TMJ disorders/ General orthodontics


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TMJ disorders/ General orthodontics

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education
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  3. 3. Introduction “
  4. 4. Temporomandibular Joint helps in openingAnd closing Temporomandibular Joint helps in openingAnd closing
  5. 5.  Each is well and wisely placed in nature If disturbed results in TEMPOROMANDIBULAR JOINT DISORDERS(TMDS)
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  9. 9. Diagnostic category Diagnosis Cranial bones Congenital & developmental disorders Aplasia Hypoplasia Dysplasia(1st & 2nd brachial arch anomalies, hemifacial microsomia, Pierre syndrome, Treacher Collin syndrome) Condylar hyperplasia Prognathism, fibrous dysplasia. Acquired disorders Neoplasia Fracture
  10. 10. Temporomandibular joint disorders Deviation in form Disk displacement (with reduction; without reduction) Dislocation Inflammatory conditions (synovitis, capsulitis) Arthritides (osteoarthritis, osteoarthrosis polyarthritides) Ankylosis (fibrous, bony) Neoplasia Masticatory muscle disorders Myofascial pain Myositis Spasm Protective splinting
  11. 11. 1. Muscle tension (hypo/ hyper activity) 2. Muscle spasm (sustained) 3. Muscle inflammation 4. Myofascial pain and dysfunction 5. Fibrosis and contracture 6. Atrophy 7. Hypertrophy 8. Muscle tears/lacerations 9. Protective splinting 10. Fibromyalgia 11. Neoplasia
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  13. 13. c. Psoriatic arthritis d. Ankylosing spondylitis e. Lupus erythematosus 3. Infectious arthritis 4. Metabolic diseases a. Gout arthritis b. Chondrocalcinosis C. Capsulitis/ synovitis D. Retrodiscitis E. Fracture F. Ankylosis
  14. 14. G. Developmental disturbances of TMJ 1. Condylar hyperplasia 2. Condylar hypoplasia 3. Condylar aplasia H. Neoplasia
  15. 15.  This describes TMD in relation to the progressive patterns of deformation in specific intracapsular structures.  This is most practical method for clarifying the exact conditions. Stage I….. Normal healthy joint Stage II… Intermittent click. Stage III a… lateral pole click. Stage III b… ….Lateral pole lock. Stage IV a….Medial pole click. Stage IV b…. Medial Pole Lock. Stage V a… Perforation with Acute Degenerative Joint. Stage V b… Perforation with Chronic Degenerative Joint.
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  18. 18. Physiologic tolerance TMD symptoms Normal function + event >
  20. 20.  Disc maintains its position on condyle , due to morphology and interarticular pressure  If the morphology of disc is altered, the discal ligaments are elongated , begins to slide.  In resting closed position, the tonicity of the SLP causes the disc to be forward and medially placed
  21. 21.  If the pull of the muscle is protracted over time, The posterior border becomes thinned.  As it thinned, it can be displaced further in discal space, so that the condyle lies on the posterior band.
  22. 22.  Longer the disc is displaced AM ,greater the thinning of the posterior border, more elongation of discal ligaments, greater the loss of elasticity in the superior retrodiscal lamina.  Disc becomes more flatter  Loses its functional positioning ability. Superior lateral pterygoid encourages anterior migration of the disc completely thru the discal space.
  23. 23.  Articular surface are separated.  If it conditions continues, the condyle will be repositioned on retrodiscal space.  Tissues breakdown occurs leading to tissues inflammation.
  24. 24.  DEFINTIVE TREATMENT: refers to methods that are directed towards controlling / eliminating the cause of the disorder.  SuppoRTIVE TREATMENT: refers to methods directed towards altering the symptoms.
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  27. 27. Negative biofeed back: electrodes are placed on masseter lead to monitor. The monitoring device is connected to sounding device, when ever clenching occurs, the feedback mechanism is activated & sound is heard.
