diagnosing disc position- does it matter in orthodontics /certified fixed orthodontic courses


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diagnosing disc position- does it matter in orthodontics /certified fixed orthodontic courses

  1. 1. Diagnosing Disc position INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  5. 5. INTRODUCTION www.indiandentalacademy.com
  6. 6.   The study of TMJ and it’s relation to orthodontics and occlusion has been and is a topic of tremendous interest due to it’s complexity coupled with lack of complete knowledge which has initiated numerous concepts, theories and treatment methods. The most fascinating and complex system in the body is craniomandibular articulation. Although much has been learned over the years, a lot more remains to be learnt about it. www.indiandentalacademy.com
  7. 7. ANATOMY OF TMJ  Each TMJ involves temporal articular tubercle and anterior part of mandibular fossa above and mandibular condyle below. It is also called ‘diarthroidal’(consisting of two articulating bony surfaces); ‘ginglymoid’(as it has hinge like movement component). In normal joint both hinge and translation occures within the lower compartment and only translatry movement in superior compartment. www.indiandentalacademy.com
  8. 8. Fibrous Capsule :  Each joint is surrounded by short capsular fibers stretch from condyle to disc and from disc to temporal bone forming two joint capsules. Longer bands extending from condyle to temporal bone may be regarded as reinforcing fibers and are present only on the lateral side of joint. capsules is attached above anteriorly to the articular tubercle, posteriorly to the lips of squamotympanic fissure and between these two to the edges of mandibular fossa and below to the condylar neck. Above the disc it is loose and below it is tant. www.indiandentalacademy.com
  9. 9.  www.indiandentalacademy.com
  10. 10.  Lateral temperomandibula r ligament : Close to capsule, is attached above to the tubercle on zygoma’s root, below to the lateral surface and posterior border of mandibular condylar neck. www.indiandentalacademy.com
  11. 11.  Sphenomandibular ligament : Medial to capsule, descend from spine of sphenoid and widening to reach the lingula of mandibular foramen. www.indiandentalacademy.com
  12. 12.  Stylomandibular Ligament : Stretches from apex and adjacent anterior aspect of styloid process to mandibular angle and posterior border. www.indiandentalacademy.com
  13. 13. DISC  An oval plate of fibrous tissue. Upper surface sagittally concavo-convex and inferior concave surface. Its circumference blends with fibrous capsule, antero-medially the tendon of lateral pterygoid. Posteriorly the venous plexus separates upper and lower layers, upper attaches to fossa’s posterior margin and lower to back of condyle. www.indiandentalacademy.com
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  15. 15.   Term disk is preferred over meniscus because latter refers to a semilunar structure that may have central perforation which is considered pathologic. In centric relation, central portion of disk is in contact superiorly with descending slope of articular eminence and inferiorly with convex articular surface of condyle. Therefore disk is biconcave in shape with anterior and posterior rims and medial and lateral rims. In midsaggital cut, disk consists of an anterior band, intermediate zone and posterior band. www.indiandentalacademy.com
  16. 16. Post natal growth of disc is upto 21 years and after 5th decade it shows degeneration. It is described as avascular noninnervated fibro-cartilage. From all aspect, one can see disk’s adaptation to its function as a shock absorber. Disk is a protector of bony component of the www.indiandentalacademy.com joint
  17. 17.  The majority of cells are fibroblasts, with some chondrocytes, keratin sulfate (KS), Chondroitin 4sulfate (C4S) chondroitin 6-sulfate (C6S), hyaluronic acid (HA) and link protein (LP) are essential components of condylar cartilage and disk fibrocartilage. These glycosaminoglycans (GAGs) are distributed mainly in load bearing areas. The negative charges on GAGs attract water and allow the disk or condylar cartilage to absorb the stresses by deforming and leaking water. After relief from compressive force, water content is restored and loaded tissues returns back to its original shape. www.indiandentalacademy.com
  18. 18. Vessels and Nerve Supply Auriculotemporal and messetric branch of mandibular nerve. Superficial temporal and maxillary arteries. www.indiandentalacademy.com
  19. 19. DEVELOPMENTAL ANATOMY OF TMJ AND DISC:  Temperomandibular joint begins to develop by 10th week of gestation from two separate blastemas, one for temporal bone component and one for condyle. Superior to condylar blastoma, a band of mesenchymal cells develops that will eventually differentiate into the disk. The temporal and condylar mesenchymal cells will differentiate into osteoblasts, which lay down membrane bone. www.indiandentalacademy.com
  20. 20.  In the centre of condyle, cartilage develops which becomes secondary cartilage that remains in condyle upto 27 years of age. It contributes to the enlargement of condyle in adulthood as a part of adaptive changes in response to overloading.  The developing disc is highly cellular and vascular. It continues anteriorly with developing lateral pterygoid muscle and posteriorly by a ligament with superior end of Meckel’s cartilage, which will develop into www.indiandentalacademy.com malleus of middle ear
  21. 21.  The developing TMJ shows all components of mature joint by the 14th week. It is interesting to note that division of disk into anterior band, intermediate zone and posterior band exist in fetus, which indicates that its morphogenesis is genetically determined. The fetal disk was found to contain nerve fibres and blood vessels at peripheries which disappear from disk but remain at disk attachment after birth. www.indiandentalacademy.com
  22. 22.  Developmentally disk, articular capsule and lateral pterygoid muscles are all derived from same mesenchymal mass. Instead of remaining on outside of joint cavity, during development articular disk enters the joint itself. Studies indicated that disc did not evolve directly with TMJ, but appeared as a relatively late phylogenetic development after separation between placental mammals from egg lying mammals and marsupials. www.indiandentalacademy.com
  23. 23. Disc Ligaments  There are anterior and posterior bilaminar zones or ligaments, the lateral and medial collateral ligaments and discomalleolar ligament. All these are vascular, innervated and fibro-elastic in nature. www.indiandentalacademy.com
  24. 24.  Anterior ligament has a superior stratum that inserts on ascending slope of articular eminence and inferior stratums that inverts inferiorly at the anterior aspect of condyle. The ligament is normally relaxed and folded on itself in centric relation. Ligament stretches downward as condyle rotates during mouth opening. www.indiandentalacademy.com
  25. 25.  Posterior ligament consists of highly elastic superior stratum that inverts on the lips of ptetrotympanic fissure and an inferior stratum that inverts on posterior aspect of condyle below. It stretches considerably during jaw opening to allow the disc to continue to cover condyle at all ranges of motion. www.indiandentalacademy.com
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  27. 27.  The medial and lateral ligaments are collagenous and firmly attach the disk to lateral and medial poles of condyle. These collateral ligaments allow medio-lateral shift of the disk during lateral chewing movements. Traumatic injury to lateral collateral ligament could lead to subluxation and medial displacement of disk proper. www.indiandentalacademy.com
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  29. 29.  It has been reported that posterior bilaminar zone in joints with anterior disk displacements without reduction undergo fibrotic changes and become a disk like structure referred to as “pseudodisk”. Most medial portion of the disk is connected posteriorly to a ligament referred to as discomalleolar or pinto’s ligament which link between disk and anterior process of malleus. www.indiandentalacademy.com
  30. 30. FUNCTIONS OF TMJ DISK  Unlike in other synovial joints the TMJ condyle and temporal bone do not fit together in absence of disk, Which fills wedge like gaps created by rounded bony edges of the joint and thus stabilizes the joint during rotation and translation www.indiandentalacademy.com
  31. 31. CARTILAGE ASSOCIATED WITH JOINT  Surface coverings of joint consists of fibro cartilage rather than fibrous tissue. Occurrence of such cartilage has a developmental explanation. A secondary growth cartilage develops within the blastema associated with developing temperomandibular joint  Condylar cartilage www.indiandentalacademy.com
  32. 32.  This cartilage in many ways akin to the epiphyseal cartilage of developing long bones, consists of proliferative layer of replicating cells functioning as progenitor cells supplying cells to growth cartilage. These cells become chondroblasts and lay extracellular matrix. Following this there will be endochondral ossification www.indiandentalacademy.com
  33. 33.  Similar growth cartilage is also found in association with development of articular eminence as at birth no eminence is evidenced. www.indiandentalacademy.com
  34. 34. BIO-MECHANICS OF TMJ WITH RESPECT TO DISC  The superior lateral pterygoid muscle attaches antero-medially to the disc which keeps the disc in most anterior position permitted. This force is opposed by the superior retrodiscal lamina which pulls the disk posteriorly www.indiandentalacademy.com
  35. 35.  Straight line opening and straight line protrusion produces nearly identical and bilaterally symmetrical translatory movements in joints. Deviated or deflected movements produce compensatory asymmetry of movement. Lateral excursion produces maximum asymmetry; the disc-condyle complex on working side pivots and that of non-working side translates. www.indiandentalacademy.com
