TEMPOROMANDIBULAR
DISORDERS
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

3/5/2...
Introduction
The Temporomandibular joint is a unique joint present in
the body and is different than other joints of the b...
Components of
Temporomandibular joint function

• Occlusion
• Muscles of Mastication
• Temporomandibular joint

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...
Occlusion
TOOTH TO TOOTH OCCLUSION

STATIC / ANATOMIC OCCLUSION:

TOOTH TO TWO TEETH OCCLUSION

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Occlusion
FUNCTIONAL OCCLUSION:

AN OCCLUSION THAT IS IN HARMONY
WITH THE JOINT AND ASSOCIATED MUSCULATURE.
ROTH’S CRITERI...
Occlusion
FACTORS CONTROLLING POSTERIOR DISCLUSION ON FUNCTIONAL
MOVEMENTS:

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Occlusion
FACTORS CONTROLLING POSTERIOR DISCLUSION ON FUNCTIONAL
MOVEMENTS:
INCISOR ANGULATIONS:

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Occlusion
FACTORS CONTROLLING POSTERIOR DISCLUSION ON FUNCTIONAL
MOVEMENTS:
INCISOR ANGULATIONS:

Upper Front Tooth Analyz...
Occlusion
FACTORS CONTROLLING POSTERIOR DISCLUSION ON FUNCTIONAL
MOVEMENTS:
INCISOR ANGULATIONS:

Lower Front Tooth Analyz...
Occlusion
FACTORS CONTROLLING POSTERIOR DISCLUSION ON FUNCTIONAL
MOVEMENTS:
INCISOR ANGULATIONS:
INTER INCISAL ANGLE OF 12...
Occlusion
FACTORS CONTROLLING POSTERIOR DISCLUSION ON FUNCTIONAL
MOVEMENTS:
OVERBITE AND OVERJET CONSIDERATIONS: CUSP HEIG...
Occlusion
FACTORS CONTROLLING POSTERIOR DISCLUSION ON FUNCTIONAL
MOVEMENTS:
OVERBITE AND OVERJET CONSIDERATIONS: CANT OF T...
Occlusion
FACTORS CONTROLLING POSTERIOR DISCLUSION ON FUNCTIONAL
MOVEMENTS:
CANINE GUIDED OCCLUSION:

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Neuromuscular Adaptation

ACCEPTABLE NEUROMUSCULAR
ADAPTATION OR CR – CO
DISCREPANCY:
1.

1 mm Antero posterior

2.

1mm V...
Functional Anatomy of the
TMJ

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Functional Anatomy of the
TMJ

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Functional Anatomy of the
TMJ
FACTORS CONTROLLING NORMAL DISC – CONDYLE POSITION:
1.

NORMAL MORPHOLOGY OF THE DISC

2.

L...
Functional Anatomy of the
TMJ
FACTORS CONTROLLING NORMAL DISC – CONDYLE POSITION:
1.

LIGAMENTS

2.

INTERARTICULAR PRESSU...
Etiology of TMD
Etiology of TMD is multifactorial

•
•
•
•

Trauma.
Psychosocial factors.
Systemic factors.
Etiology in re...
Trauma
A force that exceeds the normal functional loading of the joint can lead
to injury of the affected structures

Macr...
Macrotrauma
Macrotrauma is a sudden force to the joint that
causes structural alterations.
Causes: Injury or trauma and Ia...
Microtrauma
Microtrauma is any small force to joint structures that
occur repeatedly over a long period.

• Static loading...
Microtrauma
Static Loading: Stationary application of excessive
pressure.
Bruxism / Emotional stress / Hard chewing
Loss o...
Microtrauma
Impact loading: occurs during the stage of maximum
intercuspation when a displaced condyle unduly
compresses a...
Microtrauma
Frictional movement: Occurs due to overloaded movement
that exceeds the ability of weeping lubrication to prev...
Psychosocial factors
• A strong association is present between
emotional stress and TMD.
• Mechanistic model of pain does ...
Systemic factors
• Presence of collagen and other
connective tissue disorders predisposes
to TMD.

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Etiology in relation to
Orthodontics
•
•
•
•
•
•
•
•

General statistics
First premolar extractions
Head gear and Class II...
General statistics
• According to Graber’s study on 347 TMD patients…..
– 53% had Class II malocclusions.
– High incidence...
First premolar extractions
and TMD
“ first premolar extractions was a technique that was never designed
with the face, the...
First premolar extractions
and TMD

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First premolar extractions
and TMD
• Larsson and Rönnerman studied 23 Swedish adolescent patients who had
been treated ort...
First premolar extractions
and TMD
•
•

•

Kundinger et al radiographically (with corrected tomography) studied the condyl...
First premolar extractions
and TMD

“ The literature review shows no scientific basis for the claim that
premolar extracti...
Headgear and Class II
elastics
Grummons alleged that orthodontic mechanotherapies such as
Class II and III elastics, mandi...
RPHG and Class III
elastics
RPHG and Class III elastics produce a distal
driving force of the mandible and condyle. This w...
Midline switch / cross
elastics
When cross elastics are used there is a
displacement of the mandible and condyle to one si...
The Herbst appliance
• Pancherz and Pancherz in 1982 studied 20 patients
undergoing Herbst treatment. There was a high
pre...
The Herbst appliance
• Ruf and Pancherz in 2000 studied 62 patients undergoing
Herbst treatment. They observed:
– All cond...
Overbite and anterior
axial inclinations
• Trying to correct Upper anterior spacing
and axial inclination in deep bite cas...
Retention phase
Majority of orthodontically treated cases may have dental deep bites at
the beginning and some also have s...
Retention phase

