edentulous patients

1. Temporomandibular
disorders in edentulous
patients
By
DrVijyanta Suman

2. CONTENTS
 Introduction
 Epidemiology
 classification
 Etiology
 symptoms
 Management
 Pharmacotherapy
 Physical modaliities
 Bio-behavioral modalities
2

3. Introduction
3
Temporomandibular disorders:
conditions producing abnormal, incomplete, or impaired
function of the temporomandibular joint(s) and/or the
muscles of mastication
Also referred as temporomandibular dysfunction syndrome
Carl F. Driscoll. Martin A. Freilich. Albert D. Guckes. Kent L. Knoernschild.
Thomas J. McGarry. Glossary of ProsthodonticTerms-9. Journal of Prosthetic
Dentistry

4. 4
Temporomandibular disorder (TMD) is any disorder that affects or is affected by
deformity, disease, misalignment, or dysfunction of the temporomandibular
articulation.
This includes occlusal deflection of the temporomandibular joints (TMJs) and the
associated responses in the musculature.
These disorders include
a) Displacement of one or both joints,
b) Misalignment of the disk,
c) Diseases affecting bone or the articular surfaces,
d) Inflammation/injuries to specific intracapsular structures.
Occlusal disharmony that affects the position of theTMJs, and disorders of the
masticatory musculature are also included as specific types ofTMDs
Peter E Dawson. Functional occlusion fromTMJ to Smile Design. 1st Edition. 2006. p260-262

5. 5

6. History
6
Laskin et al; 1983 definedTMD as a collective term used to
describe a group of musculoskeletal conditions occurring in
the temporomandibular region.
The term TMDs was introduced by Dworkin and LeResche
in 1992
The definition forTMD that was presented by the National Institute of
HealthTechnologyAssessment Conference on Management ofTMD
1996:
“Depending on the practitioner and the diagnostic methodology, the term
TMD has been used to characterize a wide range of conditions diversely
presented as pain in the face or jaw joint area, limited mouth opening,
closed or open lock of theTMJ, abnormal occlusal wear, clicking or popping
sounds in the jaw joints, and other complaints.”

7. EPIDEMIOLOGY
IN
EDENTULOUS
POPULATIONS
7
TMDs in edentdous populations appears to vary considerably from
0% (LoiseUe, 1969) to 94% (Agerberg and Viklund, 1989)
Edentulous subjects generally do not present withTMD symptoms
to the extent of those having natural dentition.TMD appears to be
prevalent in complete dentures (CD) wearers in almost the same
proportion as in dentate individuals, with the prevalence varying
from 15-25%.
Different population based studies reveals that TMD is primarily a
condition of young & middle-age adults (mainly female)
Zarb Bolender. Prosthodontic treatment for edentulous patients.12th edition.Mosby.p51-55

8. Epidemiology
8
The most common subtypes of temporomandibular disorders
in clinic populations appear to be myofascial pain and
arthralgia, followed by
disc displacements with reduction
pain in the temporomandibular region is a relatively common
pain condition for adults, that occurs about twice as
frequently in women as in men.
This type of pain is most prevalent in young and middle-aged
adults, and declines in frequency among the elderly.
L.LeResche . Epidemiology of temporomandibular disorders: implications for
the investigation of etiologic factors. Critical Reviews in Oral Biology &
Medicine.1997

9. 9
pain in the temporomandibular region is relatively uncommon in children aged 7-17.
However, pain report may increase somewhat with age in this group.The gender
differences in prevalence seen in adults are not apparent in children
Various epidemiological prevalence studies have shown that up to 40-75% of the general
population may experience at least one TMD sign, such as TMJ noise, and 33% at least
one symptom, facial or TMJ pain
According to the Research Diagnostic Criteria forTMD, hard grating or crepitation is
required for a joint to meet diagnostic criteria for osteoarthritis or osteoarthrosis
the rates of crepitus appear to be higher in women than in men.
L.LeResche . Epidemiology of temporomandibular disorders: implications for the investigation of etiologic
factors. Critical Reviews in Oral Biology & Medicine.1997

