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Addressing the Issue of Compliance – Treating Severe TM Joint Pain Without Surgery by M. Alan Bagden, DMD

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Introduction

The orthodontist is only as good as a patient will allow him or her to be. This truism is all too often overlooked when evaluating patients. An orthodontist may possess superb diagnostic and clinical skills, but if the patient cannot or will not comply with directions, the case is destined for failure. Compliance takes on many forms. Compliance can be how well a patient keeps scheduled appointments, how respectful the patient is in terms of limiting breakage and in notifying the office when breakage occurs, attitude toward treatment, level of oral hygiene, and how well the patient understands, executes and follows the directions of the orthodontist.

As practitioners, we often need to evaluate which patients will have the psychological commitment to see the case through to completion. Virtually all surgical patients would rather avoid surgery, and tell us that they are committed to a non-surgical treatment plan, but it is a minority of patients who are 100 percent compliant.

The following case illustrates the importance of compliance and how with active patient participation we can effectively realize our ideal treatment plan. This is a case where the patient had sought non-surgical options for her orthodontic problems for a number of years, but always received the same assessment – that her case was only surgical in nature.

Case Presentation

Diagnosis

A 38-year-old female presented with 15-plus years of TM joint issues, lateral tongue thrust and difficulty biting, eating and chewing. She had four previous consultations that offered her two possible solutions: she couldn’t be treated, or she could be treated, but required surgery, and treatment would take at least 30 months. Despite initial advice, the patient continued to look for a solution that wouldn’t require surgery and would treat her with cosmetic appliances in less than two years.

The patient expressed clear desire for elimination of right buccal segment crossbite, good dental intercuspation, closure of the anterior open bite, control of tongue thrust and an aesthetic smile in terms of teeth, gingiva and occlusion.

Treatment Plan

With a severe lateral open bite, tongue thrust and TMJ issues coupled with transverse asymmetry, desire for cosmetic appliances and an adult patient with complete growth, an extremely organized and well-executed treatment plan was essential.

The Damon System (passive self-ligation) was the logical choice for this case due to its unique design allowing for reduced friction and reduced resistance to sliding. This case, which is extraordinarily dependent upon elastic therapy for tooth movement, called for reduced friction and sliding. Binding between teeth and wires and overpowering the biology of the periodontal complex due to the delivery of heavy forces, so common in traditional bracket systems, needed to be nearly eliminated for success. Additionally, to address the patient’s aesthetic demands, Damon Clear anterior brackets were selected for treatment.

Elastics

In case presentations where elastic band wear is required, it’s recommended to introduce elastics slowly and methodically. All too often a patient is overwhelmed by instruction to wear a myriad of elastic patterns, resulting in frustration rather than confidence. To prevent such frustration, the patient was started with one cross elastic (XE) on her first visit. The location was the most anterior elastic of the buccal segment (i.e. the premolar area), as that was the easiest for her to engage. She was instructed to wear the elastic for 22 hours a day for a week, and to return for additional instruction and progress evaluation. At the one-week appointment it was clear that she had mastered implementation and she was then instructed to wear three XEs. Two weeks later she returned, again having mastered the new pattern, at which time we gave her the remainder of the XEs necessary to correct her transverse needs.

The complete elastic progression was as follows:

Transverse: XEs were started at the initial banding appointment and were worn full time for three months and at night for the following three months. The patterned progressed from 3/16in, 2oz elastics (Quail) placed from the lingual tooth on the upper arch to the labial tooth on the lower arch. As the wire sizes increased, elastic therapy increased as follows: 3/16in, 4.5oz (Kangaroo) to 3/16in, 6oz (Impala).

Initial Through Work Wires Finishing Wires
.014 Damon Copper NiTi Upper 19x25 TMA
.018 Damon Copper NiTi Lower 17x25 TMA
14x25 Damon Copper NiTi  
18x25 Copper NiTi
(for a six-week interval)		  

Sagittal: Once the transverse dimension was under control and improving, the sagittal elastics were implemented. At month four of treatment, both transverse and sagittal elastics were used simultaneously when it was apparent that the patient was capable of understanding and implementing the instructions given.

Class III elastics were started on the left side first and then, once all transverse corrections were complete and the sagittal dimension became the aspect of concentration, progressed to include a Class III elastic on the right. As the sagittal correction developed, we instructed the patient to additionally place transverse elastics at night to ensure that the correction was maintained. These movements took place throughout the copper NiTi wire progression (listed later in article) and continued for approximately eight months.