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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 SENS...
Changes in the Muscles
Muscle splinting: is an involuntary CNS induced
hypertonic condition.
• Splinting is normal protect...
Changes in the muscles
Myospasms: are involuntary CNS induced muscular
contractions. Myospasm causes CNS to recruit motor
...
Changes in the joint
MICROTRAUMA
THINNING OF DISCAL LIGAMENTS
FUNCTIONAL DISPLACEMENT OF THE
DISC
SINGLE CLICK
RECIPROCAL ...
Normal disc-condyle
relation

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Functional dislocation with
reduction

• PAIN
•CLICKING
•JOINT PAIN AND MUSCLE PAIN,
•DEVIATED PATH OF CLOSURE.
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...
Functional dislocation
without reduction
FUNCTIONAL DISLOCATION / CLOSED LOCK

• LIMITED MOUTH OPENING
• NO PAIN
•NO CLICK...
Disc interference disorders

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Classification of
Temporomandibular disorders
•
•
•
•
•

Masticatory muscle disorders
Disc interference disorders
Inflamma...
Masticatory muscle
disorders
• Protective muscle splinting
• Masticatory myospasm
– Elevator muscle spasm
– Lateral pteryg...
Masticatory muscle
disorders
• Protective muscle splinting
– Functional myalgia without structural restraint.
– Masticator...
Disc interference disorders
•
•
•
•
•

Class I interference disorders
Class II interference disorders
Class III interferen...
Disc interference disorders
• Class I interference disorders
– Symptoms occur during clenching of the teeth.

• Class II i...
Disc interference disorders
• Class III interference disorder:
– Due to excessive interarticular pressure.
– Due to struct...
Disc interference disorders
• Internal derangement
– Detached sup retrodiscal lamina:
• Anterior dislocation of the disc.
...
Disc interference disorders
• Class IV interference disorder:
– Mouth opening extends beyond the normal
anterior limit of ...
Inflammatory disorders
•
•
•
•

Synovitis
Capsulitis
Retrodiscitis
Inflammatory arthritis

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Chronic mandibular
Hypomobility
•
•
•
•

Pseudoankylosis
Contractured elevator muscles
Capsular fibrosis
Ankylosis

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Growth disorders
• Neoplasia
• Abberant development
• Acquired change

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Diagnosis

• Functional examination
• Radiological examination

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Functional examination
• Palpation: Muscles
• Digital palpation is used
• Muscle should be evaluated
through out it’s leng...
Functional examination
• Two methods of
palpation- Flat palpation
and Pincer palpation.
• Flat palpation- use
middle finge...
Functional examination
• Temporalis: Flat palpation
when palpating the anterior,
middle and posterior
portions.
• Temporal...
Functional examination
• Palpation
• STAND IN FRONT OF THE PATIENT.
• LATERAL POLES OF BOTH CONDYLES SHOULD
BE PALPATED SI...
Functional examination
• Auscultation
• Click: A single noise of short
duration that occurs at any point in
the active ran...
Functional examination
AUSCULTATION:

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Functional examination

EARLY
INT

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LATE

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Functional examination
EARLY OPENING CLICK – 0 TO 15 mm

MIDDLE OPENING CLICK – 16 TO 30 mm
LATE OPENING CLICK – 31 TO 50 ...
Functional examination
• Functional analysis
– Postural rest position.
– Maximum mouth opening
– Path of mandible on openi...
Functional examination
• Postural rest position
– Command method
– Non command method
– Combined method

• Methods of meas...
Functional examination
• Deviated mouth
opening
• Deviation always
occurs towards the
side of decreased
mobility.
• Condyl...
Functional examination
• Path of the mandible on opening

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Functional examination
Laterotrusive movements

TOWARDS LEFT
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TOWARDS RIGHT
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Functional examination
• Path of closure from
postural rest to
centric occlusion:

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...
Functional examination
AXIOGRAPH:

• Compares hinge axis
pathways of normal
individuals and patients with
TMD.
• Records h...
Functional examination
AXIOGRAPH TRACINGS:

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Functional examination
FUNCTIONAL MOUNTING OF THE PATIENT’S MODELS:

FACE BOW TRANSFER:

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Functional examination
FUNCTIONAL MOUNTING OF THE PATIENT’S MODELS:
BITE REGISTRATION FOR CENTRIC
RELATION: ROTH’S POWER C...
Functional examination
ARTICULATOR MOUNTING:
PANADENT ARTICULATOR

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CONDYLAR POSITION INDICATOR

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Functional examination
CR – CO DISCEPANCY RECORDINGS OF THE CPI:

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Radiological examination
• Hard Tissue
– Panoramic radiograph
– Extra oral Projections
• Transcranial
• Transpharyngeal (P...
Panoramic Radiograph

•
•
•
•

A screening projection
Gross osseous changes- erosions, osteophytes
No information about co...
Transcranial projection
• Provides a sagittal view of
the lateral aspects of
condyle and temporal
component
• Only lateral...
Transpharyngeal
projection
• Provides a sagittal view
of the medial pole of the
condyle
• The temporal
component is not
im...
Transorbital projection
• Provides an anterior
view of the TMJ
• Entire mediolateral
aspect of the
condylar head and
neck ...
Conventional tomography
• A radiographic technique
that produce thin image
slices free of
superimpositions of adjacent
str...
Conventional tomography

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Conventional tomography

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Computed tomography
• Image slices are
made in both
sagittal and coronal
planes.
• 3D images can be
constructed
• Cannot p...
Computed tomography

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Computed tomography

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Arthrography
• A technique in which an indirect image of the
disk is obtained by injecting a radio opaque
contrast agent i...
Magnetic Resonance
Imaging
• Excellent images of
soft tissues
• Imaging of the disk
in all three planes
• Contraindication...
Magnetic Resonance
Imaging

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Management of TMD
• Corrective treatment
– Splints
– Splints combined with orthodontic
appliances

