The Orthopedic TMJ Blueprint: Custom Joints, Airway Collapse, and 3D Red Flags

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Hey, welcome to Dental Digest. I'm your host, Dr. Melissa Seibert. This is a podcast with a mission of enabling you to stay on the cutting edge of evidence-based dentistry. This is part two of our two-part series. In case you missed last week's episode, I highly recommend you also listen to that. Joining me again today is Dr. Scott Boulding, an oral maxillofacial surgeon known for his pioneering work in TMJ reconstruction, ligament repair, and custom total joint prosthetics. His orthopedic-driven diagnostic approach, particularly his use of MRI, has helped redefine contemporary standards for TMJ management and surgical decision making. In this episode, we dive into the modern orthopedic framework for TMJ surgery, including how ligament injury leads to disc displacement and how MRI findings guide treatment. We also examine degenerative joint disease, radiographic red flags, when total joint replacement becomes indicated, and why unaddressed joint pathology often undermines orthodontic and orthognathic outcomes.

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Why do you think that we've been so dismissive as a medical community as a whole with the TM joint? Of course, physicians, this is really outside their wheelhouse that they're comfortable with, and us as dentists, I really feel like we play hot potato with TM joint patients where we really do this thing called punting where nobody really knows. So I'm not really referring you to a colleague that I feel very confident can manage this. I just want you out of my office. Why do you think that is? Do you think it's just really up until very recently? It's not that we didn't have the technology to evaluate it. I mean, MRIs have been around for quite a while. Where did this originate from? I think it's just very interesting because again, if a patient had an ACL tear, we wouldn't tell them to go to yoga and not chew gum, but that's what we oftentimes tell our TM joint patients.

Dr. Scott Boulding: That's a great question, and it has to do with some history. Melissa, I think you saw my lecture in San Antonio. So if you look back and you look at the TMJ and you look, say, in the 1900s up into the 2000s, we were seeing progression in terms of management. Occlusal management for the joint started in about the 1940s with Dr. Costen. Actually, he was an ENT, an otolaryngologist, which was very interesting. It was followed by some other physicians, and we started occlusal therapy really in the 50s and 60s. We started looking at splints and doing things to try to unload the joint, and we found that this gave some patients relief, not only in the joint, but some of the muscle pain that they were having as well. Then we started seeing the surgeries in the 70s and 80s. But remember, the MRI for the TMJ really didn't come out until the mid-80s. So the first MRI of the TMJ was probably mid to late 80s. It was a gentleman out of Baylor, Steve Harms, who actually did the first MRI of the TMJ. He's a friend of mine. Those first MRIs were very grainy. They weren't very, very good, but they've gotten a lot better.

But something else happened in the 80s that was disastrous for us as dentists, and that was in the 80s. There was a material created by Dow Corning. It was a disc replacement device called Proplast Teflon. Proplast Teflon was a material approved by the FDA on some falsified research, and this material caused severe breakdown in the TMJ. Remember, in the 80s, we didn't have managed care. We just had insurance, and so the insurance company would basically send physicians checks for whatever their bill was. We don't see that today at all.

Dr. Seibert: Wouldn't that be great, though?

Dr. Boulding: It would be, but that's gone. It's not going to happen again. It's not coming back. But so when we started having these problems, and we started, I mean, these were serious problems. They would have erosions into the middle cranial fossa, severe giant cell reactions, pain, swelling, and the surgeons would go in and try to take this material out, and they couldn't get it out because it granulated. So these patients had very, very chronic problems. The insurance industry stopped covering TMJ completely across the board in the United States. But when the medical insurance stopped covering TMJ, all of a sudden, surgeons stopped doing it. Patients now had to pay out of pocket if they needed it, but it pretty much became taboo. And then there was a consensus paper that came out of NIH because of basically the egg that the FDA had on their face from approving this all falsified research. And the consensus paper came out and said surgery at last resort, surgery at last resort. And some of these patients have more mental problems than they do physical problems, so you just need to treat it from a psychological standpoint.