  36. 36.   As the forward phase of cycle takes place, upper surface of articular disc slides down the eminence, (rounds the crest) and move forward along its anterior plane. During return phase of cycle, disc retraces to its position. Disc rotates posteriorly on condyle as disc condyle complex moves forward in relation to eminence. During return phase disc rotates anteriorly. Greater the inclination of eminence, greater is the amount of rotation of disc on condyle. www.indiandentalacademy.com
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  38. 38. IMPORTANCE OF DISC CONTOUR  During opening and closing, disc and condyle move together, not because of ligamentous attachment, but because of disc morphology and interarticular pressure. Because some degree of interarticular pressure is always present, Condyle maintains itself on thinnest intermediate zone of disc. www.indiandentalacademy.com
  39. 39.  Thicker anterior and posterior border of disc force the disc to translate with condyle during mouth opening and closing. It is disc’s morphology, there fore that requires it to move with condyle. Alteration in intra-articular pressure or change in morphology of disc, leads to beginning of disc-interference disorders. www.indiandentalacademy.com
  40. 40.  Loss of disc contour destroys it’s self centering capacity, permitting it to function in a displaced attitude. Loss of contour posteriorly permits displacement of disc anteriorly and loss of contour anteriorly permits displacement posteriorly in closed resting position of joint inducing symptoms of disc interference www.indiandentalacademy.com
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  42. 42. DISC DISPLACEMENT DISORDERS www.indiandentalacademy.com
  43. 43.   Displacement of disc, commonly referred to as “internal derangement” is a disorder characterized by abnormal relationship between disc, condyle and articular eminence. Disc is most often displaced anteriorly or anteromedially, but medial, lateral and even posterior displacements also been reported. In order for disc displacement to occur, there must be elongation of disc attachment and deformation or thinning of borders of disc that allows the disc to slide in any direction. www.indiandentalacademy.com
  44. 44. CAUSES   When posterior border of disc becomes thinned and inferior retro-discal lamina and lateral discal collateral ligament becomes elongated, disc can assumes a slight anterior and medial position of condyle Acute macrotrauma is probably the most common cause of internal derangement. Among the incidents described are blow to the jaw, endotracheal intubation, cervical traction and iatrogenic stretching of mouth during dental or oral surgical treatment. . www.indiandentalacademy.com
  45. 45.   Excessive pressure on joint from clenching, hard biting or trauma may exhaust the synovial fluid lubrication between superior surface of disc and eminence, creating an area of resistance or adhesion which results in temporary fixation or adhesion of disc to eminence where disc remains immobile ‘Frictional inco-ordination’. Adhesions can occur in superior or inferior joint spaces. www.indiandentalacademy.com
  46. 46.  Temporary adhesion may follow clenching during sleep. As the patient attempts to move the mandible a single click is felt, representing freeing of adhesion and a normal range of movement is restored. The key in diagnosing this condition is that the click only occurs one time and can not be repeated without another prolonged period a static loading www.indiandentalacademy.com
  47. 47.  Temporary adhesions in superior joint space limit the translation of condyle – disc complex, thereby limiting the joint movement to only rotation. Clinically this limits the opening to only 25 to 30 mm. Adhesion in inferior joint space restrict rotation of disc on condyle, but allow translation of disc-condyle complex leading to normal opening. www.indiandentalacademy.com
  48. 48. www.indiandentalacademy.com
  49. 49.  It also has been proposed that so called muscle spasm that occurs in the patients with TMJ popping or clicking can also cause such problems. This concept is based on clinical observations that joint noise in many of these patients is intermittent and pain generally arises from masticatory muscles rather than joint. Such clicking and popping disappears even though the treatment is directed towards elimination of myofascial pain and dysfunction www.indiandentalacademy.com
  50. 50.  When posterior discal ligaments are elongated may be of many reasons like systemic ligament laxity, the disc can slide anteriorly on the condyle www.indiandentalacademy.com
  51. 51. DISC DISPLACEMENT WITH REDUCTION www.indiandentalacademy.com
  52. 52.  It refers to the stage in which the disc is displaced in an anterior or antero-medial position upon closing and return to more normal position relative to condyle on opening www.indiandentalacademy.com
  53. 53.  History Joint pain (variable)    Physical examination Joint tenderness (variable) Reciprocal clicking Jaw deviated towards side of click until click occurs, then returns to midline. Routine radiographs – not diagnostic Special diagnostic aids Condylar path deflection as click occurs Diagnostic splint ; eliminates symptoms Arthrogram ; displaced disc that reduces on opening www.indiandentalacademy.com
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  55. 55.  If pain accompanies, it generally originates from strained discal ligaments or from condylar pressure against posterior attachment, since they are highly innervated. Mandibular range of motion is usually normal and in fact may be more. www.indiandentalacademy.com
  56. 56. DISC DISPLACEMENT WITHOUT REDUCTION (closed lock) www.indiandentalacademy.com
  57. 57.   This condition is characterized by displacement of disc on closing followed by failure to reduce or recapture the disc during translation. patients who experience repeated dislocations with reduction may further elongate discal ligaments. Often elasticity of superior retrodiscal lamina is lost, making it more difficult for the disc to reestablish normal position on condyle during opening www.indiandentalacademy.com
  58. 58.  change in shape of disc from biconcave to biconvex and a decrease or loss of tension in posterior attachment. Contact is lost between the condyle, disc and articular eminence and disc space collapses, and trapping the disc in front of condyle leading to limited condylar translation  “Closed lock”. www.indiandentalacademy.com
  59. 59.   History Joint pain (variable) Limited opening Previous click with intermittent locking Physical examination Joint tenderness (Variable) Limited opening and lateral movement towards the opposite side. Jaw deviation towards affected side. Terminal stretch produces increased joint pain www.indiandentalacademy.com
  60. 60.   Routine radiographs – Not diagnostic Special diagnostic aids Arthrogram : Disc displacement and does not reduces on opening. Manipulation : May reduce disc www.indiandentalacademy.com
  61. 61. www.indiandentalacademy.com
  62. 62. ACUTE STAGE    Restricted opening of maximum of 25 to 30 mm with mandible deflecting towards affected side. Protrusive excurtion as well as lateral movement are also restricted. Generally, acute stage is painful due to inflamed capsule, posterior attachment and discal ligaments. In acute stage, noise is absent, but as it becomes chronic degenerative changes may occur in articular surface causing crepitus. www.indiandentalacademy.com
  63. 63. CHRONIC STAGE    Early in stage, mandibular opening may be slightly limited along with slight deflection with the time more normal range of motion returns as posterior attachment and discal ligaments continue to elongate and perhaps tear Pain, if present, is not as severe as in acute stage. Most common joint noise is crepitus, which represents degenerative changes www.indiandentalacademy.com
  64. 64. DISC DISPLACEMENT WITH INTERMITTENT LOCKING www.indiandentalacademy.com
  65. 65. Same as anterior disc displacement with education when clicking.  Same as anterior disc displacement without reduction when locked.  www.indiandentalacademy.com
  66. 66. DISC DISPLACEMENT WITH PERFORATIONS www.indiandentalacademy.com
  67. 67.   History Joint pain (Variable) Previous history of clicking, clicking with intermittent locking, and closed lock. Crepitus Physical examination : Joint tenderness (variable) Crepitus Limited opening www.indiandentalacademy.com
  68. 68.   Routine radiographs ; may show evidence of degenerative joint disease but not specifically diagnostic. A special diagnostic aids : Arthrogram shows both joint spaces fill simultaneously www.indiandentalacademy.com
  69. 69. DISPLACEMENT OF DISCCONDYLE COMPLEX www.indiandentalacademy.com
  70. 70. HYPERMOBILITY:  During normal opening, as the disc-condyle complex translates and moves forward along articular eminence, disc rotates posteriorly along the condyle. As a result of excessive opening beyond the normal limits of translatory cycle, limit of posterior disc rotation may be reached and any additional opening will occur without further rotation of disc on condyle. This can result in rough, noisy movement as disc condyle complex skid forward as a unit beyond articular crest. This is “hypermobility” previously referred as “subluxation www.indiandentalacademy.com
  71. 71.  History of wide opening during yawning or eating Clinical Features :   Near to end – point of wide opening, there may be a momentary pause in movement of condyles after which they jump forward and upward anterior to the crest of eminence, also characterized by joint noise “thud”. Displaced disc can be reduced at any point in translatory cycle, click associated with disc reduction www.indiandentalacademy.com
  72. 72. DISLOCATION    Also known as “open lock” is characterized by inability to close the mouth after wide opening. Frequently occurs in patients with history of hyper mobility. Results from excessive and irregular movement of disc condyle complex in front of eminence. condyles may be located too far anterior to the eminence. In addition, elevator muscle spasm may position condyle superiorly, preventing it from returning back over the eminence to its position in glenoid fossa www.indiandentalacademy.com
  73. 73.    Some cases of dislocation have been reported are associated with posterior disc displacement, preventing its passage over anterior band. In these cases, the condyle may not be trapped anterior to eminence. Pain due to spasm of elevator muscles. Dippresion in pre auricular region previously occupied by condyles. www.indiandentalacademy.com
