A
Multidisciplinary
Approach
Differential
Diagnosis
The Stomatognathic Triad
• Articulation Of The Teeth –
Dominant
• Joints – Accommodate
• Muscles – Accommodate
TMJ Pain
TMJ Noise
Headaches
Cervical Pain
Ear Congestion
Limited Opening
Postural Problems
Parathesia of Finger Tips
Dizziness -Vertigo
Ringing in ears - Tinnitis
Swallowing difficulty - Dysphagia
Bell’s Palsy
Trigeminal Neuralgia
Nervousn...
Video Tmj #
9
•Video TMJ # 9
•Next
No Matter How
Malpositioned
The Occlusion
Muscles Will Struggle
to Create a Centric
Occlusion (C.O.)
They Accommodate
Disc and Condyle
Rotation Then Translation
• Should move
synchronously
• Maintain spatial
relationship
• Adequate disc spa...
Asynergy of Disc and Condyle
Rotation And Translation
• Can be the result of
mechanical
impingements
• Or muscle spasms th...
Clinical Range Of Motion
•40 mm or Around Three Fingers
•Lateral About ¼ Of Max Opening
•Symmetrical – No Deviations
•Asym...
Smooth Movement
1. Centric (Habitual) Occlusion with posterior teeth in maximum
cuspation.
2. Normal opening free of click...
Uncoordinated function
• Slowing mandibular
movement
• Characteristic of
reciprocal click
• Slower closing
A. Clicks will ...
Sonography - Normal disc
• Low frequency sounds
• Amplitude is a factor
• Intact discs can have a
click or pop
Sonography - Chronic
impingement with crepitis
Severe degeneration
The Stomatognathic Triad
• Teeth – Dominant
• Joints – Accommodate
• Muscles – Accommodate
Normal
Posterior
Displaced
Condyle
The Stomatognathic Triad
• Teeth – Dominant
• Joints – Accommodate
• Muscles – Accommodate
Muscles
•Function is to Contract
•With the ability to vary
speed, power and extent of
that contraction
•This is how they a...
•The Muscle Motor Unit
consists of the nerve cell body,
a single axon of the motor
nerve, its terminal branches
and the mu...
Pain/Spasm Cycle
•Is almost universal in TMD
•As muscles are called upon
to continually accommodate
an occlusion they beco...
Hypertonicity
•A condition of excessive tone of the skeletal muscles
•Characterized by increased muscle motor unit firing ...
• Neuromuscular
Dentistry #5
• Next
A.High postural EMG activity is common in patients
with TMD.
B.The anterior temporalis is usually elevated more
than the m...
A.Lowering rest EMG activity after therapy is the desired
therapeutic objective.
B.Lowered postural EMG activity indicates...
Posterior Cervical
Muscles
“Authors who have reviewed the
TMJ literature generally agree
that muscle hyperfunction is the
principle cause of myogenou...
T.E.N.S.
NEURAL STIMULATION
TRANSCUTANEOUS ELECTRICAL
Group Action
Facial Nerve Mandibular Nerve
Muscle of Nose Masseter
Buccinator Temporalis
Risorius Medial Pterygoid
Orbicul...
3. Changes muscle metabolism
from anaerobic (lactic acid) to
aerobic
4. Endorphin effect
Low Frequency TENS
A Normal
Bite ??????
Do you have a
malpositioned
occlusion?
?????????????????
LOOKS
ARE
DECEIVING!!
Class II Div II
Posterior Displaced
Mandible And
Condyle
If it has been measured,
it is a FACT.
If it has not been measured,
it is an OPINION.
Video
Diagnosing
Problems #7
• Diagnosin
g Problems
#7
• Next
•
EMG
Electromyography
Hyper Active
•
Relaxed After Tens
Central
Nervous
System
The Trigeminal Nerve
comprises 60% of all
neural tissue of the 12
cranial nerves and is
associated with the
reticular acti...
As a noxious stimuli such
as from a bite prematurity
travels to the reticular
activating center the
message is instantly
p...
Trapezius
Sternocleidomastoid
Medial
Pterygoid
Masseter
Neuromuscular Occlusal
Objectives
• Provide An Occlusal Relationship Of
The Mandible To The Maxilla That
Minimizes The Nee...
