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Temporo mandibular joint /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call

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  • 1. TEMPORO MANDIBULAR DISORDERS INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  • 2.  Terminology  Functional Anatomy And Biomechanics Of Masticatory System  Etiology of Temporomandibular Disorders  Orthodontic Concepts of TMD Etiology  Radiographic Diagnosis of Temporomandibular Disorders  Classification of TMD’s  Clinical diagnosis and Management  Conclusion www.indiandentalacademy.com
  • 3. Terminology www.indiandentalacademy.com
  • 4. • Costens syndrome • Shore – 1959- TM J dysfunction syndrome • Ramfjord and Ash – Functional TMJ Disturbances • Occluso-mandibular disturbance • Myoarthropathy of TMJ • Pain dysfunction syndrome / MPDS / Temporo mandibular pain dysfunction syndrome. • Craniomandibular disorders • Bell –Temporomandibular disorders( ADA ) www.indiandentalacademy.com
  • 5. • Dr. James Costen – 1934 suggested that changes in dental condition is responsible for various ear symptoms. • Suggested treatment using bite raising appliance. • 1950’s – • Early scientific studies suggested that occlusal condition could influence masticatory muscle function • Masticatory Muscle Pain • Etiologies- occlusal disharmony and emotional stress • 1970’s – Intracapsular Sources www.indiandentalacademy.com
  • 6. Functional Anatomy And Biomechanics Of Masticatory System www.indiandentalacademy.com
  • 7. • The masticatory system is a complex and highly refined unit composed of • Dentition and supportive structures • The skeletal components • TMJ • Muscles and ligaments. www.indiandentalacademy.com
  • 8. TMJ • Anatomy of TMJ • Ginglymo - arthroidal joint • Compound joint • Synovial joint • Exchange of metabolites • Lubrication • Boundary lubrication – primary mechanism for joint lubrication while movement • Weeping lubrication – eliminated friction In compressed joint. www.indiandentalacademy.com
  • 9. Condyle Temporal bone www.indiandentalacademy.com
  • 10. www.indiandentalacademy.com
  • 11. Articular disc • • • • Composed of dense fibrous tissue Avascular and non innervated Flexible and adapt to functional demands Attachments www.indiandentalacademy.com
  • 12. Functional LigamentsCapsular ligament Temporomandibular ligament Collateral (discal) ligaments www.indiandentalacademy.com
  • 13. Accessory Ligaments Sphenomandibular ligament Stylomandibular ligament www.indiandentalacademy.com
  • 14. Muscles of mastication • • • • Masseter Medial pterygoid Temporalis Lateral pterygoid Jaw movements  Depression –  Lateral Pterygoid complemented by Geniohyoid , Mylohyoid & Digastrics.  Elevation –  Temporalis , Masseter & Medial Pterygoid.  Protrusion –  LPM & Medial Pterygoid.  Retrusion –  Posterior Fibers Of Temporalis, assisted By Middle & Deep Parts Of Masseter, Digastric & Geniohyoid. www.indiandentalacademy.com
  • 15. BIOMECHANICS OF TMJ • TMJ is complex joint system. • 2 joints act independently and simultaneously. • 2 joint systems are present • Tissues surrounding inferior joint cavity( condyle disc complex) • Responsible for rotation movement • Tissues surrounding superior joint cavity • Responsible for gliding movements • The disc functions ars true articular surfaces in both joint systems www.indiandentalacademy.com
  • 16. • Stability of joint is maintained by constant activity of muscle that pull of muscles that pull across the joints-elevators • Tonus- mild state of contraction of muscles in the resting state. • • • • Interarticular pressure Closed rest position- low pressure - disc space widens Clenching- high pressure disc space narrows. Increase in the interarticular pressure– condyle seats on thinner intermediate zone of disc. • Decrease in pressure – disc space widens www.indiandentalacademy.com
  • 17. www.indiandentalacademy.com
  • 18. • Ligaments do not actively participate in functions of TMJ They restrict certain joint movements while allowing others mechanically and through neuromuscular reflex. • Ligaments do not stretch Once elongated, joint function is compromised • Articular surfaces must be maintained in constant contact. www.indiandentalacademy.com
  • 19. Etiology of Temporomandibular Disorders www.indiandentalacademy.com
  • 20. • No single etiology to explain all signs and symptoms disturbances in masticatory system. • TMD symptoms arise • Normal function + event> physiologic tolerance Symptoms www.indiandentalacademy.com
  • 21. • Normal function : • Chewing, speaking, swallowing. • Brain regulates muscle action by means of muscle engrams that are appropriately selected according to sensory input received from peripheral structures. • When sudden sensory input is received, protective reflex mechanisms are activated ,creating a decrease in muscle activity in that area. www.indiandentalacademy.com
  • 22. • Event • Local events • Any change in sensory or proprioceptive input – highly placed restoration • May be secondary to trauma involving local tissues – injection of local anesthetic, mouth opening too wide, unaccustomed use – bruxism • Constant deep pain input - central excitatory effects – referred pain www.indiandentalacademy.com
  • 23. • Systemic events • Emotional stress • Stress centers in brain have influence on muscle functionincrease muscle tonicity. • Stress defined by Hans Selye as ‘non specific response of the body to any demand made upon it’ • Circumstances creating stress are called ‘stressors’ • The body reacts to stressors by creating demands for readjustment or adaptation – fight / flight response • Two types of releasing stress • External mechanism – shouting ,hitting, physical exercise, etc. • Internal – gastritis, hypertension, increase in tonicity of musculature. www.indiandentalacademy.com
  • 24. • Physiologic tolerance : • Is influenced by local and systemic factors • Local factors : • Orthopedic stability – when mandible closes with condyles in most supero-anterior position, resting against the posterior slopes of articular eminence, with disc properly interposed, there is even and simultaneous contact of all teeth, forces directed towards long axis of teeth, from that position when mandible moves eccentrically – anterior teeth contact and disocclude posterior teeth. www.indiandentalacademy.com