  74. 74. TYPES OF TMJ SOUNDS : www.indiandentalacademy.com
  75. 75.  Reciprocal click : Noise made on opening and closing from centric occlusion that is reproducible on every opening and closing and can be eliminated with anterior repositioning of jaws. Suggests an early stage disc disorder.  Reproducible opening click : Noise with every opening, no noise when closing. Suggests deviation in the form of disc or late stage disc disorder. www.indiandentalacademy.com
  76. 76.  Reproducible closing click : Noise with every closing, no noise with opening. Suggests deviation in the form of disc.  Crepitus : Grating noise on opening and closing suggestive of bone to bone contact i.e. surface defect on disc or late stage disc disorder. Cause grating noise suggestive of osteoarthritis or osteoarthrosis. www.indiandentalacademy.com
  77. 77.  POPPING: Loud sound on opening that is audible to examiner at a distance without stethoscope. Suggests early stage disc disorder.  REPRODUCIBLE LATEROTRUSIVE CLICK : Noise with every full laterotrusive movement, no noise on opening.  NON REPRODUCIBLE CLICK: Not repeatable www.indiandentalacademy.com
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  79. 79. Crepitus in the absence of pain may indicate the presence of “osteoarthrosis” a non-inflammatory degenerative process of ariticular tissue that doesnot require specific therapeutic intervention.  Only if the sounds are accompanied by the joint pain, limitation in movement and joint tenderness, therapeutic intervention is often indicated  www.indiandentalacademy.com
  80. 80. STAGES:  IN INITIAL STAGE OF TM DISORDER : The opening click reflects the condyle moving beneath the posterior band of disc until it snaps into its normal relationship on the concave surface. Closing click reflects reversal of this process. www.indiandentalacademy.com
  81. 81.  IN PROGRESSIVE STAGE OF TM DISORDER : The posterior attachment and collateral ligaments gradually removed with deposition of fibrous connective tissue. A single opening click or fine crepitus can occur as a result of irregular interferences in translation.  IN THE TERMINAL STAGES OF TM DISORDER: Disc perforation and bone to bone contact will elicit coarse crepitus upon opening and closing www.indiandentalacademy.com
  82. 82. DIAGNOSIS www.indiandentalacademy.com
  83. 83.  The major diagnostic challenge is to distinguish those patients whose signs and symptoms are caused by TMJ internal derangements from those whose disturbances are caused by muscular disorders i.e.myofascial pain and dysfunction syndrome, muscle hyperactivity or bruxism. Furthermore it must be recognized that internal derangements and muscular disorders frequently occurs together. www.indiandentalacademy.com
  84. 84.  Diagnosis of TMJ internal derangements is made through : History Physical examination Radiographs Special diagnostic procedures www.indiandentalacademy.com
  85. 85. HISTORY  The purpose of history is to furnish clues for diagnosis. During interview it is important to assess the patients reliability as a historian. Are symptoms significant or exaggerated? If so, patient will tend to exaggerate treatment effects.Are the problems accurately described in well-defined terms or is patient vague as to where and what the problem is? Patients who clearly describe their problems do better than patients who are vague. www.indiandentalacademy.com
  86. 86.  The history begins with the chief complaint(s). This should be a statement of patients reason(s) for seeking consultation and/or treatment. The patients with internal derangement’s will generally have a chief complaint of pain and dysfunction of masticatory system. Chief compliant often serves as an important clue with which to being making a diagnosis www.indiandentalacademy.com
  87. 87.  The history of present illness should be comprehensive, including an accurate description of patients symptoms, symptom chronology, how the illness affects the patient, previous treatments and patients response to those treatments. www.indiandentalacademy.com
  88. 88. LOCATION OF PAIN  Patients with joint derangements usually identify the joint area as location of most severe pain, whereas patients with muscle disorder describe diffuse areas, often following muscle distribution. Patients with symptoms of both will usually describe major component as worse www.indiandentalacademy.com
  89. 89. DURATION OF PAIN  Generally more acute the problem, more likely the problem can be managed with simple therapies, conversely, more chronic the problem, more difficult will be to resolve. Patient should be asked when and how the problems began www.indiandentalacademy.com
  90. 90. CHARACTER OF PAIN  Joint derangements are characterized by constant pain. The pain may fluctuate in intensity but generally is present at all times. Joint pain usually decreases with rest and therefore would be expected to be less in mornings. Conversely, joint pain is aggravated by function and hurts more with jaw usage www.indiandentalacademy.com
  91. 91.  Muscular disorders are characterized by intermittent pain that may vary in intensity. A most significant finding is pain that is worse in morning which indicates nocturnal muscle activity i.e bruxism. Muscle disorders are frequently cyclic, with periods of pain free. www.indiandentalacademy.com
  92. 92. JOINT NOISE   Patients with internal derangement almost always have either clicking and crepitus. If the patient has clicking, it should be determined when the jaw clicks. Clicking that occurs only on awakening is usually related to nocturnal bruxism, clicking that occurs when eating may be related to occlusal disharmony www.indiandentalacademy.com
  93. 93.    It should be determined whether the click is painful or not . Patients with internal derangement frequently experience pain before the click and decreased pain afterward. It is important to determine if the noise is changing which may indicate the presence of active etiologic factor and progression of disorder Crepitus is generally considered to represent advanced disease. www.indiandentalacademy.com
  94. 94. RANGE OF MOTION   Limited range of motion can be in two forms, limited opening and limited lateral movement. In anterior disc displacement with out reduction, patient will have limited opening (closed lock), Which may be intermittent or permanent. Patients with intermittent closed lock usually report that jaw suddenly "catches” or “get stuck”. Limited opening because of muscular disorder does not usually appear suddenly. Patients describe a tight feeling as opposed to the sensation of jaw being stuck www.indiandentalacademy.com
  95. 95. RELATED DISCOMFORTS  Tooth pain or sore teeth, assuming odontogenic pathology has been excluded, indicates bruxism. Patients should be questioned as to whether or not they grind or clench their teeth at night or during day. Many patients will not know, but others will be aware of his fact. Patient’s awareness generally indicates high level of bruxism www.indiandentalacademy.com
  96. 96.  Retroorbital headaches and earaches including ear pain, tinnitus and dizziness are the most common symptom of internal derangement frequently of affected side www.indiandentalacademy.com
  97. 97. PATIENT CHARACTERISTICS    It is important to determine “how the problem affects the patient’. Most patients with TMDs report inability to eat normal diet and some interference with jaw usage. Patients should be questioned about stress and being anxious. Although stress may or may not cause the problems, certainly it aggravates the problem. Patient should be observed for signs and symptoms of “depression” www.indiandentalacademy.com
  98. 98.  Other previous treatments such as splints, occlusal adjustments, physical therapy and surgery should be carefully assessed as to how they were done and what their outcome was. Generally the more treatments a patient has had, the more difficult the problem is to manage. www.indiandentalacademy.com
  99. 99. PHYSICAL EXAMINATION  Should evaluate the entire masticatory system including : Articular (joint) Muscular Dental www.indiandentalacademy.com
  100. 100. ARTICULAR EXAMINATION  Both TMJ should be palpated for the presence of joint tenderness and they should be palpated laterally (extra auricular) and through external auditory canal (intra auricular). Generally tenderness arising intraarticularly will be manifested laterally over the joints and also through the external auditory canal. Although it will be highly subjective, some estimate of the degree of tenderness should be made, characterizing it as mild, moderate or severe. www.indiandentalacademy.com
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  102. 102.   Mandibular range of motion should be determined.Normal range is about 50 mm vertically, 10 mm protrusive and 10 mm laterally and also normal movements are straight and symmetric. In patients with clicking the jaw may deviate toward the side of click, until click occurs and then returns towards midline. www.indiandentalacademy.com
  103. 103.   Reciprocal clicking is most common in internal derangements. It refers to click during closing movement preceded by a click during opening movement. The position of opening click is determined by measuring a vertical opening at the time of click. As a general rule, later the click, greater the disc displacement www.indiandentalacademy.com
  104. 104.  The position of closing click is being best determined by having patient protrude the mandible maximally with the teeth in light contact, then opens on protruded pathway until opening click occurs, then to close along protruded pathway, then mandible is slowly retruded towards intercuspation while doctor lightly palpates the angles of mandible. The position of retrusive click is noted. www.indiandentalacademy.com
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  106. 106.  The click can be palpated at the angle of mandible and posterior mandibular teeth shift slightly upward as click occurs. As a general rule, closer the retrusive click to the centric occlusion, better the prognosis of non-surgical treatment. www.indiandentalacademy.com
