Understanding TMDs from an Orthodontic Perspective

TEMPOROMANDIBULARTEMPOROMANDIBULAR
DISORDERSDISORDERS
•INDIANDENTAL ACADEMY
•Leader in continuing dental education
• An Orthodontic
perspective
www.indiandentalacademy.com

IntroductionIntroduction
The Temporomandibular joint is a unique joint present in
the body and is different than other joints of the body for two
reasons –
First it is not a single joint but a pair of joints working in
tandem and in a well coordinated manner to meet functional
demands.
Second, unlike other joints of the body where
movements of the joint are determined by functional demands
and anatomy of the joint, the path of movements and position of
the Temporomandibular joint at rest are determined by the teeth
of either jaw which the joint helps to keep in an occluded
position.

Components ofComponents of
Temporomandibular joint functionTemporomandibular joint function
• Occlusion
• Muscles of Mastication
• Temporomandibular joint

OcclusionOcclusion
STATIC / ANATOMIC OCCLUSION:
TOOTH TO TOOTH OCCLUSION
TOOTH TO TWO TEETH OCCLUSION

OcclusionOcclusion
FUNCTIONAL OCCLUSION: AN OCCLUSION THAT IS IN HARMONY
WITH THE JOINT AND ASSOCIATED MUSCULATURE.
ROTH’S CRITERIA FOR FUNCTIONAL OCCLUSION: - MUTUALLY
PROTECTED OCCLUSION.
• TEETH IN MAXIMUM INTERCUSPATION WHEN THE CONDYLE IS IN A
IDEAL POSITION.
• IN OCCLUSION FORCES SHOULD BE TRANSMITTED THROUGH THE LONG
AXIS OF THE POSTERIOR TEETH.
• WHEN POSTERIORS OCCLUDE AN INTER OCCLUSAL SPACE OF 0.0005
INCH SHOULD BE PRESENT IN THE ANTERIOR REGION.
• MINIMAL OVERJET AND SUFFICIENT OVERBITE TO ALLOW
DISOCCLUSION OF THE POSTERIORS IN LATERAL MOVEMENTS.
•OCCLUSAL PATTERNS SUCH AS CUSP POSITION, CUSP HEIGHT AND
FOSSA DEPTH, RIDGE AND GROOVE POSITIONS SHOULD BE IN HARMONY
WITH THE JOINT MOVEMENTS.

OcclusionOcclusion
FACTORS CONTROLLING POSTERIOR DISCLUSION ON FUNCTIONAL
MOVEMENTS:

OcclusionOcclusion
MOVEMENTS:
INCISOR ANGULATIONS:

OcclusionOcclusion
MOVEMENTS:
Upper Front Tooth Analyzer
- WhipMix Corp

OcclusionOcclusion
MOVEMENTS:
Lower Front Tooth Analyzer
- WhipMix Corp

OcclusionOcclusion
MOVEMENTS:
INTER INCISAL ANGLE OF 125 DEG
(STUART)
INTER CUSPID ANGLE OF 135 DEG
(RICKETTS)

OcclusionOcclusion
MOVEMENTS:
OVERBITE AND OVERJET CONSIDERATIONS: CUSP HEIGHT AND FOSSA
DEPTH

OcclusionOcclusion
MOVEMENTS:
OVERBITE AND OVERJET CONSIDERATIONS: CANT OF THE OCCLUSAL
PLANE

OcclusionOcclusion
MOVEMENTS:
CANINE GUIDED OCCLUSION:

Neuromuscular AdaptationNeuromuscular Adaptation
ACCEPTABLE NEUROMUSCULAR
ADAPTATION OR CR – CO
DISCREPANCY:
1. 1 mm Antero posterior
2. 1mm Vertical
3. Less than 0.5mm transverse
- According to Utt and Wong.