10. 10
A systematic review based on the content of PubMed, Scopus, and
Cochrane Library databases was performed. Nine studies were included into
our review.
Results:The relationship between estrogen levels andTMD was found in
seven out of nine reviewed papers. Results from two papers suggest that a
high estrogen level is associated with an increased prevalence ofTMD. Five
additional papers found a relationship between a low estrogen level and an
increase inTMD pain.
Marcin Berger. Leszek Szalewski. Magdalena Bakalczuk. Grzegorz Bakalczuk. Szymon Bakalczuk. jacek
Szkutnik. Association between estrogen levels and temporomandibular disorders: a systematic
literature review. Prz Menopauzalny. 2015; 14(4):260-270

11. 11
Edentulous patients generally do not present with as many
TMD symptoms as those with natural dentition.
This can probably be attributed to the fact that the
proprioceptive feedback from teeth no more exists to
initiate the symptom complex ofTMD. In individuals with
natural teeth overclosure of the jaws can predispose to
TMD
bite force and electromyographic activity are considerably
reduced in edentulous patients
fatigue resistance of the masseter muscles is reduced
Tortopidis D, Lyons MF, Baxendale RH. Bite force, endurance and
masseter muscle fatigue in healthy edentulous subjects and those
with TMD. J Oral Rehab.1999;26:321-28.
The loss of natural teeth
can cause psychological
problems that increase
emotional stress and may
contribute to the
development ofTMD
Coronatto EAS.Zuccolotto
MCC.Bataglion C. Bitondi
MBM. Association between
temporomandibular disorders
and anxiety: epidemiologic
study in edentulous patients.
Int J Dent Recife. 2009;8:6-10

12. Classification
of
TMD
12
TMD patients based on the importance of physical versus
psychosocial impairment:
(i) A biologically/somatically definedTMD patient group
(ii) An intermediate group, with patients who report
fluctuating or recurrent symptoms ofTMD, but are
generally viewed as adaptive copers; and
(iii) Complex/psycho-socially dysfunctionalTMD patient
group
Suvinen TI, Reade PC, Kemppainen P, Kononen M, Dworkin SF. Review of aetiological concepts of
temporomandibular pain disorders: towards a biopsychosocial model for integration of physical disorder factors
with psychological and psychosocial illness impact factors. Eur J Pain. 2005;9:613-33.

13. Categories
of TMD
13
Category 1
Category 2
Category 3
Category 4
Occluso-muscle disorders with no intracapsular defects
Intracapsular disorders that are directly related to
occlusal disharmony and are reversible in re-
establishing comfortable function if the occlusion is
corrected
Intracapsular disorders that are not reversible, but
because of adaptive changes, can function comfortably
if occluso-muscle harmony is re-established
Nonadapted intracapsular disorders that may be either
primary or secondary to occlusal disharmony or may be
unrelated
Peter E Dawson. Functional occlusion fromTMJ to Smile Design. 1st Edition. 2006. p264

14. 14
Stegenga 2010 suggested that, instead of positional classification relating the presence
of joint pathology to the position of the disc, a classification system based on the actual
intra-articular structural changes could be more suitable for clinical purposes
two major categories of structural disorders :
i. Arthritic disorders: inflammatory disorders affecting the joint, mainly characterized
by pain and function impairment
ii. Growth disorders: characterized by facial asymmetry
Non-arthritic disorders: non-inflammatory in nature
mechanical component (disc displacement), but are related to a joint disease due to
tissue changes, present with pain as the main symptom
Klasser GD. Manfredini D. Goulet JP. DeLaat A. Oro-facial pain and temporomandibular disorders
classification systems: A critical appraisal and future directions. J Oral Rehabil. 2018
Mar;45(3):258-268.

15. 15
Schiffman et al. 2012 as part of the ongoing expansion of TMD taxonomy and validation of
the original TMD criteria, proposed a classification of headaches attributed to TMD
i. History of temple area headache that is changed with jaw movement, function, or
parafunction
ii. Familiar report of the headache by temporalis muscle palpation or jaw movement
Machado et al. 2012
Clinical presentation of diagnostic characteristics of TMD patients
(time of onset, the location, the presence of pain and extent of the symptoms)
i. Acute muscle pain (35.0%)
ii. Non-painful articular impairment (33.9%)
iii. Acute articular pain (21.0%)
iv. Chronic facial pain (10.1%)
Klasser GD. Manfredini D. Goulet JP. DeLaat A. Oro-facial pain and temporomandibular disorders
classification systems: A critical appraisal and future directions. J Oral Rehabil. 2018 Mar;45(3):258-
268.