  107. 107. MUSCULAR EXAMINATION  Head and neck should be inspected for soft tissue asymmetry or evidence of muscle hypertrophy. Patient should be observed for signs of jaw clenching or other habits. The muscles should be palpated for presence of tenderness and spasms www.indiandentalacademy.com
  108. 108. Origin of lateral pterygoid www.indiandentalacademy.com
  109. 109. www.indiandentalacademy.com
  110. 110. Insertion of medial pterygoid (intra orally) www.indiandentalacademy.com
  111. 111. www.indiandentalacademy.com
  112. 112. Insertion of medial pterygoid (extra orally) www.indiandentalacademy.com
  113. 113. Temporalis www.indiandentalacademy.com
  114. 114. www.indiandentalacademy.com
  115. 115. Insertion of temporalis www.indiandentalacademy.com
  116. 116. Masseter (extra oral) www.indiandentalacademy.com
  117. 117. Masseter (intra oral) www.indiandentalacademy.com
  118. 118. DIAGNOSTIC IMAGING OF TMD www.indiandentalacademy.com
  119. 119.  Before the patients are subjected to the expense and in most cases, the radiation of an imaging procedure, a high probability should exist that the finding of examination will aid significantly in the process of diagnosis and will have an impact on selection of treatment. We must be concerned with the value of imaging in term of its usefulness as a diagnostic test www.indiandentalacademy.com
  120. 120.   The accuracy of a diagnostic test is measured by it’s ability to detect disease when it is present as well as it’s ability to rule out the disease when no pathology exists. Sensitivity and specificity are convenient analysis techniques that address both of these measures. One of the best gold standards for testing diagnostic accuracy of imaging is fresh autopsy specimen in which the absence or presence of disease is verified by direct www.indiandentalacademy.com observation
  121. 121. Number of specimens correctly identified as diseased by imaging technique Sensitivity = ------------------------------------Number of specimens observed to be diseased by gold standards www.indiandentalacademy.com
  122. 122. Number of specimens correctly identified as disease free by imaging technique. Specificity = -----------------------------------Number of specimens observed to be disease free by gold standards. www.indiandentalacademy.com
  123. 123.  Values range from 0 to 1.0 with 0 representing total disagreement and 1.0 representing perfect agreement between gold standards and diagnostic test. www.indiandentalacademy.com
  124. 124. TRANSCRANIAL RADIOGRAPHY:    cost effectiveness Relatively simple head positioning device to basic dental radiographic equipment allows in office capability . High quality views are technically difficult to obtain because of curved and variable anatomy of articular component and density of alveolar structures in surrounding cranial base. www.indiandentalacademy.com
  125. 125. TECHNIQUE  To avoid superimpositions of cranial base and petrous pyramids of temporal bone onto joint image, central x-ray beam to be angulated interiorly in vertical plane at an optimal angle of 20* which produces profile image of lateral portion of joint. The central and medial portion of joint are superimposed onto condylar neck. www.indiandentalacademy.com
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  127. 127.  In addition to the required vertical beam angulation, aligning the central beam with the long axis of condyle in horizontal plane minimizes potential for more medial condylar contour to be superimposed onto joint space. Errors in horizontal beam alignment as small as 50 can create this effect and change the interpretation of condylar position in fossa www.indiandentalacademy.com
  128. 128.  Because there is considerable variation in the condylar long axis angulation between individual and even from left to right in same individual, beam angle must be customed for each patient. This procedure, referred to as the corrected technique, involves measuring condylar long axis angulation on a sub-mentovertex radiograph and adjusting condylar component of head positioning device to accommodate this angle. www.indiandentalacademy.com
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  131. 131.  The trans-maxillary projection can be valuable adjunct to trans cranial view. This coronal view of condyle’s articulating surface providing information on central and medial aspects of the joint that trans-cranial view fails to supply. This should be taken in maximum open mouth position to avoid superimposing the eminence onto articular surface of condyle. www.indiandentalacademy.com
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  133. 133. DIAGNOSTIC SIGNIFICANCE  Several studies have questioned the capacity of trans-cranial radiography to validly depict joint spatial relationship. Studies have shown that trans cranial radiography consistently portrayed the condyles as being posteriorly positioned whereas actual joint measurement indicated that the condyels were concentrically placed www.indiandentalacademy.com
  134. 134. TOMOGRAPHY     Also called as pantomography or rotational radiography Improved technology More expensive and available in only selected places. Patient radiation exposure is greater www.indiandentalacademy.com
  135. 135. TECHNIQUE  Uses the principle of controlled motion of Xray beam which blurs most portions of anatomy in the beam path but leaves the section of interest less blurred than adjacent structure. The blurring is produced by moving the x-ray tube and film in opposite direction www.indiandentalacademy.com
  136. 136.  The anatomic section of interest is placed at the centre of rotation. This section experience minimal beam movement compared to section above and below and thus appear in focus. Image blurring depends on the pattern and amplitude of x-ray tube movement. www.indiandentalacademy.com
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  138. 138.   However, dense structure outside plane of interest such as zygomatic arch, can absorb radiation and reduce image fidality, refereed as “superimposition’. More complex motion patterns such as circular ellipsoid or hypocycloidal (clover leaf) minimize superimposition www.indiandentalacademy.com
  139. 139. CORRECTED OR SELECTED TOMOGRAPHY :   Similar to that used with transcranial technique involves aligning central X-ray beam with condylar axis in both horizontal and vertical plane The objective is to rotate the head so that long axis of condyle is either parallel to or right angle to the film. The obliquity of two condyles is determined by obtaining a submento-vertex projection www.indiandentalacademy.com
  140. 140.  The following points stress the value of tomography in evaluation of TMJ :  Relation of condyle to fossa can be studied when this is narrowed indicates disc damage. Mobility of condyle may be evaluated by comparing views taken in closed and open mouth. Extremely valuable for atypical clinical picture and for patient who is not responding to treatment in usual manner. Valuable in post operative evaluation. Used in evaluating efficacy of occlusal splints     www.indiandentalacademy.com
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  142. 142. The following radiologic features should be observed in tomography :         Shape of head (round, flattened, irregular). Inclination and length of ramus. Abnormalities of articular eminence. Mobility of head in relation to eminence. Depth of fossa Position of head in fossa Width of joint space Pathology (Tumor, Hypoplasia, Hyperplasia) www.indiandentalacademy.com
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  145. 145. TO BE CONTINUED TOMMOROW www.indiandentalacademy.com
  146. 146. COMPUTED TOMOGRAPHY     The 1979 Nobel prize for medicine was awarded to “Godfrey Hounsfield” and “Alan Cormack” for development of CT in 1972 Capacity to provide hard and soft tissue information from a single examination Higher cost per examination High radiation dose . www.indiandentalacademy.com
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  148. 148. TECHNOLOGY  It uses multiple thinly collimated X-ray beam arranged in fan shape to irradiate anatomic area of interest from multiple directions. The tint is placed in a circular gantry that has the source of narrowly collimated beams on one side aimed at receptor array on the opposite side. The gantry is rotated sequentially, passing to irradiate the subject at 2 °increments www.indiandentalacademy.com
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  150. 150.  Each receptor receives radiation from one of collimated beams, converts it to an electrical signal and sends the signal to computer where it is stored. The signal value or density of any particular small volume of tissue contributes to signal received by several different receptors from many different angulation and allow the computer to assign an attenuation value for each small area of tissue. www.indiandentalacademy.com
  151. 151.  A single scan or rotation of gantry produces a thin two dimensional section. A series of parallel scans adjacent to one another can produce a three dimensional matrix called “voxels. By assigning shades of spectrum of attenuation volumes, multiple planes in multiple orientations can be constructed. The sections can be manipulated until the section that best displays the area of interact is found. www.indiandentalacademy.com
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  153. 153.   Helical or spiral CT is a variation, the principle of which is different in that the patient couch moves continuously during image acquisition. This movement produces image data for a portion of spiral rather than distinct slice. Electron beams CT differs from other CT technique in that the gantry acts as anode or target, a beam of high energy electrons sweeps continuously around the gantry and produces X-radiations. www.indiandentalacademy.com
  154. 154. Components :    Gantry : Consists of detector array, and X-ray source or tube. The gantry can be tilted upto 300 which provides a method by which structures that may degrade the image can be excluded from the scan. X-ray source. Patient support couch : Provides a way to stabilize the position of patient during scan www.indiandentalacademy.com