  • 25. • Effected by genetic ,developmental or iatrogenic causes, disc displacements, arthritis. • Lack of harmony between state intercuspal position of teeth and musculoskeletally stable position of joint. • Systemic factors : • Constitutional factors • Presence of other acute/chronic illness • Sympathetic activity www.indiandentalacademy.com
  • 26. • TMD symptoms: • • • • • • • Pulptits Tooth wear Tooth mobility Masticatory muscle pain TMJ pain Ear pain Headache www.indiandentalacademy.com
  • 27. • 1. Predisposing factors : include a mixture of morphological, physiological, psychological, and environmental variables that heighten an individual's susceptibility to develop a certain problem. • 2. Precipitating factors :include various combinations of trauma, stress, hyperfunction, and possibly failure of natural inhibiting factors, all of which lead to the onset of symptoms. • 3. Perpetuating factors :include poor healing capacity, failure to control etiologic factors, secondary gains from staying sick, and negative effects from inappropriate treatment. www.indiandentalacademy.com
  • 28. • Primary vs secondary disorder Disc derangement disorders Masticatory muscle disorder Trauma Inflammatory disorders Mandibular hypomobility disorders www.indiandentalacademy.com
  • 29. Orthodontic Concepts of TMD Etiology • Thompson believed that most condyles needed to be brought downward and forward -"freeing up a distalized (trapped) mandible,“ • Ricketts , Perry, Jarabak,and Moyers • Orthodontists began attributing TM disorders to improper finishing of orthodontic cases and a lack of appreciation for "correct" concepts of functional occlusion www.indiandentalacademy.com
  • 30. • Despite considerable debate about this subject, it never was shown scientifically that any "wrong" concepts of occlusion or "improper" finishing by orthodontists using diverse methods had produced any significant number of post orthodontic TMD sufferers. • Any Superior methods of finishing cases ??????? www.indiandentalacademy.com
  • 31. "Orthodontics and Temporomandibular Disorders" - Dent Clin North Am 1988;32:529-538 • a list of 10 myths in the field 1. People with certain types of untreated malocclusion (for example, Class II Division 2, deep overbite, crossbite) are more likely to develop TM disorders. 2. People with excessive incisal guidance, or people totally lacking incisal guidance (open bite), are more likely to develop TM disorders. 3. People with gross maxillomandibular disharmonies are more likely to develop TM disorders. . www.indiandentalacademy.com
  • 32. 4. Pretreatment radiographs of both TMJs should be taken before starting orthodontic treatment. The position of each condyle in its fossa should be assessed as good or bad, and orthodontic treatment should be directed at producing a good relationship at the end. ("Good" position usually was defined as being a concentric placement of the condyle in the fossa). 5. Orthodontic treatment, when properly done, reduces the likelihood of subsequently developing TM disorders. 6. Finishing orthodontic cases according tospecific functional occlusion guidelines (eg, gnathologic principles) reduces the likelihood of subsequently developing TM disorders. www.indiandentalacademy.com
  • 33. 7. The use of certain traditional orthodontic procedures and/or appliances may increase the likelihood of subsequently developing TM disorders. 8. Adult patients who have some type of occlusal "disharmony" along with the presence of TMD symptoms will probably require some form of occlusal correction to get well and stay well. 9. Retrusion of the mandible because of natural causes or after treatment procedures is a major factor in the etiology of TM disorders. 10. When the mandible is distalized, the articular disc may slip off the front of the condyle. www.indiandentalacademy.com
  • 34. • NIDR -McNamara, Seligman, and Okeson listed eight conclusions that essentially refute all of the previous statements: i. Signs and symptoms of TMD occur in healthy individuals ii. Signs and symptoms of TMD increase with age, particularly during adolescence. Thus, TMD that originates during [orthodontic] treatment may not be related to the treatment. iii. Orthodontic treatment performed during adolescence generally does not increase or decrease the chances of developing TMD later in life. iv. The extraction of teeth as part of an orthodontic treatment plan does not increase the risk of developing TMD. www.indiandentalacademy.com
  • 35. v. There is no elevated risk for TMD associated with any particular type of orthodontic mechanics. vi. Although a stable occlusion is a reasonable orthodontic treatment goal, not achieving aspecific gnathologically ideal occlusion does not result in TMD signs and symptoms. vii. No method of TM disorder prevention has been demonstrated. viii. When more severe TMD signs and symptoms are present, simple treatments can alleviate them in most patients. www.indiandentalacademy.com
  • 36. Radiographic Diagnosis of Temporomandibular Disorders www.indiandentalacademy.com
  • 37. • Required to make an accurate diagnosis or to determine the extent of involvement. • Whether or not to order an imaging examination: • (1) What the probability is that the imaging examination will detect disease and its severity when it is present, or whether it can pre-diet its future occurrence; • (2) Which specific findings indicate the superiority of one treatment over another; and • (3) What findings may help predict the course and prognosis of the disease with and without treatment. www.indiandentalacademy.com
  • 38. • The ratio of true positive test results to the total number of diseased individuals is called the sensitivity of the test. • The ratio of true negative findings to the total number of individuals in the nondiseased group is called specificity. • High sensitivity without correspondingly acceptable specificity is undesirable because low specificity is the result of excessive false positive diagnoses, which could lead to overtreatment of individuals not having disease. • It is generally considered that both sensitivity and specificity should be greater than 0.70 for a Temporo mandibular disorder (TMD) imaging test to be clinically useful. www.indiandentalacademy.com
