Btw, special thanks to djspeece, Prometheus, Ali, and Nozzelnut for their helpful PM insights on the issue.
Before jumping in, I want to state the obvious that braces should be the domain of kids and only kids. I’m not a kid. Second, TMJ pain/disfunction/whatever mostly affects women, for whatever reason. I’m not one of those either. So, I’m currently 0-for-2. Those two issues should fall into the same categories as report cards and menopause, respectively, in terms of things that should be for others to worry about.
Nonetheless….
While I didn’t put it on this thread, my last post on the main forum asked for advice from anyone who had experienced TM joint pain toward the end of treatment and had it continue to get worse once they moved to retainers. That’s what was happening in my case during the last 6 mo before debonding (occasionally) and the first weeks after (more frequently). I initially assumed that the discomfort was caused by a move to heavier elastics, and maybe they were guiding or forcing my jaw into an unnatural position at night. It was only occasional, and I probably didn’t do a good enough job describing the issue, and I think I made the mistake of raising it with the assistant instead of my ortho. I don’t even remember at this point. I was told that your teeth undergo some natural settling after debonding, and those tiny, natural adjustments help the final occlusion. Ok, no worries then. It sounds like it might self-correct after settling.
Well, it didn’t. Instead, it continued to trend in the wrong direction starting a week or two after debonding. At the time, I thought it was likely caused by the Essix retainers and the two layers of plastic material adversely impacting my bite or jaw location. But the Essix were going to be temporary, so I thought I’d wait to see how the Hawleys went before getting nervous.
Everything else was great regarding the results. They did a nice job with straightening, rotating, crossbite, etc.
But one joint was feeling worse and worse. It wasn’t discomfort – it was pain. 
We moved from the Essix retainers to Hawleys and did some enamel tweaking to help with the settling. (Here comes the first PSA: “Stuff I learned”) Hawleys are supposed to allow for more vertical settling than an Essix, and sometimes grinding off a bit of enamel that’s interfering with the bite can also make a difference. Made sense to me. Also, the TM joint has a decent bit of tolerance, and if you’re anywhere within that acceptable range (most people are), there’s no problem. Even if your condyle is off a little bit, if everything is otherwise aligned and it doesn’t hurt you’d never know that one or both of your condyles are not exactly centered. But once you cross the line too far out of center, ouch! Sometimes a little settling and that enamel tweaking is all it takes to bring things back within tolerance. Sometimes, that’s not enough. (End PSA) It still hurt like heck and was getting more intense and building up to an every-day issue. To say that I was getting extremely worried that I’d opened a P@ndora’s B0x (really? spam block on this?) and would be dealing with this pain indefinitely would be an understatement. So, off to the next step.One of the fun diagnostics they do if you have the pleasure of getting to this stage is to take “facebow” measurements, (Part 2 of “Stuff I learned”) which involves this weird contraption that measures jaw angles and alignment. You’ll just have to google it because my description will never do justice. They use those angles and measurements to put your molds on an articulator (more new words for me) and draw whatever conclusions. What I can share with you is if you have a couple random kiddos in the chairs to either side when the ortho is using this facebow gizmo, you can feel the stares and mouths agape nearby and you couldn’t be more self-conscious if you were wearing a clown costume.
My inner monologue consisted of repeating one phrase: “Please, please, please just hurry up and finish!” If your ortho has a private consultation room, you might want to insist on using it for this thrilling experience. Anyway, it all led to having a splint made (I heard the terms “flat plane” and “occlusal” splint. Not sure if it’s the same thing). This was remarkably effective at temporarily reducing the pain,
but it’s really not practical during the workday. It’s a big hunk of acrylic and really impacts your speech. So, I’d wake up with some relief from the overnight use, but things would go downhill immediately from there. Besides helping with the pain, a flat splint is also intended to help the ortho diagnose whether there is a difference, and if so how much, between your condyles’ “centric relation” and “centric occlusion.” (You guessed it, more “Stuff I learned”). If I understand correctly, your centric relation is where your jaw lines up when the condyles are in the correct position in the joint (fossa), regardless of whether that’s your normal bite location. On the other hand, your centric occlusion is where your condyles are positioned in the joint when you bite down normally. Your brain memorizes this location as feeling like the best fit, regardless of whether it’s where the condyles should be. When your ortho asks you to bite together, what they see is your centric occlusion. Your centric relation can be a little hidden if they’re not specifically looking for it because your jaw muscles and any contact interference want to override it to go to your memorized centric occlusion position. Ideally, your condyles are in the same place in both centric relation and occlusion. If not, you get a shift when you bite. If the shift is too big, you have a problem.
