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Comprehensive ENT practice including pediatrics (tubes & tonsils), sinus surgery, sleep apnea surgery, throat surgery, facial skin cancer excision and reconstruction, and cosmetic facial surgery.
Prolotherapy was first described in the scientific literature in 1937 for the treatment of TMJ disorders. Temporomandibular joint disorders, commonly known as TMJD or TMD, are endemic in the American population. Headache is the most common TMD symptom.3 The temporalis muscle is thickest immediately behind the orbit and contracts each time the teeth are brought together. Facial pain is a common result of tension or trigger point development in the masseter muscles that extend from the zygomatic arch (“cheekbone”) to the lower and posterior border of the jaw. Temporomandibular joint (TMJ) pain is an obvious sign of TMD but is usually found on palpation, rather than a chief complaint. Restricted jaw movement, irregular jaw movement, and TMJ sounds such as clicking, popping, or crepitation are obvious symptoms of TMD, but patients may mask these symptoms. Otalgia and tinnitus are reported by as many as 65 percent of TMJ sufferers4, due to the close proximity of the external auditory meatus to the TMJ and to tension on structures such as the discomallear and malleomandibular ligaments.5 However, patients with ear symptoms rarely perceive a connection between their ear symptoms and symptoms of TMD. Firm bilateral palpation of temporalis muscles in the anterior, middle, and posterior segments. Firm bilateral palpation of the masseter muscles at their zygomatic origins, at their mid-bellies, and at their insertions on the mandible. Light palpation over both TMJs during maximal opening and closing to detect joint noises and irregularity in movement. Firm palpation with the small fingers in the patient’s ears as the patient opens and closes the mouth.
Parafunctional jaw habits, such as chewing pencils or fingernails or excessive gum chewing, can aggravate TMD.
Effective treatment of all but the most minor cases of TMD requires some understanding of the joint anatomy and function. The TMJ fossa (“glenoid fossa”) is located in the temporal bone, immediately anterior to the ear.
The anterior slope of the glenoid fossa is thick and capable of supporting masticatory pressure on the condyle. Since the disc is not adherent to either the condyle or fossa, it can be displaced by various factors including trauma. Disc displacement is often in the anterior or anteromedial direction with reciprocal posterior displacement of the mandibular condyle into the retrodiscal tissues, adjacent to the external auditory meatus. After an unpredictable period of jaw clicking on opening, the ligaments may become so injured and lax that the disc remains out of place, obstructing the condyle and limiting jaw movement. TMJ surgery is indicated only in cases with no other practical alternative and is generally considered as a last resort.
Physical therapy by a practitioner knowledgeable about TMJ anatomy and function can be very helpful, but such improvement tends to be limited and short-term if the intracapsular TMJ structures cannot be aligned and stabilized. Occlusal orthotics that are worn over the teeth 24 hours a day and have an occlusal surface that realigns the condyles and discs within their fossae can be very effective, but not all patients are willing or able to wear such appliances on a full-time basis. The first published article on Prolotherapy, short for “proliferation injection therapy” and now also known as regenerative injection therapy (RIT), focused on treating the TMJ.14 As readers of this journal undoubtedly know, the basic principle of Prolotherapy is to inject a substance that will cause a low-grade inflammatory process within the joint, drawing in fibroblasts that strengthen the attachments of tendons and ligaments.
Since TMJ disc displacement usually is anterior, our priority is to accomplish repair of the extended or torn posterior disc attachment.
The second target is the anterior disc attachment, where the disc connects to the superior portion of the lateral pterygoid muscle.
Most TMD patients have some chronic masseter tension and pain with resultant strain on its attachment to the zygomatic arch. The injection sites are wiped with alcohol, which removes the washable ink as well, and a pulse is taken for the medical record and to confirm that the patient has relaxed and is ready for discharge.