  • 39. www.indiandentalacademy.com
  • 40. • The direct visual examination is referred to as the gold standard to which the imaging test in question is being compared. • Other factors 1. cost, 2. invasiveness, 3. side effects, 4. the impact of the information gleaned on the treatment selection process www.indiandentalacademy.com
  • 41. Joint Anatomy Relative to Imaging • Diverse anatomy of the TMJ • Yale identified four markedly different naturally occurring condyle morphologies, some of which might appear abnormal on imaging to the inexperienced eye. • The mediolateral length of the condyle, averaging 20 mm, prevents reproduction of the medial portions of the joint on conventional, flat plane radiographs. • Adjacent dense osseous structures in and around the cranial base are easily superimposed on the joint image, absorbing radiation and degrading image clarity. www.indiandentalacademy.com
  • 42. • Perhaps the most technically demanding anatomic obstacle to overcome is the great variability in angulation of the long axis of the condyle both in the horizontal and vertical planes. • A five degree error in beam alignment can affect interpretation of joint space width and degrade diagnostic quality. www.indiandentalacademy.com
  • 43. Transcranial Radiographs • Technique is simple and the required equipment is widely available • Used to evaluate the status of joint hard tissue and the spatial relationship of the condyle to the fossa. www.indiandentalacademy.com
  • 44. www.indiandentalacademy.com
  • 45. • The angulation in the vertical plane avoids superimposing the dense structures in the cranial base on the joint image . • The angulation in the horizontal plane, positions the central beam parallel with the average horizontal condylar angulation. • The corrected technique minimizes error by aligning the X-ray beam with the condylar axis in the horizontal plane, the angulation of which is measured on a submento-vertex radiograph. • 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. www.indiandentalacademy.com
  • 46. • Poor sensitivity and specificity values • TR is used as a screening aid for osseous lesions in the lateral third of the joint. www.indiandentalacademy.com
  • 47. Transmaxillary / transantral / transorbital / infraorbital projection • This technique provides a frontal view of the TMJ. • The entire mediolateral profile of the condyle is imaged . • A disadvantage of the transmaxillary view is its failure to portray most of the fossa, which is hidden by the shadow of the eminence. www.indiandentalacademy.com
  • 48. • The 40° angulation in the horizontal plane is required to avoid superimposition of the mastoid process on the joint image. • The 10° angulation in the vertical plane (B) avoids superimposition of the hard palate and sphenoid bone. www.indiandentalacademy.com
  • 49. • Larheim suggests that the transmaxillary view compliments the lateral view, giving a good perspective of the entire joint comparable to the more sophisticated and expensive tomography www.indiandentalacademy.com
  • 50. Tomography www.indiandentalacademy.com
  • 51. • Horizontal angulation is individualized by measuring horizontal condylar angulation on a submento-vertex radiograph and the vertical angulation is measured on an anteroposterior radiograph. • The resulting tomographic plane closely approximates the true perpendicular to the condylar long axis www.indiandentalacademy.com
  • 52. • 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 saggital views are taken. However, early arthritic changes on the condyle, and even more advanced changes in the fossa, are not well detected. www.indiandentalacademy.com
  • 53. Panoramic Radiography • Image sharpness is typically less than with technically correct plane film radiography. • Advantages :cost effectiveness, availability, and relatively low radiation dose • Disadvantages : many early lesions will not be detected, and no information on joint soft tissue status is provided. www.indiandentalacademy.com
  • 54. Arthrography • Arthrography is a technique used to highlight or outline joint structures by using a radiopaque contrast medium to enhance their images on plane or tomographic films. • 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. www.indiandentalacademy.com
  • 55. • Fluoroscopy allows for monitoring of the needle during the injection procedure, viewing of dynamic disc movements, and visualizing contrast material moving through existing perforations. • In cases of disc displacement with reduction on mouth opening the dynamic movement of the disc during displacement and reduction is dramatically evident. • Arthrotomography – tomography when used with contrast medium in the joint, www.indiandentalacademy.com
  • 56. • The adaptation of arthrography to the TMJ was a crucial step in our understanding of joint soft tissue dynamics and aided in classification of internal joint derangements. • It remains the only imaging method providing reliable information on perforations. • Disadv : • invasive procedure • discomfort for the patient associated with injecting the contrast medium, and probably its presence in the joint affects joint dynamics and • method is technique sensitive. www.indiandentalacademy.com
  • 57. Computed tomography (CT) www.indiandentalacademy.com
  • 58. • Density differences between muscle, capsule connective tissue, and the disc are relatively subtle under the normal CT operating mode, and not well differentiated. • Discs in normal position are often lost in the background of the immediately adjacent high www.indiandentalacademy.com
  • 59. www.indiandentalacademy.com
  • 60. Magnetic Resonance Imaging • Advantages : • The substitution of relatively harmless superconducting magnets and radio wave energy for the well known hazardous of ionizing radiation. • The material of high contrast is soft tissue. • High cost www.indiandentalacademy.com
  • 61. Classification of TMD’s www.indiandentalacademy.com
  • 62. Classification I. • • Masticatory muscle disorders Acute myalgic disorders • Protective co – contraction • Local muscle soreness • Myofascial pain • Myospasm • Myositis Chronic myalgic disorders • Fibromyalgia www.indiandentalacademy.com
