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Conservative treatment of tmj disorders


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Conservative treatment of tmj disorders

  1. 1. CONSERVATIVE TREATMENT OF TMJ DISORDERS Dr. Bahjat Abu Hamdan Consultant Prosthodontist. DDS,CES, DSO Paris- France.
  2. 2. Introduction  Diagnosing and treatingTMJ disorders can be difficult and confusing task.  Proper diagnosis is the key to successful treatment.  A comprehensive knowledge of.  1.Anatomy and physiology of the masticatory system.  2.Aetiology ofTMJ disorders (intracapsular and extracapsular)
  3. 3. Introduction  3.Diagnosis ofTMDS.  4. Management ofTMDs.  A. Conservative therapy (Reversible ).  B Non conservative therapy (Irreversible).  So that these elements are important to be well known by the practitioner before starting up the diagnosis andTx ofTMJ Disorders. In this lecture we will expose mainly the conservative therapy and briefly the other aspects in relation.
  4. 4. American Dental Association, 1983 definedTMD as a group of orofacial disorders characterized by:  Pain in the preauricular area,TMJ, and muscles of mastication  Limitations/deviations in mandibular range of motion  TMJ sounds during jaw function  The spectrum ofTMJ disorders could range from congenital developmental problems to the commonly degenerative joint disease. 1990YCraniomandibular Disorders(CMD)
  5. 5. TMD Epidemiology.  The prevalence of signs and symptoms associated with TMD can be best associatedby examining epidemiologic studies.  Dorland,s illustrated medical dictionary describes epidemiology as.( the study of the factors determining and influencing the frequency and distribution of disease, injury, and other health-related events and their causes in a defined human population for the purpose of establishing programs to prevent and control their development and spread )
  6. 6. TMD: Epidemiology Defining and explaining the interrelationships of factors that determine disease frequency and distribution  Most prevalent between 20-40 years.  50% to 60% of the general population have a sign of some functional disturbances of the masticatory system -65-85% in USA experience one or more symptoms of TMD -12% experience prolonged pain or disability -Only 5-7% have symptoms severe enough to require treatment. Most cases are self-limiting
  7. 7. epidemiology  Scandanavian study: Most problems are with joint noises and jaw deflection.  Non-patient populations greater than 18 years old  40-75%: one clinical sign is evident  50% of the population will exhibit sounds and/or deviation (much more so than in patients under 18 years of age  Less than 5% have limited opening  33% of the population has one symptom  Approximately 10% of those greater than 18 years of age will exhibit pain Defining and explaining the interrelationships of factors that determine disease frequency and distribution
  8. 8. Figure 5 : Presenting sign and symptom of TMJ
  9. 9. Figure 6 : Presenting sign and symptom of the muscles of mastication
  10. 10. Figure 7 : Presenting sign and symptom of mouth opening
  11. 11. 33 76 10 38 4 5 0 10 20 30 40 50 60 70 80 One Two Three + Symptoms Signs PercentageIncidence Number of Signs & Symptoms TMD Signs & Symptoms These are the ones who really need treatment
  12. 12. Age and Sex Distribution This data is from a Seattle based , patients from 8 years old to 80 years old. The bars are on the inside. Most seek treatment between 25-40 years old. Childbearing age in females age is progressive over time….it gets better over time,NOTthe most likely time. It is after 35. 1 2 S 1 S 2 S 3 S 4 S 5 S 6 S 7 S 8 S 9 S 1 0 S 1 1 S 1 2 S 1 3 S 1 4 S 1 5 S 1 6 S 1 7 S 1 8 0 1 0 0 2 0 0 3 0 0 4 0 0 5 0 0 6 0 0 Paitents S e x A g e Only irreversible treatments will cause things to progress.
  13. 13. Age distribution of subjects with TMD
  14. 14. Figure 1: Prevalence of TMD according to gender
  15. 15. General Population 33% 41% 26% Intra-articular Extra-articular No sign or symptom Only 7% of the general population patients need treatment. There may be many signs and symptoms, but few need to be treated.