  155. 155.   Computer : Rapidity of image capture, data acquisition and larger matrix size (512 x 512) necessitates the use of high speed computers. Modern CT scans require computes that can solve upto 30,000 equations simultaneously. Control console : Which allows the operator to select the parameters of CT scan, view the images as they are being generated and determine format of output www.indiandentalacademy.com
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  157. 157. DIAGNOSTIC SIGNIFICANCE  Reconstructed planes perpendicular to the plane of scanning beams, however have reduced resolution. This presents problems for viewing the TMJ because the usual patient orientation in gantry results in axial plane scanning. In this orientation saggital plane is perpendicular to scanning plane, wholly required reconstruction results in somewhat degraded image. To avoid this problem, patient can be repositioned in the gantry aligning the sagittal plane parallel to scanner beam. This is referred to as direct sagittal CT, the most commonly used technique for TMJ. www.indiandentalacademy.com
  158. 158. www.indiandentalacademy.com
  159. 159. CT FOR DISC POSITION    Both sagittally reconstructed view and direct sagittal scanning technique can be used to identify disc position. The direct sagittal technique appears to be best suited for disc identification. Its’ sensitivity for disc displacement with reduction is 0.86 and for disc displacement without reduction is 0.96 with specificity of 1.0. CT has good potential to image osseous structure and position of disc in single examination. Difficulties, however can be encountered because of similarity in density of disc and its adjacent soft tissues in diagnosing disc position www.indiandentalacademy.com
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  161. 161. MAGNETIC RESONANCE IMAGING  It is a conceptually different modality from previous imaging techniques. Others including CT, are based on the radiation absorption characteristics of different tissues. MRI is based on varying water content in different tissues and magnetic moment of the hydrogen atoms or protons within the water molecule. Major advantage of its complete is lack of ionizing radiation. www.indiandentalacademy.com
  162. 162. Technology:  Nuclei are composed of varying number of two types of particles, protons and neutrons with each of these particles spinning around an internal axis and developing angular momentum as a result of this spin. Nucleons that spin clockwise pair up with nucleons that spin anticlockwise with their angular momentum canceling each others. www.indiandentalacademy.com
  163. 163.  If there is an odd number of nucleons, nucleus is left with net angular momentum and magnetic field because of spinning electrical charges. In effect, nucleus becomes little bar magnet. www.indiandentalacademy.com
  164. 164.  Although theoretically any nucleus with an unpaired nucleous could be used for MRI , hydrogen is used because of its abundance in body tissues, primarily in water and fat. The imaging property of hydrogen vary with type of molecule with which it is bound www.indiandentalacademy.com
  165. 165.  Radiofrequency waves directed to tissue level induces the protons to align and to process is phase and an increasing amount of energy is absorbed. When radiofrequency wave excitation is stopped, the protons relax to their original state of minimal excitation and in process, emit weak radiofrequency waves that can be detected by a receiver antenna (small coil placed over the point area in case of TMJ imaging). www.indiandentalacademy.com
  166. 166. The magnetic dipoles of protons in water are normally aligned in random fashion www.indiandentalacademy.com
  167. 167. When they are exposed to strong magnetic field of MRI scanner, however their magnetic axes align parallel with magnetic field. www.indiandentalacademy.com
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  169. 169.  The signals are location coded as a result of strength gradation in the primary magnetic field. This allows the computer to assign an intensity and location value to the emitted signals and store the data for eventual retrieval and manipulation into cross sectional images at desired tissue depth www.indiandentalacademy.com
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  173. 173. SIGNIFICANCE IN DIAGNOSIS OF DISC POSITION    Sensitivity of 0.86 Specificity of 0.63 Westersson et al attributed this relatively high false positive rate to the similar MRI appearance of lateral capsule tissue in normal joints and discs that are anteriorly displaced only in lateral position of diseased joint. www.indiandentalacademy.com
  174. 174.   Katzberg et al in 1988 did a study on coronal MRI images of autopsy specimens and found a sensitivity of 0.87 and specificity of 0.80 for disc displacements Cine MRI has been applied recently to imaging the TMJ which involves making short, 40 second, low resolution scans at incremental jaw openings and then fleshing the scans sequentially on viewing monitor. This results in cartoon like animation of joint dynamics www.indiandentalacademy.com
  175. 175. ARTHROGRAPHY:   Norgaard first applied the technique to TMJ in 1940s Arthrography of TMJ was introduced to overcome the inability of more conventional radiographic technique to characterize the soft tissue in general and position and configuration of disc in particular www.indiandentalacademy.com
  176. 176.   It involves injection of radio opaque contrast material into joint space. The space occupied by the disc can then be visualized lying between layers of contrast material. Multiple techniques of arthrography have been used www.indiandentalacademy.com
  177. 177.  One approach involves injection of contrast material into lower joint space referred as “single contrast orthrography”. Perforations of disc or posterior attachments are demonstrated by contrast material simultaneously flowing into upper joint space as lower space is injected. Fluoroscopy used with contrast provides dynamic viewing of disc movements, disc displacement with reduction can be directly observed as patient open and closes TMJ. www.indiandentalacademy.com
  178. 178.  Another technique involves injecting contrast material into both joint spaces and viewing with tomography. It shows the configuration and position of disc as contrast material is in both spaces. It is known as “double contrast arthrography” www.indiandentalacademy.com
  179. 179. TECHNIQUE :  It should be carried out using sterile procedures. The superficial and deep tissues overlying TMJ are anaesthetized with lidocaine (xylocaine) or mepivacaine, depending on desired duration of anesthesia. Then needle is inserted into the joint space, usually the lower compartment and intravascular area is anaesthetized. www.indiandentalacademy.com
  180. 180.   After verification of needle position in joint space by fluoroscopy, joint space is filled with 0.5 cc of Water based and low-ionic concentration iodine containing contrast agent Then closed, open and protrusive tomographic images are obtained. www.indiandentalacademy.com
  181. 181. DIAGNOSTIC SIGNIFICANCE IN DISC POSITION   In double contrast arthrography sensitivity was found to be 0.95 and specificity 0.84. Single contrast arthrography had slightly higher error rates i.e. sensitivity of 0.90 and specificity of 0.74 Sagittal arthrography appears to be less capable of assessing the status of disc in medio-lateral plane www.indiandentalacademy.com
  182. 182.   Strength of arthrography is it being the only technique, in which small disc perforations are visible and provides accurate information about disc morphology and position, injection of contrast agent may tear adhesions results in improved range of motion and ability to therapeutic agents like corticosteroids to be injected into the joint Weakness includes post-operative discomfort, morbidity, inability to detect medial disc displacement, allergic reactions to contrast agent and post operative infection www.indiandentalacademy.com
  183. 183. Single contrast arthrography www.indiandentalacademy.com
  184. 184. Single contrast arthrography www.indiandentalacademy.com
  185. 185. Double contrast arthrography www.indiandentalacademy.com
  186. 186. Double contrast arthrography www.indiandentalacademy.com
  187. 187. ARTHROSCOPY (DIAGNOSTIC) Dr.Kenji Takagi of University of Tokyo was the first person to use this procedure on knee joint in 1918.  Arthroscopy is nothing but visualization of potentially expandable, well confined joints like knee, shoulder or TMJ  www.indiandentalacademy.com
  188. 188. Instrumentation  Arthroscope is essentially nothing more than a long tube with magnification less at one end, through which a light source and an irrigating solution are passed. The ocular piece allows either for direct visualization or for coupling to a TV camera. Next to ocular end of arthroscope is attachment for fiber-optic light source www.indiandentalacademy.com
  189. 189.  The arthroscope is housed within the cannula which is nothing more than a sheath of 2.7 to 5.0 mm by which arthroscope is delivered into joint or by which irrigating fluid is introduced into joint. Solution used to irrigate is normal saline or Ringer lactate. There should be efflux systems which is nothing but large needle or cannula through which fluid drains out of joint www.indiandentalacademy.com
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  192. 192. Technique :  Manipulate the mandible anteriorly and inferiorly. This maneuver allows some translation of condyle out of fossa and produces a palpable preauricular depression. This pre auricular depression is a critical landmark for joint injection and arthroscopic entry. Surgeon must consistently has his left index finger in depression. www.indiandentalacademy.com
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  194. 194.  Using 20 gauge needle surgeon then injects the superior compartment with 1 to 2 ml of 0.5% lidocaine with 1:200,000 epinephrine. This is done for operative haemostasis and postoperative analgesia. Angulation of needle puncture is from infero-lateral- posterior approach so that needle tip is aimed at posterior slope of articular eminence. Next 3 to 4 ml of Ringer lactate solution is injected into superior compartment. A back flow of fluid is seen which confirms that superior compartment iswww.indiandentalacademy.com adequately filled.