  • 63. II. Temporo mandibular joint disorders 1. Derangement of condyle disc complex 1. Disc displacements 2. Disc dislocation with reduction 3. Disc dislocation without reduction 2. Structural incompatibility of articular surfaces 1. Deviation in form 1. Disc /condyle /fossa 2. Adhesions 1. Disc to condyle 2. Disc to fossa 3. Subluxation 4. Spontaneous dislocation www.indiandentalacademy.com
  • 64. 3. Inflammatory disorders 1. Synovitis 2. Capsulitis 3. Retrodiscitis 4. Arthritides 1. Osteoarthritis 2. Osteoarthrosis 3. Polyarthritides 5. Inflammatory disorders of associated structures 1. Temporalis tendonitis 2. Stylomandibular ligament inflammation www.indiandentalacademy.com
  • 65. III. • • • Chronic mandibular hypo mobility Ankylosis • Fibrous • Bony Muscle contracture • Myostatic • Myofibrotic Coronoid impedence www.indiandentalacademy.com
  • 66. IV. • • Growth disorders Congenital and developmental bone disorders • Agenesis • Hypoplasia • Hyperplasia • Neoplasia Congenital and developmental muscle disorders • Hypertrophy • Hypotrophy • Neoplasia www.indiandentalacademy.com
  • 67. Treatment of TMD www.indiandentalacademy.com
  • 68. • Definiftive therapy: elimination / alteration of etiologic factors responsible for disorder. • Supportive therapy : directed towards alteration of symptoms. • Etiology – “event” • Local trauma to tissue • Orthopedic instability – occlusal interferences - bruxism • Increased stress • All initial therapy should be conservative, reversible, non invasive www.indiandentalacademy.com
  • 69. • Occlusal therapy : • Reversible occlusal therapy: occlusal splint that alters mandibular position and contact pattern of teeth – creating harmony with optimum condyle-disc fossa relationship – hence providing orthopedic stability • Muscle relaxation appliance – splint at CR position • • • • Irreversible occlusal therapy : Orthodontic treatment Selective grinding and restorative procedures Surgical alteration of jaw position. www.indiandentalacademy.com
  • 70. • Emotional stress therapy • Patient awareness • Voluntary avoidance • Relaxation therapy – self hypnosis, meditation, yoga, Biofeedback technique www.indiandentalacademy.com
  • 71. • Supportive therapy • Pharmacologic therapy • Analgesics – NSAID’s • Antianxiety drugs • Antiinflammatory agents – NSAID’s, corticosteroids • Muscle relaxants • Local anesthetics • Physical therapy • Thermotherapy • Muscle coolant therapy • Ultrasound therapy • Electrogalvanic stimulation therapy • TENS www.indiandentalacademy.com
  • 72. • • • • • • Acupuncture Cold laser Manual techniques – Massage – superficial and deep Muscle conditioning Passive and active muscle stretching www.indiandentalacademy.com
  • 73. Clinical diagnosis and Management www.indiandentalacademy.com
  • 74. Masticatory muscle disorders • • Most common complaint of patient- muscle pain associated with manual palpation or functional manipulation of muscles. Restricted mandibular movements • • Protective co contraction / muscle splinting : Guarding / protective mechanism. • Is CNS response to injury or threat to injury • In the presence of an event the activity of appropriate muscles is altered to protect the injured part from further injury. • CNS increases the activity of antagonistic muscles during contraction of agonist muscle www.indiandentalacademy.com
  • 75. • Etiology : • Altered sensory or proprioceptive input • Constant deep pain input • Increased emotional stress • History : recent injury • Clinical characteristics • Myalgia – not major complaint. • Structural dysfunction – slow mouth opening reveals near normal range of movements • No pain at rest • Increased pain with function • Feeling of muscle weakness www.indiandentalacademy.com
  • 76. • Management • Definitive therapy • As is a protective response, no indication to treat muscle condition itself. • Treatment should be directed towards etiology • Correction/ elimination of altered sensory inputs • Identify and address the deep pain • Control of emotional stress • Supportive therapy • Initiated when etiology is trauma • Restrict the use of mandible to within painless limits • Soft diet • Simple muscle relaxation therapy, pain killers. www.indiandentalacademy.com
  • 77. • Local muscle soreness / non inflammatory myalgia: • First response of muscle to continued protective co-contraction. • Represents a change in local environment of muscle tissues • Etiology • Prolonged co contraction • Trauma • Local tissue injury – injections, tissue strains • Unaccustomed use • Pain modulation phenomenon – altered pain sensations/ referred symptoms. • Idiopathic myogenous pain www.indiandentalacademy.com
  • 78. • Cyclic muscle pain condition Trauma Protective co-contraction Local muscle soreness Deep pian www.indiandentalacademy.com
  • 79. • Clinical characteristics • Structural dysfunction - slow mouth opening reveals limited range of movements • No pain at rest • Increased pain with function • Actual muscle weakness • Local muscle tenderness www.indiandentalacademy.com
  • 80. • Management • Definitive therapy • Decrease sensory input of pain to CNS • Restrict the use of mandible to within painless limits • Soft diet, smaller bites and slower chewing encouraged. • Pt. encouraged to use muscles to within painless limits • Occlusal disengagement • Pt. Should be made aware of subconscious oral habits • Occlusal appliance therapy • Elimination of deep pain input. www.indiandentalacademy.com
  • 81. • Supportive therapy : • Reduce pain • Analgesics for 7-10 days to break the cyclic effect of deep pain • Manual physical therapy – • Passive muscle stretching, gentle massaging • Relaxation therapy to reduce stress www.indiandentalacademy.com
  • 82. • Myofascial pain ( trigger point myalgia) • Regional myogenous pain condition characterized by local areas of firm, hypersensitive bands of muscle tissue called trigger points. • First described by Travell and Rinzler in 1952. • It was suggested that certain nerve endings become sensitized by algogenic substances that create localized zone of hypersensitivity. • Local increase in temperature at site of trigger point –suggests increase in metabolic demand / reduction of blood flow . • A trigger point is a circumscribed region in which relatively few motor unit are in contraction ( myospasm- all motor units contract). www.indiandentalacademy.com
