Treatment of Chronic Temporomandibular Joint Pain and Sleep Disordered Breathing by Teledontic and Telegnathic Protocol Utilizing Total Joint Replacement

Orthopedic clinicians frequently encounter patients with temporomandibular joint (TMJ) pain and associated sleep disordered breathing (SDB) that coexists with the patient’s orthopedic conditions. The systemic effects and associated comorbidities caused by TMJ and associated SDB are commonly not recognized as potential contributors to the patient’s long-term orthopedic outcome. This article describes a comprehensive and interdisciplinary medical dental treatment, which was able to successfully address patient’s severe chronic TMJ, head, neck and shoulder pain as well as other health concerns including SDB. Moreover, a new teledontic and telegnathic treatment protocol and principles utilizing total joint replacement for care of patients with chronic TMJ pain and SDB will be introduced describing a completed case.


Introduction
TMJ disorders (TMJD) as part of masticatory disorders (MD), most often but not always characterized by painful musculoskeletal signs and symptoms in the masticatory and associated structures in head, neck and shoulder area, estimated to affect approximately 5% to 15% of the population, predominantly women [1] [2] [3] [4].
Subjective sleep disturbance has been consistently reported in MD patients [4] [6] [7]. A recent investigation employing polysomnogram (PSG) recordings and clinical sleep interviews in a sample of MD cases showed that MD is associated with primary sleep disorders, such as insomnia and obstructive sleep apnea (OSA): nearly 36% of MD cases met diagnostic criteria for insomnia, and over 28% met criteria for OSA [8]. In the same sample of MD cases, sleep efficiency on PSG was directly related to a measure of pain threshold, suggesting an association between pain and sleep disturbance in MD [8]. Additionally, a high prevalence of MD was reported in clinical patients with mild to moderate OSA referred for a clinical dental evaluation, lending further support to the association between MD and OSA [9]. It was argued that a 28% rate of OSA diagnosis in a sample of MD patients composed mainly of young females with relatively low body mass index (BMI) lends support to the possibility of elevated risk of OSA in MD, requiring further evaluation in a large scale study [8].
Further, in this sample of MD cases, the mean apnea-hypopnea index (AHI) was only borderline at 5.1 events per hour [8] [10]. While the diagnosis of OSA in these participants was based on established criteria for scoring and interpreting the respiratory disturbance index (RDI) using standard laboratory PSG, which includes respiratory effort related arousals (RERAs) in addition to apneas and hypopneas [11] [12], the degree of sleep disordered breathing among MD cases who met the criteria for OSA was predominantly mild [8] [10].
Chronic TMJ, head, neck and shoulder pain can be a debilitating condition. On the other hand, SDB can be a life-threatening disease. Obstructive sleep apnea syndrome (OSAS) is considered a more severe form of SDB and can have profound systemic effects that can affect orthopedic outcomes such as neck and shoulder instability and pain. Since the OSAS has been recognized as a major public health problem, many efforts have been made to define and understand this syndrome [13].
Breathing abnormalities during sleep are not limited to patients exhibiting typical obstructive apnea but include a continuum of events from simple snoring to OSAS that constitute a group of diseases named SDB. The upper airway resistance syndrome (UARS) as mild form of SDB was initially reported by Guilleminault et al. in 1993 [14]. This particular syndrome has been described based on the hypothesis that repetitive increases in respiratory efforts that are inducing arousals known as RERA might produce a significant disease leading to daytime sleepiness and functional symptoms and are associated with cardiovascular and cognitive morbidities [14].
Many of the etiologies that contribute to these disorders are unrecognized by clinicians dealing with these patients and one can miss an opportunity to recognize and screen for potential reversible causes of these conditions. These recognizable etiologic factors involve oral, dental, temporomandibular joint, pharyngeal and facial bone structures, which are referenced hereinafter as pharyngorofacial disorders (POFD). Having a basic understanding of the POFD that can be at the root cause of TMJ and sleep breathing disorders may allow physicians to identify underlining structural and functional pathology that is having an unrecognized profound effect on the oral and systemic health. yrs. Severe sleep apnea (AHI ≥ 30) was present in 14% (95% CI 8.15% -21%) of females aged 55 -70 yrs and in 31% (95% CI 12% -50%) of obese females with a body mass index of ≥30 kg·m (−2) aged 55 -70 yrs [19]. Asian men with severe obstructive sleep apnea have less tendency to be obese, but may present with significant posterior airway restriction leading to OSA [20].
Besides obesity there are other abnormalities in anatomy and neuromuscular function of upper airway, which clinicians need to recognize that are more important risk factors [21] [22] [23]. POFD, including hypoplastic maxilla and mandible, is common findings in SDB including OSA as well as URAS and needs to be recognized by clinicians [18]. POFD and its effects on the systemic health continue to be underestimated in the development and severity of SDB [23] [24].
Orthopedic practitioners have great opportunity in screening for the presence of SDB and OSAS as a complex health conditions contributing in development of other systemic issues such as metabolic syndrome, obesity and musculoskeletal disorders [25].
Every pound of body weight places four to six pounds of pressure on each knee joint. Osteoarthritis (OA)-a progressive "wear and tear" disease of the joints-is frequently associated with obesity [26].
A narrowed upper airway often is typically a component of SDB and OSA which can lead to postural compensation [27]. Most of these patients will try to increase the airway patency by altering the craniocervical posture during the daytime activities or sleep [28]. The anterior head carry position can lead to a number of postural aberrations that can lead to effects in the upper cervical spine, lower cervical spine, shoulders as well as lumbar spine and pelvis ( Figure   1) [27]. The case presented in this paper demonstrates the effective participation of the orthopedic physician and dental practitioner equipped with teledontics and telegnathic knowledge as a member of an interdisciplinary dental/medical team collaborating in the treatment of SDB and chronic TMJ, head, neck and shoulder pain by treatment of POFD. This article also demonstrates the effectiveness of teledontics and telegnathic surgery utilizing total joint replacement procedure in the treatment of SDB [24].   There is some evidence suggesting that obstructive sleep apnea is associated with sleep bruxism. Thus, in patients with concomitant obstructive sleep apnea and sleep bruxism, most sleep bruxism events occurred after apnea-hypopnea events, suggesting that sleep bruxism events occurring close to apnea-hypopnea events is a secondary form of sleep bruxism [29] [30]. Further evidence suggest that myofascial pain in TMJ and POF disorders is associated with mild elevation in sleep fragmentation and increased frequency of RERA events [4].