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  196. 196. As soon as lateral TM capsule is punctured, the sharp trochar is replaced with blunt obturator which can be used as a probe, fossa and eminence are gently and carefully manipulated for tactile orientation  Out flow is established by creating another portal approximately 3 to 5 mm anterior to original portal for which an outflow needle or trocher with sheath is used for puncture  www.indiandentalacademy.com
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  198. 198.  Finally blunt obturator is removed from the sheath and 1.9 mm orthroscope with attached camera head is inserted. The inflow tubing is then attached to the sheath once inflow and outflow of irrigant have been established orthroscopic examination of TMJ may proceed www.indiandentalacademy.com
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  200. 200. DIAGNOSTIC SIGNIFICANCE It provides a narrow, continuous image of surface morphology. Disc displacements were correctly diagnosed in five out of six joints  Perforations were correctly diagnosed in two out of three joints. It provides most information about location and size of perforation and associated pathological changes  www.indiandentalacademy.com
  201. 201. TREATMENT FOR INTERNAL DERANGEMENTS www.indiandentalacademy.com
  202. 202.   Successful management of disc-interference disorder is also based on the natural course of disease. In which stage of progressive description of disc interference disorder should be considered Epidemic studies reveal that a symptomatic joint sounds are common and all joint sounds are not progressive. Then which should be treated? In Jeffrey P.Okeson’s opinion only joint sounds associated with pain of intracapsular origin should be considered for www.indiandentalacademy.com treatment
  203. 203.  Treatment can be divided into non-surgical and surgical methods. Presently treatment is largely based on theoretic concepts and empirical clinical observations www.indiandentalacademy.com
  204. 204. NON-SURGICAL MODE www.indiandentalacademy.com
  205. 205.  It involves the use of bite appliance that positions the mandible slightly vertically open and anteriorly to maintenance disc in normal relation to the condyle. The position of retrusive click is used to determine the probability of successful non-surgical therapy. Closer the retrusive click to the intercuspal position, better the prognosis. www.indiandentalacademy.com
  206. 206.   Maxillary or mandibular appliances can be used, patient must wear the appliance for 24 hours. Intraocclusal registration is taken at the position of the mandible at which discs are reduced. Especially important are the inclinations to intercuspal contacts that maintain the anterior position of mandible during function www.indiandentalacademy.com
  207. 207.   After one month, patient should be re-evaluated for symptoms. An increased range of motion without clicking should be noted. Then necessary provision should be made to allow condyle to move closure to original hinge position. This adjustment of splint is continued monthly until the condyle is back to the hinge position. The patient should be maintained in position for approximately two months to allow stabilization of joint structures. Evaluation of occlusion is final position without splint is needed to plan the next phase of treatment i.e. occlusal adjustment, restorative treatment or orthodontics or all three www.indiandentalacademy.com
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  210. 210. TREATMENT FOR DISC DISPLACEMENT WITH REDUCTION   Treatment with anterior positioning splint suits this condition much. Studies concluded that anterior repositioning appliance therapy followed by stepping the condyle back to original occlusal position failed to recapture the disc. Only 25% to 36% of patients were found to be free of both pain and joint sounds www.indiandentalacademy.com
  211. 211.   Another feature that complicated this therapy was that some patients developed posterior open bite Failure to recapture the disc and possibility of posterior open bite demonstrated that these appliance were not as successful as first believed. During initial weeks of therapy, anterior repositioning appliances were more successful in reducing pain and dysfunction www.indiandentalacademy.com
  212. 212.   In many patients advancing the mandible forward for a period of time prevents condyle from articulating with highly vascular and innervated retrodiscal tissues, Which leads to immediate reduction of intracapsular pain. It is now understood that disc does not return to the condyle, instead condyle moves posteriorly to articulate with adaptive retordiscal tissues www.indiandentalacademy.com
  213. 213. DISC DISPLACEMENT WITHOUT REDUCTION   Placement of anterior repositioning appliances in this situation only aggravates the condition as forward positioning of condyle pushes the disc more anteriorly and medially. Many clinicians agree that re-establishing normal disc position can often be accomplished by manual manipulation technique. The successfulness of which depends on factors like acuteness of disease (more than a month bad prognosis) and age and post history of patient www.indiandentalacademy.com
  214. 214.   Because manual manipulation is a conservative and relatively benign procedure, attempts are recommended in all patients diagnosed with disc displacement. If disc is successfully reduced an anterior repositioning appliance is immediately inserted and protocol for disc dislocation with reduction should be followed. When manual manipulation fails to reduce the disc, surgical intervention is the method of choice www.indiandentalacademy.com
  215. 215. ADHESIONS :   There are generally resistant to non-surgical management. The exception is early sticking secondary to static loading. In such cases, treatment should not be directed towards adhesion itself, but towards controlling static loading may be due to parafunctional habits like clenching or bruxism with patient education, behavioral control of habits and stabilization appliance during sleep www.indiandentalacademy.com
  216. 216. ALTERATIONS IN FORM  The definitive treatment for both adhesions and alterations in form is often surgical intervention. Because surgical procedures have inherent risks, the degree of pain and dysfunction should be ascertained before surgical repair is considered www.indiandentalacademy.com
  217. 217. MANUAL MANIPULATION   The success of manual manipulation depends on three factors. First is the level of activity in superior lateral pterygoid muscle. This muscle must be relaxed to permit successful reduction. If it remains active because of pain or dysfunction, it should be injected with local anaesthetic solution. www.indiandentalacademy.com
  218. 218.   Second disc space must be increased so that disc can be reduced. The patient needs to be relaxed and close the mouth, as increased activity of elevator muscle increases interarticular pressure, making it more difficult to reduce the disc Third factor is that condyle must be in maximum forward translatory position. The only structure that can actively reduce the anterior dislocation of disc is retrodiscal lamina, for which the condyles must be in forward most position. www.indiandentalacademy.com
  219. 219.  Definitive treatment begins by having the patient attempt to reduce the dislocation without assistance. The patient is asked to move the mandible to contra lateral side as for as possible. From this eccentric position the mouth is opened maximally. If this is not successful at first time, should attempt this several times www.indiandentalacademy.com
  220. 220.  Thumb is placed over the mandibular molar intra-orally, on affected side. Fingers are placed on inferior border of mandible anterior to thumb position. Firm but controlled downward force is exerted on the molar at the same time upward force is placed by the fingers. The opposite hand helps to stabilize the cranium above the joint that is being distracted , the condyle is brought downward and forward, which translates it out of the fossa. www.indiandentalacademy.com
  221. 221.  Once the full range of laterotrusive excursion has been reached, patients asked to relax while 20-30 seconds of constant destructive force is applied to the joint. This force is then discontinued and patient lightly closes to incisal edge to edge position. After relaxing for few seconds open widely and returns to this anterior position (not maximum intercuspation). If the disc has been successfully reduced, an anterior repositioning appliance is immediately placed and thus managed as same as for dislocation with reduction www.indiandentalacademy.com
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  223. 223. SURGICAL MODE www.indiandentalacademy.com
  224. 224. Indications  Patients with pain and clicking whose pain does not respond satisfactorily to non-surgical therapy over a period of three months are candidates for surgical therapy, provided that pain is intracapsular and not myo-fascial in origin www.indiandentalacademy.com
  225. 225. Arthrocentesis Simple and efficient procedure that can be performed under local anesthesia  Procedure in which the fluid in joint cavity is aspirated with the needle and therapeutic substance is then injected.  Owing to it’s simplicity, it may be performed repeatedly  www.indiandentalacademy.com
  226. 226.   A line is drawn from middle of tragus to the outer canthus of eye. Posterior entrance is located along cantho-tragal line, 10 mm from middle of tragus and 2 mm below. Anterior entrance is placed 10 mm further forward and 10 mm below it. These indicates location of articular fossa and eminence respectively. A local anesthetic is injected at the planned entrance points avoiding penetration into the joints. A 19 gauge needle is inserted into superior compartment and lactated Ringer solution is injected and immediately aspirated. The procedure is repeated three times to obtain www.indiandentalacademy.com sufficient amount for diagnostic purpose
  227. 227.   Another 19 gauge needle is inserted into distended compartment in the area of articular eminence to enable free flow of solution. Like this approximately 200 ml solution is passed through joint space. On termination, a steroid solution is injected and needles are removed. The negative pressure measured in upper compartment is eliminated by introduction of needle into the compartment. It also loosens the adhered disc, reinstitutes it’s free sliding moment, removes inflammatory constituents and pain mediators there by bringing about recovery of intra-articular pressure fluctuation. www.indiandentalacademy.com
  228. 228. ARTHROSCOPY  Arthroscopy has the obvious advantage of visualization of the joint for a more complete diagnosis which provides information abut disc-position and morphology, status of articular surface, presence of adhesions that arthrocentesis cannot. Otherwise therapeutic goals of arthroscopy and orthocentesis are similar www.indiandentalacademy.com