And then we've had dentists that were doing the surgery stop doing the surgery. Then we had medical dental schools stop teaching really surgical procedures, stop training residents in surgery. And then all we had was occlusal management, but we really didn't know what we were doing because MRIs were not really in vogue at that time. And we've had probably 30 to 40 years behind. In the meantime, the orthopedic surgeons, which we were probably equal to them in that time frame, kept going and developing the techniques that they had with total joints and knee repairs. And we got left behind because we had such small numbers of surgeons paying attention to this joint. Therefore, dentists really don't get taught a lot about TMJ. You had your Gelbs and your Dawsons and your Pankey Institutes and your myelomonitoring folks, the people that were treating it, but that was all non-surgical management. And without an MRI or really good diagnosis, they were treating everyone the same. It was either a muscle problem or an occlusal problem. It could not be a surgical problem. And so I think that's a little bit of why we are where we're at today.

What we're trying to push for is more of an orthopedic approach, okay? Most of the problems can be treated by primary care dentists. Anti-inflammatories, occlusal issues, bite issues, muscle issues, that can be addressed non-surgically. And that follows the standard of care that they use with orthopedics. But if you have a tear or an anatomical problem that can't be resolved by those issues, then surgery should be considered. I do think though that we as dentists and comprehensive dentists need better training and better access to that training because we don't necessarily want the surgeon to be the only person managing it. We need someone that can help quarterback things and identify what are the medical means to treat it. And my concern is that there's this small bastion of professionals that understand management of the TMJ. Some of them are orthognathic surgeons such as yourself. Some of them are oral facial pain specialists. And then we have a few GPs that have an advanced understanding of it, people like Jim McKee. But GPs and comprehensive dentists need a better understanding so we can better quarterback these cases and help patients either medically manage it or know who the right person is to get them to.

Dr. Boulding: I totally agree, Melissa. And I think there needs to be more effort on a consensus effort on how we evaluate and manage these patients. And that's non-surgical and surgical. And I think the worst thing we can do is do what you talked about at the beginning of the talk and that's ignore them or push them off to somewhere else. Because we as healthcare providers owe it to our patients to understand that joint. I had a physician in the lounge after one of my surgeries ask me, he said, how can dentists ignore this TMJ so much? Because everything they do works around that joint. And so to your point, I think we need to have better diagnostic lectures, education on what we're really looking for. And there's some good data out there, there's good material, but many dentists just really don't focus on how Pete Dawson taught us as a general dentist, if you have really good joint stability, your restorations last forever.

Many of my patients come in and they will say to me, my dentist caused my TMJ problem. And it's interesting when they say that, but they had really, maybe they got along or they had a popping and clicking, they really didn't ignore it. But then one day they replaced a crown and all of a sudden the crown, after they had the crown, the patient started having TMJ symptoms. So remember our patients adapt. And so there's an old saying in the profession, you leave the TMJ alone long enough, it'll get better, right? Well, once you create anatomical situations where you get a perforation in the ligament and you start getting bone to bone, bone to bone really doesn't hurt, but you start getting some collapse of the condyle, the teeth start hitting heavier, your wear, so you orthodontically move teeth as things shift because your occlusion is heavier. And so these patients that adapt, what will happen is you change the occlusion and then all of a sudden you change the load distribution in the joint and you made them symptomatic. You didn't really cause their problem as the dentist, you just help them recognize that there's a problem. Because the dentists, we have so many dentists that are not even paying attention to the joint and we need better education around that area.

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You know, it's interesting the colleague that said that dentists are oftentimes ignoring it. It's not so much though that dentists are volitionally ignoring it. It's also, as you mentioned, the culture and the messaging surrounding it. So as a profession, we're hearing the messaging that after a while it's going to get better, avoid surgery at all costs, and then there's very sort of poor foundational understanding of it. Of course, we're going to try to do everything that we can to overlook it. And hopefully, people like you are part of changing that messaging. But as a culture, a dental professional, it's time for a change.

