15. Presentation15.pptx

1
BY
Dr. Chakradhar
Post graduate student
Dept of prosthodontics

Contents:
• Introduction
• Definitions
• Different Treatment Approaches
Definitive treatment
supportive treatment
• Diagnostic algorithms
• Review of literature
• Conclusion
• References
2

Introduction: 3
• The etiology of TMDs is complex and multifactorial. There are numerous
factors that can contribute to TMD
• The management of the Tmd should address these factors for the
improvement of patient condition.
• A prosthodontist should make a conservative treatment protocol and take care
when performing irreversible occlusal changes in healthy individuals

Treatment approaches
• Definitive
• Supportive
4

• Definitive treatment - refers to those methods that are directed
toward controlling or eliminating the etiologic factors that have
created the disorder.
• Supportive therapy - refers to treatment methods that are directed
toward altering patient symptoms but often do not affect the
etiology.
5
Definitions:

6
Supportive therapy
Physical therapy
Physical therapy
modalities
Thermo
therapy
Coolant therapy
Ultrasound
therapy
Phonophoresis
Iontophoresis
Trascutaneous electrical nerve
stimulation
Acupuncture
Cold laser
Manual
techniques
Soft tissue
mobilization
Superficial and
deep massage
Joint
mobilization
Muscle conditioning
Passive muscle
stretching
Assisted muscle
stretching
Resistance
exercises
Isometric exercises
Postural training
Pharmacological therapy

7
Thermo therapy
 Moist heat applied to the symptomatic muscle can often
reduce levels of pain and discomfort.
 Although the origin of muscle pain is unclear and complex, most
theories contend that the initial condition of decreased blood flow to the
tissues is responsible for local myalgia.
 Thermotherapy counteracts this by creating vasodilation in the
compromised tissues, leading to reduction of the symptoms.
 Can be applied with commercially available heat pad, hot moist towel,
hot water bottle over the towel for 10-15 min not exceeding 30 min

Coolant therapy
Coolant therapy
 It has proved to be a simple and often effective method of
reducing pain.
 Ice pack should be applied directly to the affected area and
moved in a circular motion without pressure to the tissues.
 The ice should not be left on the tissues for longer than 5 to
7 minutes.
 It is thought that during warming there is an increase in
blood flow to the tissues that assists tissue repair.
 Can be applied with ice pack, frozen Styrofoam cups, ethyl
chloride and fluoromethane vapours for 5 sec
8

9
Ultrasound therapy
 Ultrasound is a method of producing an increase in
temperature at the interface of the tissues and therefore
affects deeper tissues than does surface heat.
 This improves the flexibility and extensibility of connective
tissues.
 Kahn J based on his study suggested that surface heat
and ultrasound be used together, especially when treating
post trauma patients.

Phonophoresis
 Phonophoresis is the method of using ultrasound
waves to push particles of a pain-relieving or anti-
inflammatory drug deeper into skin tissues thereby
enhancing the delivery of topically applied drugs
10

11
Iontophoresis
• Technique by which certain medications can
be introduced into the tissues without affecting
any other organs.
• In this method the medication is placed in a
pad and the pad is placed on the desired
tissue area.
• Then a low electrical current is passed through
the pad driving the medication into the tissue.
• Local anesthetics and anti-inflammatories are
common medications used with iontophoresis

12
Cold laser
• Cold or soft laser has been investigated for
wound healing and pain relief.
• It is most commonly used in treating chronic
musculoskeletal, rheumatic, and neurologic
pain conditions.
• cold laser is thought to accelerate collagen
synthesis, increase vascularity of healing
tissues, decrease the number of
microorganisms, and decrease pain.

Trascutaneous electrical nerve stimulation
• TENS is produced by a continuous stimulation of cutaneous
nerve fibers at a sub-painful level.
• When a TENS unit is placed over the tissues of a painful area, the
electrical activity decreases pain perception.
• Portable TENS units have been developed for long-term use
by patients with chronic pain and can be effective with various
TMDs
13

14
Acupuncture
• Acupuncture uses the body's own antinociceptive system
to reduce the levels of pain felt.
• Stimulation of certain areas (or acupuncture points)
appears to cause the release of endorphins, which
reduce painful sensations by flooding the afferent
interneurons with subthreshold stimuli.
• Acupuncture appears to be a promising modality,
although its mechanism of action is not well understood.
Further investigation is certainly indicated.