Once the transverse and sagittal corrections were in place, we inserted the TMA wires. The upper TMA wire was expanded and the lower was constricted in order to maintain the transverse correction while the final vertical correction was performed. At the 12-month juncture, elastics were placed in a pattern that resembled the letter W. These are very difficult for patients to master and comply with, but provide the greatest vertical correction available. Having the 17x25 TMA wire in the lower arch allowed for arch control, but also more vertical correction, as the wire did not fully fill the slot. This method of vertical closure in open bites is extremely successful. It is the most difficult pattern for the patient to manage, but by this stage in the treatment most have become masterful in their ability to wear elastics.

Brackets and Wires

Space closure was accomplished by first consolidating all spaces by chaining the six anterior teeth together and the four right posterior teeth and four left posterior teeth as individual units, under the archwires. Once space was consolidated, closure was achieved by employing traditional Damon System mechanics whereby posted wires were inserted and medium NiTi coil springs were attached from the posts to the first molars. Doing so provided light, continuous space closing forces.

Wire progression for this case followed traditional Damon System mechanics.

Finishing

Selective rebonding of brackets was performed at the 12- month juncture for improved root angulation and marginal ridge alignment. Interproximal reduction was performed on selected anterior (upper and lower) teeth to decrease non-aesthetic “dark triangles.” Additionally, hard-tissue recontouring (enamoplasty) was performed at the band removal appointment, once adequate vertical correction had been achieved. The recontouring provided the patient with an enhanced cosmetic result, while maintaining appropriate incisal overbite.

When finishing, we focused on making sure the wire did not entirely fill the slot to allow the vertical elastics to have some wire play and positive impact on the intercuspation. To achieve this, the upper was treated with 19x25 TMA and the lower was treated with 17x25 TMA.

Retention is an important factor in a case of this nature. To support this, fixed, bonded retainers in both the upper and lower arches were inserted. In addition to the bonded retainers we utilized a Damon Splint for long-term stability and maintenance. The splint maintained the corrected tooth positions and the transverse, sagittal and vertical corrections. Both the fixed splints and the Damon Splint are recommended for the patient to wear into the foreseeable future.

Results

Due to the patient’s exceptional response from both a compliance and orthodontic progress perspective, surgical correction was not required. Throughout treatment, Damon Clear responded very well to all mechanics, underwent no breakage and allowed for elastic placement due to well-designed tie wings. Additionally, the posterior metal brackets performed to the expectations by contributing to the necessary sliding mechanics as opposed to inhibiting them.

The total treatment time was 22 months and the patient was seen more than 20 times during the active treatment period. The final result satisfied the desire of the patient from a functional, pain elimination and aesthetic position. Dental interferences were eliminated, which aided in reduction of the TM joint discomfort. The patient also reported she “no longer is taking six or more Motrin tablets every day,” and her “ability to chew, eat and enjoy food is dramatically improved.” Obvious aesthetic improvement is apparent and overall self-confidence elevated.

Conclusion

The key to this case was determining the right treatment plan and its proper execution. Incremental elastic increases were critical for aggressive elastic therapy success. Not every patient would be able to commit to the same level; therefore the doctor must be aware that mutual frustration, by both doctor and patient, is a very real possibility in a case like this.

It must also be emphasized that retention is key for long-term success. Not only is compliance critical during the course of the active orthodontic phase, the commitment and motivation must continue far after the case is complete to allow sustained results. It is suggested that cases such as this are never deleted from a doctor’s patient database and are followed on an annual basis.

The unique design of the Damon passive self-ligating bracket – the systematic protocol and mechanics for correction of severe skeletal malocclusions – and the contribution of the Damon Clear brackets made the Damon System the ideal modality to treat this case. In the end, this case was treated without surgery, but rather with logical mechanics, high-technology appliances and devout patient compliance.

Author's Bio
Dr. Alan Bagden is a seasoned orthodontist practicing in Springfield, Virginia, and is a frequent speaker at industry meetings worldwide, having presented on every continent of the world, except Antarctica. He enjoys dissecting the mechanics of complicated cases and producing transforming results for his patients. Dr. Bagden has been a driving force behind the development of Ormco's Damon System and Insignia Advanced Smile Design.

Dr. Bagden graduated from Lafayette College and then attended the prestigious University of Pennsylvania School of Dental Medicine, earning his Doctor of Dental Medicine (DMD) degree. After fulfilling a service obligation as a dentist with the United States Public Health Service he applied to and was accepted into the orthodontic residency at the University of Maryland. Following orthodontic certification he joined Dr. William Wallert in practice and the two pioneered and implemented many efficient practice management techniques.

Dr. Bagden is board certified by the American Board of Orthodontics. He has served as president of the Virginia Association of Orthodontists and the Northern Virginia Dental Society. He is a member of the Pierre Fauchard Honorary Dental Society and the American College of Dentists in recognition of his contribution to the orthodontic profession. An avid runner, Dr. Bagden has qualified for and competed in the Boston Marathon as well as many other selective long-distance races.
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