  • 83. • Trigger points are a source of constant deep pain and produce central excitatory effects - referred pain in particular predictable pattern according to location of involving trigger points. • Etiology : • • • • • • • Prolonged local muscle soreness Constant deep pain Increased emotional stress Sleep disturbances Local factors – habits, posture, strains Systemic factors - viral infections, fatigue, hypovitaminosis Idiopathic trigger point mechanisms • History : misleading - patient will complain of heterotrophic pain and not actual source of pain. www.indiandentalacademy.com
  • 84. • Clinical characteristics : • Structural dysfunction • Pain at rest • Increased pain with function • Presence of trigger points • Tenderness on palpation of trigger points and elicitation of referred pain • Trigger points become dormant /latent ,get activated by factors such as flu, upper resp.tract infections, increased heat, cold etc. • Referred pain • Secondary hyperalgesia – sensitivity to touch of scalp. • Protective co-contraction • Autonomic responses – tearing / drying of eyes, nasal discharge, blanching of tissues – on same side of pain www.indiandentalacademy.com
  • 85. • Management • Definitive treatment • Eliminate / reduce etiologic factors • Eliminate local muscle soreness • Reduce local and systemic factors contributing to myofacial pain • Sleep disturbances – sedatives, tricyclic antidepressants – Amitryptiline 10 mg before bedtime. • Treatment and elimination of trigger points – painless stretching of muscle containing trigger points • Spray and stretch • Vapocoolant ( fluoromethane spray sprayed in direction of referred symptoms and then muscle stretched • Cutaneous nerve stimulation temporarily reduces pain in the area. www.indiandentalacademy.com
  • 86. • Pressure and massage • Increase pressure to trigger point to 10 lbs for 30 – 60 secs. • If painful, discontinue • Ultrasound and electrogalvanic stimulation • Ultrasound – produces deep heat causing local muscle relaxation • High –volt electrogalvanic stimulation rhythmically pulsates the muscle to levels of fatigue, causing muscle relaxation. • Injection and stretch • 2% lignocaine without vasoconstrictor • Eliminates immediate pain • it is diagnostic of the site of origin of pain. www.indiandentalacademy.com
  • 87. • Supportive therapy • Muscle relaxants • Analgesics • Regular exercise www.indiandentalacademy.com
  • 88. • Myospasm : • CNS induced tonic muscle contraction • Etiology • Protracted local muscle soreness • Abuse of trigger point pain • Muscle fatigue and local electrolyte balance changes • Systemic conditions • Deep pain input • History : • Sudden onset of pain, tightness and change in jaw position with muscle rigidity www.indiandentalacademy.com
  • 89. • Clinical manifestations : • Structural dysfunction • Marked restriction of range of movement • Acute malocclusion • Pain at rest • Increased pain with function • Muscle tightness • Local muscle tenderness www.indiandentalacademy.com
  • 90. • Management : • Definitive treatment • Reduce pain and passively stretching involved muscle • Eliminate etiologic factors • Supportive therapy • Physical therapy – massaging and passive stretching • Pharmacologic therapy is not indicated because this is an acute condition. www.indiandentalacademy.com
  • 91. • Myositis (inflammatory myalgia) • Inflammation of muscle tissue • Non infectious myositis • Infectious myositis • History : • Duration of pain – long history of myogenous pain • Constancy of pain - pain present even at rest www.indiandentalacademy.com
  • 92. • Management • Definitive therapy • Reduction of symptoms is slow and not dramatic as is a inflammatory condition and takes time to resolve. • Elimination of etiology – will slowly resolve inflammation and reduce symptoms slowly • Restrict the use of mandible to within painless limits • Soft diet, smaller bites and slower chewing encouraged. • Pt. encouraged to use muscles to within painless limits • Avoid exercise and / or injections • Occlusal disengagement • Occlusal appliance therapy • Anti-inflammatroy therapy – NSAID’s www.indiandentalacademy.com
  • 93. • Supportive therapy • No physical therapy – as any movement cause pain • Moist heat/ice therapy • as symptoms begin to resolve Ultrasound therapy and gentle stretching can be begun. • As treatment takes time – hypotrophic changes and myostatic contractures can develop. • Isometric jaw exercises, passive stretching can be done once acute symptoms are resolved. www.indiandentalacademy.com
  • 94. • Fibromyalgia • Chronic musculoskeletal disorder • History • Chronic generalized musculoskeletal pain in numerous sites throughout body • Patient presents with sedentary lifestyle • Etiology • Constant deep pain • Emotional stress www.indiandentalacademy.com
  • 95. • Clinical manifestations : • Generalized Structural dysfunction • Marked restriction of range of movement • Pain at rest • Increased pain with function • Presence of tender points – which do not induce heterotrophic pain • Sedentary physical condition www.indiandentalacademy.com
  • 96. • Management : • Treatment should be conservative • As it is not primary masticatory muscle disorder, proper referral for rheumatology, psychology, physical therapy must be made. www.indiandentalacademy.com
  • 97. Masticatory muscle model www.indiandentalacademy.com
  • 98. Temporomandibular joint disorders • Internal derangement is a condition characterized by either an abnormal anatomic disc-condyle relationship, or a normal relationship associated with disc immobility. • Arthralgia, Dysfunction symptoms are associated with condylar movement and reported as sensations of clicking, catching of joint- constant and repeatable and some times progressive • Are divided into • Derangement of condyle disc complex • Structural incompatibility of articular surfaces • Inflammatory disorders www.indiandentalacademy.com