• Soft tissue mobilization is useful for muscle pain
conditions and is accomplished by superficial and deep
massage.
• Mild stimulation of cutaneous sensory nerves exerts an
inhibitory influence on pain
• Thus, gentle massage of the tissues overlying a painful
area can often reduce pain perception.
Soft tissue
mobilization
Manual techniques
15

16
Joint
mobilization
• Mobilization of the TMJ is useful in decreasing
interarticular pressure as well as increasing range of
joint movement.
• Gentle distraction of the joint can assist in reducing
temporary adhesions and perhaps even mobilize the
disc.
• Mild distraction of a normal joint does not produce
pain.
• If pain is elicited, the therapist should be suspicious
of an inflammatory joint disorder and discontinue the
distraction procedure.

17
Muscle conditioning
• Patients who experience TMD symptoms often decrease the use of their
jaw because of pain.
• If this is prolonged the muscles can become shorted and atrophied, for
this muscle exercises are necessary .
• patients can perform exercises on their own or they can take the help of
the physical therapist or dentist.
• These are 4 types - passive muscle stretching, assisted muscle
stretching, resistance exercises, and postural training.

18
Passive muscle stretching
• Passive muscle stretching of painful, shortened muscles can
be effective in managing some TMDs
• gentle passive stretching of a muscle can assist in
reestablishing normal muscle length and function.
• The patient should be instructed to slowly and deliberately
open the mouth until pain is felt.
• Sometimes it is helpful for patients experiencing muscle pain
to observe their mouth opening in a mirror so that they can
make the pathway straight, without defect or deviation

19
Assisted muscle
stretching
• Assisted muscle stretching is used when there is a
need to regain muscle length.
• Stretching should never be sudden or forceful
• Patients can help in providing their own stretching
since they are not likely to over stretch or traumatize
the involved tissues

Resistance exercises
• Resistance exercises utilize the concept of reflex relaxation to provide an increase in mandibular
opening
20

Physical self regulation
• Dr. Carlson and Dr. Bertrand 1995
The focus of this treatment is on -
(1)Addressing the pain and fatigue as a physiologic disturbance in need of
correction
(2) Managing autonomic dysregulation
(3) Altering dysfunctional breathing patterns and
(4) Improving sleep.
• Although it was initially designed predominately for masticatory muscle pain
disorders, it was also helpful in managing many intracapsular disorders
21

Pharmacological
therapy
Acute TMD
pain
Analgesics
Corticosteroids
Anxiolytics
Both acute
and Chronic
Muscle
relaxants
NSAIDS
Local anesthetics
Chronic
orofacial
pain
Antidepressants
22

DEFINITIVE TREATMENT
23
Occlusal
factors
Reversible
Occlusal
appliance
therapy
Stabilization appliance
Anterior repositioning appliance
Anterior bite plane
Posterior bite plane
Pivoting appliance
Soft/resilient appliance
Irreversible
Selective grinding of
teeth
Restorative procedures that
modify occlusal condition
Orthodontic treatment
Surgical procedures aimed at altering
occlusion, mandibular position
Appliances altering growth or
mandibular position

• Occlusal appliance: a removal device, usually made of hard acrylic, that fits over the
occlusal and incisal surfaces of the teeth in one arch, creating precise occlusal
contact with the teeth of opposing arch.
• Synonyms: Splint
• Bite guard
• Night guard
• Inter-occlusal appliance
• Orthopedic appliance
24
Definitive Treatment
Occlusal appliance therapy

• Uses:
• Provide more Orthopedically stable joint position
• Introduce an optimum occlusal condition that recognizes neuromuscular reflex activity.
• Reduces abnormal muscle activity
• Encourage more normal muscle function
• Protect the teeth and supporting structures from abnormal forces that may create
breakdown, tooth wear, or both.
25