16. 16
Peck et al. 2014
The expanded TMD taxonomy comprises four major classes of disorders
• Temporomandibular joint disorders
• Masticatory muscle disorders
• Headache
• Associated structures
Multiple diagnoses are allowed
TMD pain-related diagnosis: pain must have been experienced in the last 30 days
unless a different time frame is dictated by clinical circumstances. In addition, the pain
induced by the specified provocation test(s) must replicate the patient’s pain and feel as
being familiar
Klasser GD. Manfredini D. Goulet JP. DeLaat A. Oro-facial pain and temporomandibular disorders
classification systems: A critical appraisal and future directions. J Oral Rehabil. 2018 Mar;45(3):258-268.

17. 17
Schiffman et al. 2014
published the DC/TMD, which represents an evolution of the widely adopted Research Diagnostic Criteria for
Temporomandibular Disorders originally published in 1992
DC/TMD proposed a two-axis assessment, a physical (Axis I) and psychosocial diagnosis (Axis II)
this is the only classification system that incorporates standardized and reliable self- report questionnaires,
clinical examination procedures, scoring systems.
no other system integrates biophysical diagnosis to a disability index that measures the impact that pain has on
the patient’s behaviour
DC/TMD relies solely on clinical examination procedures, the utility is potentially limited regarding certain disc
displacement disorders and degenerative joint disease that are best assessed with the addition of imaging of the
temporomandibular joint
Klasser GD. Manfredini D. Goulet JP. DeLaat A. Oro-facial pain and temporomandibular disorders classification
systems: A critical appraisal and future directions. J Oral Rehabil. 2018 Mar;45(3):258-268.

18. Classification
of TMD in
Edentulous
patients
18
Dr. Bader’s Proposed classification of temporomandibular disorders (TMD) in edentulous patients
Type 1 Patients with noTMJ changes
Type 2 •Patients with mildTMJ changes: Popping
•Clicking of the jaw
•Feeling of muscle spasms
•Normal mouth opening (32–62 mm)
Type 3 Patients with mild and moderate TMJ changes
•Which include combination of type 2 and Headaches and occasionally, migraine-like
headaches
•Cervical pain
•Limited mouth opening (<35 mm)
•Deviation/deflection of mandible during opening and closing
Type 4 Patients with mild, moderate and severe TMJ changes
•Which include combination of type 3 andTenderness of muscles of mastication
•Tenderness overTMJ
•Pain while opening in mouth
•Locking ofTMJ Luxation ofTMJ
Type 5 Patients with Mild, moderate, severe and advancedTMJ changes
•Which include combination of type 4 and radiographic changes such as presence of
flattening, erosion, osteophytes and sclerosis in the joint components
Bader k Alzaria.Temporomandibular Disorders (TMD) in Edentulous Patients: A Review and Proposed Classification.
J Clin Diag Res. 2015 Apr;9(4): ZE06–ZE09.

19. Etiology
19
• Tooth loss is a predisposing factor to mandibular
dysfunction.
such dysfunction is positively correlated with the loss of
occlusal support and the number of remaining teeth or
occluding pairs of teeth
• Loss of vertical dimension of occlusion has also been
assumed to play an important role in the etiology of TMDs
in elderIy and edentuIous patients
• Age-related increase in the prevalence of degenerative
diseases

20. 20
A study was conducted to evaluate the association between tooth loss and the signs
and symptoms of temporomandibular disorders (TMDs).
150 patients with an average age of 49.2 years were divided into three groups (n =
50/group) according to the degree of tooth loss:
GI (dentate – control), GII (edentulous), GIII (partially dentate)
clinical examination & a questionnaire was used to determine degree of severity of
TMD.
The mean level of TMD according to the groups was GI – 1.95; GII – 2.15; GIII – 2.55
Conclusion: The tooth loss is directly related to the signs and symptoms of TMD. The
degree of severity of TMD was significantly higher in edentulous patients
Adriana Santos Malheiros. StéphanyeTavares Carvalhal.Teonnes Lima Pereira. Etevaldo Matos Maia
Filho.Mateus RodriguesTonetto.Letícia Machado Gonçalves.Matheus Coelho.Bandec.Rudys Rodolfo De
JesusTavarez. Association betweenTooth Loss and Degree ofTemporomandibular Disorders: A
Comparative Study. Journal of contemporary dental practice. Mar 2016;17(3):235-239