Our standard program is to repeat the injections three times, at two-week, four-week, and six-week intervals. At the one-inch depth of needle penetration, the areas described above have no major blood vessels and intravascular injections are not a significant risk with this technique, especially if aspiration is performed before each injection. A series of four Prolotherapy appointments was carried out over twelve weeks, as previously described above. A series of Prolotherapy appointments was carried out as described above but only to the left TMJ and masseter muscle.
Case #3 is a 23-year-old male who presented with audible and palpable clicking in the left TMJ, accompanied by pain that he rated at 3-4 on a scale of 5. Chart review of the most recent 30 patients treated with Prolotherapy demonstrates significant therapeutic benefit. All of these patients in this audit received Prolotherapy injections in the affected joints and ipsilateral masseter muscle origins at four separate appointments over an average of 14.2 weeks. In our office, Prolotherapy is used most often for patients who have been refractory to treatment with an intraoral orthosis, physical therapy, dietary restrictions, and home care. Please call Ear Nose & Throat Surgical Associates at (920) 734-7181 to schedule an appointment in Appleton, WI or to get more information. Schaefer II, MD is a Board Certified Otolaryngologist who received both his medical and residency training at the Medical College of Wisconsin a€“ Milwaukee.
Vandenberg, MD is a Board Certified Otolaryngologist who received both his medical and residency training at the University of Wisconsin-Madison. Bettag, MD is a Board Certified Otolaryngologist who completed his medical training at the Chicago Medical School and his residency at the University of Missouri.
McAvoy, DO is a Board-Certified Otolaryngologist who joined the Ear, Nose and Throat Surgical Associates team of physicians in August 2009. This article describes basic TMJ anatomy and the common components of TMJ dysfunction (TMD). Tension or spasm in the temporalis muscle frequently is the cause of temple-area headaches and headaches that feel like a piercing pain in the back of the eye. The masseter muscles are the primary elevators of the jaw when eating and bring the teeth into contact before the temporalis muscles contract. TMD sufferers quickly learn that chewing certain types of food is painful, and modify their diets so as to minimize frank joint pain.
Eating only soft foods and limiting mouth opening by taking only small bites can prevent noticeable joint noise. Such patients often go through repeated courses of antibiotics for suspected ear infections and may have had extensive ear imaging before being referred for a TMJ evaluation. Stethoscopes are of a specific length to optimize detection of heart sounds, rarely pick up significant TMJ sounds, and can lead to false negative conclusions. The tympanic plate of bone between the ear and the TMJ fossa is very thin, almost to the point of being transparent when observed surgically.
The mandibular condyle normally is separated from this part of the fossa by the fibrous (not cartilaginous) disc, which moves with the condyle during all jaw movements. Schematic representation of normal TMJ.The disc (gray) maintains alignment between the articular slope and eminence (A) and the condyle (C).
Low-grade, long-term trauma such as a significant malocclusion can thin the margins of the disc and cause it to lose stability. This MRI shows a distorted disc (between arrows) that is displaced anteriorly and inferiorly to the condyle. The disc has displaced anteriorly and become distorted.The condyle is beginning to remodel and develop a “beak” on its anterior surface.


This joint condition is commonly referred to as “closed lock.” The joint becomes quieter at this point but the posteriorly displaced condyle may eventually perforate the retrodiscal tissues, resulting in bone-on-bone contact and degenerative condylar changes.
Such appliances protect the teeth but do not necessarily realign the displaced structures within the TMJ. No fully functional total TMJ replacement joint is available and synthetic TMJ discs were removed from the market in 1991. The process stabilizes the joint, improves the range of motion in a hypomobile joint, helps prevent dislocation in a hypermobile joint, and relieves pain. While we work extensively with intraoral orthoses, physical therapy, home exercises, and dietary restrictions, not all patients respond optimally. We locate the posterior joint space by cleansing the skin immediately anterior to the ear with alcohol and palpating the lateral pole of the condyle as the patient opens and closes.
