Camryn’s Story Part 2: The bite’s relationship to TMD, Airway and Cranial Strain

A note from Louisville dentist Dr. Tracey Hughes: This is Part 2 of Camryn’s Story.  Last month I posted Part 1, which is at the end of this blog.  If you missed it, just scroll down toward the bottom and you’ll find it.

In June of 2018, I attended the Forward Face Orthodontic course at LVI Global (Las Vegas Institute for Advanced Dental Studies) to investigate the answers to the questions I had about how to correct the root cause of Camryn’s headaches…her underdeveloped midface and upper jaw. Here was her report of symptoms at the start of our assessment.

She was having moderate headaches and low back pain 5 times a week, mild pain in her face and neck, TMJ clicking and some TMJ pain, Ringing in her ears…all the time, and some difficulty swallowing.  And her little comment…”Fix me please!!”…where she turned her exclamation points into a smiley face 🙂

All these symptoms listed on this scale are all potential symptoms of people suffering from TMD (temporomandibular joint dysfunction)  One person may have 1 severe symptom and have TMD, and another person may have all the symptoms and obviously have TMD. My point is, you don’t have to have all these symptoms to have TMD.  Additionally, some people can have TMD, show many clinical signs such as recession, abfractions of the teeth, etc, but have no symptoms….yet. These people are very predisposed to having symptoms, it’s just a matter of time for many people.

You don’t often think of children having TMD, but so many do!  The problem is, physicians, don’t know how to recognize the signs and symptoms of a pathologic bite position in children.  They just don’t know what they don’t know. The good news? I can assess and treat children very young, ages 6-10, using a simple orthopedic growth appliance and alleviate symptoms by correcting the root cause (here’s how with RAGGA )

Part of my initial assessment of Camryn was muscle palpation.  These are all the muscles that are associated with the jaw function.  The scale is from 1-3. ( 1 = a mild discomfort, 2 = moderately uncomfortable, 3 = seriously painful /patient pulls away it hurts)

Every muscle I palpated on her was uncomfortable which is an indication of a pathologic bite position.  If the lower jaw has to function and posture in a retruded position where the teeth dictate and not where the muscles are balanced and happy, there will be PAIN!

 

Other records we obtain when doing a TMD exam include many photos.  So here she is…Look at her teeth and smile. Doesn’t look so bad right?  Straight teeth do not equate to a proper bite. The teeth can be straight, but the problem arises when the teeth aren’t in the correct location in the face.  The location of the jaw is what dictates if the bite is a good, physiologic bite vs. a bad, pathologic bite. Remember, teeth and a bite that looks straight can very much be in a pathologic bite because the lower jaw may be forced back too far (retruded).

A routine part of our photos is to ask the patient to swallow. A normal swallow is one where the head and neck don’t move, the teeth remain together, the facial muscles are calm and no movement noticed with the tongue.  Go ahead…go look in the mirror, smile really big and swallow. Watch your face, your neck, and your tongue. Did you see anything move? If not, great. But look at this:

 

Peek-a-boo.  Look at that tongue thrust.  The tongue is a POWERFUL muscle and exerts more force than orthodontic wires and brackets.  The tongue will move teeth with ease. But why does a tongue thrust develop? Visit my page on Growth and Development to learn more.

As discussed in Part 1, The Big 3 are crucial to facial growth and jaw development.

  1. Nasal Patency
  2. Absence of tongue habits
  3. Lip Seal

Camryn had a major compromise in the Big 3, which is what ultimately caused her headaches for the last 6 years of her life.

It’s all about tongue posture.  Camryn is undergoing myofunctional therapy to retrain her tongue.  She needs LOTS of reminders, so I send her random text messages with photos like this:

or this…

And she will respond, “It’s on the spot mom.” 🙂

Nasal Patency:

A simple way to evaluate nasal patency is this…breath in through the nose swiftly.  If nasal patency is clear, the nostrils should flare. Here’s what happens when Camryn tries…

 

Look at the strain in her neck and look at her nostrils collapse.  She is now working on clearing her nasal passages by 1) using them more regularly and 2) allergy control.