21. 21
There are numerous factors that can contribute to this disorder, mainly grouped into three
categories.
• Predisposing factors: increase the risk of developingTMD
• Initiating factors: cause the onset of the disease
• Perpetuating factors: interfere with the healing process or enhance the progression ofTMD
Initiating factors: primarily related to trauma or adverse loading of the masticatory system.
Perpetuating factors may include the following:
Behavioral factors: grinding, clenching and abnormal head posture
Social factors: affect perception and influence of learned response to pain
Emotional factors: depression and anxiety
Cognitive factors
Chisnoui AM. Picos AM. S Popa. PD Chisnoiu. Factors involved in the etiology of temporomandibular
disorders - a literature review. CJMED.2015;88(4): 473–478

22. 22
Predisposing factors:
Biomechanical:Occlusal overloading and parafunctions (bruxism)
Neuromuscular
bio-psychosocial: stress, anxiety or depression
Biological: increased levels of estrogen hormones
Costen was the one who first established with certainty the involvement of occlusion in the development ofTMD.
Chisnoui AM. Picos AM. S Popa. PD Chisnoiu. Factors involved in the etiology of temporomandibular disorders -
a literature review. CJMED.2015;88(4): 473–478

23. Costensyndrome (1934):
Etiology: irritation ofthe auriculotemporaland/orchordatympanic nerves asthey emerge
fromthe tympanic plate causedbyaltered anatomicrelations
Symptoms frequentlyobserved:
-Derangements ofthe temporomandibularjointassociated with loss ofocclusalvertical
dimension
-Lossofposteriortoothsupport,and/orothermalocclusions,
-Headacheaboutthe vertexandocciput, tinnitus, pain aboutthe earimpaired hearing, and
pain aboutthe tongue
CarlF.Driscoll.MartinA.Freilich.AlbertD.Guckes.KentL.Knoernschild.ThomasJ.McGarry.GlossaryofProsthodontic
Terms-9.JournalofProstheticDentistry
23

24. 24
Macrotrauma
Whiplash-type injuries to the head or neck are commonly considered significant risk factor
A study including 400 patients with TMD revealed that in 24.5% of them, the presence of TMJ pain was
directly correlated with a history of trauma
[De Boever JA. Keersmaekers K.Trauma in patients with temporomandibular disorders: frequency and
treatment outcome. J Oral Rehabil. 1996;23:91–96]
Parafunctions
Miyake et al. identified bruxism and chewing gum on one side as risk factors forTMD. In individuals who frequently
chew gum, more than four hours a day, auricular pain is more frequent at rest and during movements and there is a
higher frequency of joint noise
[Miyake R.Ohkubo R.Takehara J. Morita M. Oral parafunctions and association with symptoms of
temporomandibular disorders in Japanese university students. J Oral Rehabil. 2004;31:518-523.]

25. 25
Bruxism in 87.5% of patients with disc displacement and joint pain
Huang et al. identified a strong correlation between tooth clenching and the presence of myofascial
pain
Israel HA. Scrivani SJ.The interdisciplinary approach to oral, facial and head pain. J Am Dent
Assoc. 2000;131:919-926.]

26. 26
Joint hyperlaxity and joint hypermobility
Some authors have reported no association betweenTMD and systemic hyperlaxity or betweenTMJ mobility and
systemic hypermobility, while others found a positive relationship between generalized joint hypermobility and
TMD
Hereditary factors
Michalowicz et al. evaluated the hypothesis that signs and symptoms ofTMD may be hereditary and concluded
that genetic factors and the family environment exert no relevant effect upon the presence of symptoms and signs
of theTMJ.
Chisnoui AM. Picos AM. S Popa. PD Chisnoiu.Factors involved in the etiology of temporomandibular disorders -
a literature review. CJMED.2015;88(4): 473–478

