TEMPOROMANDIBULAR DISORDERS

Terminology
Temporomandibular disorders (TMD) are a collection of pathologic and functional conditions affecting the temporomandibular joint (TMJ) and the muscles of mastication as well as contiguous tissue components.

 1934 james costen group of symptom centered around the tmj . Called it as the costen syndrome 1959: shore introduced the term temporomandibular joint dysfunction syndrome. Bell suggested temporomandibular disorders which became popular. This term does not suggest merely problems that are isolated to the joint but includes all disturbances associated with the function of the masticatory system. The ADA began to use tmd to include all functional disturbance of the masticatory system.

Development of functional disturbances in the masticatory system

Ocassionaly some kind of events interrupt normal functioning of the masticatory system. Many of these events are tolerated by the system with no consequence, therefore no clinical effect is seen . However if it exceeds the physiological tolerance limit , then disturbance sets in.

Etiology of TMD
Etiology of TMD is multifactorial OCCLUSAL CONDITION TRAUMA EMOTIONAL STRESS DEEP PAIN INPUT PARAFUNCTIONAL ACTIVITIES
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Occlusion
FUNCTIONAL OCCLUSION: AN OCCLUSION THAT IS IN HARMONY WITH THE JOINT AND ASSOCIATED MUSCULATURE.

ROTH S CRITERIA FOR FUNCTIONAL OCCLUSION: MUTUALLY PROTECTED OCCLUSION.

Teeth in maximum intercuspation when the condyle is in a ideal position. In occlusion forces should be transmitted through the long axis of the posterior teeth. When posteriors occlude an inter occlusal space of 0.0005 inch should be present in the anterior region. Minimal overjet and sufficient overbite to allow disocclusion of the posteriors in lateral movements. Occlusal patterns such as cusp position, cusp height and fossa depth, ridge and groove positions should be in harmony with the joint movements.

OCCCLUSAL CONSIDERATIONS
Occlusal factor in causing tmd- Strongly debated Orthopedic stability = stable icp of teeth + ms position of the condyles in the fossa

Functional forces can be applied to the teeth and joints without tissue injury

Neuromuscular Adaptation
ACCEPTABLE NEUROMUSCULAR ADAPTATION OR CR CO DISCREPANCY: 1. 1 mm Antero posterior 2. 1mm Vertical 3. Less than 0.5mm transverse - According to Utt and Wong.

Joint instability
Degree of orthopedic instablity Orthopedic instabilty of 1 to 2mm not significant enough to cause a problem As the discrepancy between the ms position and icp increases greater risk of intra capsular disorders The amount of loading Bruxism patients with orthopedic instablity Presents higher risk than non bruxers with the same degree of orthopedic instability

Intracapsular disorder

Occlusal interference affect muscle symptoms

Occlusal inteference
acute chronic

precipitate a protective response- protective co contraction

Alteration of the muscle engrams Tooth movement to accommodate the heavy loading. Muscle engrams cannot adapt continued muscle co contraction

This may induce muscle symptoms

Trauma
A force that exceeds the normal functional loading of the joint can lead to injury of the affected structures
Macro trauma Microtrauma

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Macrotrauma
Macrotrauma is a sudden force to the joint that causes structural alterations. Causes: Injury or trauma and Iatrogenic. Changes:

Macrotrauma
Dislocation or fracture of the disc Loosening of the ligaments due to elongation

Haemarthrosis, bruising & laceration

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Microtrauma
Microtrauma is any small force to joint structures that occur repeatedly over a long period.
Static loading.

Impact loading. Frictional movement.

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Microtrauma
Static Loading: Stationary application of excessive pressure.
Bruxism / Emotional stress / Hard chewing Loss of occlusal molar support Force transmitted to the joint rather than maxilla Deformation of disc - deepening of central bearing area Roughening of articular surfaces Perforation of the disc
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Microtrauma
Impact loading: occurs during the stage of maximum intercuspation when a displaced condyle unduly compresses an anchored disc. Cause: Occlusal disharmony CR-CO discrepancy. Loss of disc contour. Loss of self centering capability of the disc. anteromedial pull on the disc thinning of the posterior disc border and subsequent elongation of the inferior retrodiscal lamina

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Microtrauma
Frictional movement: Occurs due to overloaded movement that exceeds the ability of weeping lubrication to prevent damage to the articular surfaces from friction. Cause: Gross functional disharmony when the teeth are clenched. Eg: Class II Div II malocclusions. Remodeling of articular eminence. Loss of disc contour. Elongation of disc collateral ligaments.

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Systemic factors
Presence of collagen and other connective tissue disorders predisposes to TMD.

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Emotional stress
Stress- activates hypothalamus increased activity of gamma efferent It sensitizes the spindel such that even slight stretching of the muscles will cause reflex contraction Increased tonicity of muscles

Pathogenesis of TMD

Changes in the Muscles Changes in the Joint

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Changes in the Muscles

EMOTIONAL STRESS BRUXISM PREMATURE CONTACT ALTERED RESTING POSITION OF MANDIBLE ALTERATION IN SENSORY OR PROPRIOCEPTIVE INPUT TO THE CNS

MUSCLE SPLINTING

MYOSPASM
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Changes in the joint

MICROTRAUMA THINNING OF DISCAL LIGAMENTS FUNCTIONAL DISPLACEMENT OF THE DISC

SINGLE CLICK RECIPROCAL CLICK FUNCTIONAL DISLOCATION WITH REDUCTION (OPEN LOCK) FUNCTIONAL DISLOCATION WITHOUT REDUCTION (CLOSED LOCK)
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HISTORY AND CLINICAL EXAMINATION

Chief complaint (may be more than one) A. Location of pain B. Onset of pain 1. Associated with other factors 2. Progression C . Characteristics of pain 1.Quality of pain 2.Behavior of pain a.Temporal b.Duration 3.Intensity of pain 4.Concomitant symptoms 5.Flow of the pain D. Aggravating and alleviating factors 1.Function and parafunciion 2.Physical modalities 3.Medications 4.Emotional stress 5.Sleep disturbances E. Past consultations and/or treatments F. Relationship to other pain complaints Medical history Review of systems Psychologic assessment

Clinical examination Ear examination:

70% of the patient with tmj pain also complain of ear discomfort . Some pt may not have tmj pain but the ear pain is radiating out The dentists role is merely to rule out ear disease with otologic examination.