  229. 229. DISC REPOSITION SURGERY  Through a pre-auricular incision, a partial thickness plication was performed. Recontouring of articular eminence was performed in the areas of bony irregularities or impingement, if the disc position was satisfactory with teeth in occlusion and during manual jaw movement, surgical site was closed in layers. Movement of TMJ was instituted immediately after surgery www.indiandentalacademy.com
  230. 230. CONDYLOTOMY   Oral vertical ramus osteotomy The bone is cut and inferior 50 to 60% of medial pterygoid muscle is detached from proximal segment to permit anterior and inferior displacement of condyle. www.indiandentalacademy.com
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  232. 232. DISCECTOMY (AND REHABILITATION Only disc should be removed to maximize retention of synovial surface for secretion of synovial fluid. Small osteophytes and adhesions should be removed  Proper rehabilitation is extremely important for a good result  www.indiandentalacademy.com
  233. 233.  The various interpositional grafts are ; Auricular cartilage Dermal grafts Temporal fascia-muscle – pericranial grafts Alloplastic implant materials like Teflon-Proplast, Silicon, Silastic etc. Metal implants like stainless steel fossa and vitalium glenoid fossa, cobaltchromium molybdemus www.indiandentalacademy.com
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  235. 235. IT’S RELATION TO ORTHODONTICS www.indiandentalacademy.com
  236. 236. TMD AND ORTHODONTIC ISSUES   Improper orthodontics can be contributory to TMD, if not causalgic. Orthodontics should be TMD neutral or lessening severity of it’s influences Lack of screening or attention to TM disorder, orthodontist may be incriminated for having caused these problems. Such disorders are typically evident or subclinical prior to commencing with orthodontics, unless documented or effectively managed, chances to misinterpret post treatment signs and symptoms to have been result of orthodontics www.indiandentalacademy.com
  237. 237. Contributing factors        Inappropriate diagnosis and treatment plan. Lack of differential diagnosis and treatment for skeletal components underlying the malocclusion. Inadequate attention to detailing and finishing. Lack of attention to the neuro-muscular aspect. Related systemic, endocrine illness Parafunctional habits which go unmanaged. www.indiandentalacademy.com TMJ loading incompatibilities
  238. 238. WARNING SIGNALS BEFORE OR DURING ORTHODONTIC TREATMENT       Pain Limited and/or irregular mandibular movements Cripitius, clicking Loose ligaments Cuspal interferences with braces or wires Elastics and chin cup therapy : Unfavorable TMJ loading and compression www.indiandentalacademy.com
  239. 239.        Lingually tipped uppers entrapping the mandible. Not treating or recognizing skeletal problems with facial orthopedics or orthognathic surgery when appropriate. Lack of transverse up righting of arches (Curve of Wilson). Vertical collapse. Loss of posterior support due to : missing teeth, inadequate eruption, attrition. Clenching / grinding pattern. Oversized splint which violates freeway www.indiandentalacademy.com space
  240. 240. OCCLUSAL INTERFERENCES AND TMD  occlusal interferences that cause extreme subluxation of condyles in lateral extrusion and /or protrusive and /or closure to maximum interdigitation, twisting and torquing of mandible during centric closure results in stretching of musculature which leads to increased muscle tension thus making individual predisposed towards developing pain – dysfunction symptoms. www.indiandentalacademy.com
  241. 241. Protrusive interferences of molars in the form of missing ,drifted and supraeruption are the most damaging of all types.  Protrusive interferences of anterior teeth in the form of malpositioned in the arch or anterior crossbite  www.indiandentalacademy.com
  242. 242.  Non-working interferences or balancing interferences are probably more damaging than working interferences. The non working condyle is moving condyle has a wider range of movements during lateral excursion and more vulnerable to forces generated by deflective occlusion www.indiandentalacademy.com
  243. 243. Orthodontic reasoning for these interferences are ;     Failure to achieve true antero-posterior correction of jaw relation. Insufficient lingual crown torque of maxillary first and second molar. Too much lingual crown torque of mandibular molars. In co-ordination of arch widths and arch form www.indiandentalacademy.com
  244. 244. MALOCCLUSION AND TMD  Most of the studies says no co-relation between Angle’s Classification and TMD. Class II Division I malocclusion Class III Anterior open bite, Crowding, spacing, tipping and rotation Incisor and buccal crossbite, www.indiandentalacademy.com
  245. 245. Class II Div. I To improve their profiles, often position the mandible forwards, moving the condyles forward on articular eminence. The muscle and ligaments may be overstressed and fatigued. These individuals do not normally have disclusion on anterior teeth during protrusive movements www.indiandentalacademy.com
  246. 246. Class II Div. II Often have “locked” anterior bite due to excessive vertical overlap of anteriors which can cause the condyles to be deflected posteriorly and distally which can produce trauma to retrodiscal tissues. These also have limited range of mandibular function. These individuals have excessive anterior disclusion. www.indiandentalacademy.com
  247. 247.   Class III : These lack anterior disclusion, especially during protrusive movements when the canines are not properly positioned. Open bite : In cases of both anterior and posterior open bites, individual may exhibit gross occlusal interferences on posterior teeth. www.indiandentalacademy.com
  248. 248.  Posterior bite Collapse : This can be due to tilted, drifted and/or rotated posteriors. When posteriors that normally act as posterior stops are absent individual often presents with condyles displaced distally and superiorly till anteriors becomes stop www.indiandentalacademy.com
  249. 249. ORTHODONTIC TREATMENT AND TMD  Initially, in Costen’s syndrome, it was common to identify TMD by the perceived etiology of deep bite. Lack of posterior support by the dentition was thought to be an integral part of the syndrome itself. Thus it was no surprise to find abundant literature on relation between jaw dysfunction and malocclusion www.indiandentalacademy.com
  250. 250.  However, it is difficult to understand why correction of malocclusion through orthodontic treatment was suddenly received full blame. Supposed etiology, such as orthodontic treatment, was mentioned though not proven to be associated with TMD. The condyle disc assembly was assumed to be displaced, through orthodontic intervention which was supposedly caused dysfunction www.indiandentalacademy.com
  251. 251. FUNCTIONAL APPLIANCES AND TMD  Ample of excellent clinical studies especially of European origin were done to inquire about relation between TMD and functional orthodontics. These concluded that functional appliances were never related to TMD and long term study failed to find different prevalence between treated and untreated individuals. Some authors concluded that dysfunction was consistently less prevalent in treated than reference population. www.indiandentalacademy.com
  252. 252. FIXED APPLIANCE AND TMD  Studies on fixed appliance (Edgewise as well as Begg) and TMD report consistently concluded that : fixed appliance treatment and dysfunction are not related, such a conclusion is reached after many, research protocols www.indiandentalacademy.com
  253. 253. A longitudinal study Orthodontics and TMD  In January 1970, a longitudinal and prospective study began in Groningen, Netherlands with the aim of monitoring any development of TMD in a group of children receiving orthodontic treatment. www.indiandentalacademy.com
  254. 254.  In 1972, 172 children were documented with an average age of 12.5 years. They were documented before starting their treatment, annually from the start of treatment through at least one year out of retention, followed by an interval of five year without retention. Follow ups were then performed in1980, 85 and 90. Orthodontic treatment consisted of all three categories of removable appliances, mostly functional; Begg Class I and II fixed appliance; chin cup and/or Begg Class III treatment. About one third treated with extraction of all four first premolars, one third non – extraction and remaining combination of extraction www.indiandentalacademy.com
  255. 255. Three totally different treatment modalities, relying upon different bio-mechanics with different reaction forces within joint, should generate different frequencies after treatment, if at all ortho treatment was truly considered harmful. At the end, they concluded that no relationship between TMD and orthodontics could be substantiated www.indiandentalacademy.com
  256. 256. Extraction Therapy and TMD  Studies to investigate the relation between TMD and extraction approaches, compared all first bicuspid, other extraction and nonextraction groups and observed that cases with all four first bicuspid extraction seemed worse in the long run. www.indiandentalacademy.com
  257. 257. Gianelly et al (AJO, 1988) reasoned and questioned whether a result of extraction may be the reclining of upper front teeth inward, forcing condyles backward in fossa Evidence in the literature, unequivocally points to no relationship between orthodontic treatment and symptoms of dysfunction. www.indiandentalacademy.com
  258. 258. ORTHOGNATHIC SURGERY AND TMD  Anders westermark et al (Int J Adult Ortho and Orthognathic Surgery) conducted a study on 1516 patients undergone orthognathic surgery, evaluted 2 years after surgery found that preoperatively 43% and post-operatively 28%of patients reported symptoms of TMDs, which indicates an overall beneficial effect of surgery probably a result of improved occlusion. www.indiandentalacademy.com
  259. 259.   In the study mandibular retrognathia was less favorable result than prognathia. Sagittal ramus osteotomy was less effective than vertical ramus osteotomy www.indiandentalacademy.com
  260. 260. Maintenance of inter condylar width, angle and position are major concern during mandibular procedure www.indiandentalacademy.com
  261. 261. MANAGEMENT OF INTRA AND POST-ORTHODONTIC TMD PROBLEMS  Most of the problems arise during orthodontic treatment do not require any specific procedure to be initiated, but if painful symptoms arrive during treatment, it may be necessary to modify the active therapy : for example reduce forces on extra oral head gear, eliminate direct mandibular distalizing force (chin cup) and remove or lighten class II elastics, eliminate gross occlusal interference generally will allow sore joint to recover www.indiandentalacademy.com enough.