27. Symptoms of
TMD
27
Some of the common symptoms ofTMD such as pain, psychological discomfort,
physical disability and limitation of mandibular movements can become chronic
and affect quality of life
250 completely edentulous patients were selected, 138 of the patients had an
existing set of complete dentures and the remaining 82 had no dentures
Examination of patients
Denture evaluation
Interocclusal distance
Deviation on opening
Centric relation interceptive contact
Retention
stability
• Palpation ofTMJ, muscles of mastication, Sternocleidomastoid muscle,
Suprahyoid, Infrahyoid,Trapezius
• joint sounds: clicking, crepitus
Sakurai K. Giacomo TS. Arbree NS. Yurkstas AA. A survey of temporomandibular joint dysfunction in
completely edentulous patients. The Journal of Prosthetic Dentistry. 1988 ;59(1):81–85

28. 28
Sakurai K. Giacomo TS. Arbree NS. Yurkstas AA. A survey of temporomandibular joint dysfunction in completely
edentulous patients. The Journal of Prosthetic Dentistry. 1988 ;59(1):81–85
• The three main signs ofTMJ dysfunction: deviation of mandible, tenderness on palpation, andTMJ noise
• Completely edentulous patients should be examined more carefully forTMJ dysfunction if their dentures
are more than 6 years old

29. 29

30. 30
Jeffrey P Okesson. Management of temporomandibular disorder and occlusion. 7th Edition. 2013.
Mosby Elsevier

31. 31
The aim of this study was to investigate the prevalence of signs and symptoms of TMD among completely
edentulous denture-wearing and non-denture wearing patients and to evaluate the influence of new
dentures on TMD symptoms at 3 months and 3 years after denture insertion
investigation was conducted among 250 patients (118 non denture wearers and 132 denture wearers)
for symptoms of TMD such as
TMJ sounds, locking, fatigue or stiffness of the jaws, difficulty in opening, luxation, pain on movement of the
mandible, pain in jaws or face, ear pain
Clinical examination included maximum mouth opening, deviation on mouth opening, palpation and
auscultation of the TMJ, palpation of the masticatory muscles, pain on movement of the mandible
Dervis E. Changes in temporomandibular disorders after treatment with new complete dentures.
Journal of Oral Rehabilitation 2004 31; 320–326

32. 32
No relationship could be found between occlusal errors and signs and symptoms ofTMD
excessive occlusal vertical dimension may causeTMD symptoms as the absence of a free
way space may induce clenching of the teeth.
there is a correlation between the frequency and duration of clenching and signs and
symptoms ofTMD. old, poorly fitting and unstable dentures are the main reason for
clenching in these patients
no association between denture retention or stability and the signs and symptoms of
TMD was found
Dervis E. Changes in temporomandibular disorders after treatment with new complete dentures. Journal of Oral
Rehabilitation 2004 31; 320–326

33. 33
The aim of this study is to investigate the anatomic changes in theTMJ in completely edentulous patients
with clicking
25 completely edentulous patients were selected to participate in this study.The study was based on bilateral
MRIs of 15 patients (with articular sound) and 10 symptom-free volunteers (control)
Results. MRI in edentulous patients showed Disc displacements in 45% and 70% in the control and joint
sounds group respectively. Clicking was the most frequent clinical finding for disc displacement with
reduction. the superior or normal position was the most prevalent condyle position for control group. Mild
tenderness to palpation was detected, while pain was not an usual finding for any type of Disc displacement
They verified significant association between reducing disc displacement and biconvex disc.
Conclusion. These observations demonstrated that internal derangements can not be associated to clicking
joints or symptoms of temporomandibular disorders in elderly edentulous patients, and the presence of
displaced discs seems to be associated to altered disc morphology, but not to osseous abnormalities.
PortoVC. Salvador MCG. Paulo C. Evaluation of disc position in edentulous patients with complete
dentures . Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;97(1):116-21.

34. How to
examine if
TMJs are
healthy
34
Six ways to verify that theTMJs are healthy
1. Screening history: Every patient should be asked key
questions about theTMJs before treating.

35. 35
2. Load test. For verification of comfort in centric
relation or adapted centric posture. Any sign of
tension or tenderness warrants further evaluation.

36. 36
3. Range and path of movement tests: Normal range
is 10- 14 mm in protrusive. About 10 mm toward right
and left. Maximum opening without discomfort is
about 40-60 mm.