Cervical examination:
Cervicospinal pain and dysfunction can be refered to the masticatory apparatus Therefore screening examination for craniocervical disorders should be done

Muscle examination
Muscle palpation To determine muscle tenderness .Healthy muscle does not elicit tenderness or pain when palpated. Degree of discomfort should be evaluated. 0- no pain 1-uncomfortable 2-definite discomfort or pain 3- evasive action,eye tearing. Check for trigger points.

Specific examination of muscles

Temporalis Anterior region: palpated above the zygomatic arch and anterior to the tmj . Fibres in this region are essentially vertical Middle region: directly above the tmj and superior to the zygomatic arch. Fibers in this region run in an oblique direction. Posterior region: above and behind the ear . Fibres run in a horizontal direction Palpation of tendon: some tmd may cause temporalis tendonitis . It is palpated by placing the finger of one hand intraorally on the anterior border of the ramus and finger of the other hand extarorally on the same area.

Masseter: It is palpated bilaterally at its superior and inferior attachments. Superior : finger placed on each zygomatic arch and then dropped down slightly to the part where the massater is attached to the zygomatic arch just anterior to the joint . Inferior: inferior border of the ramus

Sternocleidomastoid muscle: It does not function directly in the moving mandible. But pain in the scm can be reffered to tmj. Palpation done near its insertion on the outer surface of the mastoid fossa behind the ear down to its origin near the clavicle.

Functional manipulation
Three muscles that are basic to jaw movements but impossible or nearly impossible to palpate are
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(1) the inferior lateral pterygoid (2) superior lateral pterygoid (3) medial pterygoid.

Functional manipulation of the inferior lateral pterygoid

Contraction: When the inferior lateral pterygoid contracts, the mandible is protruded, the mouth is opened, or both. Functional manipulation is best accomplished by having the patient make a protrusive movement, because this muscle is the primary protruding muscle. Therefore the most effective manipulation is to have the patient protrude against resistance provided by the examiner If the inferior lateral pterygoid is the source of pain, this activity will increase the pain

Stretching. The inferior lateral pterygoid stretches when the teeth are in maximum intercuspation. Therefore if it is the source of pain when the teeth are clenched, the pain will increase. When a tongue blade is placed between the posterior teeth, the intercuspal position (ICP) cannot be reached; therefore the inferior lateral pterygoid does not stretch. Consequently biting on a separator does not increase the pain but may even decrease or eliminate it.

Superior lateral pterygoid

Contraction. The superior lateral pterygoid contracts with the elevatormuscles(i.e.,temporalis,masseter,medialpterygoid), especially during a power stroke (i.e., clenching). Therefore if it is the source of pain, clenching will increase the pain. If a tongue blade is placed between the posterior teeth bilaterally and the patient clenches on the separator, pain again increases with contraction of the superior lateral pterygoid. These observations are exactly the same as for the elevator muscles. Stretching is needed to enable superior lateral pterygoid pain to be distinguished from elevator pain.

Stretching-As with the inferior lateral pterygoid, stretching of the superior lateral pterygoid occurs at maximum intercuspation. Therefore stretching and contracting of this muscle occur during the same activity clenching. If the superior lateral pterygoid is the source of pain, clenching will increase it. Superior lateral pterygoid pain can be differentiated from elevator pain by having the patient open widely. This will stretch the elevator muscles but not the superior lateral pterygoid. If opening elicits no pain, then the pain of clenching is from the superior lateral pterygoid.

Medial pterygoid
Contraction: The medial pterygoid is an elevator muscle and therefore contracts as the teeth are coming together. If it is the source of pain, clenching the teeth together will increase the pain. When a tongue blade is placed between the posterior teeth and the patient clenches against it, the pain is still increased because the elevators are still contracting Stretching: The medial pterygoid also stretches when the mouth is opened widely. Therefore if it is the source of pain, opening the mouth wide will increase pain.

Intracapsular disorders: can be another source of pain causing confusion with muscle pain. Here the pain in increased due to movement of inflamed tissues across opposite surfaces. In this case the patient is asked to bite on a separator on the side of pain and then asked to protrude

Maximum interincisal distance

Normal range- 53-58 mm Less than 40 mm- reasonable point to designate restriction.

Functional examination
Deviated mouth opening Deviation always occurs towards the side of decreased mobility. Condylar hyperplasia is an exception.

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Functional examination
Path of the mandible on opening

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Functional examination

TOWARDS LEFT

TOWARDS RIGHT

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Joint examination
Signs and symptoms of pain and dysfunction Joint pain- digital palpation. Finger tips placed on the lateral poles of the condyle applying medial force. Palpated in static and opening and closing positions. At maximum opening . Fingers are to be rotated to posterior aspect of condyle

Joint sounds
Click: A single noise of short duration that occurs at any point in the active range of mandibular motion. Crepitus: A grating or gravelly noise caused by degenerative changes in the articular joint surfaces. A loud popping noise or thud at the end of mouth opening indicative of joint hyper mobility when the disc condyle complex moves over the articular eminence.