Case Report
At meanwhile patient's husband was appointed to a new job in Pakistan. Based on these developments and possible lack of access to effective treatment after relocation including access to uninterrupted electricity for use of CPAP, patient requested treatment plan with more predictable results for reduction of accompanying symptoms including presence of chronic pain and excessive daytime sleepiness and fatigue.
The alternative treatment plan was proposed including the counterclockwise maxillomandibular advancement (CC-MMA) as teledontic/telegnathic protocol to correct the retrusive position of the maxillofacial components to improve the occlusion and facial skeletal discrepancies. Another anticipated goal was to improve the existing SDB by significant expansion of POF complex.
When orthodontic and orthognathic surgical procedures are used for the expansion and restoration of the POF complex for treatment of SDB and OSA, they are referred to as teledontics and telegnathic surgery [24] [31] [32]. This treatment protocol avoids the use of procedures and techniques, which can retract or constrict the jaws or dentition including; extraction of teeth, use of headgear or functional appliances that in long run impacting the upper airway negatively [33] [34].

Treatment Results
A balanced facial profile with improved chin protrusion was obtained ( Figure 5) but, most importantly, the patient reported a significantly improved level of alertness and absence of TMJ pain, headaches, neck and shoulder symptoms. Her spouse reported almost no disturbances during sleep, and the postsurgical polysomnography showed an AHI of 2.7 and RDI of 2.8 and lowest blood oxygen saturation of 93%, which is normal. A remarkable increase in the retropalatal, retroglossal, as well as hypoglossal airway spaces concomitant with maxillary and mandibular advancement was evident in pre and post-treatment cephalometric radiograph ( Figure 6).

Discussion
The most favorable care for patients with SDB is treatment provided by an interdisciplinary team that includes members from the appropriate dental and medical disciplines. Prescribed therapies might include weight loss, behavior modification, oral appliances, soft-tissue surgery, skeletal surgery, or some combination thereof [25] [37]. The field of dentistry and its involvement with the POF environment, provides the dental practitioner with an opportunity in screening for the presence of SDB and OSA as a complex health condition or participation in its treatment [24].
Teledontics and telegnathic treatment protocol is the science and technologies for diagnosis, prevention, management and treatment of SDB by means of expansion, restoration and maintenance of POF complex [24] [31] [32].   CC/MMA as teledontic/telegnathic protocol by expansion of the posterior nasopharyngeal opening also augment the nasal cavity. A nasal cavity volume increase should reduce the resistance to nasal airflow [38]. If the upper airway is considered a simple tube, as the radius of the tube increases, the resistance to flow decreases exponentially to the fourth power (resistance = 8 Lη/πr4) [39].
Therefore, even small increases in the diameter of the tube can dramatically decrease the resistance to nasal or pharyngeal air flow [39].
Nonsurgical approach including the retraction of the upper dentition would have addressed the orthodontic aspects of this patient's malocclusion. Although correction of the malocclusion was not stable in the past and only was one of the objectives of the treatment, overshadowed by SDB, as a more health threatening condition.
Constricting the dental arches and upper airway due to retraction of upper  [35]. This paper helps the readers to understand the interrelation of POFD including TMJD and development of SDB. Also, a comprehensive and interdisciplinary medical and dental treatment planning that was able to successfully address the patient's health issues including chronic TMJ as well as cervical pain and sleep disordered breathing.

Conclusions
Orthopedic specialist and subspecialty physicians commonly encounter patients with multiple orthopedic and chronic pains who also suffer from other comorbidities of SDB and OSA.
Physicians evaluating patients with TMJ pain, maxillofacial pain and cervical spine complaints as well as SDB and OSA should obtain a medical history that includes a basic dental history and sleep history to unmask possible POFD as a cause or contributing factor. Physicians can rapidly learn the basic screening tools necessary to identify possible POFD and make appropriate referrals to physicians and dentist with special training and expertise in teledontic dentistry and telegnathic surgery.
Physicians unaware of this link between previous dental and orthodontic treatment and the associated POFD that can arise from this treatment will miss an opportunity to identify contributing factors to the patient's clinical presentation.
There is a pandemic of SDB and OSA in both pediatric and adult population globally with a significant medical and socioeconomic impact. Physicians should be aware of an evolution of understanding in regard to impact of POF discrepancies that can play a critical role in the development of these conditions and its impact on systemic health of patients.
While oral surgeons are moving away from "orthognathic" to a "telegnathic" approach which reflects the forward positioning of the maxilla and mandible for the treatment of SDB, orthodontists with an understanding of a "teledontic" approach will be able to prevent and treat SDB in pediatric and adult patients by