  16. 16. Pain Clinic Populations Internal Derangement 31% Arthritis 39% Myofascial 30% These are relatively equal distributions, overall. This does not take into account the dominant treatments done by a general practitioner. It really depends on who is running the clinics and their clinical reputations.
  17. 17. Adaptation Normal Adaptation Pathology Flattening of the condyle is exhibited. There is no joint space. No asymmetries are seen, no pain , no visible problems, there is no limitation of movement and no deflections of the mandible. This is a good example of adaptation. All of us are in some state of adaptation. This is why we don’t see a progression in this disease. Patients should undego treatment first, then have their TM condition evaluated. Dr. Rigg
  18. 18. Adaptation Normal Injury/Pathology Adaptation + - Disability Death Impairment (articular disc is out of place, but the patient is still able to function)
  19. 19. Signs & Symptoms 10 20 30 40 50 60 70 Pain Dysfunction Decrease ROM Noise TMD appears to be progressive-non Joint noise will increase with time, but it can be managed. This is looking at a cross section of the population. This follows the biopsychosocial syndrome.
  20. 20. Reciprocal click
  21. 21. Disc dislocation w/o reduction
  22. 22. Etiology of TMD  Trauma  Excessive stress  Arthritis of theTMJ  Whiplash injury  Postural abnormality  Ligamentous laxity  Psychosocial distress (stresses)
  23. 23. Etiology  Bruxism  (teeth grinding)  Unaligned teeth  Congenital  Jaw abnormalities  Prolonged mouth breathing  Thumb sucking
  24. 24. RiskfactorsassociatedwithTMD
  25. 25. Etiology of TMD
  26. 26. Assessment  History & Examination.  The effectiveness and success of treatment lie in the ability of the clinician to establish the proper diagnosis.  One must be suspicious of the pt who reports the location of the pain to beTMJ or masticatory muscles, yet those whose history and Exam. Reveals no alteration in range of jaw movement or increase in pain during function. So that its useless to direct the treatment of the MS, the examiner must find the true source of pain.
  27. 27. History 1. Pain 2. Joint Sounds 3. Restriction of Opening 4. Swelling  Over the maxilla  In the area of parotid gland
  28. 28. CLINICAL EXAMINATION 1. The symmetry of the mandible and the face 2. TMJ & muscles tenderness 3. Lateral deviation on opening and closing 4. Inter-incisal opening (normal=35-45mm) 5. Joint sounds 6. Dentition
  29. 29. Muscular tenderness
  30. 30. Lateral deviation
  31. 31. Normal=35-45mm Inter-incisal opening
  32. 32. Joint sounds
  33. 33. Dentition
  34. 34. In an ideal occlusion, protrusive movement is guided by anterior teeth. Early lateral movements are ideally canine-guided.
  35. 35. 1. Tempromandibular Pain Dysfunction Syndrome (TMPDS) / Deviation in Form 2. Internal Derangement / Articular disorders 1. Disc displacement with reduction 2. Disc displacement without reduction 3. Pathological Disorders TMJ Disorders Classification TMD
  36. 36.  Extra-articular (all muscle)  Intra-articular (within the joint)  Synovitis  DDWR (disc displacement with reduction)  DDWOR (disc displacement without reduction)  Osteoarthrosis  Rheumatoid arthritis  Condylar subluxation Arthrosis: non-painful osseous remodelling of tissues Temporomandibular Disorders
  37. 37. one of two or moreThe determination of a patient is suffering from byconditions systematically comparing and contrasting their historical and clinical findings. History gathering is the most important thing to do. Differential Diagnosis
  38. 38.  Intracranial Pain Disorders  Primary Headache Disorders  Neurogenic Pain Disorders  Intraoral Pain Disorders  Temporomandibular Disorders (our focus in this presentation)  Associated Structures  Axis II, Mental Disorders Sources of Orofacial Pain
  39. 39. Initial (conservative) Further (specialist) Management  Reassurance.  Education .  Habit management.  Rest.  NSAID, analgesic and muscle relaxants.  Removable occlusal splints.  Physio –therapy/ jaw exercises  Psychologycal intervention.  Antidepressant.  Occlusal adjustment.  Intra-articular injection.  Manipulation under GA.  Arthroscopy.  Surgery.
