Fixpoint

There aren't enough nudes on this blog, wouldn't you agree?

Let's start with the visual, then, looking through skin and soft tissue all the way through to the bone, in panoramic exposure with a probably-harmless dose of Roentgen rays to penetrate the subject:

That's me with my full complement of 32 adult teeth, largely happy and healthy in their somewhat quirky array of shapes and sizes, but nonetheless making up an overall system that's not quite so happy nor healthy.

For historical perspective, here's that same shot from my eighteenth year, the summer of 2008:

It's awkwardly digitized using a home scanner from a somewhat degraded film, but that notwithstanding, the imaging tech has clearly improved quite a bit since the Kodak days. Either that, or they just zapped me with extra radiation this time to get the better detail.

Since I went digging in the archives, here's some color from that same summer, messing about in boats with the old(er) man on the Maine coast:

Back then, the hometown dentist was trying to sell me on removal of some or all wisdom teeth (third molars), especially the impacted lower right one. Supposedly the human masticatory apparatus has this implementation flaw whereby we grow more teeth than can comfortably fit in our jawbones, a problem to be solved by experts with fancy drills and glorified pliers. But I wasn't hearing it, chiefly because those teeth weren't causing me any actual problem at the time. Sure, some day they might, and the solutions indicated then might be more difficult, painful or costly than merely extracting the teeth today. But how are we to know, really? The extraction itself may be a common enough procedure, but no surgery is without risk. What if I got an infection, or they damaged some unrelated nerve? Heck, even routine dental cleanings often leave me with a split lip. I figured, I'm too young to be dealing with that shit if I don't have to. They didn't have statistics to offer me on either side of the decision; it seemed like it was just what they were programmed to recommend because it's what the textbooks said and so nobody could blame them. So I declined; and I don't really have any regrets there, it was the right decision based on what I could figure out with a reasonable effort at the time.

So what changed in the intervening 16 years? The upper two wisdom teeth came out fully exposed; they don't do anything functional and they're a bit harder to clean, yes; they stick out a bit to the outside and there were some years where my right cheek tended to get bit painfully while chewing, but that seems to have subsided as my motor routines were gradually retrained by the feedback. The lower two remained largely as they were, fully beneath the gums. However, the rest of the teeth moved to some degree. What's most easily visible is the lower incisors, from their relatively neat lineup after my teenage braces, now crowded in a front-to-back staggered pattern. Also various molars do not mesh properly ("malocclusion of the jaw"), the Panamanian dentist now tells me.

Where the tooth alignment or lack thereof becomes more than cosmetic is in how it's affected my temporomandibular joint (TMJ). For several years now - I can't think when it started, since all of this has been such a gradual development - I've had clicking, popping or grinding feelings where the jawbone meets the skull, always on the right side. It's not particularly painful (yet), but it certainly doesn't feel good.

It presumably contributed that I stopped using my nighttime retainers.⁽ⁱ⁾ The pressure from the wisdom teeth presumably also contributed. The braces themselves may have contributed.⁽ⁱⁱ⁾ Perhaps there were other factors too, or just bad luck.

The confession here is that I've known about this problem and avoided confronting it, or even really mentioning it to anyone who might be able to do something about it.⁽ⁱⁱⁱ⁾ It wasn't from laziness, but rather some deep inner resistance, perhaps unwillingness to accept the reality, to truly admit my loss, whatever that might be.

Moreover, it wasn't strength of will that finally brought me around; rather it was external pressure that forced it, in that the discomfort got worse in recent months, to the point of becoming impossible to ignore. That was enlightening as well as humbling, I'd say, regarding man's capacity and inclination to improve his condition.

Boy, was I a sight. I had all the information lined up; I'd researched online, learned about TMJ anatomy and how the bite can be the root cause of these problems; I had phone numbers for multiple dental clinics that people had offered me, to try as many as needed until I got my answers. And I decided no more delaying, I'm acting TODAY to schedule a first consultation. But there I sat, and stood, and paced the room, and lay on the bed, for upwards of an hour, phone in hand but unable to dial. Ostensibly a grown man, but variously occupied staring down or else hiding from the unseen monster, regressing to childhood. So I decided to at least accept the feelings I was having, to let them play out and let all the objections be heard. What if they only speak Spanish? What if my mouth is all dry and I can't talk? How do I pick which number to start with? What if they can't see me RIGHT NOW!? What if they can't help anyway? What if they make it worse? What if in my irrational state I lose my skepticism and let them take advantage of me?

With the fountain of unhelpful fears thus exhausted, I was finally unblocked and made the call. Or tried to, but found my cell carrier out of service, as they're wont to go at the most inconvenient moments; just perfect. Fortunately the signal came right back. As it happened, I communicated the general issue just fine and got an appointment made for the next day, all in Spanish. I thought the call indeed started a bit awkwardly, but the receptionist sounded friendly and I ended up calm and smiling. Later as I unwound and the tension released, there came the urge to cry, so I indulged that as well, alone and quietly, in the intensity that's struck on really only a few memorable occasions in my adult life.

Clearing the psychological blockage may well be the biggest step here; of course in this case it doesn't by itself solve anything. Let's return, then, to the current X-ray. Follow the mandible to its outer, upper ends, the knob or "hinge pin" called the condyle on either side. On the patient's left (image right), it has a cleanly defined border, with a clear gap to the adjoining bone of the temporal fossa, presumably occupied by the cartilaginous disk or meniscus which grants the jaw its smooth sliding abilities. On the patient's right, it's not entirely clear what's going on but it's certainly different. The bone sort of fades away instead of having a crisp inner edge, and the gap looks smaller.