37. 37
4. Doppler analysis. An intact healthy joint is quiet on rotation and
translation
5. Radiography/imaging. Not necessary if other tests and history are
negative. Selection of type of imaging should be based on signs and
symptoms
6. Anterior bite plane for muscle deprogramming. Can be used to
determine if occlusion is a factor and to determine if an intracapsular
disorder is contributing to the pain. If a flat, permissive anterior bite plane
does not relieve pain or discomfort at theTMJs, suspect an intracapsular
disorder as a source of pain

38. 38
If all answers are YES, suspect that the problem is occluso-
muscle disorder with no intracapsular disorder
Peter E Dawson. Functional occlusion from TMJ to Smile Design. 1st Edition. 2006

39. Management
of TMD in
Edentulous
patients
39
Unless there are specific and justifiable indication to the contrary,
treatment be based on use of conservative and reversible therapeutic
modalities
these types of pain conditions must be managed within a biopsychosocial
framework, in which behavioral approaches supplement conservative
medical care
Electrophysical modalities, such asTENS devices and ultrasound, may
provide reduction of symptoms. Although their benefit may be palliative
and useful in facilitating other treatment processes

40. 40
Charles S Green. Managing the care of patients with temporomandibular disorders: A new guideline
for care . J Am Dent Assoc. 2010;14(1):1086-1088
Guidelines for management of TMDs in edentulous patients:
• The differential diagnosis ofTMDs or related orofacial pain conditions should be based primarily
on information obtained from the patient’s history, clinical examination, and when indicatedTMJ
radiology or other imaging procedures
• In addition standardized and validated psychometric tests may be used to assess the psychosocial
dimensions of each patient’sTMD problem
• Treatment ofTMD patients initially should be based on the use of conservative, reversible and
evidence-based therapeutic modalities
• Professional treatment should be augmented with a home care program, in which patients are
taught about their disorder and how to manage their symptoms

41. 41
TREATMENT OF FIBROMYALGIA
Treatment of fibromyalgia can serve as a model for the treatment ofTMD in general.This treatment
involves the use of splints in addition to physical therapy, medications, and psychologic and medical
care
Functional treatment of the stomatognathic system has been shown to be valuable in treating
mandibular dysfunction and headache
The first line of treatment should include a soft diet, mild analgesics, non- steroidal anti-inflammatory
medication, and the use of heat or cold coupled with voluntary attempts to discontinue undesirable
oral habits
Robson F. C. Practical management of internal derangements of the temporomandibular joint
in partially and completely edentulous patients.The Journal of Prosthetic
Dentistry.1991;65(6):828–832.

42. 42

43. 43
TREATMENT OF ARTHRALGIA
The treatment of arthralgia uses the principles of basic splint therapy as they apply to the treatment of
fibromyalgia
With early displacements, disk function can be accomplished normal with the use of a night orthotic and
muscle therapy
In patients with advanced degenerative joint disease (DJD), a basic muscle therapy approach is used
The denture-bearing tissue must be used to absorb even more force if anterior repositioning is to be
accomplished,The prosthetic devices may not allow for care that is as definitive as that for dentulous
patients

44. 44
DISK DISPLACEMENT WITH REDUCTION
Mechanical therapy becomes a part ofTMD care when an orthotic device is used to reposition the
mandible anteriorly in an attempt to normalize disk function
It is important to consider disk position and function when anterior repositioning therapy is used.
Arthrographic studies of disk position with these devices demonstrate that elimination of joint noise is
possible without recapture of the displaced disk.

45. 45
The technique for establishing the recaptured position and the
proper choice of patients for attempting recapture are
important considerations but are not scientifically proven
The presence of dentures may also complicate recapturing
The partially and completely edentulous patient may need more
anterior positioning and may have difficulty with trauma to the
edentulous ridge

46. 46
Disk displacement without reduction can be divided into acute and chronic displacement.The
acute phase is typically easy to diagnose and treatment is more dramatic
In this phase, range of motion of the affected joint is restricted severely. In chronic displacement,
joint noise may be absent and some patients show a hypermobility
the mandibular condyle is moved inferiorly and anteriorly to allow the disk to resume a more
normal relationship between the condyle and posterior slope of the articular eminence

47. 47
Treatment is compromised greatly in the completely edentulous ridge, which may interfere with
successful treatment
Chronic displacements without reduction can be treated with basic splint therapy or as a disk
displacement with reduction that cannot be recaptured