Functional Anatomy of theFunctional Anatomy of the
TMJTMJ

TMJTMJ
FACTORS CONTROLLING NORMAL DISC – CONDYLE POSITION:
1. NORMAL MORPHOLOGY OF THE DISC
2. LIGAMENTS
3. INTERARTICULAR PRESSURE
NORMAL MORPHOLOGY OF THE DISC AND LIGAMENTS:

TMJTMJ
FACTORS CONTROLLING NORMAL DISC – CONDYLE POSITION:
1. LIGAMENTS
2. INTERARTICULAR PRESSURE
INTER ARTICULAR PRESSURE:

Etiology of TMDEtiology of TMD
• Trauma.
• Psychosocial factors.
• Systemic factors.
• Etiology in relation to Orthodontic
treatment planning and execution.
Etiology of TMD is multifactorial

TraumaTrauma
A force that exceeds the normal functional loading of the joint can lead
to injury of the affected structures
Macro trauma
Microtrauma

MacrotraumaMacrotrauma
Macrotrauma is a sudden force to the joint that
causes structural alterations.
Causes: Injury or trauma and Iatrogenic.
Changes:
Macrotrauma
Dislocation or
fracture of the
disc
Class II disc
interference
disorder.
Class III disc
interference
disorder.
Loosening of the
ligaments due to
elongation
Haemarthrosis,
bruising & laceration

MicrotraumaMicrotrauma
Microtrauma is any small force to joint structures that
occur repeatedly over a long period.
• Static loading.
• Impact loading.
•Frictional movement.

Static Loading: Stationary application of excessive
pressure.
Bruxism / Emotional stress / Hard chewing
Loss of occlusal molar support
Force transmitted to the joint rather than maxilla
Deformation of disc - deepening of central
bearing area
Roughening of articular surfaces Perforation of the disc
Class II disc interference disorder

Impact loading: occurs during the stage of maximum
intercuspation when a displaced condyle unduly
compresses an anchored disc.
Cause: Occlusal disharmony – CR-CO discrepancy.
•Loss of disc contour.
•Loss of self centering capability of the disc.
• anteromedial pull on the disc
• thinning of the posterior disc border and subsequent
elongation of the inferior retrodiscal lamina
•Grating noise.
•Class I and Class II disc interference disorder.

Frictional movement: Occurs due to overloaded movement
that exceeds the ability of weeping lubrication to prevent
damage to the articular surfaces from friction.
Cause: Gross functional disharmony when the teeth are
clenched. Eg: Class II Div II malocclusions.
•Remodeling of articular eminence.
•Loss of disc contour.
•Elongation of disc collateral ligaments.

Psychosocial factorsPsychosocial factors
• A strong association is present between
emotional stress and TMD.
• Mechanistic model of pain does not apply to
TMD: All pain arises from somatic disease or
structural damage.
• Biopsychosocial model: One cannot separate
the mind from the body when analyzing pain.
Both somatosensory and psycho social input
for pain is present.

Systemic factorsSystemic factors
• Presence of collagen and other
connective tissue disorders predisposes
to TMD.

Etiology in relation toEtiology in relation to
OrthodonticsOrthodontics
• General statistics
• First premolar extractions
• Head gear and Class II elastics
• Herbst appliance- cause or cure?
• RPHG and Class III elastics
• Midline switch / Cross elastics
• Overbite and anterior axial inclination
• Retention phase

General statisticsGeneral statistics
• According to Graber’s study on 347 TMD patients…..
– 53% had Class II malocclusions.
– High incidence of Class III malocclusions with
anterior displacements, cross bite and tongue
dysfunction..
– Most had a deep bite and horizontal growth
pattern.
– 68% had abnormal peri oral muscle function.
– 21% showed tongue dysfunction.