  • 99. • Internal derangements can be classified into four stages. • The earliest stage involves an incoordination phase, - not associated with joint pain or noise, and is only recognized when patients are asked if their jaw joint moves smoothly and they reply that they feel a slight catching or binding sensation. • The onset of limited mouth opening associated with adhesion of the disc to the fossa in a relatively normal position • The next stage is anterior or anteromedial displacement of the disc, which returns to a normal relationship with the condyle during the opening movement and is associated with a clicking or popping sound. www.indiandentalacademy.com
  • 100. • If the degree of disc displacement progresses,reduction to a normal relationship on mouth opening does not occur, the patient's jaw is locked, and opening is initially limited to 23 to 25 mm • This stage is not characterized by joint clicking or popping www.indiandentalacademy.com
  • 101. Derangement of condyle disc complex • • • • • Etiology: • Breakdown of normal rotational function of disc on condyle. • Elongation of discal collateral ligaments and inferior retrodiscal lamina • Thinning of posterior border of disc • Trauma Types Disc displacements Disc dislocation with reduction Disc dislocation without reduction www.indiandentalacademy.com
  • 102. • Disc displacements: Inferior retrodiscal lamina and discal collateral ligament – elongated Disc can be positioned anteriorly by superior pterygoid muscle + thinning of posterior border of disc Disc anteriorly positioned Abnormal translatory shift of mandible during opening [ click ] www.indiandentalacademy.com
  • 103. www.indiandentalacademy.com
  • 104. • History : • trauma ^ joint sounds • Pain - +/- ( intracapsular and concomitant with click, directly related to joint function) • Clinical characteristics • joint sounds • Reciprocal clicking- two clicks at different degrees of opening and closing click- near intercuspal position. • Normal range of jaw movements www.indiandentalacademy.com
  • 105. • Disc dislocation with reduction: Inferior retrodiscal lamina and discal collateral ligament – further elongated + posterior border of disc sufficiently thinned Disc slip/forced completely through the discal space, condyle and disc not articulating  If patient can manipulate the jaw so as to reposition the condyle on the posterior border of disc- disc is reduced. www.indiandentalacademy.com
  • 106. www.indiandentalacademy.com
  • 107. • History: • Long history of clicking ,recent catching sensation. • Pain +/• Clinical characteristics : • Unless the jaw is shifted to the point of reducing the disclimited range of opening • Opening reduces the disc – deviation in path of opening • After disc is reduced – normal range of mandibular movements present. • Click – at piont of recapturing of disc. www.indiandentalacademy.com
  • 108. • Disc dislocation without reduction : • Elasticity of superior retrodiscal lamina lost – recapturing of disc more difficult • When disc is not reduced ,forward translation of condyle pushes the disc in front of condyle. • History • Patient knows when dislocation has occurred. • H/O Clicking before the locking • Restricted jaw opening- closed lock jaw • Pain – when trying to open beyond joint restriction • Clinical characteristics : • Limited jaw movement • Pain – when trying to open beyond joint restriction • Pain when loading joint bilaterally manually www.indiandentalacademy.com
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  • 110. • Management • Disc displacements and Disc dislocation with reduction • Reestablishment of normal disc – condyle relationship • Farrar ( early 1970’s)introduced anterior repositioning appliance, which provides an occlusal relationship that requires the mandible to be positioned forwardly, that will reestablish the normal disc condyle relationship. • This anterior repositioning will recapture the disc onto the condyle. • Worn 24 hrs /day for 4 – 6 months. • This appliance reduced painful joint symptoms by improving disc - condyle relationship. • What next ????? www.indiandentalacademy.com
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  • 112. • Two different belief systems existed. 1. Mandible to be permanently repositioned in this position • Occlusal adjustments 2. Once the discal ligaments are repaired, the mandible should be returned to musculoskeletally stable position and the disc would remain in proper position. • Neither was supported by long term data www.indiandentalacademy.com
  • 113. • In early short term studies, the anterior repositioning appliance proved to be much more effective in reducing intracapsular symptoms than the more traditional muscle relaxation appliance. • This, lead the profession to believe that returning the disc to its proper relationship with the condyle was an essential part of treatment. • The long term studies reveal that that anterior repositioning appliances are not effective • They are helpful in reducing painful symptoms in 75% cases, but joint sounds are more resistant to therapy and do not always indicate a progressive disorder. www.indiandentalacademy.com
  • 114. • Anterior repositioning appliance cannot recapture the disc, instead as the condyle returns to the fossa, it posteriorly to articulate on adaptive retrodiscal tissue. • If the tissues are adequately adapted, loading occurs without pain. • Result is painless joint with clicking on condylar movement. • Earlier, dental profession believed that presence of join t sounds indicated treatment failure. • Studies show that Some dysfunction is likely to persist once the joint structures are altered. • Controlling pain while aloowing joint strucutres to adapt is the most important role of the therapist. www.indiandentalacademy.com
  • 115. • A few long term studies do support that permanent alteration of occlusal conditions is successful in controlling major symptoms. • Such treatment regimen should be reserved only for those patients with significant orthopedic instability www.indiandentalacademy.com
  • 116. • Disadvantage of use of ARA – • development of posterior open bite – due to reversible myostatic contracture of inferior lateral pterygoid muscle. • Gradual re- lengthening of the muscle can be accomplished by slowly stepping back the condyle to more stable anterosuperior position in fossa. • Can be done by • Adjusting the appliance to allow the condyle to return to musculoskeletally stable position • Slowly decreasing use of appliance. • Degree of myostatic contracture α length of time appliance is worn • Only night time wearing – gradually reduced as symptoms reduce. www.indiandentalacademy.com