Angle and depth for injection of posterior joint space with a one-inch needle, behind the translated condyle and into the depth of the fossa. Also, an alternative local anesthetic must be used in patients who are allergic to lidocaine. Some authorities have stated that the lumen of a 30-gauge needle is too small to admit red blood cells, but clinical experience in injecting other, more vascular areas has shown that blood can easily be drawn up through this small needle. Her original chief complaints included temporalis-area headaches one to two times per week, bilateral facial pain that was worse on the left side, and bilateral TMJ clicking. On follow-up 11 weeks later, her mandibular range of motion remained good and her maximum mandibular protrusion had increased from five millimeters to 10 millimeters. She had TMJ clicking for several years and her jaw became locked four months prior to her initial examination at our clinic. By the fourth visit, maximum opening had improved to 38 millimeters and lateral and protrusive range of movement had improved as well. Treatment alternatives were presented and treatment with an intraoral orthosis to be worn full-time for four to six months was recommended. At 12-week recall, 43 joints (78%) had substantial improvement in clicking (no longer detectable by clinical palpation and perceptible only as reported by the patient) and 32 had completely quit clicking (no clicking perceptible by palpation or by patient report).
Our clinical results in our office indicate that Prolotherapy can be very effective, even in these difficult patients. This technique continues to demonstrate its safety and effectiveness, even in patients who do not respond adequately to other forms of nonsurgical therapy.
Otologic symptoms of temporomandibular disorder and effect of orofacial myofunctional therapy. Anatomical and functional aspects of ligaments beween the malleus and the temporomandibular joint.
Effects of jaw clenching while wearing an occlusal splint on awareness of tiredness, bite force, and EEG power spectrum.
Surgical treatment of internal derangement of the temporomandibular joint: long-term evaluation of three techniques.
Diagnostic methods used to identify TMD are listed and the technique for injecting the TMJ is detailed. Such faulty posture combined with the unbalanced weight of the head, often ten to fifteen pounds, places a heavy load on the posterior cervical muscles, where many migraines begin. TMD-related jaw misalignment often results in parafunction of the masseters, with pain extending over the lower half of the face.
Conversely, some TMD sufferers often discover that it feels better to keep something such as chewing gum between their teeth, minimizing compression of painful structures within the TMJs. Also, patients with minor joint sounds may not perceive these noises to be abnormal unless the noise is accompanied by pain. If palpation does not provide definitive results such as clicking or crepitation, closer examination with either an obstetric or vascular Doppler may be helpful. Encouraging the patient to discontinue non-functional jaw activities and work on stress reduction may provide some benefit, especially in cases with smooth joint function and only minor facial muscle pain;6 however, jaw parafunction and stress have never been proven to cause internal TMJ derangement. This thin plate of bone is not suited to bearing any significant load and, in a healthy joint, the mandibular condyle remains a few millimeters anterior to it, even during forceful chewing.
This disc is loosely attached and remains properly positioned between the condyle and fossa due to its biconcave shape that closely adapts to the convexity of the condyle and the eminence, and by peripheral ligaments that normally limit its movement. The condyle remains well-separated from the external auditory meatus (EAM) with no significant pressure on the retrodiscal tissues (R).
Direct trauma such as a blow to the jaw can cause joint misalignment and disc displacement.
Reciprocally, the condyle is displaced posteriorly into the retrodiscal tissues adjacent to the external auditory meatus. Even if alignment is achieved overnight, leaving the appliance out during the day allows joint misalignment during waking hours and the degenerative process within the joint may continue.
Some patients are reluctant or unable to wear an intraoral appliance full-time because such appliances can interfere with speech.
Injecting the Prolotherapy solution here can strengthen the tendinous attachment of this muscle to the disc at the same time the anesthetic component anesthetizes and elongates the muscle, which can allow the disc to reposition itself over the condyle and often produces an immediate reduction in TMJ clicking. We palpate the masseter attachment along the inferior border of the zygomatic arch at the same time that we palpate and mark the posterior and anterior aspects of the condyle, and mark the area of the masseter that is most tender to palpation. We palpate the joints for pain and noise, and palpate the affected muscles for pain, at each appointment. On rare occasion, the local anesthetic will diffuse forward and partially paralyze the lower eyelid.