• Palliative / supporti...
Splints
Splints are hard or soft removable acrylic appliances covering the
teeth.
MODE OF ACTION :
• Eliminate occlusal di...
Types of splints
STABILIZATION SPLINT:
OTHER NAMES: Muscle deprogramming splint, Flat
plane splint, Superior repositioning...
Types of splints
STABILIZATION SPLINT:
MODE OF ACTION:
• Changes tooth contact
• Alters muscle function

USES:
• Treatment...
Types of splints
ANTERIOR REPOSITIONING SPLINT:
OTHER NAMES: Repositioning splint, LARS ( Ligated
Anterior Repositioning S...
Types of splints
ANTERIOR REPOSITIONING SPLINT:
MODE OF ACTION:
• Change in tooth contact
•Change in muscle function
•Alte...
Types of splints
BITE PLANE SPLINT:
OTHER NAMES: Anterior jig, Luca jig, Hawley with ABP,
Anterior deprogrammer, Six point...
Types of splints
BITE PLANE SPLINT:
USES:
• When premature contacts are present in the
posterior segments.
• Reduce muscle...
Types of splints
PIVOT SPLINT: Based on the principle of joint traction.
DESIGN:

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1...
Types of splints
PIVOT SPLINT:
MODE OF ACTION:
• Unloading of the joint in cases of inflammation and internal
derangement....
Types of splints
SOFT SPLINT: An emergency appliance.
OTHER NAMES: Positioner, mouth guard, night guard.
DESIGN:

3/5/2014...
Types of splints
SOFT SPLINT:
USES:
• Athletics.
• For reducing parafunctional activity (not
substantiated).
• On a tempor...
Types of splints
MORA: Mandibular Orthopedic Repositioning Appliance.
OTHER NAMES: Gelb Splint.
USES:
• Change posterior o...
Types of splints
HYDROSTATIC SPLINT:
USE: Equalizes biting pressure over all teeth.
DESIGN:

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Management of TMD
• Type I disorder
– Mainly a muscle problem

• Type II disorder
– Mainly a disc problem
– Functional dam...
Management of Type I
disorder
PATIENT COMPLAINS OF…..
• Pain from different areas in the head, neck and shoulders but not ...
Management of Type I
disorder

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Management of Type I
disorder

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Management of Type I
disorder
TREATMENT:
• Splints
• Six point splint/ / Bite plane splint
• Stabilization splint

• Ortho...
Management of Type II
disorders
PATIENT COMPLAINS OF……..

• Increase in myogenic type of pain
• Onset of arthrogenic type ...
Management of Type II
disorders
TREATMENT:
• Splint
• Michigan plane / Stabilization splint
• Antero superior repositionin...
Management of Type III
disorders
PATIENT COMPLAINS OF…..
• No pain
• Impossible to eat
• Limited mouth opening

AIM OF TRE...
Management of Type III
disorders
TREATMENT:
• PHASE I:
• Immediately free the joint

• Type III splint
• PHASE II:
• Secti...
Conclusion
The TMJ is a very complex joint to deal with as
a whole. As people who move teeth and change
occlusion, the ort...
REFERENCES
• Extraction-non extraction dilemma as it relates to TMD –
Mclaughlin, Bennet; AO 1995, No 3
• The physiology o...
Thank you
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Temporomandibular disorders /certified fixed orthodontic courses by Indian dental academy