EXAMINATION OF THE DENTITION

MOBILITY WIDENING OF THE PDL SPACE OSTEOSCLEROSIS HYPERCEMENTOSIS PULPITIS TOOTH WEAR PREMATURE OCCLUSAL CONTACTS

Radiographic examination

Transcranial Radiographs
Transcranial radiography (TR) used extensively as a diagnostic aid for TMDs partly caused by the technique's simplicity and the wide availability of the required equipment. Historically, transcranial radiographs have been used to evaluate the status of joint hard tissue and the spatial relationship of the condyle to the fossa. The angulation in the horizontal plane, set at 15, which positions the central beam parallel with the average horizontal condylar angulation. However, condylar angulation is highly variable (the standard technique is predisposed to errors if individual condylar angulation varies 5 or more from the 15 average setting.

The TR image represents a profile view of the lateral third of the joint because the central and medial portions of the joint are projected inferiorly onto the condylar neck by the vertical angulation of the X-ray beam This may be an advantage when looking for osseous lesions

The angulation in the vertical plane avoids superimposing the dense structures in the cranial base on the joint image.

Transpharyngeal projection
Provides a sagittal view of the medial pole of the condyle The temporal component is not imaged well Limited diagnostic value Only for osseous changes in the condyle.

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Transorbital projection
Provides an anterior view of the TMJ Entire mediolateral aspect of the condylar head and neck is visible.

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The condyle should be translated to the height of the eminence either by opening the mouth or protruding the mandible maximally.

Panoramic Radiography
Panoramic radiography is closely related to tomography because in both techniques the X-ray source and film cassette move in opposite directions, with the area of interest near the center of rotation.

However, with panoramic radiography the film also moves within the film cassette. This film movement allows variation in the position of the focus plane or trough during the exposure, allowing the focus layer to follow the irregular curve of the mandible and maxilla.

Conventional tomography
Better view for depicting true condylar position. Tomography is generally accepted as being superior to plane film radiography for assessing joint spaces and detecting osseous lesions, especially when frontal as well as sagital views are taken. However, early arthritic changes on the condyle, and even more advanced changes in the fossa, are not well detected.
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The tomographic image is generated by rotating the X-ray beamsource and the film cassette in opposite directions around the area of interest Objects near the center of rotation, called the Tomographic plane

Computed Tomography
Computed tomography (CT) is a technologically advanced form of tomography using computerized storage of data from a series of thin X-ray tomographic sections taken from multiple directions. The exposures are recorded by an array of sensors positioned on the opposite side of the rotating gantry from the radiation source

Computed tomography
CT has good validity for diagnosing osseous abnormalities However, tomography should be considered for this purpose because it costs much less and its validity is comparable with that of CT. Probably the best use of CT is for diagnosing intraosseous lesions

Arthrography
The contrast medium is injected Into the upper or lower joint space or both The disc then appears as a radiolucent mass against the background of contrast medium on conventional radiographs, tomography, or fluoroscopy.

Magnetic Resonance Imaging

Excellent images of soft tissues Imaging of the disk in all three planes Contraindications: ferromagnetic materials, Non ferrous metals and cardiac pacemakers.
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Magnetic Resonance Imaging

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Other methods
Mounted casts Electromyography Sonography Vibration analysis Thermography

MUSCULAR DISORDERS Protective co-contraction Local muscle soreness Myofascial pain Fibromyalgia Myospasm TEMPOROMANDIBULAR JOINT DISORDERS A.Derangement of condyle disc complex Disc displacement Disc Dislocation with reduction Disc Dislocation without reduction B.Structural Incompatability of articular surfaces Deviation in form Adhesions Subluxation Spontaneous dislocation C.Inflammatory disorders Synovitis Retrodiscitis Arthritis D. Inflammatory disorders of asoociated structures Temporal tendonitis Stylomandibular ligament inflammation CHRONIC MANDIBULAR HYPOMOBILITY Ankylosis (fibrous, bony) Muscle contracture(myostatic ,myofibrotic) Coronoid impedance GROWTH DISORDERS Bone disorders Muscle disorders

Classification

Masticatory muscle disorders

Protective muscle splinting
Functional myalgia without structural restraint. Masticatory function is restrained due to inhibitory influence of pain and weakness.

Masticatory myospasm:
Spasms of all muscles Functional myalgia Muscular dysfunction due to sustained isometric / isotonic contractions.

Masticatory myositis:
Inflammation of the muscles Immobilization Soreness at rest and severe pain during function

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Masticatory Muscle Model

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Anatomy of the joint space

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Derangements of the Condyle-Disc CondyleComplex

Cause. The most common causative factor associated with breakdown of the condyle-disc complex is trauma. The three types of derangements of the condyle-disc complex are: (1) disc displacement, (2) disc dislocation with reduction, and (3) disc dislocation without reduction.

Disc displacement
If the inferior retrodiscal lamina and the discal collateral ligament become elongated, the superior lateral pterygoid muscle can position the disc more anteriorly.
When this anterior pull is constant, a thinning of the posterior

border of the disc may allow the disc to be displaced in a more anterior position condyle resting on a more posterior portion of the disc an abnormal translatory shift of the condyle over the disc can occur during opening. Abnormal condyle-disc movement is a click, which may be felt just during opening (i.e., single click) or during both opening and closing (i.e., reciprocal clicking).

History. A history of trauma is commonly associated with the onset of joint sounds. There may or may not be any accompanying pain. If pain is present, it is intracapsular Clinical Characteristics. Examination reveals joint sounds during opening and closing. A normal range of jaw motion during both opening and eccentric movement characterizes disc displacement..

Disc dislocation with reduction

If the inferior retrodiscal lamina and discal collateral ligaments become further elongated and the posterior border of the disc sufficiently thinned, the disc can slip or be forced completely through the discal space. If the patient can manipulate the jaw to reposition the condyle onto the posterior border of the disc, the disc is considered to be reduced. History. Normally a long history of clicking in the joint, catching or a stuck feeling. The catching may or may not be painful

Clinical Characteristics. Unless the jaw is shifted to the point of reducing the disc, the patient displays a limited range of opening. When opening reduces the disc the opening pathway shows a noticeable deviation. In some instances a sudden loud pop will be heard during the recapturing of the disc. After the disc is reduced, a normal range of mandibular movement is present.