Here are the results of her allergy testing this year:

This poor child was allergic to 34 environmental allergens (all weeds, grasses, and trees, with the exception of pine!  O’ Christmas Tree, O’ Christmas tree), cats and dogs (we have 2 dogs, although thought to be “hypoallergenic”. Who can resist a “doodle’?

 

No, we aren’t getting rid of the dogs!

Camryn with Roxy, our 2 ½-year-old Bernedoodle (Hands down, best dog EVER!)

She has begun immunotherapy (allergy shots) and taking the following nutritional supplements: high dose Vit C, Quercetin and Bromelain.  It is crucial to get control of nasal breathing for orthodontic treatment to be successful. Other sources of nasal patency issues in people could be a deviated septum, enlarged adenoids (usually a major cause of mouth breathing in babies and children) or enlarged turbinates.  I work very closely with a local ENT and refer many of my patients to be evaluated for the above issues.

Remember, it’s all about the tongue.  If someone cannot breathe through their nose, their tongue will be in the wrong position and cause the teeth and jaws to have issues.  Camryn was a mouth breather. Her tongue was not high in the roof of her mouth which resulted in an underdeveloped mid-face. Dr. David Buck taught me how to use the Bolton Norms profile overlay to assess facial development.  Here’s what the standard 14-year old’s profile looks like laid over Camryn’s profile photo. The black profile line is where her facial profile should be developed, however, you can see the deficiency in forward, horizontal growth of her face.

 

Another characteristic I evaluate is the jawline in patients.  Someone with a normal forward growth pattern will have a horizontal jawline as depicted below on the left.  Someone, in contrast, who had a compromise in the Big 3 (mouth breather for example) will have a vertical growth pattern and a longer look to their face.

 

 

In the diagram below, see how the angle of the jaw is much different in a vertical grower on the right.

 

Take note of the 90-degree angle of the ramus (or back part of the lower jaw) in a normal growth pattern.  In a vertical grower, that angle becomes very obtuse because the lower jaw has to rotate up and back to compensate for the under-developed upper jaw.  I will talk more about the jaw shape and how it can actually remodel to correct itself during AGGA treatment!

I am always very cautious when speaking with parents and children about their facial features.  Many kiddos are very sensitive to this, and I actually prefer NOT to have the child in the room during consultations with the parents, especially when I discuss airway and the serious health ramifications of a small airway.  It can be scary and the parent needs to realize the seriousness of it, but not with the child in the room.

Camryn has also been a student at LVI, she had the opportunity to sit in class with me during the Ortho 2 course one ½ day and is extremely knowledgeable. (wow, sometimes I feel so smart until I realize…I don’t know how to spell “knowledgeable”!)   I reviewed this blog with her prior to posting and obtained her permission.

Posture and facial symmetry are also very important characteristics to evaluate when it comes to the bite.  Yes, a bad bite can cause forward and rotated head posture as well as facial plane asymmetries (cranial side bends)

      

The illustration above indicates how a bad bite exerts forces that are not at right angles to the upper jaw (which is attached to the skull)  uneven forces will cause uneven orbits (eye sockets) making the eyebrows appear unlevel, as well as a “cant” of the maxilla (tipping of the upper jaw)  Also, notice as in Camryn’s case, she has a rotated and tilted head posture. You can see more of her left ear than her right.

 

This too is a result of her pathologic bite position.  Orthopedic growth guidance has been shown to unravel these cranial strains and side bends and I will be anxiously waiting to evaluate her progress through treatment.

This case below is courtesy of Dr. David Buck, my orthodontic instructor at LVI.  Her cranial strain side bends were eliminated after 6 months of guided growth treatment.

Cranial strain side bends eliminated within 6 months of growth guidance treatment.

Airway!  The most important thing we can put in our body?  Oxygen. You can live 3 weeks without food, 3 days without water and only 3 minutes without air.  I find this to be THE most exciting part of what I do with face forward orthodontics, or jaw development orthodontics. This treatment opens the airway 100% of the time, often, eliminating obstructive sleep apnea.

As part of the diagnostic workup, all my TMD/OSA patients have a 3D CBCT scan taken.  This is one of the amazing views I get with this image.

An airway volume assessment tells me the actual total volume of the airway, as well as the surface area at its narrowest point.  The narrowest point should be greater than 175mm2. My poor baby girl’s airway was 24.4mm2 at its narrowest. (No! That is not a typographical error, I typed 24.4mm2…teeny, tiny airway) Red, Orange, Yellow, and Green are BAD.   The entire airway should be blue and white. One of our goals with Physiologic Dentistry is to open and protect the airway.