  1. 1. TEMPOROMANDIBULAR DISORDERS INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com 3/5/2014 www.indiandentalacademy.com 1
  2. 2. Introduction The Temporomandibular joint is a unique joint present in the body and is different than other joints of the body for two reasons – First it is not a single joint but a pair of joints working in tandem and in a well coordinated manner to meet functional demands. Second, unlike other joints of the body where movements of the joint are determined by functional demands and anatomy of the joint, the path of movements and position of the Temporomandibular joint at rest are determined by the teeth of either jaw which the joint helps to keep in an occluded position. 3/5/2014 www.indiandentalacademy.com 2
  3. 3. Components of Temporomandibular joint function • Occlusion • Muscles of Mastication • Temporomandibular joint 3/5/2014 www.indiandentalacademy.com 3
  4. 4. Occlusion TOOTH TO TOOTH OCCLUSION STATIC / ANATOMIC OCCLUSION: TOOTH TO TWO TEETH OCCLUSION 3/5/2014 www.indiandentalacademy.com 4
  5. 5. 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. 3/5/2014 www.indiandentalacademy.com 5
  6. 6. Occlusion FACTORS CONTROLLING POSTERIOR DISCLUSION ON FUNCTIONAL MOVEMENTS: 3/5/2014 www.indiandentalacademy.com 6
  7. 7. Occlusion FACTORS CONTROLLING POSTERIOR DISCLUSION ON FUNCTIONAL MOVEMENTS: INCISOR ANGULATIONS: 3/5/2014 www.indiandentalacademy.com 7
  8. 8. Occlusion FACTORS CONTROLLING POSTERIOR DISCLUSION ON FUNCTIONAL MOVEMENTS: INCISOR ANGULATIONS: Upper Front Tooth Analyzer - WhipMix Corp 3/5/2014 www.indiandentalacademy.com 8
  9. 9. Occlusion FACTORS CONTROLLING POSTERIOR DISCLUSION ON FUNCTIONAL MOVEMENTS: INCISOR ANGULATIONS: Lower Front Tooth Analyzer - WhipMix Corp 3/5/2014 www.indiandentalacademy.com 9
  10. 10. Occlusion FACTORS CONTROLLING POSTERIOR DISCLUSION ON FUNCTIONAL MOVEMENTS: INCISOR ANGULATIONS: INTER INCISAL ANGLE OF 125 DEG (STUART) INTER CUSPID ANGLE OF 135 DEG (RICKETTS) 3/5/2014 www.indiandentalacademy.com 10
  11. 11. Occlusion FACTORS CONTROLLING POSTERIOR DISCLUSION ON FUNCTIONAL MOVEMENTS: OVERBITE AND OVERJET CONSIDERATIONS: CUSP HEIGHT AND FOSSA DEPTH 3/5/2014 www.indiandentalacademy.com 11
  12. 12. Occlusion FACTORS CONTROLLING POSTERIOR DISCLUSION ON FUNCTIONAL MOVEMENTS: OVERBITE AND OVERJET CONSIDERATIONS: CANT OF THE OCCLUSAL PLANE 3/5/2014 www.indiandentalacademy.com 12
  13. 13. Occlusion FACTORS CONTROLLING POSTERIOR DISCLUSION ON FUNCTIONAL MOVEMENTS: CANINE GUIDED OCCLUSION: 3/5/2014 www.indiandentalacademy.com 13
  14. 14. 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. 3/5/2014 www.indiandentalacademy.com 14
  15. 15. Functional Anatomy of the TMJ 3/5/2014 www.indiandentalacademy.com 15
  16. 16. Functional Anatomy of the TMJ 3/5/2014 www.indiandentalacademy.com 16
  17. 17. Functional Anatomy of the TMJ FACTORS CONTROLLING NORMAL DISC – CONDYLE POSITION: 1. NORMAL MORPHOLOGY OF THE DISC 2. LIGAMENTS 3. INTERARTICULAR PRESSURE NORMAL MORPHOLOGY OF THE DISC AND LIGAMENTS: 3/5/2014 www.indiandentalacademy.com 17
  18. 18. Functional Anatomy of the TMJ FACTORS CONTROLLING NORMAL DISC – CONDYLE POSITION: 1. LIGAMENTS 2. INTERARTICULAR PRESSURE INTER ARTICULAR PRESSURE: 3/5/2014 www.indiandentalacademy.com 18
  19. 19. Etiology of TMD Etiology of TMD is multifactorial • • • • Trauma. Psychosocial factors. Systemic factors. Etiology in relation to Orthodontic treatment planning and execution. 3/5/2014 www.indiandentalacademy.com 19
  20. 20. Trauma A force that exceeds the normal functional loading of the joint can lead to injury of the affected structures Macro trauma Microtrauma 3/5/2014 www.indiandentalacademy.com 20
  21. 21. 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 3/5/2014 Loosening of the ligaments due to elongation Haemarthrosis, bruising & laceration Class II disc Class III disc interference interference disorder. disorder. www.indiandentalacademy.com 21
  22. 22. Microtrauma Microtrauma is any small force to joint structures that occur repeatedly over a long period. • Static loading. • Impact loading. •Frictional movement. 3/5/2014 www.indiandentalacademy.com 22
  23. 23. 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 3/5/2014 Perforation of the disc www.indiandentalacademy.com Class II disc interference disorder 23
  24. 24. 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 •Grating noise. •Class I and Class II disc interference disorder. 3/5/2014 www.indiandentalacademy.com 24
  25. 25. 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. 3/5/2014 www.indiandentalacademy.com 25
  26. 26. Psychosocial factors • A strong association is present between emotional stress and TMD. • Mechanistic model of pain does not apply to TMD: All pain arises from somatic disease or structural damage. • Biopsychosocial model: One cannot separate the mind from the body when analyzing pain. Both somatosensory and psycho social input for pain is present. 3/5/2014 www.indiandentalacademy.com 26
  27. 27. Systemic factors • Presence of collagen and other connective tissue disorders predisposes to TMD. 3/5/2014 www.indiandentalacademy.com 27
  28. 28. Etiology in relation to Orthodontics • • • • • • • • General statistics First premolar extractions Head gear and Class II elastics Herbst appliance- cause or cure? RPHG and Class III elastics Midline switch / Cross elastics Overbite and anterior axial inclination Retention phase 3/5/2014 www.indiandentalacademy.com 28
  29. 29. General statistics • According to Graber’s study on 347 TMD patients….. – 53% had Class II malocclusions. – High incidence of Class III malocclusions with anterior displacements, cross bite and tongue dysfunction.. – Most had a deep bite and horizontal growth pattern. – 68% had abnormal peri oral muscle function. – 21% showed tongue dysfunction. 3/5/2014 www.indiandentalacademy.com 29