Disc dislocation without reduction

As the elasticity of the superior retrodiscal lamina is lost recapturing of the disc becomes more difficult. When the disc is not reduced, the forward translation of the condyle merely forces the disc in front of the condyle .

Clinical Characteristics The range of mandibular opening is 25 to 30 mm, Loading the joint with bilateral manual manipulation is often painful because the condyle is seated on the retrodiscal tissues. With time, continued forces applied to ligaments cause them to become elongated. This elongation results in a greater range of jaw movement, making the differential diagnosis more difficult. In some patients the only definitive way to be certain that the disc is permanently dislocated is by soft tissue imaging (i.e, magnetic resonance imaging |MRI|).

Structural Incompatibilities of the Articular Surfaces

Cause. A common causative factor is macrotrauma. A blow to the jawcauses impact loading of the articular surfaces, and this may lead to alterations in the joint surfaces. In addition, any trauma-producing hemarthrosis can create structural incompatibility. Hemarthrosis, likewise may result from injury to the retrodiscal tissue (e.g., a blow to the side of the face) or even from surgical intervention.

The four types of structural incompatibilities of the articular surfaces are: (1) deviation in form, (2) adhesions, (3) subluxation, and (4) spontaneous dislocation.

Deviation in form
Cause. Deviations in form are caused by actual changes in the shape of the articular surfaces. They can occur to the condyle, the fossa, and the disc. Alterations in form of the bony surfaces may be a flattening of the condyle or fossa or even a bony protuberance on the condyle. Changes in the form of the disc include both thinning of the borders and perforations. History; The history associated with alteration in form is usually a long-term dysfunction that may not present as a painful condition. Often the patient has learned a pattern of mandibular movement (i.e., altered muscle engrams) that avoids the deviation in form and therefore avoids painful symptoms.

TMD s

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Clinical Characteristics. Most deviations in form cause dysfunction at a particular point of movement. Therefore the dysfunction becomes very repeatable observation at a repeatable point of opening During opening, the dysfunction is observed at the same degree of mandibular separation as during closing. This is a significant finding because disc displacements and dislocations do not present in this manner.

Adherences and adhesions

CAUSE.
An adherence represents a temporary sticking of the articular surfaces and may occur between the condyle and the disc (i.e, inferior joint space) or between the disc and the fossa (i.e, superior joint space). Adherences commonly result from prolonged static loading of the joint structures. Although adherences are normally temporary Adhesions are produced by the development of fibrous connective tissue between the articular surfaces of the fossae or condyle and the disc or its surrounding tissues.

History Adherences can be diagnosed only through the history. (such as clenching during sleep), followed by a sensation of limited mouth opening. The adherence occurs because static loading of the joint exhausts weeping lubrication As soon as enough energy is exerted through joint movement to break the adherence, boundary lubrication takes over and sticking does not recur unless the static loading is repeated.

Clinical Characteristics. When adherences or adhesions occur between the disc and fossa (i e superior joint space), normal translation of the condyle-disc complex is inhibited. Therefore movement of the condyle is limited only to rotation, patient displays mandibular opening of 25-30 mm. this is similar to the finding of a disc dislocation without reduction. The major difference is that when the joint is loaded through bilateral manipulation, the intracapsular pain is not provoked. No pain is noted. With a disc dislocation without reduction, loading occurs on the retrodiscal tissues, which will likely
produce pain.

If long-standing superior joint cavity adhesions are present, the discal collateral and anterior capsular ligaments can become elongated. With this the condyle begins to translate forward, leaving the disc behind. When the condyle is forward, it would appear as if the disc is posteriorly dislocated. In reality the condition is better described as a fixed disc

Adherences or adhesions in the inferior joint space are often more difficult to diagnose. the normal rotation between them is lost but translation between them and the fossa is normal .The result is that the patient Can open to close-to-maximum width but senses a stiffness or catching on the Way to maximum opening.

Subluxation
Subluxation (i.e, hypermobility) of the TMJ represents a sudden forward movement of the condyle beyond the crest of the eminence during the latter phase of mouth opening., the condyle appears to jump forward to the wide open position. CAUSE. Subluxation occurs in the absence of any pathologic condition, it represents normal joint movement as a result of certain anatomic features. a TMJ with an articular eminence that has a steep short posterior slope, followed by a longer anterior slope that is often more superior than the crest, tends to subluxate.

 Clinical Characteristics Subluxation can be observed clinically merely by requesting the patient to open widely. At the latter stage of opening, the condyle will jump forward, leaving a small depression in the face behind it. The midline pathway of mandibular opening will be seen to deviate and return when the condyle moves over the eminence. Usually no pain is associated with the movement unless it is repeated often Subluxation is a repeatable clinical phenomenon that does not vary with changes in speed or force of opening.

Spontaneous dislocations
Cause. Spontaneous dislocation (i.e., open lock) fixes the joint in the open position. This condition is clinically referred to as an open lock because the patient cannot close the mouth. When the condyle is in the full forward translatory position, the disc is rotated to its fullest posterior extent on the condyle. In this position the strong retracting force of the superior retrodiscal lamina, along with the lack of activity of the superior lateral pterygoid, prevents the disc from being anteriorly displaced.

 History. Spontaneous dislocation is often associated with wide openmouth procedures, such as a long dental appointment, but it may also follow an extended yawn. The patient reports that the mouth cannot be closed. Pain is associated with the dislocation, and this usually causes great distress.