48. 48
SURGICAL CARE
SurgicalTMJ care is recommended for specific joint problems that significantly interfere with a
patient's quality of life and do not respond adequately to reversible therapeutic techniques
If adequate pain reduction cannot be established in a reasonable amount of time, surgery may be
considered
Prolonged care with orthotic devices that may lead to permanent changes in tooth position and
adaptive remodeling of joint structures is not recommended
Psychologic aspects of chronic pain in long-term non-surgical therapies also should be considered
in the surgical decision

49. 49
Disk repositioning by surgical or nonsurgical means can create a change in position of
the mandible and alteration of dental occlusal relationships
The treatment of fibromyalgia can alter muscle splinting and result in a clinically
changed mandibular position
Dental care to provide dental support for theTMJ is frequently needed after these
treatments
Unsatisfactory dentures have been reported to result in an increase in recurrent
headache and mandibular dysfunction

50. 50
Objectives: This study was performed with the purpose
of investigating electromyographic (EMG) activity of the
anterior temporalis and masseter muscles in edentulous
individuals with temporomandibular disorder (TMD),
before and after using sliding plates on complete
dentures in the mandibular rest position
Materials and methods: The patients were edentulous
for at least 10 years. EMG recordings were made before
the insertion of the dentures and after 4, 9, 12 months
of using the sliding plates
Zucolotto MC.Vitti M. Antonio K. Electromyographic evaluation of masseter and anterior temporalis muscles in
rest position of edentulous patients with temporomandibular disorders, before and after using complete dentures
with sliding plates. Geriodontology;4(2):105-110

51. 51
Results:
Temporalis muscle showed significant increase in EMG activity compared with initial
values (p < 0.01)
Masseter muscles showed significantly lower mean values (p < 0.01) compared with
initial values
Conclusion: The sliding plates allowed the process of neuromuscular deprogramming,
contributing to muscular balance of the masticatory system, and are therefore indicated
to be used before the fabrication of definitive complete dentures in patients withTMD
Zucolotto MC.Vitti M. Antonio K. Electromyographic evaluation of masseter and anterior temporalis muscles in
rest position of edentulous patients with temporomandibular disorders, before and after using complete
dentures with sliding plates. Geriodontology;4(2):105-110

52. Pharmacotherapy
52
When previous therapies fail, pharmacotherapy is required
For Acute pain: NSAIDs and Cox2 inhibitors
Anti-inflammatory medications, such as ibuprofen and naproxen can substitute
for aspirin
Also effective are muscle relaxants such as cyclobenzaprine, chlorzoxazone
Codeine, often in combination with analgesics, may be administered for brief
periods of time
Tricyclic antidepressant medications can be of value such as amitriptyline
Robson F. C. Practical management of internal derangements of the temporomandibular joint in partially and
completely edentulous patients. The Journal of Prosthetic Dentistry.1991;65(6):828–832.

53. 53
For limited periods of time, antianxiety medications such as alprazolam, lorazepam
can be beneficial
Other medications such as antibiotics, antihistamines, and dietary supplements
may have use on an individual basis
Psychological care is needed occasionally in the basic treatment protocol

54. 54
To assess the effectiveness of a new protocol built up to relieve pain with pharmacological treatment
of chronicTMD, compared to the traditional occlusal therapy protocol by Michigan splint without
effective pharmacological therapy
35 patients were enrolled in this study, who were diagnosed withTMD
Used Drugs Delorazepam,Thiocolchicoside
examinations were performed by panoramicX-ray (OPG) and magnetic resonance of theTMA.
A visual-analogue scale was used in order to evaluate the intensity pain referred by patients
consequent to palpation
F Inchingolo. COMBINED OCCLUSAL AND PHARMACOLOGICALTHERAPY INTHETREATMENT
OFTMDs. Eur Med Journal. 2011

55. 55
The first group (19 patients) received an occlusal therapy with “Michigan resplint” and
pharmacological therapy with “delorazepam drops” and “thiocolchicoside tablets”
The second group (16 patients) received occlusal therapy with “Michigan splint” and “Placebo”
Results Comparisons betweenVAS values of the two experimental groups (Unpaired t-test) before
to begin the treatment, gave not significant results
At 12 months and 18 months from the beginning of the treatment,VAS data comparisons gave
significant results
This pilot-study showed that the Michigan splint, combined together with our pharmacological
protocol, could improve the predictability in the treatment of theTMD-related pain without a
clinical relapse into the following months