  30. 30. First premolar extractions and TMD “ first premolar extractions was a technique that was never designed with the face, the stability of the occlusion and the health of the TMJ in mind” - Witzig and Spahl First premolar extraction Over retraction of incisors Premature contacts Distally displace the mandible and condyle 3/5/2014 www.indiandentalacademy.com 30
  31. 31. First premolar extractions and TMD 3/5/2014 www.indiandentalacademy.com 31
  32. 32. First premolar extractions and TMD • Larsson and Rönnerman studied 23 Swedish adolescent patients who had been treated orthodontically 10 years previously–18 with fixed appliances and 5 with functional appliances (activators). They concluded that extensive orthodontic treatment could be performed without fear of creating complications of TMD • Janson and Hasund studied 60 patients who were an average of 5 years out of retention. These patients presented with Class II, division 1, malocclusions and they were treated as adolescents. Thirty of the patients were treated with the extraction of first premolars and 30 were treated on a nonextraction basis. These authors also concluded that there was not a significant risk of developing TMD when undergoing orthodontic treatment with or without premolar extraction. •Dibbets and Van der Weele stated: “It is evident that over a 15 year period there exists no relationship at all between the choice of not to extract or to extract or to extract either first premolars or any other teeth and the registration of pain, limitation of mouth opening, crepitation, and radiological signs. 3/5/2014 www.indiandentalacademy.com 32
  33. 33. First premolar extractions and TMD • • • Kundinger et al radiographically (with corrected tomography) studied the condyle positions of 29 upper and lower premolar extraction cases and 29 untreated patients with no evidence of TMD. Gianelly evaluated the extraction of upper first premolars only to determine if this procedure led to posterior condylar displacement. In a study of 12 Class II patients treated with upper first premolar extractions, he observed that the condyles were in a similar position, an “anterior position,” when compared with an untreated control sample. Årtun et al tested the hypothesis that retraction of maxillary anterior teeth may lock the mandible in a posterior position and evaluated the relationship between condylar position and signs and symptoms of internal derangements in the temporomandibular joints. The authors concluded that they could not rule out the possibility that some patients acquire a more posterior location of the condyles during correction of Angle Class II, division 1, malocclusions with extraction only of maxillary premolars. However, the prevalence of patients with definitely posterior displacement of the condyles or joint sounds shortly after therapy was similar to the control group. 3/5/2014 www.indiandentalacademy.com 33
  34. 34. First premolar extractions and TMD “ The literature review shows no scientific basis for the claim that premolar extraction results in a higher incidence of TMJ disorders.” - Richard P. McLaughlin, John C. Bennett. AO 1995. 3/5/2014 www.indiandentalacademy.com 34
  35. 35. Headgear and Class II elastics Grummons alleged that orthodontic mechanotherapies such as Class II and III elastics, mandibular headgears, facial masks, chin cups, and balancing side occlusal interferences, can cause TMD. Finally, Solberg and Seligman, Thompson and Ricketts expressed similar viewpoints. William E Wyatt: 3/5/2014 www.indiandentalacademy.com 35
  36. 36. RPHG and Class III elastics RPHG and Class III elastics produce a distal driving force of the mandible and condyle. This would produce a reciprocal forward displacement of the disc and pressure on retrodiscal tissues. •It is better to have the patient wear lower or reverse headgear and Class III elastics only during waking hours. •Muscle tone (tension) positions the mandible forward. •When worn at night, the muscles are relaxed and there is more distal pressure on the condyle because compensating muscle activity is not in play. 3/5/2014 www.indiandentalacademy.com 36
  37. 37. Midline switch / cross elastics When cross elastics are used there is a displacement of the mandible and condyle to one side, resulting in unilateral distal driving force on the condyle. Can be used during day alone when the resting muscle tone can counter act the distal driving force. 3/5/2014 www.indiandentalacademy.com 37
  38. 38. The Herbst appliance • Pancherz and Pancherz in 1982 studied 20 patients undergoing Herbst treatment. There was a high prevalence of muscle and joint tenderness – 45% during treatment which decreased to 15% after treatment and to 10% 1 year after treatment. • Hansen et al in 1990 did a follow up study on 19 male subjects treated with Herbst 7.5 years earlier. TMJ sounds were detected in 26% and muscle tenderness in 32%. 8% of the condyles were posteriorly displaced. • Ruf and Pancherz in 1998 did a follow up study on 20 subjects who had undergone Herbst treatment 4 years earlier. They found moderate to severe signs of TMD in 25% of the subjects and mild signs and symptoms in 15% of the patients. 3/5/2014 www.indiandentalacademy.com 38
  39. 39. The Herbst appliance • Ruf and Pancherz in 2000 studied 62 patients undergoing Herbst treatment. They observed: – All condyles were positioned significantly forwards but returned to the normal position after removal of the appliance. – A temporary Capsulitis was present during the course of treatment. – Herbst appliance did not have the potential to cause muscular TMD. – Reduced the prevalence of structural bony changes of the TMJ. – Did not induce disc displacement. – Resulted in a stable disc position in partial disc displacement – Could not recapture the disc in cases of total disc displacement. 3/5/2014 www.indiandentalacademy.com 39
  40. 40. Overbite and anterior axial inclinations • Trying to correct Upper anterior spacing and axial inclination in deep bite cases without bite opening. • Correcting lower anterior crowding in deep bite cases without prior bite opening. • Both cause anterior premature contacts. 3/5/2014 www.indiandentalacademy.com 40