Camryn’s airway- minimum surface area = 24.4mm2

Compare Camryn’s airway to my normal sized airway- minimum surface area = 189mm2

 

How does a bad bite cause a constricted airway?  When the upper jaw is underdeveloped (remember, it’s part of the midface, and if the tongue wasn’t up high in the palate, the jaw didn’t develop forward enough) the lower jaw is the “retruded” or forced back further than it should be.  The base of the tongue is attached to the lower jaw, so if the jaw is forced back, so is the tongue…back, into the airway.

Wow, this is getting to be a really long blog and I hope I’m not losing you all!  

TMJs

The CBCT is also extremely useful of evaluating the TMJs. I am able to view the joints from every angle and in 3D form.  I typically review this angle with my patients.

 

The big black circle in each image is the ear canal in the skull. The hook-shaped thing in Camryn’s image is the condyles of her lower jaw that fit into the skull “socket” or glenoid fossa.  And so you are aware, the condyle shouldn’t be bent forward like a hook 🙁 (note the red angel in the image on the right) That is early degenerative changes in her joint…she is 14-years old. The bone has remodeled in response to being forced too far back.  The other thing I’m looking for when I evaluate the TMJs is the space behind the lower jaw’s condyle or the space between the skull and the condyle (see the red arrow pointing to space in the image on the left). This space occupies a cartilage disc as well as soft tissues, vital nerve, and blood vessels. As you can imagine, if the jaw is retruded back toward the skull, this space gets compressed.  Camryn’s is very compressed. This can be the cause of pain, joint clicking, and ear symptoms including ear stuffiness or tinnitus (ringing in the ears)

Below is another view of the TMJs where we can see the superior (or top) aspect of the ball in the socket.  

Again, the red arrows are pointing to space where vital structures reside. The more compressed this space in the joint, the more severe degenerative changes can occur over the years.  Another goal of Physiologic Dentistry is to decompress these spaces where the joints can function optimally.

So how exactly does a physiologic dentist know how to establish a proper bite position?  It’s very scientific actually…we utilize EMGs and jaw tracking technology using a BioPak.

State of the art, computerized equipment shows me exactly what the muscles are doing wherever the jaw is in space.  Here’s one of the very important scans we see when using the BioPak.

 

 

 

EMG’s read muscle activity, and when the muscles are calm, the squiggles on the screen are very small.  When the muscles contract or overactive, the squiggles are BIG. See above, BIG RED squiggles on the left = overactive muscles = pain.  Small red squiggles on the right = calm muscles = happy pain-free muscles. Now, there is quite a bit more that goes on in evaluating these scans, but you get the basics of where we are headed.

So look at Camryn’s scans below.  I always run a baseline “Rest” scan where I have the patient just relax their jaw in what feels to be the most comfortable position, usually teeth apart and jaw just hanging down a bit (no contact on the back teeth).  This is the first half of the scan and shows her muscles can find a happy resting spot.

The 2nd half of the scan you see BIG RED squiggles.  This was when I asked Camryn to close on her back teeth gently. Massive difference in her resting jaw position vs. closed gently on back teeth.

The top red muscles are the Anterior Temporalis muscles. They actually attach the lower jaw to the skull and are the muscles that cause most pain in patients with a bad bite position. The green muscles are the Masseter muscles, and the activity of these tell me if the jaw is resting, biting down lightly, or if the patient is clenching hard.

BIG RED squiggles = headaches.  For 6 years, my daughter has had headaches, increasingly worse in 2017-2018.  Her EMGs do not lie.

 

In summary, for Part 2, Camryn has a retruded lower jaw causing headaches, and you now know why.  If you don’t please visit my FB page and post a question under this blog post I shared on my page.  I always answer questions on Boulder Valley Dental Center’s FB page.  But if you go to my page, please become a fan and click “Like”!  🙂 AND, if you know anyone suffering from headaches or TMJ, go to the same FB post and share it with that person or on your page.  Thank you

People, I cannot tell you, how common headaches are due to a bad bite.  Dr. Bill Dickerson at LVI Global claims there has not been 1 migraine sufferer he has not helped with Physiologic Dentistry, and this man has been doing this a LONG time!  