INFLAMMATORY DISORDERS
Arthritides refers to the inflammation of the articular surface. Osteoarthriitis and osteoarthrosis Etiology-when articular surface of the joint can no longer tolerate the effect of loading. History-unilateral joint pain -constant pain C/F-limited mandibular opening -crepitations -structural changes in the radiograph.
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 Ankylosis By definition means abnormal immobility of the joint. Classified as-based on the 1.Site 2.Tissue involved. 3.Jaw joint .
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 Etiology-Macrotrauma -abnormal intrauterine development -birth injuries -condylar fractures -inflammation of the joint -surgery -infection.
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General considerations in the treatment of TMD s

Treatment approach

Definitive treatment

Supportive treatment

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General considerations in the treatment of TMD s

Definitive treatment-Occlusal therapy -reversible -irreversible -Emotional stress therapy - patient awareness. -voluntary avoidance. -relaxation therapy.
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DEFINITIVE OCCLUSAL THERAPY

Occlusal therapy is considered to be any kind of treatment that is directed towards altering the mandibular position and/or occlusal contact pattern of the teeth. 1. Reversible - that alters patient occlusal condition temporarily

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2. Irreversible which permanently alter the occlusal condition and /or mandibular position Reversible

Irreversible
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 Emotional stress therapy- Patient awareness . - Voluntary avoidance . - Relaxation therapy. -substitutive -active

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Definitive treatment consideration for emotional stress

relaxation therapy. two types of relaxation therapy can be instituted to reduce levels of emotional stress: (1) substitutive and (2) active Substitutive relaxation therapy is a substitution for stressors in an attempt to lessen their impact on the patient. It is more accurately described as behavioral modification and includes any activity that is enjoyable and removes the patient from a stressful situation. Eg sports, hobbies, or recreational activities..

 Active relaxation therapy directly reduce muscle activity. One very common complain of patients with functional disturbances is muscle pain and tenderness. If a patient can be trained to relax the symptomatic muscles, establishment of normal function can be aided. Jacobson's method, developed in 1968. The patient tenses the muscles and then relaxes them until the relaxed state can be felt and maintained. The patient is instructed to concentrate on relaxing the peripheral areas (i.e., hands and feet) and to move progressively centrally to the abdomen, chest, and face.

 Another form of progressive relaxation uses a reverse approach. Instead of asking the patient to contract the muscle and then relax, the muscles are passively stretched and then relaxed. It has one major advantage over the Jacobson technique: Patients with masticatory muscle disorders often report pain when asked to contract their muscles. This increase in pain makes relaxation more difficult. In contrast, gentle stretching of the muscle seems to assist in relaxation. Therefore, many patients find this technique more suitable than the Jacobson technique

Definitive Treatment Considerations for Trauma

As previously discussed, trauma can occur in two forms: (1) macrotrauma and (2) microtrauma. In the case of macro-trauma, definitive treatment has little meaning because the trauma is usually no longer present. Once macrotrauma has produced tissue injury, the only therapy that will help resolve the tissue response is supportive therapy. preventive measures should always be considered. When macrotrauma is likely, such as when participating in a sporting event, proper protection of the masticatory structures should be considered. Wear a soft occlusal appliance or mouth guard.

 Microtrauma When it is present, definitive treatment is indicated to curtail the trauma. Micro-trauma may result from repeated loading of the joint structures, such as with bruxing or clenching. In this condition, definitive treatment would consist of reducing or eliminating these parafunctional activities.

 In another situation the microtrauma may result from normal functional loading, but the loading occurs on the retrodiscal tissues because of an anteriorly displaced disc. In this case, definitive treatment would be aimed at establishing a more favorarable condyle disc relationship that would unload the rdt . This is accomplised by the use of occlusal appliance

Definitive Treatment Considerations for Parafunctional Activity

The exact mechanism that activates muscle hyperactivity has yet to be clearly described. Bruxism can be either diurnal or nocturnal. Diurnal activity may be more closely related to an altered occlusal condition, to an increased level of emotional stress, or both. Because diurnal activity can usually be brought to the patient's level of awareness, often it is managed well with patient education and cognitiveawareness strategies.

 Nocturnal bruxism, however, seems to be different. It appears to be influenced less by tooth contacts and more by emotional stress levels and sleep patterns. Because of these differences, nocturnal bruxism responds poorly to patient education, relaxation and biofeedback techniques, and occlusal alterations.

Patient education
Patient education should begin with informing the patient that the teeth should only contact during chewing, speaking, and swallowing. During all other times the jaw should be positioned with the teeth apart. Once made aware of tooth contacts, the patient should be asked to make a conscious effort to keep the teeth apart during all waking

Other methods
Other training methods also encourage relaxation but are used to a lesser degree. Hypnosis Meditation yoga

SUPPORTIVE THERAPY
The two general types of supportive therapies are (1) pharmacologic therapy and (2) physical therapy. Pharmacologic therapy : Patients should be aware that medication does not usually offer a solution or cure to their problems. However, medication in conjunction with appropriate physical therapy and definitive treatment can offer the most complete approach to many problems.

 The most common pharmacologic agents used for the management of TMD include analgesics, nonsteroidal antiinflammatory drugs (nsaids), corticosteroids, anxiolytics, muscle relaxants, antidepressants, and the local anesthetics. Acute tmd pain- Analgesics, Corticosteroids, And Anxiolytics acute and chronic conditions- Nsaids, Muscle Relaxants And Local Anesthetics Chronic orofacial pain - Tricyclic Antidepressants

Physical therapy modalities.

Physical therapy modalities represent the physical treatments that can be applied to the patient. They can be divided into the following types: Thermotherapy, Coolant Therapy, Ultrasound, Phonophoresis, Iontophoresis, EGS Therapy, Transcutaneous Electrical Nerve Stimulation (TENS), Acupuncture, And Laser.