  41. 41. Retention phase Majority of orthodontically treated cases may have dental deep bites at the beginning and some also have skeletal deep bites Relapse will cause: •It separates the upper anterior teeth. •It may crowd lower anterior teeth. •It tends to move the maxilla forward. •Drive the mandible distally. 3/5/2014 www.indiandentalacademy.com 41
  42. 42. Retention phase 3/5/2014 www.indiandentalacademy.com 42
  43. 43. Pathogenesis of TMD • Changes in the Muscles • Changes in the Joint 3/5/2014 www.indiandentalacademy.com 43
  44. 44. 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 3/5/2014 www.indiandentalacademy.com 44
  45. 45. Changes in the Muscles Muscle splinting: is an involuntary CNS induced hypertonic condition. • Splinting is normal protective reaction to any change in the masticatory system that might be perceived as threat to its integrity. •A clinically discernible. •No discomfort in the resting stage. •Pain only on muscle contraction. •No increase in EMG activity. •A hypertonic reaction with resistance to stretch. 3/5/2014 www.indiandentalacademy.com 45
  46. 46. Changes in the muscles Myospasms: are involuntary CNS induced muscular contractions. Myospasm causes CNS to recruit motor unit for continuous contraction. Causes: emotional stress, deep pain and muscle splinting can lead to myospasms. • Muscle is tender on palpation and firm. •Patient complains of myogenic type of pain. •Tenderness usually present in areas of insertion of the muscles. •Patient complains of vague, chronic diffuse pain over head, neck and face. 3/5/2014 www.indiandentalacademy.com 46
  47. 47. 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) 3/5/2014 www.indiandentalacademy.com 47
  48. 48. Normal disc-condyle relation 3/5/2014 www.indiandentalacademy.com 48
  49. 49. Functional dislocation with reduction • PAIN •CLICKING •JOINT PAIN AND MUSCLE PAIN, •DEVIATED PATH OF CLOSURE. 3/5/2014 www.indiandentalacademy.com 49
  50. 50. Functional dislocation without reduction FUNCTIONAL DISLOCATION / CLOSED LOCK • LIMITED MOUTH OPENING • NO PAIN •NO CLICKING 3/5/2014 www.indiandentalacademy.com 50
  51. 51. Disc interference disorders 3/5/2014 www.indiandentalacademy.com 51
  52. 52. Classification of Temporomandibular disorders • • • • • Masticatory muscle disorders Disc interference disorders Inflammatory disorders Chronic mandibular hypomobility Growth disorders 3/5/2014 www.indiandentalacademy.com 52
  53. 53. Masticatory muscle disorders • Protective muscle splinting • Masticatory myospasm – Elevator muscle spasm – Lateral pterygoid muscle spasm • Masticatory myositis 3/5/2014 www.indiandentalacademy.com 53
  54. 54. 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 3/5/2014 www.indiandentalacademy.com 54
  55. 55. Disc interference disorders • • • • • Class I interference disorders Class II interference disorders Class III interference disorders Class IV interference disorders Class V interference disorders • Abnormal sensations, noises and movements • Arthralgic type of pain • Arrested movement (locking) 3/5/2014 www.indiandentalacademy.com 55
  56. 56. Disc interference disorders • Class I interference disorders – Symptoms occur during clenching of the teeth. • Class II interference disorder: – Symptoms occur during the first opening movements after Max intercuspation. • Class III interference disorder: – Numerous symptoms occur during the course of normal translatory movement. 3/5/2014 www.indiandentalacademy.com 56
  57. 57. Disc interference disorders • Class III interference disorder: – Due to excessive interarticular pressure. – Due to structural irregularity. – Due to non inflammatory degenerative joint disease. – Internal derangement 3/5/2014 www.indiandentalacademy.com 57
  58. 58. Disc interference disorders • Internal derangement – Detached sup retrodiscal lamina: • Anterior dislocation of the disc. • Irregular movement during the forward translatory phase of movement. – Disc displacement: • Loss of disc contour and elongation of ligaments. • Symptoms of clicking, catching and locking. – Damaged disc: • Deformation and perforation of the disc • Grating noise • Irregular movements – Adhesions. 3/5/2014 www.indiandentalacademy.com 58
  59. 59. Disc interference disorders • Class IV interference disorder: – Mouth opening extends beyond the normal anterior limit of translatory movement of disc-condyle complex. • Class V interference disorder: – Spontaneous anterior dislocation. – Due to wide opening – Disc trapped anteriorly preventing closure –”open lock”. 3/5/2014 www.indiandentalacademy.com 59
  60. 60. Inflammatory disorders • • • • Synovitis Capsulitis Retrodiscitis Inflammatory arthritis 3/5/2014 www.indiandentalacademy.com 60
  61. 61. Chronic mandibular Hypomobility • • • • Pseudoankylosis Contractured elevator muscles Capsular fibrosis Ankylosis 3/5/2014 www.indiandentalacademy.com 61
  62. 62. Growth disorders • Neoplasia • Abberant development • Acquired change 3/5/2014 www.indiandentalacademy.com 62
  63. 63. Diagnosis • Functional examination • Radiological examination 3/5/2014 www.indiandentalacademy.com 63
  64. 64. Functional examination • Palpation: Muscles • Digital palpation is used • Muscle should be evaluated through out it’s length – origin, muscle belly and insertion. • Should be evaluated at rest, stretched and contracted position. • Examined bilaterally for comparison. • Palpate horizontally and parallel to their attachments. 3/5/2014 www.indiandentalacademy.com 64
  65. 65. Functional examination • Two methods of palpation- Flat palpation and Pincer palpation. • Flat palpation- use middle finger to press the muscle against underlying bone. Soft but firm palpation in a small circular motion. • Pincer palpation – palpate muscle between forefinger and thumb. 3/5/2014 www.indiandentalacademy.com 65