The flat splint allows your jaw to slide around where it wants without any interference, guidance, or feedback from your teeth touching and, over time, find where your jaw naturally lines up best when it’s most relaxed and the condyles are allowed to properly center (centric relation) and the brain’s muscle memory isn’t overriding it. My ortho referred to it as allowing the jaw/bite to “reprogram” to it’s centered positioned. If there’s too much of a discrepancy between those two positions, you have the problem I described earlier about exceeding the joint’s tolerance when your condyle if forced too far out of its centered position when you bite. I’m sure my description and understanding isn’t perfect, but close enough. (End of PSAs. Fascinated yet? I didn’t think so.)
That exercise showed that when I’m centered my lower arch is built a little to the left overall and rotated a minute or two (the way I think of it) to the left of 12 o’clock relative to the maxilla. It was always there, but I guess when my bite was wonky and things didn’t fit correctly anyway, it was easy for my bite/brain to cheat one way or the other and stay within range and undetected (or at least unmentioned) by any of my four consultations. So, I really don’t fault my ortho. If you don’t have joint pain at a consultation, why would they go looking for the causes of joint pain? But it can screw up the best treatment plan if (when) it rears its head and starts causing problems. So, if it's not initially obvious there's a discrepancy, your ortho can ask you to bite together as many times as they want, but if your jaw automatically goes right to that pre-memorized location and there’s no pain, there’d be no reason to suspect an issue with condyle orientation. It’s the old “it’s not a problem until it’s a problem.” However, once the arches were coordinated toward the end of treatment, they fit perfectly in one – and only one – best position, as you’d expect. At that point there's was no way to subconsciously cheat on the bite position, and unfortunately that great fit forced a slight shift and rotation of my lower jaw I wasn’t even aware of. It didn’t become symptomatic until the shift to “best fit” started forcing the condyle too far to the back of the joint. Apparently there are nerves there (“Yeah, I already figured that out, Doc.”). Shockingly, you’re not supposed to press on those repeatedly. They don’t like it.
So, next came a choice: A) we try an interim step of using a few brackets (nothing obvious) and elastics at night to see if it would provide enough of a nudge to calm things down without requiring full braces to get the job done, or B) we assume that the amount of arch movement needed to prevent the condyle from being forced too far back will ultimately require braces anyway, and in that case just use braces from the start (also referred to as “the easiest solution” if you’re the ortho or, alternatively, “worse case scenario” if you’re the recipient). I jumped on A since I’d just been debonded and wasn’t keen on going right back into braces. My ortho estimated, however, that there was ~25% chance that going the A route would be enough without braces. Not great odds, but if he’s willing to try it, so am I if there’s any chance to avoid option B. At least he wasn’t trying to build false expectations.
We got to the point where the pain peaks weren’t as high – so that’s good – but it was still consistently painful and distracting, and then progress really slowed down. At the next few appointments, he’d gently suggest that braces would be more effective and try to gauge whether I was ready to throw in the towel. I wasn’t. After a few of those appointments, he said that things weren’t moving as much as he’d hoped and more discussion about braces being a better approach. I finally waved the white surrender flag. I think he was just patiently waiting me out until I capitulated so that I wouldn’t think he was rushing or pushing the braces option so soon after wrapping up the first round, which I guess I should start calling part one of a two-part treatment.
So, I’m back in the club for a while and just hoping that this works. He’s not charging anything extra, which I guess is his holiday gift to me, but I don’t ever want a Secret Santa like that again.
If you made it to the end of this post, you deserve some sort of prize! Hopefully this is helpful to someone out there. Happy holidays to everyone! No biting on candy canes this year I guess. Bah, humbug.
So, overall, I'm probably more lucky than unlucky with this. Also, I've seen so many posts that talk about not being able to ask questions or getting much information when they do. My guy makes time and seems to enjoy explaining what's going on. The only downside to that is I get all of this detail that becomes a "mother of all posts" assault on your attention span, like the one above.