  • 117. • In some pts, posterior open bites develop even after careful use of appliance. • Causes • Myofibrotic contracture of inferior lateral pterygoid muscle. • Thickened retrodiscal tissue- not allow the condyle to seat in fossa • Preexisting orthopedic instability. www.indiandentalacademy.com
  • 118. • Main aim is to Reduce intracapsular pain not recapture the disc. • Muscle relaxation appliance • Anterior repositioning splint • Night /day wear( less time – minimal occlusal effects.), reduce as symptoms resolve. • Elimination of appliance – return of symptoms • – not enough time given for adaptive process • - there is orthopedic instability – dental therapy indicated. www.indiandentalacademy.com
  • 119. • • • • • Supportive therapy : Decrease loading of joint – soft diet, slower chewing etc. Not allow joint to click. If inflammation present – NSAID’s Passive exercises. www.indiandentalacademy.com
  • 120. • Disc displacements without reduction: • Definitive therapy: • Initial therapy include - Recapture disc by manual manipulation • Success depends on three factors : • Level of activity of superior lateral pterygoid- it has to be fully relaxed – local anesthetic injection if remains active due to pain / dysfunction • Disc space increased – relaxation of elevator muscles • Condyle must be maximum forward translatory position for maximum activity of superior retrodiscal lamina activity. www.indiandentalacademy.com
  • 121. • Reduce displacement without assistance –move mandible to contra lateral side and then open moth maximally. • Reduced by operator by applying downward forward distraction force on condyle. Once reduced – ARA given . • www.indiandentalacademy.com
  • 122. • If disc does not reduce – superior retrodiscal lamina lost its elastic property • Conservative approach first attempted -Muscle relaxation appliance - encourages adaptation of retrodiscal tissues. • If this fails – surgical procedures considered. www.indiandentalacademy.com
  • 123. • Surgical considerations for condyle disc derangement disorders: • Conservative methods • Arthrocentesis • Pumping the joint • Arthroscopy • Arthrotomy – open joint surgery • Plication • Discectomy • Discal implants • Silastic implants • Proplastic teflon discal implants • Dermal and auricular cartilage grafts www.indiandentalacademy.com
  • 124. Structural incompatibility of articular surfaces • • • • Etiology Macrotrauma Trauma causing hemarthrosis Surgical intervention • Types 1. Deviation in form 1. Disc /condyle /fossa 2. Adhesions 1. Disc to condyle 2. Disc to fossa 3. Subluxation 4. Spontaneous dislocation www.indiandentalacademy.com
  • 125. Deviation in form : • Actual changes in shape of articular surfaces • Disc – thinning or perforations • condyle /fossa flattening • • Clinical Characteristics: Repeatable observation at a repeatable point of opening • • Management : Surgical approach • Bony incompatibility – bone smoothened and rounded • Discoplasty www.indiandentalacademy.com
  • 126. • Adhesions : • Prolonged static loading of joint – exhausts weeping lubrication of joint • Hemarthrosis • History : • Temporary adhesions: catching sensation limited opening afetr prolonged static loading of joint • Click/popping sound • Return of normal joint function • Permanent adhesions: Reduced function , pain on opening more- stretching of ligaments www.indiandentalacademy.com
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  • 128. • Clinical Characteristics : • Adhesions in superior joint cavities : • Limited opening – only rotatory movements of condyle as translatory movements inhibited • No pain on bilateral manipulation. • Fixed disc /Posterior dislocation of disc : • Normal opening with restriction during closing • Deviation during closure • Adhesions in inferior joint cavity : • Difficult to diagnose • Patient can open to normal interincisal distance but senses a catching or jumping on way to maximum opening. www.indiandentalacademy.com
  • 129. • • • • Management : Muscle relaxation appliance Permanent adhesions - Arthroscopic surgery Supportive therapy to alleviate he pain and dysfunction. www.indiandentalacademy.com
  • 130. • Subluxation / Hyper mobility : • Condyle movement beyond crest of eminence – jump forward to wide-open position. • Articular eminence anatomy – steep posterior slope and long anterior slope. • History : • Jaw ‘goes out’ whenever pt opens wide • Clinical features • Repeatable phenomenon • No pain – unless abused • Examination – at later stage of opening condyle will jump forward leaving depression/ void behind it. www.indiandentalacademy.com
  • 131. • Management : • Surgical alteration of joint itself Eminectomy – reduces the steepness of articular eminence, hence reduces the posterior rotation of condyle during full translation. www.indiandentalacademy.com
  • 132. • Spontaneous dislocations : • Hyperextension of TMJ leading to anterior dislocation of disc. • Premature activity of superior pterygoid muscle- forward pull of disc through anterior disc space – spontaneous anterior dislocation • Associated with long dental appointments • Pt cannot close mouth • Pain present • Called open lock www.indiandentalacademy.com
  • 133. • Management : • Treatment is directed towards increasing disc space- allows the superior retrodiscal lamina to retract the disc. www.indiandentalacademy.com
  • 134. Inflammatory disorders • Synovitis/ Capsulitis / Retrodiscitis: • Inflammation of synovial tissue or capsular ligament or retrodiscal tissue. • • Etiology : trauma ,repeated abuse Clinical features: • Continuous deep pain accentuated by function • Tenderness on palpation • Limited opening secondary to pain • Edema- condyle displaced inferiorly – ipsilateral posterior open bite. • Retrodiscitis – edema displaces condyle forward and down the eminence www.indiandentalacademy.com
  • 135. • Management • NSAID’s • Hot fermentation • Ultrasound therapy www.indiandentalacademy.com
  • 136. Arthritides • Inflammation of articular surfaces of joint • Categorized into • Osteoarthritis • Osteoarthrosis • Polyarthritides www.indiandentalacademy.com