  40. 40. Indication for surgical treatment  About 10% of the chronicTMD cases are indicated for surgical treatment.  Degenerative joint disease.  Condyle fracture.  Joint intra capsular pathology (osteochondroma, chondromatosis ).  Tumor involvement of condylar head.
  41. 41. Treatment should begin with conservative, reversible therapies and progress to non- reversible therapies, if needed. Treatment of TMD
  42. 42.  TMD can be difficult to treat because of its multifactorial origin.  Primary goal is to allow the muscles to relax and restore a normal range of motion; pain usually decreases when this happens.  Before any treatment therapies are initiated, the patient should be educated and counseled on the nature and causes ofTMD. Educating the patient may relieve the stress enough to alleviate symptoms. Treatment of TMD
  43. 43. 1) NSAIDS - are non-steroidal anti - inflammatory drugs like ibuprofen. 2) Muscle relaxants.  3) Narcotics - should be prescribed in regular doses over a short period of time.  4) Tricyclic antidepressants - may be used to reduce bruxism.  5) Corticosteroids - may be injected into the joint for arthritis. TMD Treatments: Medications
  44. 44.  Reversible procedures should be tried before irreversible procedures.  Goal is to reduce muscle activity and parafunctional habits by correcting occlusal scheme.  Occlusal splint provides orthopedic stability.  Correcting occlusal interferences with selective grinding or construction of new restorations are irreversible procedures. Occlusal Therapy
  45. 45. Occlusal thrapy  Occlusal appliance is useful in reducing symptoms, literature revealed that its effectiveness is between 70 to 90%.  Because the splint provide more orthopedic stable joint position, optimum occlusal position that reorganizes the neuromuscular activity to the normal limits  Protect the teeth and supportive structures from abnormal forces.  The success or failure of occlusal appliance depend on the selection, fabrication and adjustment, as well as patient cooperation.  If the occlusal appliance does not affect the symptoms, the malocclusion is probably not a cause and certainly the need for irreversible occlusal therapy should be questioned.
  46. 46.  Increase patient awareness of muscular activity and incidence of parafunctional habits.  Psychotherapy - referral may be indicated to help patient deal with stress.  Relaxation therapy – exercise and yoga.  Hypnosis for relaxation. Stress Therapy
  47. 47.  Other physical therapy techniques: 1) Thermal or coolant therapy 2) Ultrasound  3) Electrical stimulation of muscles  4) Acupuncture  5) Massage Patients may improve range of opening through exercises designed to stretch the muscles. Physical Therapy6
  48. 48.  Hard acrylic  Technically demanding  Maxillary splint is easier to adjust  Worn at night  Long-term use  must provide ideal occlusion at rest & function (CR =CO) Stabilization splint
  49. 49. stabilization appliance  Soft or resilience appliance , treatment gaol is to achieve an even simultaneous contact with the opposing teeth.  Its well supported use is as protective device for athletes .  Soft appliances have not been shown to decrease bruxing activity. Scientific evidence support the use of hard appliances for reduction of symptoms related to clenching and bruxing activity.  Soft appliances have been advocated for Pts who suffer from repeated or chronic sinusitis resulting in extremely sensitive posterior teeth.
  50. 50.  Clear the occlusion to allow the condyles to be fully seated superiorly/anteriorly  Elimination of discrepancies between seated joints and seated occlusion (CR = CO)  A large surface area of shared biting force  Reduce joint loading by decreasing muscle activity also by consequence myogenous pain decreases.  Idealized functional occlusion  SS decrease parafunctional activity that accompanies periods of stress, local muscle soreness or chronic centrally mediated myalgia also its helpful in cases of retrodiscitis due to trauma. Stabilization splint How it works!