• Success or failure of appliance therapy depends on
• Selection of appliance
• Fabrication and adjustment of the appliance
• Patient cooperation
26

Indications:
• Muscle pain disorders
• Bruxism
• Local muscle soreness
• Centrally mediated myalgia
• Retrodiscitis secondary to trauma
27

Treatment goals:
• Eliminate any orthopedic instability between occlusal position and
the joint position
28

• Fabrication:
29

31

32

35
Adjusting the Eccentric Guidance

Following criteria should be achieved before stabilization appliance is given to the patient
1. It must accurately fit the maxillary teeth, with total stability and retention when
contacting the mandibular teeth and when checked by digital palpation.
2. In centric relation all posterior mandibular buccal cusps must contact on flat surfaces with
even force
37

3. During protrusive movement the mandibular canines must contact the appliance
with even force.
4. In any lateral movement only mandibular canine should exhibit laterotrusive
contact on the appliance.
5. The mandibular posterior teeth should contact the appliance only in centric
relation closure.
38

6. In the upright position the posterior teeth must contact the appliance more
prominently than anterior teeth.
7. The occlusal surface of the appliance should be as flat as possible with no
imprints for mandibular cusps.
8. The occlusal appliance should be polished so it will not irritate any adjacent soft
tissues.
39

Instructions to the patient:
• Finger pressure is used initially to align and seat appliance initially.
• Once it is pushed onto the teeth it can be stabilized with biting force.
• Removal is by catching it near the first molar area with the fingernails of
index fingers and pulling the distal ends downward.
40

Disorder Use of appliance
Bruxism Night time use
Retrodiscitis More frequently
Myogenous pain disorders Part-time use (especially
nighttime use)
Intracapsular disorders Continuous use
41

• The anterior positioning appliance is an inter-occlusal device that
encourages the mandible to assume a position more anterior than
the intercuspal position (ICP).
• It may be useful for the management of disc derangement
disorders.
42
Anterior Positioning appliance

Indications:
• Disc derangement disorders
• Joint sounds
• Intermittent or chronic locking of the joint
• Some inflammatory disorders like Retrodiscitis
43

Treatment goal:
• Change the mandibular position temporarily so as to enhance adaptation
of the retrodiscal tissues.
• Once tissue adaptation has occurred, the appliance is eliminated, allowing
the condyle to assume the Musculo Skeletally stable position and painlessly
function on the adaptive fibrous tissue
44

Fabrication:
45

46

Criteria to be achieved for the appliance:
• It should accurately fit the maxillary teeth with total stability and retention
when in contact with the mandibular teeth and when checked by digital
palpation.
• In the established forward position, all the mandibular teeth should contact
it with even force.
48

• The forward position established by the appliance should eliminate the joint symptoms
during opening and closing to and from that position.
• The appliance should be smoothly polished and compatible with adjacent soft tissue
structures.
49

Instructions:
• Night time wear only.
• During the day, the appliance should not be worn so that normal function
of the condyle will promote the development of fibrotic connective tissue
in the retrodiscal tissue
• If pain is present during day, it can be used for limited time only.
50

• The anterior bite plane is a hard acrylic appliance worn over the maxillary
teeth, providing contact with only the mandibular anterior teeth.
51
Anterior bite plane

Treatment goal:
• It is primarily intended to disengage the posterior teeth and thus eliminate their
influence on the function of the masticatory system.
52

Indications: Muscle disorders related to orthopedic instability
• Acute change in occlusal condition
• Parafunctional activity for short periods
Complications:
• Unopposed mandibular posterior teeth may supraerupt
• Anterior open bite
53
Anterior bite plane

• The posterior bite plane is usually fabricated for the mandibular
teeth and consists of areas of hard acrylic located over the
posterior teeth and connected by a cast metal lingual bar.
54

Treatment goal:
• The treatment goals of the posterior bite plane are to achieve major alterations in
vertical dimension and mandibular positioning.
55