Symptoms were not known to be related to any particular incident or injury and had been present for about four years prior to her initial examination in our office.
The patient reported that she was feeling much better as her facial pain and TMJ clicking had dissipated.
Chief complaints include limited ROM and throbbing pain in the left TMJ, which had begun spreading over her lower face and into both temples. Headache and facial pain had resolved and no significant tenderness was reported on palpation of the left TMJ or temporalis or masseter muscles. The patient declined this treatment plan as he worked as a professional model and was concerned that wearing a dental appliance would adversely affect his facial appearance.
All clicking was easily palpable and reported pain on firm preauricular palpation of these joints averaged a level of 2.8 on a scale of 5, and these signs and symptoms had persisted despite at least 5 months of treatment with an intraoral orthosis, home exercises, and dietary restrictions. The palpation pain report had improved to a level of 1 or less on a scale of 5, in 39 joints (71%), and had reached a level of zero in 23 joints (42%). We speculate that Prolotherapy success would be even greater when used in milder cases of TMD but we do not yet have the statistics to support this hypothesis. Schaefer has been practicing medicine in the Appleton area since 1995 and is currently accepting new patients.
Vandenberg has been practicing ENT medicine in Appleton since 1998 and is currently accepting new patients. Bettag has been practicing Ear, Nose and Throat medicine in Appleton since 2002 and is currently accepting new patients.
McAvoy completed his residency training in Otolaryngology and Facial Plastic Surgery at Henry Ford Macomb Hospital-Warren Campus where he served as Chief Resident.
She completed her Bachelors of Science degree in Communicative Disorders in 2006 Cum Laude. Without a physical examination that includes TMJ palpation, TMD diagnosis is easily missed.


The retrodiscal tissues are uncompressed and the retrodiscal ligaments stabilize the posterior aspect of the disc. So-called “indirect trauma” involving violent acceleration and deceleration of the head and jaw has been shown to damage the restraining ligaments and allow disc displacement and misalignment of the joint. This means that many teachers, salespeople, receptionists, and others who speak for a living are reluctant to wear an orthosis during the day, or simply refuse to do so. We also use a dextrose solution whenever possible, as it causes less post-injection soreness than fish oil or pumice, and pumice is difficult to express through a 30-gauge needle. We locate this target area at the same time we palpate the location of the posterior joint space, note the location of the slight depression just anterior to the condyle when the mouth is closed, and mark this point with washable ink.
Asking the patient to clench the teeth makes the masseter stand out, and the area that is most rigid to palpation is usually the most tender as well.
When this happens, it is immediately apparent and the patient is told to make a conscious effort to blink that eye frequently for the next hour or so, until the anesthetic effect diminishes, to lubricate the eye and prevent a corneal abrasion. Her maximum opening at the initial exam was about half of normal at only 29 millimeters with deflection of her jaw to the left on opening.
He opted for Prolotherapy, which was done at four separate appointments over a 12-week interval. It should be noted that these patients were essentially refractory to such typical nonsurgical care. None of these patients had any significant bruising, and only one had an event of paresis of the lower eyelid, which lasted approximately 90 minutes. Continued research into Prolotherapy effectiveness in patient populations with varying histories, symptom sets, and levels of TMD severity is needed. His goal is to provide excellent medical and surgical care to all of his patients, treating them as he would any family member.
He enjoys all aspects of Otolaryngology, with a particular interest in pediatrics and allergy, as well as thyroid and sinus conditions.
He obtained his Doctor of Osteopathic Medicine degree in 2004 from the Kirksville College of Osteopathic Medicine. In her spare time, Nicole enjoys gardening, boating and watching sports events with her family. She is a member of the American Speech-Language-Hearing Association (ASHA) and American Academy of Audiology. A clinical survey of 30 patients treated with Prolotherapy is presented and documents the effectiveness of TMJ Prolotherapy, even in cases refractive to conventional treatment with an intraoral orthosis, physical therapy, home exercises, and dietary restrictions.