General considerations in the treatment of TMD s

II.Physical therapy - modalities - manual techniques. Thermotherapy - utilizes heat as a prime mechanism

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General considerations in the treatment of TMD s

Coolant therapy - relaxation of muscles Ultrasound therapy - increase in the temperature at the interface of the tissue and therefore affects deeper tissue

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General considerations in the treatment of TMD s

Iontophoresis is a technique by which certain medications can be introduced into the tissues . TENS brings about continuous stimulation of cutaneous nerve fibers thereby decreasing pain perception.

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General considerations in the treatment of TMD s

TENS
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General considerations in the treatment of TMD s

Manual technique- Soft tissue mobilizationgentle massage of the soft tissue overlying the painful area. - Restricted use ,relaxation therapy.

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General considerations in the treatment of TMD s

Joint distraction
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Splints
Splints are hard or soft removable acrylic appliances covering the teeth. MODE OF ACTION : Eliminate occlusal disharmony Prevent wear and mobility of teeth Reduce bruxism and parafunction Treat muscle dysfunction Correct internal derangement
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Types of splints
STABILIZATION SPLINT: OTHER NAMES: Muscle deprogramming splint, Flat plane splint, Superior repositioning splint, CR splint, Tanner splint (Mandibular), Shore splint (Maxillary), Michigan plane. DESIGN:

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STABILIZATION SPLINT: MODE OF ACTION: Manages tooth contact Alters muscle function USES: Treatment of muscle and joint pain from occlusal contact discrepancy and parafunctional activity. Mandibular position deprogramming. Vertical dimension alteration.
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ANTERIOR REPOSITIONING SPLINT: OTHER NAMES: Repositioning splint, LARS ( Ligated Anterior Repositioning Splint), Orthopedic positioner. DESIGN:

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MODE OF ACTION: Change in tooth contact Change in muscle function Alters the stress and loading of the joint Disc recapture USE: Alter condylar position at occlusal contact Meniscus recapture.
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Types of splints
BITE PLANE SPLINT: OTHER NAMES: Anterior jig, Luca jig, Hawley with ABP, Anterior deprogrammer, Six point splint. DESIGN:

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BITE PLANE SPLINT: USES: When premature contacts are present in the posterior segments. Reduce muscle activity. MODE OF ACTION: Interrupts mandibular position sense Eliminates propioceptive feedback from posterior teeth. Reduces muscle activity.
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SOFT SPLINT: An emergency appliance. OTHER NAMES: Positioner, mouth guard, night guard.

USES: Athletics. For reducing parafunctional activity (not substantiated). On a temporary basis for relief of symptoms.

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MORA: Mandibular Orthopedic Repositioning Appliance. OTHER NAMES: Gelb Splint. USES: Change posterior occlusion. Eliminate anterior tooth contact.
DESIGN:

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Twin block in temporomandibular joint therapy

Twin Block Therapy helps in alleviating Tmj Dysfunction in two conditions:Anterior Disc Displacement unilateral condyle Displacement

How Does The Twin Block Help? 1.The disc is recaptured by posturing the mandible down ward and forward to advance the condyles.

2. Not only does it act as a passive splint but the twin

block is so designed to move the teeth that are causing occlusal imbalance.

 During bite registration the bite is so selected that the mandible is guided downward and forward. This helps in restoring the proper condyle disc relation by posturing the condyle anteriorly over the disc. Pain is relieved immediately when the twin block are fitted or in difficult cases within 4 -7 days. If pain is not relieved by forward posture , it indicates that the disc does not appear to be recaptured. There may be internal derangement or folding of the disc which will not respond to twin block therapy.

Bionator and tmd

A majority of tmj problems are associated with clenching and bruxism Wearing the bionator at night tends to relax the muscle spasm that occurs particularly of the lateral pterygoid.

 Petrovic has stated that the protracted wear of this type of propulsion appliance in adults can permanently shorten the lateral pterygoid muscle thus helping the patient maintain a protracted mandibular posture even during the day thus clicking and other unfavorable tmj sequelae dissapear. This decrease in muscle activity inturn reduces the forces exerted by the condyle on the the disc. Also the forward and lowered position of the
mandible improves the condyle disc relationship in cases of mild clicking where in the disc has been displaced anteriorly to the condylar head.

GOOD MORNING

CONE BEAM CT
Viewing condyle in multiple planes 3D imaging of condyle Imaging of both hard and soft tissue Advantage: Less radiation Disadvantage: Expensive

SPECT
Radiolabelled material injected into the area Material concentrated on area of increased activity Emission image obtained Do not discriminate between bone remodeling and degeneration. Adjunct to clinical observation.

Management of TMD
Type I disorder
Mainly a muscle problem

Type II disorder
Mainly a disc problem Functional damage to the joint

Type III disorder

Major bone damage Structural damage to the joint components

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Management of Type I disorder

TREATMENT: Splints Six point splint/ Bite plane splint Stabilization splint Orthodontics Selective grinding Medication Counseling
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Management of Type II disorders

TREATMENT: Splint Michigan plane / Stabilization splint Antero superior repositioning splint Orthodontics with splint

2/8/2012

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Management of Type III disorders

TREATMENT: PHASE I: Immediately free the joint Splint PHASE II: Sectional orthodontics with splint Achieving normal dental relationships Prosthetic replacements. surgery
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Management of TMJ symptoms arising during orthodontics

A) Muscle pain patient education. Removing unnecessary tooth contact. b) Pain NSAIDs or moist hot towel. If the symptoms are unresponsive to above therapies then orthodontic treatment is discontinued Soft appliances. Stabilization appliance . Anterior bite plane. Therapy for specific disorder

Disc displacements
Cause Elongation of capsular ligaments. Thinning of articular disc. Def treatment stabilization appliance. Anterior positioning appliance. Supportive treatment Education. NSAIDs. Moist heat or ice.