First premolar extractionsFirst premolar extractions
and TMDand TMD
“ first premolar extractions was a technique that was never designed
with the face, the stability of the occlusion and the health of the TMJ
in mind” - Witzig and Spahl
First premolar extraction
Over retraction of incisors
Premature contacts
Distally displace the mandible and condyle

and TMDand TMD

and TMDand TMD
• Larsson and Rönnerman studied 23 Swedish adolescent patients who had
been treated orthodontically 10 years previously–18 with fixed appliances and
5 with functional appliances (activators). They concluded that extensive
orthodontic treatment could be performed without fear of creating
complications of TMD
• Janson and Hasund studied 60 patients who were an average of 5 years out of
retention. These patients presented with Class II, division 1, malocclusions and they
were treated as adolescents. Thirty of the patients were treated with the extraction of
first premolars and 30 were treated on a nonextraction basis. These authors also
concluded that there was not a significant risk of developing TMD when undergoing
orthodontic treatment with or without premolar extraction.
•Dibbets and Van der Weele stated: “It is evident that over a 15 year period there exists
no relationship at all between the choice of not to extract or to extract or to extract either
first premolars or any other teeth and the registration of pain, limitation of mouth
opening, crepitation, and radiological signs.

• Kundinger et al radiographically (with corrected tomography) studied the condyle
positions of 29 upper and lower premolar extraction cases and 29 untreated
patients with no evidence of TMD.
• Gianelly evaluated the extraction of upper first premolars only to determine if this
procedure led to posterior condylar displacement. In a study of 12 Class II
patients treated with upper first premolar extractions, he observed that the
condyles were in a similar position, an “anterior position,” when compared with
an untreated control sample.
• Årtun et al tested the hypothesis that retraction of maxillary anterior teeth may
lock the mandible in a posterior position and evaluated the relationship between
condylar position and signs and symptoms of internal derangements in the
temporomandibular joints. The authors concluded that they could not rule out the
possibility that some patients acquire a more posterior location of the condyles
during correction of Angle Class II, division 1, malocclusions with extraction only
of maxillary premolars. However, the prevalence of patients with definitely
posterior displacement of the condyles or joint sounds shortly after therapy was
similar to the control group.
and TMDand TMD

and TMDand TMD
“ The literature review shows no scientific basis for the claim that
premolar extraction results in a higher incidence of TMJ disorders.”
- Richard P. McLaughlin, John C. Bennett. AO 1995.

Headgear and Class IIHeadgear and Class II
elasticselastics
Grummons alleged that orthodontic mechanotherapies such as
Class II and III elastics, mandibular headgears, facial masks, chin
cups, and balancing side occlusal interferences, can cause TMD.
Finally, Solberg and Seligman, Thompson and Ricketts
expressed similar viewpoints.
William E Wyatt:

RPHG and Class IIIRPHG and Class III
elasticselastics
RPHG and Class III elastics produce a distal
driving force of the mandible and condyle. This would
produce a reciprocal forward displacement of the disc
and pressure on retrodiscal tissues.
•It is better to have the patient wear lower or reverse headgear and
Class III elastics only during waking hours.
•Muscle tone (tension) positions the mandible forward.
•When worn at night, the muscles are relaxed and there is more distal
pressure on the condyle because compensating muscle activity is not
in play.

Midline switch / crossMidline switch / cross
elasticselastics
When cross elastics are used there is a
displacement of the mandible and condyle to one side,
resulting in unilateral distal driving force on the condyle.
Can be used during day alone when the resting
muscle tone can counter act the distal driving force.

The Herbst applianceThe Herbst appliance
• Pancherz and Pancherz in 1982 studied 20 patients
undergoing Herbst treatment. There was a high
prevalence of muscle and joint tenderness – 45% during
treatment which decreased to 15% after treatment and to
10% 1 year after treatment.
• Hansen et al in 1990 did a follow up study on 19 male
subjects treated with Herbst 7.5 years earlier. TMJ sounds
were detected in 26% and muscle tenderness in 32%. 8%
of the condyles were posteriorly displaced.
• Ruf and Pancherz in 1998 did a follow up study on 20
subjects who had undergone Herbst treatment 4 years
earlier. They found moderate to severe signs of TMD in
25% of the subjects and mild signs and symptoms in 15%
of the patients.

