The Case of How Invisalign is Related to TMJ Disorder

I see new patients every day who are contemplating doing Invisalign, or aligners of some kind, in order to ‘fix’ either their TMJ problem or to re-align their bite when they already had braces done in the past. There is a chance that doing aligners might help them, but in truth there is a greater chance that moving the teeth with aligners will make things worse. Let me explain.

As all of my new patients know, they sit in a bar stool when they come to my office and I spend a moment or so just looking at them. I know at first it seems a bit odd having a dentist look at your eyes/ears/nose/chin, but it works! Then as I explain why I am doing this, they understand that I am not just looking at their teeth. I am looking at the bones of their skull to see if there are any imbalances, i.e. are there any distortions that might make doing those aligners a bit more difficult. What you have to realize is that if the bones in your skull are not level, and then you force the teeth to go level, you end up with the teeth and skull bones working against each other. This is why you are required to retainers when done with aligners- the cranial bones will take over and re-twist the teeth otherwise.

As an aside, dear readers, I actually stepped away from writing this blog for about an hour to meet a new patient to our office. She was super nice, super friendly, but in a super amount of pain- she had headaches, neck and back pain, tinnitus (ear ringing/buzzing), ADD/OCD, and sleep disordered breathing. The interesting thing is that she just finished Invisalign last year and came to me because she is grinding holes through her clear retainers. So, as usual, I sat her in the bar stool across from me so I could just look at her first. She actually turned a bit red in the face and said ‘no one has really just looked at me so intently before’ and I explained that I am just taking a critical look to check for any imbalances. Well, what I saw kind of surprised her. Her right ear/eye/eyebrow were elevated relative to her left side. Her upper right teeth were pulling upward as well. In other words, her cranial bones were so distorted that they moved her teeth and now the upper front teeth were crooked. So, the explanation that moving the teeth into a position just to look good when the more serious underlying issue- distortions to the cranial bones- was ignored allowed her to understand why she was grinding through her retainers. In English- doing aligners like Invisalign is like putting two nice new tires on the front of your car when the frame of the car is distorted and out of balance. The nice new tires will wear down much more quickly than they should because that distorted frame will pull and push on them unevenly. So I told her to go across to the nearby gas station and get a front end alignment.  NO.. Not really. But that was how it should have been done- first align the cranial bones and work on the airway (whoops, forgot to mention that to you folks-that’s another blog)  and then finally align the teeth to the position where the body seems to work well.

So, I digress, but when do I not? 😊 It’s my blog. 😉The moral of the story, as they say, is that you need to look at the whole person prior to doing any type of treatment. In my soon-to-be-released Orthodontic Oath, I make a check list of what the patient should know prior to initiating any form of orthodontic treatment- whether it is braces, invisalign, aligners, or similar. And one of the key components of that oath is that you as the patient need to understand that when teeth are forced into an arbitrary position just to look nice and straight, this may violate what the body allows and pain will ensue. Let me explain this some more. If, for example, the patient has what is called a maxillary cant, i.e. the upper jaw is literally bent higher on one side than the other- an uneven smile as they call it, then orthodontically you would bring down the teeth on the higher side so they are now more level across. Well, that is all fine and dandy, but if the cranial bones above those teeth are a bit distorted/bent, then this will pull on the jaw bone and can lead to TMJ disorder. In other words, we should try to identify if there is potentially an underlying TMJ problem BEFORE we move the teeth around. In so many cases, the cranial bones, the jaw joints, and the cervical spine are completely ignored for the sake of making the teeth straight.

In regard to the Orthodontic Oath, here is a rough draft- this thing is a work in progress and I just started it a few days ago, but here it is for your consideration when contemplating orthodontic treatment:

THE ORTHODONTIC OATH

As your orthodontic provider, I feel very strongly that you, as the patient, should be well informed prior to beginning orthodontic treatment (braces or aligners like Invisalign). It is important that you understand your status prior to the treatment, along with what might happen because of the treatment.

My Oath to you is to provide you with the following information prior to treatment:

  • You should be made aware of the condition of your condyles/jaw bones and whether or not there is wear and tear present, if the condyles are worn, or if they are set too far back or too high in the sockets. If they are not in the proper position, then the orthodontic treatment should be geared toward improvement of that position. Improper condyle position is one of the main causes for TMJ disorder so if the teeth are simply moved for cosmetic reasons, this will likely further damage an already compromised joint.
  • Your ROM (Range Of Motion- how big you can open your mouth) should be documented before treatment and at each and every visit to make sure your body is responding well to the treatment. Your opening should be at least 50mm or so at the beginning and should hold fairly steady during the course of treatment. If the range of opening decreases, it means there might be a problem in the jaw joints.
  • The discs in the jaw joints should be analyzed prior to treatment as well- i.e. are the joints clicking/popping? Is there pain on opening? Sometimes an MRI is required to analyze the joints more completely. If the discs inside the joints are not in their proper anatomic position, you are not ready for braces.
  • The dentist needs to inform you if the cranial bones (i.e. the bones in your skull) are out of place or uneven- and this is often the case in almost all patients that we treat. So, when teeth are moved orthodontically, this movement may make the distortions to the cranial bones worsen and could lead to head and neck pain eventually. In other words, sometimes the cosmetic treatment may not be worth it. Only you can decide if you wish to take the risk as long as you are well informed.
  • In almost all cases, it is very important to grow the teeth ‘taller’, i.e. erupt them taller in order to better support the jaw joints. If this is not being done, then you deserve an explanation as to why not.
  • You also need to be informed that certain teeth may already be compromised from past procedures like root canals, crowns, large fillings, gum disease, and even braces or Invisalign. These teeth may not respond favorably and may not move orthodontically and options may need to be discussed.
  • And finally, the proper way to treat a patient for orthodontics is to re-align the cranial bones FIRST, get the discs back into position FIRST, align the cervical spine FIRST, and then once all this is accomplished, consider proceeding with orthodontic treatment. This way, the teeth are more likely to stay in proper position and the patient will have less pain and sleep problems in the future.