Disc dislocations without reduction.

Cause Trauma. Def treatment Manual manipulation. it depends on 3 factors 1) Lateral pterygoid muscle activity. 2) Increased disc space. 3) Maximum forward translatory condyle position.

Supportive treatment Education. NSAIDs. Decrease gum chewing.

Cause trauma due to sudden blow. Def treatment surgical procedures. Supportive treatment Education. NSAIDs.

Deviation in form.

Stabilization appliance.

Subluxation.
Cause it is a result of anatomic form. Def treatment Eminectomy. Supportive treatment Education. NSAIDs. Intra oral devices to restrict mouth opening

Inflammatory disorders
It includes synovitis. capsulitis. Retrodiscitis. Arthritides.

Synovitis and Capsulitis.

Cause Trauma or spread of infection from adjacent structures. No def treatment Supportive treatment - NSAIDs. Moist heat. Ultrasound therapy. Corticosteroid inj.

Retrodiscitis.
Cause Trauma. Supportive treatment NSAIDs. Soft diet. Corticosteroid inj. Stabilization appliance.

Arthritis.
Inflammation of articular surfaces. It may be a) Degenerative ( osteo arthritis). cause over loading of articular surfaces. Def treatment - Stabilization appliances.

b) traumaticCause Trauma. No def treatment. Supportive treatment Stabilization appliance. NSAIDs. Decreased jaw use.

c)Infectious: Cause Bacterial infection due to puncture wounds. Def treatment Antibiotic medication. Treating original source of infection. Supportive treatment Passive exercises and ultrasound. d ) Rheumatoid: Unknown cause. Supportive treatment Stabilization appliance. NSAIDs. Arthocentesis. Arthroscopy

Herbst appliance therapy and temporomandibular joint disc position:

A prospective longitudinal study- magnetic resonance imaging study Luis Antonio de Arruda Aidar, Marcio Abrahao , Helio K. Yamashita , Gladys Cristina Dominguez (AJODO :MAY 2006)

 The adaptation mechanism of the TMJ to mandibular advancement during correction of a Class II Div 1 malocclusion debated? The objective of this study was to verify possible changes of the disc position in the TMJ in adolescents with retrognathic mandibles and treated with the Herbst appliance

 20 white Brazilian adolescents (7 boys, 13 girls) received Herbst therapy for 12 months to correct their malocclusions. Mean age at pretreatment was 12 years 8 months S.D I year 1 month (range, 11 years-14 years 6 months). Based on the results, during a l2-month treatment period with the Herbst appliance in patients with normal positions of the articular disc at pretreatment, mild changes in the position of the disc occurred. These changes were within normal physiological limits when evaluated in the short term

 Herbst treatment did not result in any negative or pathologic changes of articular disc position. On the contrary the appliance could possibly be useful in the treatment of patients with milder forms of anterior disc displacement

Changes in the TMJ disc condyle fossa relationship following functional treatment of skeletal Class II Division 1 malocclusion: A magnetic resonance imaging study Z. Mirzen Arat, DDS, PhD,a Hatice Gkalp, DDS, PhD,b Dilek Erdem, Am J Orthod Dentofacial Orthop 2001;

 Aim of this study was to examine, with the use of magnetic resonance imaging,the mandibular condyle disc fossa relationship in subjects with Class II Division 1 malocclusions who weretreated with the Andresen activator. The sample consisted of 18 subjects with Class II Division 1 malocclusion, 9 treated with the Andresen activator and 9 control subjects. The anterior, posterior, and superior joint spaces were measured on the magnetic resonance images, and the posterior, medial, and anterior disc angles were measured for the determination of the disc position. The condyle was found to be located anteriorly. However, the changes in the disc position were found to be statistically insignificant

Effects of fixed functional appliance treatment on the temporomandibular joint Selim Arici,a Huseyin Akan,b Kamran Yakubov,c and Nursel AricidAm J Orthod Dentofacial Orthop 2008;133:809-14)

 Transverse computed tomography images were taken of the temporomandibular joint region in 60 children with Class II Division 1 malocclusion. Thirty randomly selected patients were treated with a fixed functional orthodontic appliance (Forsus nitinol flat-spring, 3M Unitek Corp, Monrovia, Calif) for7 months; another 30 patients without treatment were used as controls. Computed tomography images taken at the beginning and end of fixed functional appliance treatment were used for estimating the condyle-glenoid fossa relationship, including the volumes of condyle, glenoid fossa, and anterior and posterior joint spaces. Results: volumes of the anterior and posterior joint spaces changed, the condyle was more posteriorly positioned in the glenoid fossa

Orthodontics as a risk factor for temporomandibular disorders (TMD). II ajodo 1992 Charles R. Kremenak, DDS, Ms D., David Kinser, DDS, MS ,Thomas J. Melcher, DDS, MS ,G. Randall Wright, DDS, MS ,Steven D. Harrison, DDS, MS ,Robert R. Ziaja, DDS, MS ,Heidi A. Harman, DDS, MS Judith G. Demro, DDS, MS,John N. Ordahl, DDS, MS ,Curtis C Menard, DDS, MS ,Kenneth A. Doleski, DDS, MS ,Jane R. Jakobsen, BS, MA

The purpose of this study was to present information about possible relationships between orthodontic treatment and temporomandibular disorders (TMD) from a prospective longitudinal study begun in 1983. Here all 109 patients enrolled in the study have data from a TMD examination before starting orthodontic treatment and from at least one posttreatment examination. Mean age at the ontset of treatment was 18.9 years compared with 19.7 years for the entire sample of 109 patients; duration of treatment averaged 1.8 years, as did that for the entire sample.