Indications:
• Severe loss of vertical dimension
• Changes in anterior position of mandible is needed
• Disc derangement disorders
• Complications:
• Potential supra-eruption of unopposed teeth
• Intrusion of occluded teeth
56

• The pivoting appliance is a hard acrylic device that covers one arch and usually
provides a single posterior contact in each quadrant.
• This contact is usually established as far posteriorly as possible.
57
Pivoting appliance

• When superior force is applied under the chin, the tendency is- to push
the anterior teeth close together and pivot the condyles downward
around the posterior pivoting point.
58
Pivoting appliance

Indications:
• To lessen interarticular pressure
• Disc displacement or disocclusion
• Osteoarthritis
59
Pivoting appliance

• The soft appliance is a device fabricated of resilient material that is
usually adapted to the maxillary teeth.
• Treatment goals are to achieve even and simultaneous contact with
the opposing teeth.
60
Soft resilient appliance

Indications:
• Protective athletic splints
• Clenching and bruxism
• Repeated or chronic sinusitis
61
Soft resilient appliance

Selective grinding
The primary objectives of selective occlusal reshaping are as follows:
• To redistribute forces parallel to the long axes of the teeth by
eliminating contacts on inclined planes and creating cusp-fossa occlusion
• To eliminate deflective occlusal contacts
62

• To improve worn occlusal anatomy, enhance cuspal shape, narrow occlusal
tables, and reemphasize proper developmental and supplemental grooves in
otherwise flat surfaces
• To correct marginal ridge discrepancies and extrusions so oral hygiene will be
easier
• To correct tooth malalignment through selective reshaping
63

Contra-indications
1. A bruxer whose habit cannot be controlled
2. A diagnostic correction that indicates that too much tooth structure will be
removed
3. A complex spatial relationship (e.g., an Angle Class II and a skeletal Class III)
4. An open anterior occlusal relationship
64

5. Excessive wear
6. Before orthodontic or orthognathic treatment
7. Before physical or occlusal appliance therapy
8. A patient with Temporomanibular pain
9. A patient whose jaw movements cannot be manipulated easily
65

• Selective grinding is done in a sequence
• Elimination of centric interferences
• Elimination of lateral interferences
• Elimination of protrusive interferences
66

68
Patient awareness
•First treatment is educate the patient regarding the relationship between
emotional stress, muscle hyperactivity and the problem.
•An awareness of this relationship should be created before any treatment
begins.
•Establishing an awareness of nonfunctional tooth contacts, muscle hyperactivity
and stress management is essential to treatment.

69
Restrictive use
•Painful movements should be avoided
•Function within a painless range of motion
•Softer diet
•Smaller bites
•Chew slowly
“If It Hurts Don’t Do It”

70
Voluntary avoidance
•The patient should be instructed that the teeth should be disengaged any time they
contact except while chewing, swallowing or speaking.
•puffing little air between lips and teeth allows the jaw into relaxed position.
•Decreases muscle activity, minimizes interarticular pressure

71
Relaxation therapy
Relaxation
therapy
Substitutive
Behavioral
modification
Regular exercise
Active
Progressive relaxation
Jacobson’s
technique
Meditation
Yoga
Hypnosis
Biofeedback
training
Negative feed
back

Trauma
Macro
Prevention
Occlusal
appliances
Supportive therapy
Micro
Repeated
loading
Parafunctional
activities
Occlusal
appliances
72

73
Deep pain input
• orofacial pain is very complex
• There are many structures in the head and neck that can produce pain
complaints that mimic TMD along with the referral pains
• It is the most commonly overlooked etiologic factor associated
with a TMD is another source of deep pain input.
• In these patients, a TMD is identified during the history and examination
but if the TMD is treated without managing the deep pain input, the
treatment will fail.

