7 position in non-extraction expansive orthodontics. There was a landmark legal case involving a 4 bicuspid extraction patient who ended up requiring TMJ surgery following extraction orthodontics. Witzig was the expert witness and the patient ended up receiving over a million dollars, which was a huge settlement at the time. Dawson realized in the 1980s along with the glossary of prosthodontic terms that the gnathologists had no biologic or physiologic evidence for a retruded centric position. They followed Gelb, but in more conservative anterior superior position (Figure 4).

 ...

Dentistry will now start to understand that jaw position is dependent on the development of the maxilla and mandible. Most maxillas (82% ) are underdeveloped and iatrogenically retruded by dentists and orthodontists as taught by major dental schools and orthodontic programs in the country. We can now understand the folly of Stuart, Stallard, and McCollum, perpetuated by Peter K. Thomas, Pankey, and Dawson in restoring a jaw in the most reproducible retruded nonphysiologic iatrogenic position. Even more harmful was the extraction of permanent teeth during orthodontics, which closed airways and retruded jaws. It is now time for the professionals to become aware of the benefits of the Gel-B Bite Balance Breathing System and AIRWAY CENTRIC ™ appliances.
http://ww1.prweb.com/prfiles/2012/12/03/10199255/Gelb_ebook_AirwayCentricDentistry_FINAL-11-12-12.pdf

loss of cortical plate or flattening of the superior surface of the condyle

even with a modern panoramic, the relative position of the condyle in the glenoid fossa cannot be determined. You cannot see boney changes such as loss of cortical plate or flattening of the superior surface of the condyle on a panoramic x-ray. The reason for this stems from the angulation of the x-ray beam through the condyle itself. Because the x-ray beam is directed from a position under the joint, the lateral pole of the condyle is projected upward and therefore details are lost because the image is superimposed over other boney structures. A panoramic may provide lots of information about other things, but don’t depend on a panoramic to tell you much of anything about the joint.

http://halligantmj.com/quick-and-easy-tmj-xray-basics/

various, often contradictory, occlusal philosophies practiced by these well-meaning dentists

I believe that all dentists want to do their best for their patients. We chose dentistry as our profession to be helpers and healers. Yet, there are various, often contradictory, occlusal philosophies practiced by these well-meaning dentists. Why is that the case? Dental training and education should equip us to come to our own conclusions on the validity of these occlusal philosophies, which are reviewed here. In my opinion, choosing an occlusal methodology should be entirely based on what we would use for our own families when financial considerations are not a factor. This is our profound obligation to our patients. Therefore, it matters not who and with what credentials or titles makes pronouncements about occlusion.

http://www.dentaltown.com/dentaltown/article.aspx?aid=2498

Things to Consider when Choosing an Orthodontist

Consider education and experience.

Once you have a list of a few orthodontists, do a little research. Find out about their educational background, where they went to school, and what kinds of continuing education or specialty training they’ve had. Before you set up a consultation with an orthodontist, make sure he or she is a licensed member of the American Association of Orthodontists. This ensures that they remain up-to-date on the newest and most effective clinical procedures.

Dr. Markham is a Diplomate of the American Board of Orthodontics and an Affiliate Member of the Edward H. Angle Society of Orthodontists. He has years of experience using the finest orthodontic treatments and techniques to ensure you achieve a life-transforming smile.

Get a consultation from more than one office.

Orthodontists have different treatment styles, so getting a consultation from more than one office is a great idea. Some may offer specific orthodontic treatment options or products that others may not. Compare the length of recommended treatment time with the cost of that treatment. It’s also important to feel comfortable with your orthodontist. Do they have a pleasant chairside manner? Do you feel like they’re really paying attention to your concerns? Is the staff friendly and helpful? By visiting more than one office, you’re more likely to find an orthodontist who can meet your individual needs while staying within your budget.

Here at Markham Orthodontics, the answer to all those questions is a resounding “Yes!” We believe that we offer the finest orthodontic experience in our neighborhood! And we know that perfection is never achieved, it is only pursued; we pursue that perfection with a passion!

Ask questions.

During your complimentary consultation at our Sacramento or Auburn offices, don’t be afraid to ask questions. After all, that’s why you’re here! It’s important for you to understand what type of orthodontic issues you have and the most effective ways to treat them. The more informed you are about your own dental health, the better decisions you will be able to make.

During your complimentary initial consultation, Dr. Markham will evaluate your jaw joints, jaw bone alignment, tooth alignment, and gum tissue health. He will put together a treatment proposal, and your treatment coordinator will present a financial plan with affordable payment options.

A few things to consider:

• Who will be overseeing your treatment: the orthodontist or assistants? At Markham Orthodontics, Dr. Markham and Dr. Chiang oversee all aspects of their patients’ treatment and ensure that treatment is progressing appropriately at every visit.
• Is the office located near your home or work to make appointments as convenient as possible? With two locations in Sacramento and Auburn, Markham Orthodontics is nearby wherever you are!
• Do they offer extended office hours before or after work and school? We work hard to make scheduling appointments at our Sacramento and Auburn orthodontic offices as convenient as possible.
• What types of insurance does the office work with and what kind of financing do they offer? We work with many insurance plans that cover orthodontic treatment. In addition, Markham Orthodontics offers affordable, no-interest payment plans.
• Do the orthodontist and staff seem interested in making your experience personalized or do you feel like “just a number?” As our patient, you are the most important person in our office. We want you to enjoy your visits, so we strive to maintain a happy, fun environment, where you’re comfortable and feel at home.

splint brings back TMJ to the right position

In Oriental clinics, we treat facial asymmetry in the following manner.

First step is TMJ adjustment. Patients with clear TMJ disorder symptoms such as TMJ pain, lockjaw or clicking noises are prescribed with splint to wear while they sleep in order to balance the TMJ. At the same time, Chuna chiropractic and acupuncture are administered in the clinic. Patients are recommended to wear a splint for a minimum of seven hours per day which helps bring the TMJ back into the right position. The tension in the muscles and tendons of the TMJ can be relieved with Chuna chiropractic and acupuncture. Such treatment aims to adjust the twisted TMJ into its right position and at the same time achieves aesthetic improvements by alleviating facial asymmetry.

Patients with asymmetry arising from overdeveloped masseter muscles on one side due to favoring one side of the mouth when chewing can be treated with cosmetic acupuncture. Cosmetic acupuncture stimulates the six meridian systems and the muscles in the face without anesthetics or surgery. It promotes the rejuvenation of the skin while relaxing the muscles, with the end-result being lessened asymmetry and smoother jaw line.