The next update, Part 3, I will discuss and illustrate exactly what treatment I did for Camryn that eliminated her headaches within the first month of treatment.  Longer-term expectations of treatment include an enlarged, more normal sized airway and reduction of cranial side bend strains and an improved forward, facial development of her profile.

Here is a peek at her BioPak EMGs 1 month into treatment.  You are correct, there are no longer BIG RED squiggles.

 

So what does that mean?  Take a look at her TMJ pain scale 1 month after starting treatment on the right compared to her ratings one month prior to starting treatment.  She wrote “85% improvement”.

I can tell you today… 4 months later, she has not had a single headache since September (3 months headache free) all thanks to Physiologic Dentistry Phase 1 orthotic therapy and Phase 2 Jaw Development Orthodontics with AGGA.

Stay tuned for Part 3- The actual treatment: Jaw Development Orthodontics with AGGA

Part 1: Camryn’s Growth and Development

A note from Louisville dentist Dr. Tracey Hughes: Thank you for reading my blog. Something you should know— this is a professional, yet VERY personal journey of how I became so passionate about Physiologic Dentistry, treatment of TMD, headaches and sleep apnea using Orthopedic Guided Jaw Development: AGGA (Anterior Guided Growth Appliance) and ControlledArch Protractive Orthodontics.

Professionally: I began my post-graduate dental education at the Las Vegas Institute for Advanced Dental Studies (LVI) 10 years ago learning more complex, comprehensive, cosmetic dental treatments designing beautiful smiles and helping patients suffering from TMD (temporomandibular joint dysfunction). I earned my fellowship at LVI, and for almost 10 years, I’ve helped many people live a headache free lifestyles using the skills and techniques I learned at LVI. I am very proud to have been invited to be an instructor at the prestigious Las Vegas Institute just last year in 2017. Now I share my passion and knowledge with other aspiring dentists beginning their journey as physiologic dentists.

Personally: My continued dental education took me in a very specific direction for the last 7 years as my daughter began to struggle with headaches at the young age of 7.

It is very difficult to see your child suffer from pain. I was highly motivated—determined really, to gain the knowledge I needed to help my own child, which has resulted in my ability to help many other patients suffering from the same issues.

My blog is being written from the perspective of a TMJ specialist as well as a nurturing mother…mama bear of sorts, driven to help her daughter thrive pain-free. My #1 reason for learning the physiologic orthodontic techniques was to help my own children. Ben’s story is more focused on airway than TMD symptoms.  More about my 15-year-old son’s case coming soon in another blog.

Learning is a journey…it takes both a time and financial investment. It wasn’t until this last year, all the pieces of the knowledge puzzle finally fit together. I learned what TMD was and how to treat it early in this journey, but this year, I learned the true cause of headaches and TMD (a bad bite, caused by an underdeveloped midface), and my educational journey came around full circle.

Believe it or not—it’s all about allergies and the tongue! I invite you to read my page on Growth and Development, but I think an easier way to understand this is to read my daughter’s story…

Meet beautiful big, blue-eyed Camryn, now 14…18 months old in this picture.

What I didn’t know at this time, was her open mouth breathing habit would potentially cause her a lifetime of suffering…migraine headaches, TMD and even possibly obstructive sleep apnea as an adult. Parents (and grandparents) there are early signs of airway issues and the biggie is Open Mouth Breathing. Observe your child. If they don’t have their lips sealed, or don’t have clear nasal patency, they need help now! Call and schedule your child for a growth and development consultation with me at Boulder Valley Dental.

But why was her mouth always open? Why was she always “sick” with a cold once a month…watery eyes, runny nose, sneezing? We, as parents, just thought she had colds from germs at daycare.

This is the look of an allergic child.

Poor baby couldn’t breathe through her nose because of her enlarged adenoids (due to allergens, most commonly cow’s milk, gluten and environmental). If a child’s adenoids are enlarged, they will not be able to breathe normally through their nose which is the primary mode of breathing. If they cannot breathe through their nose, they will have to compensate by mouth breathing. Mouth breathing is a secondary “emergency” mode of breathing. Our bodies compensate for survival.