75
MYOFASCIAL PAIN :
ETIOLOGIC CONDITIONS:
• Constant deep pain
• Increased emotional stress
• Sleep disturbances
• Systemic factors: nutritional inadequacies, fatigue, viral infections
• Idiopathic
CHARACTERISTICS:
• Structural dysfunction
• Pain at rest
• Increased pain with function
• Presence of trigger points
• Heterotopic pain

76
Myofascial pain
•Explain the disorder to the patient (cause and natural course of the disorder)
•Identify the local and systemic factors (muscle strain, emotional stress,
posture)
Therapy
•Address any local and systemic factors
•Begin appropriate supportive therapy
•Begin spray and stretch techniques, pressure, and massage
•Begin physical self-regulation
Positive results
Negative results
•Teach patient proper muscle exercise and stretching, proper
posture, relaxation techniques.
•Continue with physical self-regulation

77
Negative results
A few well-defined trigger points
that demonstrate referral
Multiple trigger points are present in
multiple muscles with vague referral
Trigger point injection and
stretch techniques
Referral to physical therapy for
•Ultrasound
•Electro galvanic stimulation
•Moist heat
•Spray and stretch
Positive results
Positive results
Negative results
Negative results
Identify and eliminate the original source of deep
pain input that is creating the Myofacial pain disorder
Address the sleep disorder
Consider psychotherapy, as indicated for the patient’s
condition (e.g., anxiety, depression, posttraumatic
stress disorder)
Teach patient proper muscle
exercise and stretching,
proper posture, relaxation
techniques
Continue with physical self-
regulation

78
Disc displacement and disc dislocation with reduction
CLINICAL CHARACTERISTICS:
• Relatively normal range of motion with restriction occurring only in association
with pain
• Discal movement can be felt by palpating the joints during opening and closing
• Deviations in the opening pathway

79
Disc displacement and disc dislocation with reduction
•Teach the patient the effects of local and systemic events
•Identify the predisposing events
Therapy
•Teach the patient to function in a manner that reduces joint sounds and pain
•Consider stabilization appliance at night (only occasionally during day for pain
reduction)
Negative results
Reduction in pain
Time, reevaluation
Decrease use of appliance
If bruxism is present
Continuation during sleep

80
Anterior positioning appliance at night (only
occasionally during day for pain reduction)
Reduction in pain No change in pain
Beginning of 24-hr
use of APA
Reduction in pain No change
Recall, reevaluation
Decrease use of appliance
No pain
(consider
SA only if
bruxism is
present)
Return of pain Reevaluation of APA
for effectiveness
Return to APA
Reevaluation of
source of pain

81
Intracapsular
source of
pain)
Extracapsular
source of
pain)
Surgical
evaluation
Treatment dirrected
to the appropriate
extracapsular source
Return to APA
Recall, reduces pain
Conversion of APA to SA
No pain
Evaluate for
orthopedic
stability
Return of pain
Orthopedically stable:
Therapy: frequent recall, gradual decrease use of SA
(no dental therapy needed)
Orthopedically unstable:
Therapy: evaluation of appropriate method needed to
achieve stability

82
Disc dislocation without reduction
• Reveals limited mandibular opening ( 25 to
30mm)
• Deflection to ipsilateral side during maximal
opening
• Restricted eccentric movement to contra-
lateral side

83
Disc dislocation without reduction
If acute
Attempt manual manipulation to
reduce dislocation If chronic (permanent disc dislocation)
•Begin patient education (restrict use and
range of movement)
•Consider a SA to reduce loading
Successful
reduction of
disc
Unsuccessful
reduction of
disc
Therapy: anterior positioning appliance
Continue with treatment sequence used for disc
displacement and disc dislocation with reduction

84
Dysfunction
with pain
Dysfunction
without pain
Evaluate the degree of
pathosis and alteration in
quality of life
Begin exercise and
physical therapy to
increase functional
range of mandible
Therapy (observation)
•Supportive therapy
•Slight anterior positioning appliance
to promote comfort
•Monitoring signs for progression of
the disorder
Therapy (consider surgical options)
•Arthrocentesis
•Arthroscopy
•Arthrotomy
•discectomy

85
DEVIATION IN FORM
• If there is Deviation in form of the condyle, fossa or disc it will commonly
show a repeated alteration in the pathway of the opening and closing
movements
• When a click or deviation in opening is noted, it will always occur at the
same position of opening and closing.