The individual
will experience
pain and
pathology when
the stress
exceeds their
ability to adapt.
NTI Appliance And Migraines
Video A Dental
Perspective #1
• Next #1
• NTI and Migraines
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Patient Only Transitions

  1. 1. Trigem inal Neuralgia A Dental Perspective
  2. 2. A Multidisciplinary Approach Differential Diagnosis
  3. 3. The Stomatognathic Triad • Articulation Of The Teeth – Dominant • Joints – Accommodate • Muscles – Accommodate
  4. 4. Articulation of the teeth (Bite) Bite
  5. 5. TMJ Pain TMJ Noise Headaches Cervical Pain Ear Congestion Limited Opening Postural Problems Parathesia of Finger Tips
  6. 6. Dizziness -Vertigo Ringing in ears - Tinnitis Swallowing difficulty - Dysphagia Bell’s Palsy Trigeminal Neuralgia Nervousness/ Insomnia Non-Specific Facial Pain
  7. 7. Video Tmj # 9
  8. 8. •Video TMJ # 9 •Next
  9. 9. No Matter How Malpositioned The Occlusion
  10. 10. Muscles Will Struggle to Create a Centric Occlusion (C.O.) They Accommodate
  11. 11. The Temporomandibular Joints Accommodate
  12. 12. Disc and Condyle Rotation Then Translation • Should move synchronously • Maintain spatial relationship • Adequate disc space • Synchronous non- hypertonic musculature
  13. 13. Asynergy of Disc and Condyle Rotation And Translation • Can be the result of mechanical impingements • Or muscle spasms that result in uncoordinated disc movement
  14. 14. Clinical Range Of Motion •40 mm or Around Three Fingers •Lateral About ¼ Of Max Opening •Symmetrical – No Deviations •Asymmetrical – Deviates To The Side Of The Dysfunction •Clicking Joint •Non Reducing Disk
  15. 15. Smooth Movement 1. Centric (Habitual) Occlusion with posterior teeth in maximum cuspation. 2. Normal opening free of clicks and dyskinesia. 3. Normal Closing. 4. Maximum speed of opening. 5. Maximum speed of closing. 6. Speed of mandible at moment of tooth contact. 7. Note: Lack of lateral deviation during opening and closing movements.
  16. 16. Uncoordinated function • Slowing mandibular movement • Characteristic of reciprocal click • Slower closing A. Clicks will be more reproducible during “normal” opening. Patient overrides clicks during “fast” opening. B. Click in velocity trace is usually accompanied by a lateral shift in the jar movement in the frontal plane. C. Lateral deviation may be anatomic (condyle/disk) or unilateral muscle spasm.
  17. 17. Sonography - Normal disc • Low frequency sounds • Amplitude is a factor • Intact discs can have a click or pop
  18. 18. Sonography - Chronic impingement with crepitis
  19. 19. Severe degeneration
  20. 20. The Stomatognathic Triad • Teeth – Dominant • Joints – Accommodate • Muscles – Accommodate
  21. 21. Normal
  22. 22. Posterior Displaced Condyle
  23. 23. The Stomatognathic Triad • Teeth – Dominant • Joints – Accommodate • Muscles – Accommodate
  24. 24. Muscles •Function is to Contract •With the ability to vary speed, power and extent of that contraction •This is how they act as Mandibular Accommodators
  25. 25. The structural units are Actin And Myosin With ATP Being The Energy Source
  26. 26. •The Muscle Motor Unit consists of the nerve cell body, a single axon of the motor nerve, its terminal branches and the muscle fibers supplied by these branches •It’s the occlusion that determines the amount of joint compression however this will not occur until muscle motor units are called upon to move the mandible under function or Parafunction
  27. 27. Pain/Spasm Cycle •Is almost universal in TMD •As muscles are called upon to continually accommodate an occlusion they become contracted and function at a decreased working length •This results in lymphatic and vascular impingement, inhibits metabolism with the resultant build up of spasmogenic metabolites
  28. 28. Hypertonicity •A condition of excessive tone of the skeletal muscles •Characterized by increased muscle motor unit firing to maintain posture at rest Video Neuromuscular Dentistry #5
  29. 29. • Neuromuscular Dentistry #5 • Next
  30. 30. A.High postural EMG activity is common in patients with TMD. B.The anterior temporalis is usually elevated more than the masseter since it is a posturing muscle. The masseter is a force muscle. C.High posterior temporalis activity is common in patients with cervical myofacial dysfunction.