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  29. 29.  Diurnal activity: Patient education : Relaxation. : Biofeed back.  Nocturnal : Occlusal therapy.  Recently, the NTI(Nociceptive trigeminal inhibition): prevents the nocturnal parafunctional &reduces the muscle triggering component.  Mainly indicated for treating migraine headaches.  Anterior bite stop.
  30. 30.  Pharmacologic therapy: NSAIDS.  Corticosteriods. Anxiolytic agents. Muscle relaxants. Antidepessants. Physical therapy:Thermotherapy. : coolant therapy. : ultrasound. : phonophoresis.
  31. 31.  TENS  Neuralogic- pain inhibition of small C fibers by forcing the large myelinated A fibers to carry light touch sensation  Physiologic-increasing the blood circulation  Pharmacologic-by release of endorphins  Psychologic-Placebo effect
  32. 32.  Soft tissue mobilization.  Joint mobilization.  Muscle conditioning
  33. 33.  Chronic Tmd often not resolved by simple dental procedures(occlusal appliance),,,, mostly due to psychosocial issues.  Dr peter bertrand:  Addressing the pain & fatigue as a physiologic disturbance in need of correction.  Managing autonomic dysregulation.  Altering dysfunctional breathing.  Improving the sleep.
  34. 34.  Disc displacement divided in to stages based On signs symptoms combined with imaging findings • Anterior disc displacement with reduction (clicking joint) • Anterior disc displacement without reduction (closed lock)
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  38. 38. Well informed patient play a significant role in therapy  Patient should instructed to - Decrease loading of joint as much as possible - Soft food diet - Slower chewing - Smaller bites - Not to allow joint to click -Not to open his mouth forcefully If Inflammation is present than NSAIDS.
  39. 39.  Moist heat or ice.  PSR: Reduces the loading to the joint & generally down regulate the central nervous system.
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  41. 41.  When the condition is acute, the initial therapy is to reduce the disc by manual manipulation.(first episode).  Technique for manual manipulation.  First point: The Level of activity in the sup. Lateral pterygoid muscle …. Relaxed.  Second point: The Disc space must be increased so that disc can be repositioned .  Third point: The Condyle must be in the maximum forward position.
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  43. 43.  If the disc is dislocated permanently?????  Patients with disc dislocation should be given a stabilization appliance that will reduce forces to retrodiscal tissues.  If this fails than surgical repair.
  44. 44.  Educating the patient, of the restricted mouth opening, if attempted than more pain .  Decrease hard biting, gum chewing.  If pain is there than anti-inflammatory drugs.
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  46. 46.  Arthrocentesis coupled with lavage and manipulation has been the procedure of choice  Joint is anesthetized by LA and the patient is under conscious sedation, 20-gauge needle is placed in the upper compartment about 1 cm in front of the ear, hydraulic pressure is created by injecting about 2ml of Ringer’s Lactate Solution  The second 20-gauge is placed about 1cm anterior to the first needle and the joint is irrigated with 50-100ml of Ringer’s Lactate Solution
  47. 47.  A single needle is introduced to the joint & fluid can be forced in to space in an attempt to free articular surfaces.This is called “Pumping The Joint.”
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  49. 49.  The cannula attached to the rigid arthroscope is inserted in the upper joint compartment and the arthroscope is connected to a television camera equipped with video monitor  The upper joint compartment is thoroughly examined either directly through ocular or indirectly from the monitor  The most common procedures performed by arthroscopy are lysis and lavage  Improvement reported is 73 % to 93 %
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  56. 56.  Cause  Created by actual changes in the smooth articular surface of the joint & disc. Flattening of the condyle & fossa, Even bony protuberance on the condyle Perforation & thinning of the disc.
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  58. 58.  Cause is change in the articular surface so treatment is to return altered form, surgery.  Various options are:  Bony compatibility smoothed & round the surface.  If the disc is perforated discoplasty.
  59. 59.  Most of cases : Education.  Patient will learn a manner of opening & chewing that minimizes the dysfunction.