Given that I hadn't been in any fist fights lately, the dentist's interpretation was that darker area of the faded edge constitutes bone lost from the condyle due to striking against other bone over the years. He predicted the cusps and pits of my molars would be misaligned, and confirmed this upon looking. ("It's a disaster!") The idea is that the nervous system does what it can to adapt to what it's given, and since it can't change the teeth, it compensates - in chewing, while sleeping and otherwise - more or less automatically by moving the jaw around, in a search to minimize the "trigger points" where teeth collide and keep them as well closed as possible. This sometimes manifests as grinding teeth at night (bruxism). In my case I take it that my jaw has "learned" to adopt a resting position that pulls back and to the right, bringing the bones closer than they belong and sometimes popping out the disk.

I need to do something to stop the progression, because in the worst case, even with unlimited funds there is currently no successful surgery to artificially recreate a TMJ; it's one of the most complex joints in the body, with its great freedom of movement: left to right, front to back, pivoting for small openings and sliding entirely out for wide openings. Treatment options, then, involve mechanically addressing the problems of the bite. The simplest is a night guard, which fits over the upper teeth to relieve the trigger points and create more space between the teeth and thus hopefully within the joint. But he told me the wisdom teeth had to go and I would need orthodontics (braces again). I'm especially unhappy about that last part, especially since he said he prefers the traditional brackets and wires over Invisalign (or equivalent: a computer-generated series of removable transparent aligners) which seems to me the far less brutal option and worth every extra penny. So I'll be looking for further opinions and meanwhile went with the night guard. I learned that it fits quite snugly to the teeth, so won't be usable anymore if I do go with braces, but it gave me something much cheaper and more acceptable to try in the short term.

So far I like it a lot! It's taken some getting used to - I didn't sleep well the first night and I could really feel that "search" process as the old muscle memory no longer worked - but it makes it far more comfortable to hold my jaw in a more forward position (the lower incisors rest on the plastic so their force is distributed evenly rather than concentrated on the one or two big upper incisors) and at the same time more difficult for it to slide backward (the material over the right third molar in particular gets in the way there). I'm wearing it during the day too when I can - it's not too noticeable and I can talk fine - and when I remove it to eat, I feel how poorly the teeth fit, the discomfort that I'd been numb to. The popping in the jaw is not gone and I still have to chew carefully, but it is already much reduced.

With all the painless steps taken, I gave it some time for the sake of pacing and budgeting, but next up is the wisdom tooth extractions and they're scheduled for next Monday, July 15th. They're bringing in a specialist in maxillofacial surgery - fancy me! Except I'm having some last doubts about it. The exposed upper wisdom teeth have some cavities, perhaps making yet another argument to do it. But even if it's harder to work on teeth so far back, perhaps the cavities could still be filled less invasively. I don't think those teeth ever got the same sealants that the rest of the molars did, so maybe doing that could prevent the cavities from recurring (I never in my life had them until recently). My old objection that the teeth weren't causing any problem is no longer quite true; except the causal link is still indirect and non-obvious. This guy seems to know what he's talking about, at least more than some, but that doesn't mean he has the final word on TMJ issues which I gather are not widely understood even among dentists. For instance, I learned elsewhere that another option is a "splint" which is like a night guard but more finely tuned.

Maybe I'm worrying too much about this. ("Worry HERE!") It's the problems we don't consider at all that usually bite the hardest, right? I've prepared myself in mind, funds and schedule for the procedure and recovery. I'd hate to cancel if it's only to put off something that needs to be done anyway, and I don't really expect to hear something different from another dentist, unless I basically go looking until I find the one who says what I want to hear, at which point what would it mean anyway? I've talked to some friends and family and heard varying stories - most have had the teeth out - but ultimately they can't decide for me. This article makes for the last of that effort: if you, reader, have something to say on the subject, please do, and soon!

1. After maybe ten years of mostly obediently wearing them, the mineralization buildup got kind of nasty and made cleaning harder, and besides I was fed up with it, dragging this magic item around everywhere throughout my life like a security blanket. I felt I'd done my share, and if my teeth weren't stable by then, what was the point of it all anyway? Pretty sure they didn't communicate to me during the initial sale of the braces this aspect where "our products will now be a permanent fixture in your mouth". [^]
2. For one thing, I had soreness in my jaw when opening wide for some time after having the braces removed, which I attributed to these horrid asymmetrical rubber bands they used near the end of the treatment. This contributed to an aversion to dentistry in general since they always want you to hold it open as wide as possible. For another thing, the original primary reason for the braces was overbite, meaning my upper front teeth were pulled inwards, which perhaps improved things in some ways but changed the way they had naturally grown to fit together. But I didn't rock the boat and confront anyone about it at the time, so by now I don't have all that clear information on it. I don't have any 3D representation of how the teeth were after treatment; they gave me a cast model of how they started out but that was lost from a back closet shelf somewhere along the way. [^]
3. I did mention it, once to a dental hygienist and once to a general physician; they didn't really take it seriously or have anything intelligent to say about it. In particular the physician suggested trying jaw exercisers, which I went as far as ordering, but before starting decided it would be a horrible idea without knowing more about what was going on. Maybe I hadn't been clear enough with them that this was a real problem here, and I had to be more insistent; but in any case I wasn't going to trust them with more of my time on it; they had their chance to be curious and delve, and missed it. [^]