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A new dental laboratory in Sydney is contributing to the rapid growth of specialist dental provider TMJ Clinics while offering hope to patients suffering from temporomandibular joint dysfunction. By Cameron Cooper
At a time when many dental laboratories in the western world are shutting their doors, two surgeons are bucking the trend.
Associate Professor Dylan Hyam and fellow surgeon Dr Sam Kim are co-founders of TMJ Clinics, a national provider of treatments for temporomandibular joint (TMJ) dysfunction. They have set up a dedicated laboratory to ensure the supply of high-quality dental appliances for their clinics across the country. The lab, unveiled in North Sydney early this year, features 3D printing and 5-axis milling as part of the manufacture of specially designed dental splints.
TMJ disorder, which is now affecting a wider demographic after once being seen as primarily a disease afflicting women, can cause severe pain in the jaw joint and the muscles that control jaw movement. The pain typically stems from factors such as stress-related bruxism (or teeth clenching), jaw injuries, and conditions that occur along with TMJ disorder, including fibromyalgia and osteoarthritis.
Although TMJ Clinics has had strong relationships with Australian dental laboratories in the past, A/Prof Hyam and Dr Kim have made the leap of faith to run their own facility.
“Our main business through the lab is making splints for patients, and we didn’t want to outsource our principal product,” A/Prof Hyam explains. “From a quality control point of view, from a timeframe point of view, from an intellectual property point of view, it just made sense to have control internally.”
He is confident the lab will make a difference for TMJ Clinics’ patients, noting that China’s growing domination of dental product manufacture has created some supply challenges for dental practices in Australia. “We are prepared to invest in a lab at a time when people are closing Australian labs so that we have business sustainability.”
Joining forces
Dr Kim, the most experienced TMJ surgeon in the country, supervises the clinical side of the work at TMJ Clinics, and A/Prof Hyam manages the business. Treatments offered span physiotherapy, medical treatments, medication, splints, dry needling and acupuncture, plus keyhole and open-joint surgery.
After starting his career as a dentist in the Australian Army, A/Prof Hyam took up his first residency post at Westmead Hospital in Sydney before later going to medical school. Additional maxillofacial training in Sydney and the UK schooled him in the management of head and neck cancer, orthognathic surgery and complex bone-grafting procedures.
Now settled in Canberra, the move to establish TMJ Clinics with Dr Kim came after observing the rising need for TMJ treatments, which commonly include physical therapy, medication and, as a last resort, surgery.
Never in a million years did I think I’d be doing this. But I love the vitality of it. There’s always something to do and somewhere to grow. You tick off a task and the next one becomes apparent within a millisecond.
A/Prof Dylan Hyam, co-founder, TMJ Clinics
Dr Kim discovered maxillofacial surgery and then TMJ surgery as a young medical resident before completing a dentistry degree to become a maxillofacial surgeon. He is now a regular international speaker.
“Demand for such services is definitely increasing,” says A/Prof Hyam, who suggests that anywhere from 12 per cent to 30 per cent of people will experience TMJ pain at some stage in their life. “People are more health aware than ever before, and they don’t really accept living with pain.”
The first clinic opened in Canberra in 2017, and TMJ Clinics has since added clinics in Melbourne, Brisbane and Adelaide, plus North Sydney, Bankstown, Kogarah, Norwest and Newcastle in NSW. The group has about 50 staff across the network.
Hi-tech production line
The North Sydney lab will make about 2000 dental splints a year for its own clinics, with no plans at this stage to supply external clients.
Splints protect the jaw joint from arthritic change and relieve jaw joint pain. A/Prof Hyam estimates that a specially designed TMJ Clinics splint can reduce the peak force to the TMJ by up to 35 per cent, compared with 15 per cent for generic splints.
TMJ Clinics uses relatively rare ‘non-permissive’ splints, which means they have indents on both sides of the appliance—a crucial factor in positioning the TMJ in a neutral position and reducing the load that goes through the patient’s joint.
A focus on digital technology has also been advantageous, allowing the technicians to make or remake splints easily, as well as helping to ensure the patient has a retruded bite position. This refers to the alignment of the jaws whereby the mandible (lower jaw) is positioned as far back as it can comfortably go in relation to the maxilla (upper jaw) while the teeth are in contact. “This allows the deloading of the joint,” A/Prof Hyam explains. “It’s wonderful because it reduces the forces through the joint by more than double.”
TMJ Clinics’ lab also plans to develop a new orthodontic splint for people wearing braces who experience TMJ pain.
But one challenge has been sourcing cost-effective splint blanks, the prefabricated discs or sheets of material that are molded over a dental model.
The lab uses a five-axis mill to make polymethyl-methacrylate (PMMA) splints, and it then prints models using an Asiga or Formlabs 3D printer.
“There’s a bit of a learning curve just in terms of setting tolerances and manufacturing standards for newer digital software,” A/Prof Hyam says. “We use Exocad software for that.”
Skills to the fore
On the personnel side, TMJ Clinics has recruited an experienced dental technician and a biomedical engineer to work in the lab.
All splint manufacturing for now is done out of the North Sydney lab, but the hope is that each clinic will one day have its own printers so that patients can get same-day splints.
“That’s probably a little way away for us, but in time we could have a central lab along with clinic-located mills so that the lab can do the design and then send it to a clinic in another state to be milled,” A/Prof Hyam says.
He and Dr Kim both hope the success of TMJ Clinics can help expand knowledge and technical excellence relating to TMJ disorders, an area in which required medical skills can include expertise in everything from craniofacial and orofacial pain to rheumatology and sleep disorders.
As the TMJ Clinics lab technician team grows, the emphasis will be on honing skills across analogue and digital technologies.
The impact of AI
With an eye to the future, there is an expectation that AI will help TMJ Clinics and other providers deliver better TMJ treatments. Nevertheless, the pair do not think AI will replace clinicians. “We see AI working as a co-pilot for clinicians so that it assists in their decision-making, but we don’t see it completely replacing humans because there’s always a human factor to every patient,” A/Prof Hyam says.
The immediate strengths of AI are likely to be around the accuracy of patient diagnosis and improvements with treatment planning. On a practical, time-saving level at TMJ Clinics, A/Prof Hyam expects AI to assist with the rapid assessment of comprehensive patient questionnaires. “We’ll be able to tell what problems they have before they even get in the door, but being able to customise the treatment and explain the treatment really requires human input.”
As he reflects on TMJ Clinics’ success in the past eight years, A/Prof Hyam says splitting his work between maxillofacial surgery and TMJ treatments has come as a surprise. “Never in a million years did I think I’d be doing this. But I love the vitality of it. There’s always something to do and somewhere to grow. You tick off a task and the next one becomes apparent within a millisecond.”