  60. 60. b.Adherences and Adhesions Disc to condyle Disc to fossa Mechanism Static loading Exhaustion of weeping lubrication Adherence Persistent adherence,hemarthrosis
  61. 61. Adherence in superior joint space Limited to rotation Adherence freed click may be felt
  62. 62. Permanent adhesion between disc and fossa Condyle moves onto anterior border of disc Fixed disc
  63. 63.  Decrease the loading of the joint  For nocturnal a stabilization appl  For diurnal patient awareness & PSR.  When adhesions , breaking of fibrous attachment is done arthroscopic surgery. Diurnal clenching nocturnal
  64. 64.  Adhesions: passive exercises : ultrasound. : distraction of the joints. learn the pattern of opening.
  65. 65.  It is due to variation in anatomic , with steep short posterior slope of articular eminence &longer flat anterior slope.  During the final opening, the condyle can be seen suddenly jump forward with a Thud sensation.  Pre auricular depression.  No clicking.
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  67. 67. Normal condyle-disc relation Maximum translation Disc pulled forward anterior capsular
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  69. 69.  The main objective of the treatment is to increase the discal space& allow the superior retrodiscal lamina to retract the disc.  Forceful closure should be avoided elevator muscle spasm & aggravate the dislocation.  Reduction should be done.
  70. 70.  Patient ask to open widely as in yawning, will activate the mandibular depressors & inhibit the elevators.  At the same time , slight posterior pressure is applied to the chin will reduce a spontaneous dislocation.
  71. 71.  If the dislocation is chronic than , patient should be taught self reduction.  If the condition is intolerable than Eminectomy.  Conservative treatment is botulinum toxin, inject it in inferior lateral pterygoid bilaterally. Supportive treatmentSupportive treatment  Prevention , which begin with same supportive therapy as for subluxation.  Recurrent than self reduction.
  72. 72.  a.Synovitis/Capsulitis  b.Retrodiscitis  c.Arthritides _ Osteoarthritis _ Osteoarthrosis _ Polyarthritides
  73. 73. Clinical characteristics Capsular ligament can be palpated by finger on lateral pole. Limited Mandibular opening. If the edema is present condyle may be displaced inferiorly ,disocclusion of ipsilateral posterior teeth
  74. 74.  When the cause is trauma , the condition is self limiting ,as trauma is absent.  No definitive treatment for inflammatory condition. Supportive therapySupportive therapy o Restrict the movements within painless limits. o Soft Diet, slow movements & small bites. o NSAIDS, thermotherapy. o Ultrasound. o Acute traumatic injury ,, corticosteroids.
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  76. 76. Extrinsic Trauma: cause is macro trauma, becoz is generally not present , no definitive treatment. Supportive therapy.Supportive therapy.  When acute malocclusion is not evident; than analgesics , thermotherapy, corticosteroids.  When acute malocclusion is evident , stabilization appliance for occlusal stability.
  77. 77.  Cause : intrinsic trauma, like anterior displacement, treatment is towards the cause. Supportive therapySupportive therapy  Restricting the use of mandible with in painless limits.  Analgesics ,  Thermotherapy,  Corticosteroids
  78. 78.  DJD : is also referred to as osteoarthosis, osteoarthritis, degenerative arthritis, is primarily a disorder of articular cartilage and subchondral bone, with secondary inflammation of the synovial fluid .  Body response to increase loading , the articular surfaces are softened, the subarticular bone begins to resorb, thin & fibrilation breaks away during activity.
  79. 79.  C/f:  Limited mandibular opening Crepitation  Lateral palpation + manual loading of the condyle increases the pain .  Radiographs: structural changes in subarticular surfaces.
  80. 80.  Decrease the mechanical loading of the joint.  Attempt to correct the condyle- disc relationships.  Since osteoarthritis are associated with chronic derangements , anterior positioning are not always helpful.  Stabilization appliance…… muscle hyperactivity. .
  81. 81.  Reassurance to the patient.  Anti-inflammatory drugs.  When symptoms are intolerable after 1-2 months of supportive therapy, single injection of corticosteroid can be used. Surgical therapy.  When tmj pain persist r/g changes are, than surgery is indicated.  An arthroplasty , which removes osteophytes & erosive products is c/m preferred.