  • 137. • Osteoarthritis / Osteoarthrosis : • Non inflammatory condition with deterioration of articular surfaces and underlying bone due to mechanical overloading of joint( more than condylar remodeling capacity. • Active condition – Osteoarthritis • As condylar remodeling occurs, condition is more stable – bone morphology remains altered- Osteoarthrosis • Two forms : primary or secondary form www.indiandentalacademy.com
  • 138. • Primary disease is a gradually developing process and is caused by the normal wear and tear to which the joint is subjected. • occurs bilaterally • occurs in persons > 50 yrs • The large weight bearing joints are most commonly involved. • When the distal interphalangeal joints are involved -enlargements are called -Heberden's nodes. • proximal interphalangeal joints -Bouchard's nodes. • Primary degenerative disease of the TMJ is generally asymptomatic, although patients may occasionally complain of joint stiffness, crepitation, and mild pain. www.indiandentalacademy.com
  • 139. • Secondary degenerative joint disease • 20 -40 years of age. • It is caused by a speeding up of the degenerative process by trauma, persistent parafunction, or increased stress on the joint produced by loss of teeth or severe malocclusion. • It is characterized by TMJ pain, joint tenderness, limitation of mouth opening and, in the late stages - crepitation. • Frequently unilateral. www.indiandentalacademy.com
  • 140. • Radiographic changes : • The earliest change is subchondral sclerosis. • As the condition progresses, there is condylar flattening and lipping, erosion, or osteophyte formation. • In the late stages, breakdown of the subchondral bone gives rise to a bone "cyst“ within the condyle. • When the intra-articular disc becomes involved, there will be narrowing of the joint space. • Changes are more severe in the secondary than in the primary form www.indiandentalacademy.com
  • 141. • Polyarthritides : • Group of disorders in which articular surfaces become inflamed. • • • • Traumatic arthritis Infectious arthritis Rheumatoid arthritis Hyperuricemia www.indiandentalacademy.com
  • 142. Rheumatiod arthritis • Pt complain of • a deep, dull, aching pain in the preauricular region exacerbated by function, • swelling of the preauricular tissues during the acute phases, and progressive limitation of jaw movement. • Severe destruction of the condyle occurs in the late stages - a progressive Class II malocclusion and an anterior open bite develop due to loss of ramal height. • The radiographic features include • a loss of the intra-articular joint space, • condylar destruction, • erosion of the glenoid fossa. www.indiandentalacademy.com
  • 143. • • • • • laboratory tests: Test for rheumatoid factor The erythrocyte sedimentation test The presence of antinuclear antibodies, The presence of HLA-DW5 and HLA-DR8 • • • • • • • Juvenile form - under 16 years of age. two peaks of onset - ages of 1-3 yrs and 8 -12 yrs. three subtypes: systemic (Still's disease), Polyarticular – most common pauciarticular. a characteristic feature is micrognathia and a Class II relationship, referred to as a birdface deformity. • Ankylosis is more common with juvenile rheumatoid arthritis than with the adult onset type. www.indiandentalacademy.com
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  • 146. • Inflammatory disorders of associated structures • Temporalis tendonitis – prolonged activity of temporal muscle Unilateral , Constant pain in temple region, aggravated during function Restricted jaw opening Intraoral palpation of temporal tendon produces pain • Stylomandibular ligament inflammation: Intraoral palpation- tender www.indiandentalacademy.com
  • 147. Chronic mandibular hypomobility • Long term painless restriction of mandible. • Pain elicited on if forceful opening beyond limitations is attempted. • According to etiology • Ankylosis • Muscle contracture • Coronoid process impedence www.indiandentalacademy.com
  • 148. • • • • • Ankylosis Bony / fibrous intracapsular adhesions. Restricted mandibular movements. Etiology- macro trauma, hemarthrosis, surgery If unilateral- ipsilateral deviation of mandible. • Muscle contracture : • Clinical shortening of resting length of muscle without interfering with in its ability to contract further. • Painless limitation of mouth opening. • Myostastic contracture : results when muscle is kept from fully relaxing( due to pain in associated structure) for prolonged time. www.indiandentalacademy.com
  • 149. • Myofibrotic contracture : • Excessive tissue adhesions within muscle or its sheath • Follows myositis / trauma to muscle • Condylar impedance: • Protrusive movements especially limited • Trauma /infection in area anterior to coronoid process – leading to fibrous adhesions in these tissues. www.indiandentalacademy.com
  • 150. • Management : • • Ankylosis : Surgical treatment – arthroscopic surgery • • • • Muscle contractures Passive stretching exercises Resistant opening exercises Surgical detachment and reattachment of muscles • • • Coronoid impedence Ultrasound therapy with passive stretching exercises Surgery contraindicated • No supportive therapy indicated as all are asymptomatic conditions www.indiandentalacademy.com
  • 151. Conclusion • Much of the difficulty encountered by clinicians in successfully treating TMD patients is based on diagnostic inaccuracy and, therefore, considerable emphasis has to be placed on the proper recognition of the various temporomandibular disorders. • Faced with a variety of imaging techniques, the clinician needs to decide when imaging should be used and the accuracy of the information that the imaging will provide. • In addition to accurate diagnosis, having an understanding of the etiology of a condition is helpful in determining therapy. www.indiandentalacademy.com
  • 152. • Of the various conditions encountered in the orthodontic patient, the two most common are masticatory myofascial pain and dysfunction and the internal derangements of the temporomandibular joint. • These conditions are of particular concern, not only because their presence may require modification in orthodontic treatment, but also because there have been claims that they can be caused by such therapy . • Hence , a rational approach to the general management of these conditions is required www.indiandentalacademy.com
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