  66. 66. Functional examination • Temporalis: Flat palpation when palpating the anterior, middle and posterior portions. • Temporalis tendon: Bidigital palpation intraorally and extra orally along the anterior border of the ramus. • Masseter: Superficial and deep masseter – flat palpation. • Pincer palpation for anterior border of superficial fibres. • Pterygoids: Intra oral palpation. 3/5/2014 www.indiandentalacademy.com 66
  67. 67. Functional examination • Palpation • STAND IN FRONT OF THE PATIENT. • LATERAL POLES OF BOTH CONDYLES SHOULD BE PALPATED SIMULTANEOUSLY USING DIGITAL PRESSURE. •ASK THE PATIENT TO OPEN THE MOUTH SLIGHTLY AND PALPATE 10 TO 20 mm IN FRONT OF THE EXTERNAL AUDITORY MEATUS. •TO CHECK FOR POSTERIOR WALL TENDERNESS ASK THE PATIENT TO MOVE THE MENDIBLE TO THE CONTRALATERAL SIDE OR USE THELITTLE FINGER TO PALPATE FRO WITHIN THE EAM. 3/5/2014 www.indiandentalacademy.com 67
  68. 68. Functional examination • Auscultation • 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. 3/5/2014 www.indiandentalacademy.com 68
  69. 69. Functional examination AUSCULTATION: 3/5/2014 www.indiandentalacademy.com 69
  70. 70. Functional examination EARLY INT 3/5/2014 LATE www.indiandentalacademy.com 70
  71. 71. Functional examination EARLY OPENING CLICK – 0 TO 15 mm MIDDLE OPENING CLICK – 16 TO 30 mm LATE OPENING CLICK – 31 TO 50 mm EARLY CLOSING CLICK – 31 TO 50 mm MIDDLE CLOSING CLICK - 16 TO 30 mm LATE CLOSING CLICK - 0 TO 15 mm 3/5/2014 www.indiandentalacademy.com 71
  72. 72. Functional examination • Functional analysis – Postural rest position. – Maximum mouth opening – Path of mandible on opening and closing. 3/5/2014 www.indiandentalacademy.com 72
  73. 73. Functional examination • Postural rest position – Command method – Non command method – Combined method • Methods of measurement – Direct intra oral – Direct extra oral – Indirect extra oral 3/5/2014 www.indiandentalacademy.com 73
  74. 74. Functional examination • Deviated mouth opening • Deviation always occurs towards the side of decreased mobility. • Condylar hyperplasia is an exception. 3/5/2014 www.indiandentalacademy.com 74
  75. 75. Functional examination • Path of the mandible on opening 3/5/2014 www.indiandentalacademy.com 75
  76. 76. Functional examination Laterotrusive movements TOWARDS LEFT 3/5/2014 TOWARDS RIGHT www.indiandentalacademy.com 76
  77. 77. Functional examination • Path of closure from postural rest to centric occlusion: 3/5/2014 www.indiandentalacademy.com 77
  78. 78. Functional examination AXIOGRAPH: • Compares hinge axis pathways of normal individuals and patients with TMD. • Records hinge axis movements in three planes. 3/5/2014 www.indiandentalacademy.com 78
  79. 79. Functional examination AXIOGRAPH TRACINGS: 3/5/2014 www.indiandentalacademy.com 79
  80. 80. Functional examination FUNCTIONAL MOUNTING OF THE PATIENT’S MODELS: FACE BOW TRANSFER: 3/5/2014 www.indiandentalacademy.com 80
  81. 81. Functional examination FUNCTIONAL MOUNTING OF THE PATIENT’S MODELS: BITE REGISTRATION FOR CENTRIC RELATION: ROTH’S POWER CENTIC BITE REGISTRATION. 3/5/2014 www.indiandentalacademy.com 81
  82. 82. Functional examination ARTICULATOR MOUNTING: PANADENT ARTICULATOR 3/5/2014 CONDYLAR POSITION INDICATOR www.indiandentalacademy.com 82
  83. 83. Functional examination CR – CO DISCEPANCY RECORDINGS OF THE CPI: 3/5/2014 www.indiandentalacademy.com 83
  84. 84. Radiological examination • Hard Tissue – Panoramic radiograph – Extra oral Projections • Transcranial • Transpharyngeal (Parma) • Transorbital – Conventional tomography – Computed tomography • Soft tissue – Arthrography – MRI 3/5/2014 www.indiandentalacademy.com 84
  85. 85. Panoramic Radiograph • • • • A screening projection Gross osseous changes- erosions, osteophytes No information about condylar position or function Superimposition of the skull base and zygomatic arch 3/5/2014 www.indiandentalacademy.com 85
  86. 86. Transcranial projection • Provides a sagittal view of the lateral aspects of condyle and temporal component • Only lateral joint contours are visible • Superimposition of the petrous ridge may be present. • Image is usually distorted and the position is of the condyle is not reliable. • For identifying gross osseous changes and range of motion (open views) 3/5/2014 www.indiandentalacademy.com 86
  87. 87. 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. 3/5/2014 www.indiandentalacademy.com 87
  88. 88. Transorbital projection • Provides an anterior view of the TMJ • Entire mediolateral aspect of the condylar head and neck is visible. • Can give a limited view depending upon the degree of mouth opening. 3/5/2014 www.indiandentalacademy.com 88
  89. 89. Conventional tomography • A radiographic technique that produce thin image slices free of superimpositions of adjacent structures. • Produce images at right angles to the condylar axis – better view for depicting true condylar position. • Corrected sagittal tomography using the aid of a SMV projection or a 20 degree head rotation. 3/5/2014 www.indiandentalacademy.com 89
  90. 90. Conventional tomography 3/5/2014 www.indiandentalacademy.com 90
  91. 91. Conventional tomography 3/5/2014 www.indiandentalacademy.com 91
  92. 92. Computed tomography • Image slices are made in both sagittal and coronal planes. • 3D images can be constructed • Cannot produce accurate images of the disc 3/5/2014 www.indiandentalacademy.com 92
  93. 93. Computed tomography 3/5/2014 www.indiandentalacademy.com 93
  94. 94. Computed tomography 3/5/2014 www.indiandentalacademy.com 94
  95. 95. Arthrography • A technique in which an indirect image of the disk is obtained by injecting a radio opaque contrast agent into one or both joint spaces under fluoroscopic guidance. • Single space and double space tomograms • Disk position, function, morphology and integrity of diskal attachments. • Risks- Pain, infection, iatrogenic damage and allergy. 3/5/2014 www.indiandentalacademy.com 95
  96. 96. 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. 3/5/2014 www.indiandentalacademy.com 96