Dr. Scott Boulding: I agree 100%. I think in the medical profession, the less we understand something, and you could describe this to other disciplines beyond medicine, but the less we understand things, the more we start to break up into factions. And you see that in occlusion. And I think that's reflective of our general lack of consensus understanding, even lack of consensus recommendations where people begin to fit into camps. And they'll say, well, Dawson teaches X, other person teaches Y, et cetera, et cetera. And then therefore, that is gospel law, and that is what I believe. But I think that's really reflective of our general lack of understanding. You know, I agree, Melissa. And, you know, if you look at the medical community and the way they treat patients, and they're referred within the various specialties, they're more data-driven. They're more data-driven and follow more of a data process, even though there are camps in the medical community, so don't think there aren't. But within us, we tend to follow what our latest CE guy told us. And, you know, it's almost like our politics in the United States today, but we really need to be careful, especially when we're starting to look at airway, and we're starting to look at joints. And, you know, I was a good friend of Pete Dawson's, and the older Pete got before he passed away, the more he started understanding other guys' philosophies as well. And when you look at it, at the end of the day, we're all trying to do the same thing. We're trying to make the patient healthier. And so as soon as I think I've got something figured out, I was telling a group of physicians this today, as soon as I think I've got something figured out, and it's my way or the highway, that's usually when I'm wrong. So I think it's as dentists, it's important that we understand that we need to follow the data, be very careful, and listen to a lot of different thoughts and develop your own philosophy with what works with you. But we also need to pay attention to our physician colleagues. And remember, we're probably, especially now that we understand airway, we're just as important as any other specialty in medicine.

Dr. Melissa Seibert: What are your thoughts and what is your conviction on total joint replacement? Earlier this summer, we were at a meeting, several orthognathic surgeons, and you can really see across the board, there are different sentiments around that. Some view it as almost a little destructive and preemptive. Others would say that they're very comfortable frequently doing it.

Dr. Scott Boulding: So let's follow the orthopedic literature, right? Let's follow the orthopedic model. And what we've looked at in joint surgery over the years is, did we have something that could replace the anatomy itself? Well, in the early 80s, when we had this Proplast-Teflon, it was a disaster. But as a result of this Proplast-Teflon, several surgeons and one of my mentors started working on an artificial joint, similar to what they did with hips and knees. So they followed the orthopedic literature to a T, worked with the FDA very closely. And now the joint systems that we have on the market in the United States have a database of about 36 years of data. The TMJ total joint has been a tremendous workhorse for the last 36 years. We're not seeing that the total joint needs to be replaced like hips and knees after 15 to 20 years. The patients that have destructive joint disease, severe degenerative arthritis with tissues that are not repairable, the discs are not repairable, the ligaments are not repairable, or they've had total resorption or lack of condylar height and fossa. Those patients do very, very well with total joints. There's two joints on the market in the United States. There's a stock joint and there's also an artificial custom joint.

I tend to use the custom joint just because we many times with these patients remember if they've lost condylar height, that means their mandible has repositioned posteriorly and affected the airway. So almost every single patient that I see that has degenerative arthritis and loss of condylar height needs advancement of their mandible. It's hard to do that with a stock joint. So with the custom joints, we can actually advance the mandible and plan where we want the airway and have the joints made specifically to that position. So I'm a big fan of total joint prosthesis for the patient that needs it. If we are not able to repair the structures inside the joint, then I would proceed to a total joint. There's a faction out there of guys that don't really like to do total joints or don't recommend total joints. And that's okay. And I'm friends with those guys. We still talk. What they have found, which is really interesting, is the patients, if they do jaw surgery on these joints or don't operate on the joints, to try to keep the joints stable, they need two things. One is a very stable occlusion and make sure that they stay as stable as possible. And the second thing is they'll put them on a regimen of medications that the patients really need to take for life to try to prevent any further condylar resorption. The key is trauma because once you have degenerative arthritis, the joint has no reparative capabilities because the cartilage cells are gone and all you're going to have is osteoclastic and osteoblastic activity at the level. So obviously what they eat has to be careful. They have to be careful. Their occlusion needs to be as perfect as possible and protective. And these medications also help the joint prevent from resorption and keep the inflammation down. And there's also compliance with these medications with time.