Physical or mental handicaps can prevent some patients from being able to care for, or function with, an intraoral appliance. Compounding pharmacies can provide pre-mixed solutions, but we mix our solutions directly in the syringe. Marking this point before injecting the posterior aspect of the joint is advisable, as it becomes much more difficult to palpate this depression after the posterior joint recess has been injected. The patient is told to relax the jaw, and the final mL is injected directly into this area, again at or near the full one-inch length of the needle. Patients typically report some improvement after the first injection appointment but often have some increased discomfort shortly before the second appointment.
Fair-skinned patients may display some minor bruising for a day or two but this is more common if the operator has difficulty locating landmarks and moves the needle laterally after insertion.
She was treated with a home care program, therapy, and wore an intraoral orthosis for four months with some success.
Mild intermittent clicking was palpable in the left TMJ but the patient reported that this was steadily diminishing. Use of an intraoral orthosis along with home care and physical therapy over three months produced only minor improvement with myalgia and slight improvement in range of movement. Prior to medical school, he was involved in research at several major universities and the National Institutes of Health. Her doctorate of Audiology was earned through Pennsylvania College of Optometry-School of Audiology. Some disc displacements are so severe that an intraoral appliance cannot reasonably be made to the dimensions necessary to recapture the discs. The injection needle penetrates the skin at the marked point and is directed medially and slightly anteriorly to avoid penetration into the ear.
For this injection, the bite block is removed and the patient is instructed to close gently, moving the condyle back into the fossa.
The following appointments generally produce more benefit, quieter joints, and symptom relief without rebound.
The most significant improvement was reduction of her headaches, but TMJ clicking indicative of persistent disc displacement, and intermittent facial pain remained. Schaefer enjoys time spent with his wife and two children as well as sailing, skiing, hunting and painting. Vandenberg enjoys spending time with his family and participating in a variety of activities such as hiking, biking, swimming, basketball and golf. Bettag resides in the Appleton area with his wife and four children and enjoys photography, fishing and music.
McAvoy grew up in Neenah, and enjoys spending time with his wife, Leah, daughter Meghan, and son Ian. Some patients with particularly lax or damaged ligaments experience pain relief while wearing the orthosis, but pain and joint noise returns as soon as the appliance is removed.
Using a 25-gauge needle to draw up the solutions speeds the process, then the needle is changed to 30-gauge and the syringe is shaken and the air expressed. Surface skin and connective tissue is deceptively thick in this location and the needle usually penetrates to, or nearly to, its full one-inch length before encountering the medial wall of the fossa. We insert the needle at the marked point, again directing the tip medially and angulated slightly anteriorly to, or nearly to, its full one-inch length. We expect the healing process to continue for at least twelve more weeks and schedule a final recall three months out.
Until the 2mL of injection solutions dissipates from the joint, which may take one to four days, the condyle will rest lower in the fossa and the posterior teeth may not fully occlude.
Borgen is trained to diagnose and treat hearing loss in patients of all ages; her goal is to educate those patients and their families on hearing loss and its effects on their relationships. In her free time, she enjoys cooking, snowshoeing with her husband, leisure reading, spending time with family and friends, and watching sporting events. Slight negative pressure is exerted on the plunger to confirm that the needle tip is not in a vessel, even though no vessels of any size are expected to be encountered within the fossa. It is important to warn the patient that this is likely, and to be careful to chew food carefully and thoroughly before swallowing.
The precise concentration of dextrose is not critical so long as it is strongly hypertonic and causes adequate cell wall lysis to attract fibroblasts and begin the regenerative process. She enjoys spending time with her two children, community involvement, reading, kick boxing, skiing, hiking and scrap booking.



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