[image:DSC_0021_05_21_14.jpg][image:DSC_0022_05_21_14.jpg][image:DSC_0023_05_21_14.jpg][image:DSC_0024_05_21_14.jpg][image:DSC_0025_05_21_14.jpg][image:DSC_0026_05_21_14.jpg][image:DSC_0027_05_21_14.jpg][image:DSC_0029_05_21_14.jpg][image:DSC_0030_05_21_14.jpg][image:Generic_06-03-14.jpg]Hi Everyone,

I'd like to get your ideas on treatment for a personal friend who has been suffering with TMJ pain for 8 months.

Natalie received a blow under the chin from her dog when it ran full speed at her and jumped up as she was bending down. She experienced pain in her joints but did not see anyone for a few days thinking that it would get better. It didn't so Natalie saw a "TMJ dentist" nearby who is often referred to. He placed in a a Gelb appliance for daytime wear and a mandibular repostioning appliance for nighttime wear. The pain did not subside. He then placed her on the following meds: RPR injections; Meloxicam 15mg once daily; a topical tetracaine cream that was formulated at the pharmacy; Tizanidine 2mg one Q8H; Alprazocam 15mg once daily; Cyproheptatine 4mg 1/2 to 1 tab at bed; Cyclobenzaprine 10mg tow at bedtime; indomethacin 75mg once daily; Trokendi XR once daily.

Natalie described her pain at the inital appt. with me as "tight band over my head" and in front of the TMJ, worsening during the day and affecting her sleep. Natalie is a type A personality so I can see why the stree would be effecting her as the day wears on.

My TMJ exam revealed the following: moderate pain in the masseter on the R and L; moderate pain in the temporalis on the L only' Dopler showed crepitus on opening and closing on th R and also in protrusive and in left lateral (not right); maximum opening is 35mm, 5mm protrusive, 5mm right lateral and 6mm left lateral; 3mm OB/OJ; mandible deviates to left on opening then back to midline.

I referred Natalie for an MRI. The radiologists report states "There are bilateral trace TMJ effusions, left side more prominent than right.Degeneration of the posterior band of the left TMJ meniscus. Anterior translation of the left conduyle stops just short of the apex of the artticular eminence with maximal open mouth positioning. Mild degeneration of the intermediate zone of the right TMJ meniscus. The right condyle demonstrates normal anterior translation onto the apex of the articular eminence with maximal open mouth positioning."

The photos show that Natalie can't occlude on any posterior teeth. I feel this is do to wearing the Gleb appliance for 6 to 8 months causing either intrusion of the posteriors, eruption of the anteriors, or both. I've included photos with the appliances in her mouth. She is no longer taking any of the medications due to many side effects and not wanting to be on all of the meds without feeling any relief.

I have made Natalie and anterior jig to wear at nightime only. It's only about 2mm think and I want to see if she is clenching or grinding. I'll determine what the next step is based on how she responds to the jig, but I want to open this up for discussion. This is a challenging case for me and I'd like your help in helping Natalie. Thanks.

Jim[image:DSC_0021_05_21_14.jpg][image:DSC_0022_05_21_14.jpg][image:DSC_0023_05_21_14.jpg][image:DSC_0024_05_21_14.jpg][image:DSC_0025_05_21_14.jpg][image:DSC_0026_05_21_14.jpg][image:DSC_0027_05_21_14.jpg][image:DSC_0029_05_21_14.jpg][image:DSC_0030_05_21_14.jpg][image:Generic_06-03-14.jpg]