  262. 262.  Elimination of TMJ clicking is not desirable or possible as a part of orthodontic therapy. However if desired maxillo-mandibular relationship is one that also reduces a displaced disc for example advancing class II mandible and opening it to reduce deep bite, then it can be incorporated into orthopeadic or orthodontic treatment plan www.indiandentalacademy.com
  263. 263.  It is not common, for TMD symptoms to arise during or shortly after the retention phase of treatment. When they do occur, the orthodontist should re-evaluate both retention appliance and the final occlusion www.indiandentalacademy.com
  265. 265.  Erik Larsson and Assar Ronnerman (EJO, 1981) concluded that extensive orthodontic treatment can be carried out without fear of TMD and no over representation of symptoms in patients in whom sagittal and vertical movement of teeth was especially great. But special attention should be paid to torque the molar during treatment or during expansion of upper jaw. If they arrive should be eliminated by grinding. Ortho treatment prevents, rather causes TMDs www.indiandentalacademy.com
  266. 266.  Michael Johnson and Asbjorn Hasuud (EJO, 1981) says orthodontically treated cases presents less functional problems than untreated malocclusion. In patients with Class II Division I who can be treated without extraction, early ortho treatment can be regarded as prophylactic treatment. Cases treated without extraction showed significantly less clinical disturbances than both extraction and control group. www.indiandentalacademy.com
  267. 267.  G.Madone and B.Ingervall (EJO, 1984) found that signs and symptoms in group of patients who had undergone activator treatment conform prevalence in untreated series. It is possible that subjects in this series if left untreated would have more signs and symptoms www.indiandentalacademy.com
  268. 268.  Frank E.Cordray (Quintessence 2002) considers establishing functional occlusion and seated condylar position as one of the goal of orthodontic treatment. For that he suggests that discrepancy between seated and unseated condylar position should be identified and eliminated when occlusion is re-organized. Identification of this discrepancy through the use of diagnostic cast that has been taken from unprogrammed patient and mounted in seated condylar position on a semi-adjustable articulator through estimated face bow transfer. www.indiandentalacademy.com
  269. 269.  Sabine Ruf, Hans Pancherz (AO, 2000) concluded that bite jumping with Herbst did not result in any muscular TMD, rather reduced the prevalence of capsulitis, did not induced disc displacement in subject with normal pre treatment disc position, resulted in stable repositioning of disc in subjects with partial disc displacement with reduction, but could not re capture the disc in subject with total disk displacement with or without reduction. However disc displacement does not seem to be contraindication for Herbst treatment www.indiandentalacademy.com
  270. 270.  Dibbets and Van der Weele (AJO, 1991) concluded that neither removable nor Begg mechanics are associated with TMD, except for therapy that involves all first bicuspid extraction with which there was segregation of higher frequency of objectively identified clicking which the study could not reveal weather was due to extraction or because of sampling effect www.indiandentalacademy.com
  271. 271.  O.Reilly et al (AJO, 1993) did a study to find relation between TMD and orthodontic treatment with straight wire mechanotherapy along with extraction and Class II elastics and concluded that mechanotherapy has no effect on TMJ except for pain on palpation lateral to TMJ capsule which was observed in 40% of study sample for which there is no logical explanation www.indiandentalacademy.com
  272. 272.  Gianelly et al (AJO, 1988 and1989) conducted a study to evaluate two hypothesis. One particulates that condylar position in patients treated with four premolar extraction would be more posterior. Second, condylar position in patients with deep bite would be more posterior. He concluded that neither of these hypothesis are associated with posterior positioning of condyle www.indiandentalacademy.com
  273. 273.  Dr.H.P.Bimler (Functional Orthodontist, 2000) says that modern fixed appliance methods start routinely by flattening the curve of spee which definitely disturbs the physiological path of mandibular movement which can be suspectable reason for grouping number of TMJ problmes. Free floating loose appliance, leave the teeth free to arrange themselves into an optimalposition with regards skeletal as ell as functional matrices of stomatognathic system www.indiandentalacademy.com
  274. 274. Dr.Grant R.N.Bowbeer (Funct. Ortho. 1993) has        given seven keys for facial beauty and TMJ health : Proper maxillary A-P position Proper maxillary arch width and form Proper vertical dimension (Lower face height) Proper mandibular A-P position in relation to properly located maxilla. Mandibular symmetry (mandibular skeletal midline aligned to maxilla). Proper uprighting of lower posterior and arch from. Proper condylar position i.e. seated properly in fossae www.indiandentalacademy.com
  275. 275.  McNamra (OOO, 1997) concluded that the signs and symptoms of TMD increases with age, particularly during adolescence and therefore TMDs that originate during orthodontic treatment may not be related to treatment Ortho treatment performed during adolescence does not increase or decrease the chances of developing TMD in later time www.indiandentalacademy.com
  276. 276. The extraction of teeth as a part of orthodontic treatment doesnot increase the risk of TMD nor the mechanics is associated Although stable occlusion is the goal, not achieving a specific gnathological ideal occlusion does not result in TMD and also there is little evidence that orthodontic treatment prevents TMD. www.indiandentalacademy.com
  277. 277.   Reint M.Reynders (AJO, 1990) in his review of literature from 1966-1988 on orthodontics and TMD (88 articles) concluded that orthodontic treatment should not be considered responsible for TMD. He also rejects that ortho treatment is specific or necessary to cure TMD. Luther (AO, 1998) in his review article says that ortho treatment has nothing to do with inducing or curing TMD www.indiandentalacademy.com
  278. 278.   Klans et al (EJO, 1991) conducted a study that failed to reveal ortho treatment as frequent cause of stomatognathic dysfunction symptoms John Artun et al (AJO, 1992) says that it can not be ruled out that some patients acquire more posterior location of condyles during correction of Class II Division I malocclusion with extraction of maxillary premolars. However prevalence of patients with definite posterior displacement of condyles or joint sounds shortly after therapy in similar to that seem in controls www.indiandentalacademy.com
  279. 279.   Martin Olsson and Berit Lindquist (EJO, 1995) reveals that orthodontic treatment can to some extent prevent further development of and cure TMD J.M.H. Dibbets and L.Th.Van Der Weels (AJO, 1987) conducted a study of 10 year old long term post orthodontic treatment cases (Begg and Activator) and concluded that registration of symptoms during ortho treatment should be attributed to age changes rather to treatment procedures www.indiandentalacademy.com
  280. 280.  In patients with TMJ dysfunction, proper sequence of treatment is ; Correct the TMJ disfunction- repositioning splint Correct skeletal problem- orthopedic appliance Correct the dentition- fixed appliance Replace missing teeth- prosthesis www.indiandentalacademy.com
  281. 281.   Dr. Timothy J.Flacherty (Funct Ortho 1994) has the opinion that Jaw repositining in the vertical and antero-posterior dimensisn is an accepted and effective technique for relief of TMD weather it be maloclcusion, trauma or airway induced Dr. James M. Broadbent (Funct Orhto 1994) says that functinal jaw orhtopedics is an important mehod of correcitonof certain malocclusion and TMJ disorders www.indiandentalacademy.com
  282. 282.  Dr.Terrance J.Spahl (First Ortho 1996) says that extraction of bicuspids does not cause “TMJ” disroder. It does not matter of where the disc or condyle resides at full oclcusion, it’s matter of where the condyle resides comfortably at full oclcusion that is the real key. www.indiandentalacademy.com
  283. 283.  Dr. Duane C.Keller (Fuset Ortho 1996) says that “orthodonics plays an important role as both cause and a treatment for TMD. Treatment for internal derangemnets necessitates correction of abnormal condylar position before the disc can be properly positioned. One of the problem with conventional orhtodonics involves lack of contorl over condylar positoin www.indiandentalacademy.com
  284. 284. CONCLUSION  In evaluating the orthodontic literature and treatment as it regards TMD’s, perhaps the state of issue can be best described as “It ain’t so much that get’s us in trouble. It’s the things we know that ain’t so”. www.indiandentalacademy.com
  285. 285.  Orthodontic movement of teeth and incidence of TMDs are associated just like every other aspect of rehabilitative dentistry is related to the joint around which oral structures function www.indiandentalacademy.com
  286. 286.  Attempting to avoid the issue, claiming “no-reposibility”, presenting skewed or distorted material which does not follow accepted or valid scientific methods and presenting just one side of issue,borders an inappropriate professional action and substantiates a need for professional dialogue. www.indiandentalacademy.com
  287. 287. BIBLIOGRAPHY       Temperomandibular joint and masticatory muscle disorders. George A.Zarb, Barry J.Sessle, Gunnar E.Carlson, Norman D.Mohl. Temperomandibular disorder, classification, diagnosis and management – Welden E.Bell. Clinical Management of Tempero-mandibular disorders and oro-fascial pain. – Richard A.Perter, Sheldon G.Gross. Occlusal correction – Principles and Practice – Albert Solnis, Donald C.Curntte. Diseases of Tempero-Mandibular Apparatus. – Douglas H.Morgan. TMJ, Internal Derangement and Arthrosis – M.F.Dolwick, B.Sanders. www.indiandentalacademy.com
  288. 288.        Temperomandibular disorders and oro-facial pain. DCNA, Jan 1991. TMJ Dysfunction and Treatment – DCNA, July 1983. Current controversies in Surgery for Internal Derangements of TMJ. – O.M.F.S.C.N.A., May 1994. Adult Orthodontics – D.C.N.A. Maxillofacial Imaging, Principles and Application. O.M.F.S.C.N.A. Nov 2001. Oral Radiology – Goaz and White. Tempero-Mandibular Disorders – Fonseca, 4th Volume www.indiandentalacademy.com
  289. 289.    Diagnostic and Surgical Arthroscopy of TMJ – Sanders, Marakoni and Clark. Fundamentals of Occlusion and Temperomandibular disorders – Jeffrey P.Okeson. Gray’s Anatomy – Peter L.Williams www.indiandentalacademy.com
  290. 290. THANK YOU For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com