56. 56
to determine whether pharmacological muscle relaxant and anti-anxiety strategies during splint use would be a
beneficial adjunctive treatment. occlusal splint therapy (S), nonsteroid anti-inflammatory with a muscle-relaxant
drug (orphenadrine citrate) (O), and an anxiety-relief drug (benzodiazepine) (B)
Clinical analyses were recorded in accordance with the HelkimoTMD index and applied before and after
treatments.
Twenty-one female patients were treated, all of whom were subjected to the three random therapeutic
associations proposed: SBO, BOS, and OSB.
The same operator applied the three specific associations over a period of 21 days in the proposed sequence,
seven days for each therapy
Marisa Rizzatti-Barbosa. Denise Aparecida Martinelli.Therapeutic Response of Benzodiazepine,
Orphenadrine Citrate and Occlusal Splint Association inTMD Pain. journal of craniomandibular practice.2003

57. 57
The results show that all the groups presented the best results in terms of relief from
pain after the therapeutic association (28.5% showed a decrease and 47.6% showed
an absence of symptoms)

58. Physical
modalities
58
A wide range of phsical modalities can be suggested to patients, including
the use of heat and cold therapies, diet and lifestyle changes
massage, joint mobilisation & stretching, and can be adminstered either by
the patient or by a clinician
Although local heat application is widely used for pain relief, its benefit has
been questioned because raised temperature increases tissue inflammation.
On the other hand, the superiority of cold over heat therapy for reducing
inflammation and swelling has been documented

59. Biobehavioral
modalities
59
It refers to the safe methods that emphasizes on self management
and acquisition of self control not only on the pain but also on their
cognitive attributions while maintaining a productive level of
psychological functions
Among biobehavioral therapies prescribed most common are:
biofeedback
Stress management
Relaxation
Hypnosis
education

60. Review of
Literature
60

61. 61
Treatment of edentulous patients who have temporomandibular disorders is difficult because of the
poor stability of their conventional complete dentures
With an implant-supported bar and a clip-to-bar overdenture, mandibular dentures can be stabilized
Prospective clinical study of 10 edentulous patients with temporomandibular disorders
Before and 3 years after wearing the implant-supported overdentures, patients were interviewed and a
clinical functional analysis was taken
Patients with displacement of the articular disc or bone destruction of the joints had a decrease in pain,
an enhanced mobility of the mandible, and a decrease in temporomandibular joint sounds
Engel E. Weber H.Treatment of Edentulous PatientsWithTemporomandibular DisordersWith
Implant-Supported Overdentures. International Journal of Oral & Maxillofacial Implants .
Nov/Dec1995; 10 (6):106-115

62. 62
Millet C. Management of an edentulous patient with temporomandibular disorders by using CAD-CAM
prostheses: A clinical report.The Journal of Prosthetic Dentistry. 2018
The purpose of this clinical report was to
describe the digitally assisted fabrication of
CDs for an edentulous patient withTMD
symptoms
poorly fitting worn CDs, mucosal ulceration,
habitual nonfunctional occlusion, loss of
vertical dimension, and pseudoprognathism of
the mandible, grinding and crepitation in the
TMJs,Tenderness to palpation of the lateral
pterygoid

63. 63

64. 64

65. Conclusion
65

66. References
66
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• Zand Bolender. Prosthodontic treatment for edentulous
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• L.LeResche . Epidemiology of temporomandibular disorders:
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factors. Critical Reviews in Oral Biology & Medicine.1997

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• Engel E. Weber H.Treatment of Edentulous Patients WithTemporomandibular Disorders With Implant-
Supported Overdentures. International Journal of Oral & Maxillofacial Implants. Nov/Dec1995; 10
(6):106-115
• Millet C. Management of an edentulous patient with temporomandibular disorders by using CAD-CAM
prostheses: A clinical report.The Journal of Prosthetic Dentistry. 2018
• Marisa Rizzatti-Barbosa. Denise Aparecida Martinelli.Therapeutic Response of Benzodiazepine,
Orphenadrine Citrate and Occlusal Splint Association inTMD Pain. journal of craniomandibular
practice.2003
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ThankYou