  51. 51.  Maxillary or mandibular  Hard acrylic, full coverage  Occlusal record with mandible protruded  Indicated for disc displacement with reduction  Ideally used 24hrs/day for 12 weeks  Avoid in adolescents Anterior positioning splint
  52. 52. Occlusal appliance  No more pain Occlusion is the cause Pain continues look for another cause Irreversible Occlusal Treatment
  53. 53.  It positions the condyle anteriorly away from the fully seated joint position  Used in case of trauma inducing retrodiscal edema Guide the mandibular condyles away from retrodiscal tissues.  Used in case of anterior disc displacement Help aligning the disc over the condyle (back to normal position) hoping that it will keep this relation with time.  Posterior pivoting appliance is advocated for the treatment of symptoms related to osteoarthritis of theTMJs, its the only appliance that can routinely distract a condyle from the fossa by a unilateral pivot . Its use should be limited to one week. Otherwise the second molar will be intuded. Anterior positioning splint When & How it Works!
  54. 54. Case 1.  A 21 yrs old female came to the dental office with leftTMJ pain and sounds associated with muscle pain.  The symptoms started 10 month ago, no specific event relating to the onset of the symptoms, yawning increase the pain for several hours.  Examination revealed reciprocal clicking on the leftTMJ with pain to palpation specially during opening that accentuate the sounds muscle tenderness L,R mass. and temp. LL pterygoid was painfull to function manipulation.  Diagnosis, pt was diagnosed with DD with reduction.  Tx.An APA was fabricated that positioned the mandible forward enough to eliminate the reciprocal clicking. Pt instructed to wear the appliance day and night for 7 days. Limit the movements to painful limits, mild analgseic prescribed for 10 days. In 1 w pain and popping subsided, 9 w later pain subsided completely but not the clicking , pt is asked to carry the appliance at night for 8-12 w at night . pt. told that joint sound would likely be permanent but pain may not return.
  55. 55. Case 2  50 yrs old female. C/cTMJ pain, headache and neck pain.  Pt has a history of car accident which still hanged in her mind.  She started suffering of neck pain at the right u/ region underneath her skull , with pain radiation to jaw ,face and eyes.  She soughtTx from massage chiropractor and dentist but she has been suffering for about 5 years.  Chiropractic exam. Reveals upper neck injury radiating to jaw face and neck.Treatment done, 2 month later pain is over.  The injury stemmed to the car accident 5 yrs ago.
  56. 56. Case 3  20 yrs old female pt.  She arrived complaining ofTMJ pain in the left side with clicking when she opens widly.  Exam/ pt has mandibular prognathy with anterior cross bite, left TMJ is painful to palpation which increase while opening.  OPG revealed deep glenoid fossa which indicates dominant open close movement with limited gliding, guiding the mandible CR position and during closing revealed premature contact between 21,31 shifting the mandible into anterior cross bite.  Case referred to orthodontic clinic for cross bite and anterior shift correction as main cause in displacing theTMJ anterior to its stable position.
  57. 57. Case 4  20 yrs old female pt arrived complaining of pain in the left TMJ area 5 month ago.  Examination :Pt has pain in the left side more sensitive to palpation in front of the left ear, also temporal and masseter muscle were painful to palpation on the same side, looking at the OPG revealed supraerupted 18, 28 with missing opposed third molars.  After muscle relaxation, the mandible is guided into CR position and during closing a severe premature contact in both sides is found between the mesial of 18 and the distal of 47, the mesial of28 and the distal of 37 causing capsular ligament extention resulting in that severe pain.  Adjustment is done, 1 week later pt feels signifigant improvement.
  58. 58. Case 5  A 48 yrs old male pt reported to dental office complaining of R /TMJ sounds.The popping had been present for 15 yrs ago and had never caused any pain or discomfort.  Exam/ revealed a single click at 31 mm of opening the click can not be eliminated by 2 tongue depressor placed bilaterally between the post. Clinical muscle exam was negative, his teeth were in good repair.  The pt was diagnosed with chronic adapted disc displacement with reduction.  Tx.The history and exam revealed that this disc displacement was chronic and asymptomatic.There was no evidence that it was a progressive disorder. In fact, more evidence suggested that the joint tissue had physiologically adapted to the condition.Therefore no definitive treatment instituted.
  59. 59. Thanks For your Attention.