  82. 82.  Temporalis tendonitis  Stylomandibular ligament inflammation
  83. 83. Chronic hyperactivity of this muscle can create tendonitis C/F : Pain during function . : Retrorbital pain Definitive treatment: resting of muscle. A Stabilization appliance if bruxism. PSR. Supportive therapy. Analgesics if pain . Ultrasound, thermotherapy.
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  85. 85.  Ankylosis.  Muscle contracture  Coronoid process impedance  The predominant feature of this disorder is inability to open the mouth to a normal range.  Rarely accompained by painful symptoms.
  86. 86.  Abnormal immobility of a joint.  Two types : bony : fibrous. o A fibrous is common & occur b/w the condyle & disc or disc & fossa. o A bony ankylosis occur b/w the condyle & fossa. o It is more chronic & extensive.
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  88. 88.  Treatment:Treatment:  If the movements are not restricted than no treatment.  If function is inadequate than surgical.  Arthroscopic surgery.  Surgical removal of osseous bridge  Condylectomy  Osteoarthroplasty (gap arthroplasty)  Interpositional arthroplasty • Silastic implant, tentalum foil, teflon. • Ear cartilage graft • Temporalis muscle flap
  89. 89.  It is the fibrosis of the ligament, the movement of the condyle is restricted. Definitive treatment is contraindicated.  1) The Fibrosis restricts only outer movement & not functional problem of the patient.  2) becoz surgery can cause this disorder. Supportive therapySupportive therapy  As it is asymptomatic so no treatment.
  90. 90.  Is a painless shortening of muscle.  Myostatic  Myofibrotic Myostatic contracture.  Results when a muscle is kept from fully lengthening for a prolonged period of time.  Often due to another disorder. Definitive Treatment: Disorder should be eliminated. Than toward lengthening of the muscle.
  91. 91.  Two types of exercise :  passive stretching  Resistant opening.
  92. 92.  Occur as result of excessive tissue adhesions within the muscle or its sheath, which prevents the muscle fibers from sliding over themselves, disallowing full lengthening.  C/F: painless limited opening. Definitive treatmentDefinitive treatment:  The muscles fibers can relax but the muscle length does not increase. It is permanent.  some elongation can occur by elastic traction.  Surgical detachment & reattachment.
  93. 93.  It is often difficult to diagnose the two by history & examination, the key to diagnosis lies in treatment.  When muscle regains muscle length, myostatic contracture is confirmed.
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  95. 95.  Bone disorders  Muscle disorders.  Bone disorders: Agenesis : Hypoplasia : Hyperplasia : Neoplasia.
  96. 96.  Enlargement & occasionally deformity of the condylar head.  Have a secondary effect on mandibular fossa as it remodels to accommodate.  Etiology:  Overactive cartilage,  Persistent cartilaginous rests  Increasing thickness of entire cartilaginous & precartilaginous layers.
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  98. 98.  Failure of the condyle to attain normal size.  Condyle is small but condylar morphology is normal.  Inherited or acquired.  Early injury or injury to articular cartilage by birth trauma or intraarticular inflammatory lesion.
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  100. 100.  Hypotrophy  Hypertrophy  Neoplasia.  The Common characteristic is feeling of muscle weakness with hypertrophy.  Hypotrophy is difficult to recognize only.  Large masseter in case of hypertrophy.
  101. 101.  Definitive treatmentDefinitive treatment:  Must be tailored to the patient’s condition.  Treatment is restore the function, while minimizes the trauma.  When hypertrophy is present secondary to bruxism than muscle relaxation procedure.
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  105. 105. o Management of temporomandibular disorders & occlusion-5th edition o Jeffrey P Okeson o 2Clinical management of temporomandibular disorders and orofacial. o Richard A Pertes o .Bell’s Orofacial pain -5th edition. Okeson o Evaluation Diagnosis and treatment of occlusal problems 2nd edition Peter E Dawson o Surgery of temporomandibular joint David keith 2th edition. o Jips 2005,5(2) 56-61. o Dental update 2007.
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