The results are in general agreement with those of previous investigators who have failed to identify important orthodontic risk factors for TMD. Although the fact that 10% of sample in this experienced slight worsening of TMD status after completion of treatment alerts us to the need for continuing study. general conclusion is that the TMD status of the vast majority (90%) of the orthodontic patients treated stays the same or improves after completion of treatment.

Does Bite-Jumping Damage the TMJ? A Prospective Longitudinal Clinical and MRI Study of Herbst Patients
Sabine Rut, DDS, Dr Med Denta; Hans Pancherz, DDS, Odont AJODO : 2006)

The aim of this prospective longitudinal study of 62 consecutively treated Class II malocclusions was to determine whether bite-jumping causes temporomandibular disorders (TMD). The function of the TMJ was assessed anamnestically, clinically, and by means of magnetic resonance images (MRIs) taken before (TI), after (T2), and I year after (T3) Herbst treatment

Over the entire observation period from before treatment to I year after treatment, bite-jumping with the Herbst appliance: 1) did not result in any muscular TMD 2) reduced the prevalence of capsulitis and structural condylar bony changes 3) did not induce disc displacement in subjects with a physiologic pretreatment disc position 4) resulted in a stable repositioning of the disc in subjects with pretreatment partial disc displacement with reduction 5) could not recapture the disc in subjects with a pretreatment total disc displacement with or without reduction

 A pretreatment total disc displacement with or without reduction did not, however, seem to be a contraindication for Herbst treatment. In conclusion, bite-jumping using the Herbst appliance does not have a deleterious effect on TMJ function and does not induce TMD on a short-term basis.

Temporomandibular disorders, occlusion and orthodontic treatment T. Henrikson and M. Nilner

Journal of Orthodontics 2003

 To prospectively and longitudinally study symptoms and signs of temporomandibular disorders (TMD) and occlusal changes in girls with Class II malocclusion receiving orthodontic fixed appliance treatment in comparison with untreated Class II malocclusions and with normal occlusion subjects. Sixty-five girls with Class II malocclusion who received orthodontic treatment, 58 girls with no treatment, and 60 girls with normal occlusion The normal group had a lower overall prevalence of TMD than the orthodontic and the Class II group at both registrations.

 Conclusions: (i) Orthodontic treatment either with or without

extractions did not increase the prevalence or worsen pretreatment symptoms and signs of TMD. (ii) Individually, TMD fluctuated substantially over time with no predictable pattern. However, on a group basis, the type of occlusion may play a role as a contributing factor for the development of TMD. (iii) The large fluctuation of TMD over time leads us to suggest a conservative treatment approach when stomatognathic treatment in children and adolescents is considered.

Does orthodontic treatment cause TMD?

studies comparing treated patients with untreated controls. Such retrospective studies lack information relating to factors such as the functional status of patients pretreatment (were they similar?), and they suggest that orthodontic treatment tends to neither ease nor exacerbate TMD. Longitudinal studies provide more information, and Generally, there is a tendency in longitudinal studies for orthodontically treated patients to actually have fewer signs of TMD.

Clinical studies suggest that orthodontic treatment has little role to play in worsening or precipitating TMD when treated patients are compared with untreated individuals, with or without malocclusion, or when different types of orthodontic treatment are compared; indeed, longitudinal studies tend to show a reduction in TMD signs in orthodontically treated individuals.

Conclusion
The TMJ is a very complex joint to deal with as a whole. As people who move teeth and change occlusion, the orthodontist may be the one who alters joint function the most. Based on currently available evidence, it seems that neither the possession of a malocclusion nor orthodontic treatment can be said to cause or cure TMD A thorough knowledge of TMJ function and disorders and functional occlusion is essential to establish long term goals for the occlusion and the joint.

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REFERENCES:
GRAY S Anatomy I.B. Singh Anatomy Human anatomy (B.D. Chaurasia) TenCate s Oral Histology Temporomandibular Joint & Occlusion ( OKESON- 6TH EDITION)

 Changes in the TMJ disc condyle fossa relationship following functional treatment of skeletal Class II Division 1 malocclusion: A magnetic resonance imaging study Z. Mirzen Arat, DDS, PhD,a Hatice Gkalp, DDS, PhD,b Dilek Erdem, Am J Orthod Dentofacial Orthop 2001 Effects of fixed functional appliance treatment on the temporomandibular joint Selim Arici,a Huseyin Akan,b Kamran Yakubov,c and Nursel AricidAm J Orthod Dentofacial Orthop 2008;133:809-14)

 Condyle and fossa shape in Class II and Class III skeletal patterns: A morphometric tomographic study . (Am J Orthod Dentofacial Orthop 2005;128:337-46) Morphology of the temporomandibular joint in subjects with Class II Division 2 malocclusions Elias G. Katsavrias Am J Orthod Dentofacial Orthop 2006;129:470-8 Orthodontics as a risk factor for temporomandibular disorders (TMD). II ajodo 1992 Charles R. Kremenak, DDS, Ms D., David Kinser, DDS, MS ,Thomas J. Melcher, DDS, MS ,G. Randall Wright, DDS, MS ,Steven D. Harrison, DDS, MS ,Robert R. Ziaja, DDS, MS ,Heidi A. Harman, DDS, MS Judith G. Demro, DDS, MS,John N. Ordahl, DDS, MS ,Curtis C Menard, DDS, MS ,Kenneth A. Doleski, DDS, MS ,Jane R. Jakobsen, BS, MA

 Temporomandibular disorders, occlusion and orthodontic treatment T. Henrikson and M. Nilner Journal of Orthodontics 2003 Herbst appliance therapy and temporomandibular joint disc position: A prospective longitudinal study- magnetic resonance imaging study Luis Antonio de Arruda Aidar, Marcio Abrahao , Helio K. Yamashita , Gladys Cristina Dominguez (AJODO :MAY 2006) study

Thank you