Because she was always snotty and unable to breathe through her nose during her early years, Camryn’s tongue has been positioned incorrectly, low in her mouth, thrusting forward to open her little airway to allow her to breathe. After all, Oxygen is the #1 most important thing our body requires. The tongue, one of the strongest muscles in the body, exerts way more force than orthodontic brackets and wires and can move teeth and cause the jaws to develop inadequately and this is what causes a cascade of negative effects into adulthood.


During Camryn’s development, I didn’t have a clear understanding of allergies, tongue position and the effect on facial development. Were there things I could have done for her sooner? Yes. Am I going to beat myself up that I didn’t gain the knowledge sooner? No. Spoiler alert…she is doing very well today, and I will share her treatment story in the next blog.

I am, however, very passionate about helping your child/children achieve maximum forward face and dental arch development while they are still growing at age 3-10 to prevent the problems my daughter and the many adults I see suffering from TMD and headaches. I will be writing future blogs on establishing the full genetic potential for growth in children very soon.

Starting during infancy, the tongue should be positioned high in the palate (roof of the mouth) to act as a natural palatal expander. Because her tongue was lower in her mouth and had a functional tongue thrust, her upper jaw and midface did not fully develop, causing a higher palate and narrow dental arch.


Interesting Fact: Did you know, excess sclera display (seeing the whites of the eyes below the beautiful blue iris) is a sign of incomplete development of the midface, a result of the tongue not being in its proper position during development due to mouth breathing? It sure is! The bones of the midface below the eyes support the soft tissue of the eyelids. If the midface is underdeveloped, there will be no support for the eyelids, and they will drop, causing excess display of the whites of the eyes.

Our first effort to improve Camryn’s airway was age 8; allergy testing (which came back a false negative) and finding an ENT who would remove her adenoids and tonsils to open her airway.

Little did we know, after being told at age 8 she had no allergies, only that her skin was a little sensitive to the testing, that she actually WAS allergic….to everything. (more on this later)

Tonsillectomy and adenoidectomy was the next step in Camryn’s airway health, but her tongue had already developed an abnormal posture and function which began altering her facial and nasomaxillary growth, in turn, affecting her lower jaw position. Because her tongue was not in the proper position, high in the roof of her mouth, her upper jaw did not fully develop. The lower jaw compensated, having to retrude back, compressing her TMJs causing headaches and TMD symptoms.

The muscles memory of the tongue is incredible. Camryn is 3 months post-tonsillectomy and adenoidectomy but look at her tongue position while she is sleeping. Her tongue was trained the first 8 years of her life to thrust forward to allow her to breathe properly.

Myofunctional therapy was necessary to retrain Camryn to find her correct resting tongue position, high in the roof of her mouth, and to correct her improper tongue thrust swallow. We are still working on correcting her abnormal swallow pattern today as well as lip taping during sleep to retrain her resting lip posture.

Age 10, headaches continue…

Camryn’s tongue thrust caused her front teeth to “buck” out, so she started conventional braces to pull them back. What I didn’t know, at that time, that conventional, retractive orthodontics would make the situation worse. Retracting the upper jaw with traditional braces, shoved her lower jaw back, even more, compressing her TMJs and causing contracted temporalis muscles in her head, worsening her headaches.   Look how retracted her front teeth were. Imagine what her lower jaw had to do to function behind the upper front teeth.

Look how conventional braces tipped her front teeth back, making less room for her tongue, forcing it back into her airway.

And look how contracted her neck muscles had become as a result of her retruded bite, which caused forward head posture. Conventional, retractive orthodontics vs. physiologic, protractive orthodontics.

Age 13…. Migraine headaches with nausea began.

This year I attended LVI’s F2O Forward Face and Controlled Arch Orthodontics courses when I learned about the maxilla, one of the most important bones in the entire body! Stay tuned for Camryn’s diagnostic physiologic work-up, physiologic orthodontic treatment plan and the beginning of her headache-free life.

Stay Tuned For Part Two

This post is part one of a multi-blog series. We will be posting periodic updates as Camryn progresses in her journey to a headache free life! If you have any questions, please feel free to contact our team at Boulder Valley Dental Center in Louisville, CO. To contact us, call 303-214-4009 or request an appointment online.