86
• Restriction in mouth opening until click occurs ------ temporary adhesion
• Limited mouth opening, dysfunction --------- permanent adhesion
• Opening movement will deflect to ipsilateral side ------ adhesion in only
one joint
• sudden jerky movements during opening --------- adhesion in inferior
joint cavity
• 25 to 30mm mouth opening --------- adhesion in superior joint cavity
ADHESIONS

87
Deviation in form and adhesions
Teach patient proper mandibular movements that avoid the structural disorder
Pain
Significant dysfunction
No pain
Mild dysfunction
Observation
Monitor signs for progression of
the disorder
Bruxism absent
Bruxism present
•Use stabilization appliance at night.
Continued pain
and dysfunction
No pain
Mild dysfunction

88
No pain
Mild dysfunction
Observation
Monitor signs for
progression of
the disease
Consider
appropriate
surgical procedure
to resolve the
disorder
Continued pain
and dysfunction

89
Subluxation and spontaneous dislocation
SUBLUXATION :
• During final stage of maximal mouth opening, the condyle can
be seen to suddenly jump forward with a thud sensation
SPONTANEOUS DISLOCATION/LUXATION/OPEN-LOCK:
• Wide open mouth condition

90
Subluxation and spontaneous dislocation
•Teach the patient anatomic considerations of the disorder
Diagnosis: Subluxation Diagnosis: spontaneous dislocation
Voluntary restriction of use to
within range that doesn't lead to
disorder
Consider a manipulation technique to
reduce the dislocation
Positive results
(no recurrence)
Therapy is
Observation
Negative results
(recurrence)
Use A restrictive
appliance

A restrictive appliance
Positive results
(no recurrence)
Therapy:
Observation
Negative results
(recurrence)
Evaluate the severity
of dysfunction and
effect on the patient’s
quality of life
Mild
dysfunction)
Significant
dysfunction
Consider appropriate
surgical procedure
needed to resolve
disorder
91

92
Capsulitis and sinuvitis, retrodiscitis
CAPSULITIS :
• Pain in felt directly in front of the ear
• Lateral aspect of the condyle is tender on palpation
• Pain is constant and increased on jaw movements
RETRO-DISCITIS:
• Constant pre-auricular pain increased pain with jaw movements
• Clenching of teeth increases pain
• Swelling of the retrodiscal tissues can force the condyle forward, resulting
in an acute malocclusion

93
Capsulitis and sinuvitis, retrodiscitis
Trauma is no longer present as etiological
factor
Trauma is still present as etiological
factor
Therapy
•Begin appropriate supportive
therapy
therapy
Therapy
•Use an occlusal appliance developed in
appropriate mandibular position to
eliminate trauma to structures.
•Begin physical self-regulation therapy
Negative results
Positive results
Therapy
None indicated
Negative results Positive results
Therapy
Allow time, then gradually reduce the use of the appliance (treat
as disc displacement)

94
Negative results
Therapy
•Observe and continue supportive therapy
and physical self regulation
Consider appropriate surgical
procedure needed to resolve
disorder
•Evaluate the alteration in quality of life

95
Osteoarthritis
• Limited mandibular opening
• crepitus
Clinical Characteristics.

96
Osteoarthritis
•Provide patient reassurance
Therapy
•Consider occlusal appliance developed in a comfortable mandibular position.
Negative results
(continuation of symptoms)
Positive results
(reduction or elimination of symptoms)
Therapy
•Observe
•Evaluate need to correct any pathologic sequelae.
Occlusal therapy No therapy
indicated

97
Negative results
(continuation of symptoms)
Evaluate quality of life
Further treatment is
indicated
Therapy
•Observe
•Evaluate need to correct any pathologic
sequelae.
Therapy
•Single intraarticular injection of an
anti-inflammatory (steroid) .
Positive results Negative results
Therapy
•Surgical procedure directed
toward the symptoms.
Occlusal therapy No therapy indicated