  31. 31. A.Lowering rest EMG activity after therapy is the desired therapeutic objective. B.Lowered postural EMG activity indicates improved physiologic status.
  32. 32. Posterior Cervical Muscles
  33. 33. “Authors who have reviewed the TMJ literature generally agree that muscle hyperfunction is the principle cause of myogenous TMJ disorders.” JADA, 12:283-290, 1990 Hypertonicity:
  34. 34. “There is a general agreement among both clinicians and investigators that masticatory muscle activity is greater in symptomatic patients as compared to normal subjects.” McCall, W.D., A Textbook of Occlusion, Quintessence, 1988 Hypertonicity:
  35. 35. T.E.N.S. NEURAL STIMULATION TRANSCUTANEOUS ELECTRICAL
  36. 36. Group Action Facial Nerve Mandibular Nerve Muscle of Nose Masseter Buccinator Temporalis Risorius Medial Pterygoid Orbicularis Oris Lateral Pterygoid Muscles of Lower Lip Tensor Palati Platysma Mylohyoid Stylohyoid Ant Belly Digastric Post Belly Digastric
  37. 37. Low Frequency TENS 1. Pumps waste metabolites and lactic acid from hypertonic muscles 2. Increases vascular flow, oxygen, ATP, Glucose, and Calcium
  38. 38. 3. Changes muscle metabolism from anaerobic (lactic acid) to aerobic 4. Endorphin effect Low Frequency TENS
  39. 39. A Normal Bite ??????
  40. 40. Do you have a malpositioned occlusion? ?????????????????
  41. 41. LOOKS ARE DECEIVING!!
  42. 42. Class II Div II Posterior Displaced Mandible And Condyle
  43. 43. If it has been measured, it is a FACT. If it has not been measured, it is an OPINION.
  44. 44. Computerized Jaw Tracking
  45. 45. Video Diagnosing Problems #7
  46. 46. • Diagnosin g Problems #7 • Next
  47. 47.
  48. 48. EMG Electromyography
  49. 49. Hyper Active
  50. 50. • Relaxed After Tens
  51. 51. Central Nervous System
  52. 52. The Trigeminal Nerve comprises 60% of all neural tissue of the 12 cranial nerves and is associated with the reticular activating (awakening) center. Sensory information from the occlusion is carried along the 5th cranial nerve to the awakening center.
  53. 53. As a noxious stimuli such as from a bite prematurity travels to the reticular activating center the message is instantly processed and the mandible is pulled away from the prematurity. Significant accommodation is often required. This OCCLUSAL PROPREOCEPTION often becomes a common cause of muscle hypertonicty.
  54. 54. Myofascial Triggers And Referred Pain
  55. 55. Trapezius
  56. 56. Sternocleidomastoid
  57. 57. Medial Pterygoid
  58. 58. Masseter
  59. 59. Therapeutic Objectives • Restore Normal Blood Flow (aerobic metabolism) • Eliminate Sources Of Nerve And Vascular Entrapments • Eliminate Neuromuscular Trigger Points • Restore Postural Integrity At Rest With Minimal Muscle Activity • Elimination Of Neuromuscular And Temporomandibular Joint Compression
  60. 60. Neuromuscular Occlusal Objectives • Provide An Occlusal Relationship Of The Mandible To The Maxilla That Minimizes The Need For Muscle Accommodation • Provide An Occlusal Relationship That Allows Normal Decompression Of Neural And Vascular Intracapsular Tissue And Associated Connective Tissue
  61. 61. The individual will experience pain and pathology when the stress exceeds their ability to adapt.
  62. 62. NTI Appliance And Migraines Video A Dental Perspective #1
  63. 63. • Next #1 • NTI and Migraines

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