Handling TMJ Problems in an Edentulous 88-Year-Old Patient: When Conventional Splints Are Not Straightforward

By Dr Samintharaj Kumar

One of the more intellectually challenging aspects of clinical dentistry is managing TMJ dysfunction in the fully edentulous elderly patient.

Today, I saw an 88-year-old Chinese gentleman in Singapore who came in suffering with significant left-sided TMJ pain, rating it 7 out of 10. He was accompanied by his son, who has been closely involved in helping him manage his day-to-day function at home.

At first glance, TMJ pain may seem straightforward. In many patients, our treatment pathway often includes occlusal stabilisation with a night guard or clear acrylic splint, alongside physiotherapy, behavioural modification, and muscle relaxation strategies.

However, this case reminded me why good clinical medicine and dentistry is rarely algorithmic.

The core challenge: no bite, no splint

This gentleman was completely edentulous and wearing complete dentures, with only limited prosthetic support available. The central dilemma was simple:

How do we reduce nocturnal TMJ loading when the patient has no natural occlusion to stabilise?

In dentate patients, a splint works because it provides:

• a stable occlusal platform

• posterior support

• redistribution of muscular forces

• reduction in parafunctional clenching

But in an edentulous patient, particularly one with severely resorbed maxillary and mandibular ridges, the usual splint approach becomes much more complex.

At 88 years old, and with the degree of ridge resorption present, options such as implant-retained prostheses or implant-supported occlusal rehabilitation were discussed but not considered ideal at this stage. The invasiveness, anatomical limitations, and burden of treatment must always be balanced against quality of life.

What we did today

Radiographically, there were chronic osteoarthritic changes of the left TMJ, but no acute pathology.

Given the severity of pain and the need for immediate relief, I decided on a conservative interventional approach:

• steroid injection into the left TMJ joint

• botulinum toxin to the left masseteric musculature

The rationale was to address both:

1. intra-articular inflammation, and

2. muscular hyperactivity from clenching and elevator muscle overuse

This is often particularly relevant in edentulous patients, where the loss of vertical support may paradoxically increase parafunctional muscle contraction during sleep.

The gratifying moment

What made this case memorable was the immediate response.

By the time the patient had walked to the reception area—within 5 to 10 minutes of treatment—he smiled and told us that the pain was already improving.

Moments like this are deeply rewarding, especially in elderly patients who have often been suffering silently.

What happens if symptoms persist?

The challenge, of course, is not just short-term pain relief but sustainable nocturnal control.

If he does not demonstrate a significant improvement over the coming week, the next stage of management may include:

• a clear acrylic splint fabricated over the denture concept

• physiotherapy

• shockwave therapy

• PRP or regenerative biologic injections

• reassessment of denture vertical dimension and posterior support

In edentulous TMJ patients, sometimes the real issue is not the joint alone, but the loss of stable vertical dimension during sleep, leading to over-recruitment of the masseters and temporalis muscles.

A broader reflection

This case is a reminder that TMJ disorders in elderly edentulous patients require us to think beyond the textbook splint.

Sometimes the answer lies in:

• reducing inflammation

• reducing muscle force

• improving prosthetic support

• preserving comfort rather than pursuing aggressive rehabilitation

At this age, our role is not simply to “treat the TMJ”, but to restore comfort, sleep, dignity, and function with the least burden possible.

We will review him again in one week, reassess his symptoms, and decide whether he needs to progress into more definitive supportive therapy.

Cases like this continue to remind me that the art of dentistry lies in adapting principles to the patient in front of us, rather than forcing the patient into a protocol.