• Lerman MD introduced a new type of fluid-bearing
appliance called hydrostatic applainace and
conducted a study on 26 subjects.
• The hydrostatic cell is interposedbetween the
maxillary and mandibular arches ,this eliminates all
direct occlusal contacts.
• All occlusal disharmonies are neutralized
systematically ; premature and displacing contacts
merely sink deeper into the cell, while the intervening
fluid layer compensates by becoming correspondingly
thinner at these points
Lerman MD. The hydrostatic appliance: a new approach to treatment of the TMJ pain-dysfunction syndrome. J Am Dent Assoc. 1974 Dec 1;89(6):1343-50.
99

• The occlusal forces that araise individually from the tooth contacts are now
created as whole within the hydrostatic cell and distributed to each tooth
that contacts the cell.
100

concluded that-
• Improvement was seen in 84% of the previously unsuccessfully treated
patients
• And thus, hydrostatic appliance is a very effective approach in
treating pain dysfunction syndrome.
101

Ayyildiz S, Emir F, Sahin C. Evaluation of low-level laser therapy in TMD patients. Case reports in dentistry. 2015.
Ayyildiz S, Emir F, Sahin C in their study on the Evaluation of low-
level laser therapy in TMD patients concluded that-
A low level diode laser from 632-685 nm wavelength was found
penetrates musculoskeletal tissues better
The treatment protocol of application of 632nm diode laser for 30
sec three times a week for one month found to be having better
results.
They suggested that Low Level Laser therapy is an appropriate
treatment for TMD related pain and limited mouth opening and
should be considered as an alternative to other methods.
102

Imhoff B in 2019 discussed about a new therapeutic approach called
cerezen device in the management of TMD and bruxism .
This method is based on custom-made ear inserts that can be worn during
the day and at night
Simply inserted into the ear the device works by exerting subtle pressure
on the walls of the ear canal when the jaw is in the closed position.
Imhoff B. New therapeutic approaches for craniomandibular dysfunction. know compact. 2019 Feb; 13 (1): 49-
58.
103

Thus it is claimed that it encourages the patient to return to
open bite position and decrease the symptoms of TMD.
The mechanism of action has not yet been fully clarified
104
Imhoff B. New therapeutic approaches for craniomandibular dysfunction. know compact. 2019 Feb; 13 (1): 49-
58.

Conclusion:
• Functional disturbances of the masticatory system can be as complicated
as the system itself.
• Although numerous treatments have been advocated, none are
universally effective for every patient every time.
• Effective treatment selection begins with a thorough understanding of
the disorder and its etiology.
• An appreciation for the various types of treatments is essential for
effective management of the symptoms.
105

References:
1. Okeson JP. Myogenous temporomandibular disorders: diagnostic and
management considerations. Dent Clin North Amec 2007;51:61-83.
2. Dawson PE. Functional occlusion to smaile design.6th ed ;Edinburgh:
Elsevier Mosby: 2006.
3. Marbach JJ, Lipton AJ. Biopsychological factors of the
Temporomandibular Pain Dysfunction syndrome. Dent Clin North Amec
1987; 31(3):473-486.
106

4. Charles R. Carlson. Physical Self-Regulation Training for the Management of
Temporomandibular Disorders. J OROFAC PAIN 2001;15:47–55.
5. Koh H, Robinson PG. Occlusal adjustment for treating and preventing
temporomandibular joint disorders. J Oral Rehab 2004; 31:287–292
6. Imhoff B. New therapeutic approaches for craniomandibular dysfunction.
know compact. 2019 Feb; 13 (1): 49-58.
107

7. Ayyildiz S, Emir F, Sahin C. Evaluation of low-level laser therapy in
TMD patients. Case reports in dentistry. 2015.
8. Lerman MD. The hydrostatic appliance: a new approach to treatment
of the TMJ pain-dysfunction syndrome. J Am Dent Assoc. 1974 Dec
1;89(6):1343-50.
9. Kahn J: Iontophoresis and ultrasound for postsurgical
temporomandibular trismus and paresthesia, Phys Ther 60(3):307–308,
1980.
108

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