Every year, I'll redo about 12 to 20 orthodontic surgeries. And most of the orthodontic surgeries that I have to redo, they're not my cases. They've usually been done somewhere across the United States. Almost every one of them is patients that have needed joint surgery or needed the joint addressed. And the joint was the breakdown problem and why they ended up having to have their orthodontic surgery redone. There's some surgeons that really do a great job by not doing the joint. So I think if you select those patients well, and it's not a huge airway advancement, then that's okay. Not go without a total joint if that's what you want. But my patients generally would receive an artificial joint because I think it's going to give them more predictability long-term. And it's something that they don't have to take medications for the rest of their life.

Dr. Melissa Seibert: Can you just speak about the radiographic findings you might find that would indicate that there's degenerative arthritis? Because that's something very important to catch. And my fear is it's so often overlooked.

Dr. Scott Boulding: 100%. So if you simply, obviously with your dental x-rays, you can't see the joint. So there's, it has to be at minimum a Panorex. But a Panorex is a very challenging screening tool. But looking in the mouth will give you some indications. If you just see significant teeth wear, you need to look at the joints. If you see significant crowding or changes in the occlusal patterns, you need to look at the joints. And looking at the joints with the Panorex will give you a screening. The CBCT really is the best tool because you can actually look into the joint. A lot of the CBCTs go below the condyle. So you've got to make sure you position the patient in the CBCT so that you can get the joints and fully view them. But so the CBCT is really the best way. And what you'll see typically, and you need to look at the anterior view, anterior posterior view, as well as the lateral view. In the AP view, you can see flattening of the lateral pole. You can see changes where you don't see the harmony of the circle across the head of the condyle. You see disruption of the head of the condyle. Severe degeneration, you can start, you can see cysts, you can see irregularities, you can see osteophytes and sharp areas of bone. You also want to look at the fossa. And many times when you see lateral displacement, you'll start seeing a groove on the articular eminence, where you'll see some wear of the ligament coming across that bone. On a lateral view, on the Panorex, sometimes if you see beaking, just a little condylar beaking, and usually that starts on the lateral pole because of the way the lateral pterygoid muscle pulls. But you'll start seeing some condylar changes there. But obviously the CBCT is the gold standard.

The other thing you want to look at is joint space. So, both in the AP view and the lateral view, if you have very minimal to no joint space between the condyle and the base of the skull, then you truly may have some degenerative changes there, or at least have a displaced disc and it's not in position and have ligament damage. In the AP view, you can often see maybe joint space on the medial pole, but no joint space on the lateral pole. And that may be indicative that you may have a lateral ligament damage, medial displacement of the disc or herniation medially.

Dr. Melissa Seibert: Well, this has been amazing. I actually wrote you 10 different questions that we never even got a chance to get to. So that is the hallmark of a great conversation. Do you have any closing remarks? This hour flew by.

Dr. Scott Boulding: Melissa, I just want to commend you for what you're doing and trying to educate the dental community. And we have a great profession. As dentists, we went into the healthcare profession for a variety of reasons, but I think for the most part, most of us went into it to make a difference in people's lives. And it's not just about teeth. And I think as dentists, we need to start understanding that, that it's about the human behind that. It's the jaws, it's the airway, it's the heart, it's everything else that goes along with it. And the dental community, and I think many of my medical colleagues support this now as well. It's much more important than we probably ever thought. And the medical community doesn't get a real good education in dentistry. And so it's up to us to really hold the profession to that high standard. It's not about how many crowns you can do, how many fillings you can do, or how many surgeries you can do, etc. It's about making our patients optimally healthy. And I think with what you're doing with this podcast, teaching dentists around the world how to look at patients maybe a little differently is awesome. And I'm just proud to be a part of the conversation.

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