  97. 97. Magnetic Resonance Imaging 3/5/2014 www.indiandentalacademy.com 97
  98. 98. Management of TMD • Corrective treatment – Splints – Splints combined with orthodontic appliances • Palliative / supportive treatment – Sedatives – Analgesics – Counseling 3/5/2014 www.indiandentalacademy.com 98
  99. 99. 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 • Limiting the extent of potentially harmful movements. 3/5/2014 www.indiandentalacademy.com 99
  100. 100. 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: 3/5/2014 www.indiandentalacademy.com 100
  101. 101. Types of splints STABILIZATION SPLINT: MODE OF ACTION: • Changes 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. 3/5/2014 www.indiandentalacademy.com 101
  102. 102. Types of splints ANTERIOR REPOSITIONING SPLINT: OTHER NAMES: Repositioning splint, LARS ( Ligated Anterior Repositioning Splint), Orthopedic positioner. DESIGN: 3/5/2014 www.indiandentalacademy.com 102
  103. 103. Types of splints ANTERIOR REPOSITIONING SPLINT: 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. 3/5/2014 www.indiandentalacademy.com 103
  104. 104. Types of splints BITE PLANE SPLINT: OTHER NAMES: Anterior jig, Luca jig, Hawley with ABP, Anterior deprogrammer, Six point splint. DESIGN: 3/5/2014 www.indiandentalacademy.com 104
  105. 105. Types of splints 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. 3/5/2014 www.indiandentalacademy.com 105
  106. 106. Types of splints PIVOT SPLINT: Based on the principle of joint traction. DESIGN: 3/5/2014 www.indiandentalacademy.com 106
  107. 107. Types of splints PIVOT SPLINT: MODE OF ACTION: • Unloading of the joint in cases of inflammation and internal derangement. USES: • Internal derangement. • Intracapsular inflammation. DISADVANTAGE: • Changes in tooth position occur due to the limited areas of tooth contact. • No control over condylar position. 3/5/2014 www.indiandentalacademy.com 107
  108. 108. Types of splints SOFT SPLINT: An emergency appliance. OTHER NAMES: Positioner, mouth guard, night guard. DESIGN: 3/5/2014 www.indiandentalacademy.com 108
  109. 109. Types of splints SOFT SPLINT: USES: • Athletics. • For reducing parafunctional activity (not substantiated). • On a temporary basis for relief of symptoms. DISADVANTAGES: • Incapable of causing occlusal adjustments due to the resilient nature. •Can cause tooth movements. 3/5/2014 www.indiandentalacademy.com 109
  110. 110. Types of splints MORA: Mandibular Orthopedic Repositioning Appliance. OTHER NAMES: Gelb Splint. USES: • Change posterior occlusion. • Eliminate anterior tooth contact. DESIGN: 3/5/2014 www.indiandentalacademy.com 110
  111. 111. Types of splints HYDROSTATIC SPLINT: USE: Equalizes biting pressure over all teeth. DESIGN: 3/5/2014 www.indiandentalacademy.com 111
  112. 112. 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 3/5/2014 www.indiandentalacademy.com 112
  113. 113. Management of Type I disorder PATIENT COMPLAINS OF….. • Pain from different areas in the head, neck and shoulders but not in the joint area. ON CLINICAL EXAMINATION…… • Presence of a dual bite. (occlusal precontact) •Tension in the masticatory muscles • Tenderness on palpation of the muscles. Esp Lateral Pterygoid. • Abnormal mandibular movements. AIM OFTREATMENT……… • To eliminate muscular tension and pain. • Correct alignment of teeth in both arches. 3/5/2014 www.indiandentalacademy.com 113
  114. 114. Management of Type I disorder 3/5/2014 www.indiandentalacademy.com 114
  115. 115. Management of Type I disorder 3/5/2014 www.indiandentalacademy.com 115
  116. 116. Management of Type I disorder TREATMENT: • Splints • Six point splint/ / Bite plane splint • Stabilization splint • Orthodontics • Selective grinding • Medication • Counseling 3/5/2014 www.indiandentalacademy.com 116
  117. 117. Management of Type II disorders PATIENT COMPLAINS OF…….. • Increase in myogenic type of pain • Onset of arthrogenic type of pain • Clicking noise • Occasional acute locking •Limited movement on one side ON EXAMINATION: • Pain on palpation • Clicking, grating • Deviation in path of mandible AIM OF TREATMENT: • Restore normal condyle – disc – fossa relationship (DISC RECAPTURE) 3/5/2014 www.indiandentalacademy.com 117
  118. 118. Management of Type II disorders TREATMENT: • Splint • Michigan plane / Stabilization splint • Antero superior repositioning splint • Orthodontics with splint 3/5/2014 www.indiandentalacademy.com 118
  119. 119. Management of Type III disorders PATIENT COMPLAINS OF….. • No pain • Impossible to eat • Limited mouth opening AIM OF TREATMENT: • Treat for ‘ BEST ANATOMIC COMPROMISE’ 3/5/2014 www.indiandentalacademy.com 119
  120. 120. Management of Type III disorders TREATMENT: • PHASE I: • Immediately free the joint • Type III splint • PHASE II: • Sectional orthodontics with splint •Achieving normal dental relationships •Prosthetic replacements. •surgery 3/5/2014 www.indiandentalacademy.com 120
  121. 121. 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. The importance of treating from a centric relation position to a centric relation position cannot be stressed any more. A thorough knowledge of TMJ function and disorders and functional occlusion is essential to establish long term goals for the occlusion and the joint. 3/5/2014 www.indiandentalacademy.com 121
  122. 122. REFERENCES • Extraction-non extraction dilemma as it relates to TMD – Mclaughlin, Bennet; AO 1995, No 3 • The physiology of splint therapy – Roger A Boero; AO 1989 No 3 • Occlusion with particular emphasis on the functional and parafunctional role of anterior teeth: Part 1 - JCO 1979 Sep (606-620): William H McHorris • Concepts in functional occlusion and management of functional disorder of TMJ- Dr. N.R. Krishnaswamy. 7th IOS PG students convention. • Garden of Orthodontics – • TMD- Weldon E Bell • TMD a practitioner’s guide – Annika Isberg. 3/5/2014 www.indiandentalacademy.com 122
  123. 123. Thank you 3/5/2014 www.indiandentalacademy.com 123

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