The Herbst applianceThe Herbst appliance
• Ruf and Pancherz in 2000 studied 62 patients undergoing
Herbst treatment. They observed:
– All condyles were positioned significantly forwards but
returned to the normal position after removal of the
appliance.
– A temporary Capsulitis was present during the course of
treatment.
– Herbst appliance did not have the potential to cause
muscular TMD.
– Reduced the prevalence of structural bony changes of the
TMJ.
– Did not induce disc displacement.
– Resulted in a stable disc position in partial disc displacement
– Could not recapture the disc in cases of total disc
displacement.

Overbite and anteriorOverbite and anterior
axial inclinationsaxial inclinations
• Trying to correct Upper anterior spacing
and axial inclination in deep bite cases
without bite opening.
• Correcting lower anterior crowding in
deep bite cases without prior bite
opening.
• Both cause anterior premature
contacts.

Retention phaseRetention phase
Majority of orthodontically treated cases may have dental deep bites at
the beginning and some also have skeletal deep bites
•It separates the upper
anterior teeth.
•It may crowd lower anterior
teeth.
•It tends to move the maxilla
forward.
•Drive the mandible distally.
Relapse will cause:

Retention phaseRetention phase

Pathogenesis of TMDPathogenesis of TMD
• Changes in the Muscles
• Changes in the Joint

Changes in the MusclesChanges in the Muscles
EMOTIONAL STRESS
BRUXISM
ALTERED RESTING POSITION OF MANDIBLE
ALTERATION IN SENSORY OR PROPRIOCEPTIVE INPUT TO THE CNS
MUSCLE SPLINTING
MYOSPASM
PREMATURE CONTACT

Changes in the MusclesChanges in the Muscles
Muscle splinting: is an involuntary CNS induced
hypertonic condition.
• Splinting is normal protective reaction to any
change in the masticatory system that might be
perceived as threat to its integrity.
•A clinically discernible.
•No discomfort in the resting stage.
•Pain only on muscle contraction.
•No increase in EMG activity.
•A hypertonic reaction with resistance to stretch.

Changes in the musclesChanges in the muscles
Myospasms: are involuntary CNS induced muscular
contractions. Myospasm causes CNS to recruit motor
unit for continuous contraction.
Causes: emotional stress, deep pain and muscle
splinting can lead to myospasms.
• Muscle is tender on palpation and firm.
•Patient complains of myogenic type of pain.
•Tenderness usually present in areas of insertion of the muscles.
•Patient complains of vague, chronic diffuse pain over head, neck and face.

Changes in the jointChanges in the joint
MICROTRAUMA
THINNING OF DISCAL LIGAMENTS
FUNCTIONAL DISPLACEMENT OF THE
DISC
SINGLE CLICK
RECIPROCAL CLICK
FUNCTIONAL DISLOCATION WITH REDUCTION (OPEN
LOCK)
FUNCTIONAL DISLOCATION WITHOUT
REDUCTION (CLOSED LOCK)

Normal disc-condyleNormal disc-condyle
relationrelation

Functional dislocation withFunctional dislocation with
reductionreduction
• PAIN
•CLICKING
•JOINT PAIN AND MUSCLE PAIN,
•DEVIATED PATH OF CLOSURE.

Functional dislocationFunctional dislocation
without reductionwithout reduction
FUNCTIONAL DISLOCATION / CLOSED LOCK
• LIMITED MOUTH OPENING
• NO PAIN
•NO CLICKING

Disc interference disordersDisc interference disorders

Classification ofClassification of
Temporomandibular disordersTemporomandibular disorders
• Masticatory muscle disorders
• Disc interference disorders
• Inflammatory disorders
• Chronic mandibular hypomobility
• Growth disorders

Masticatory muscleMasticatory muscle
disordersdisorders
• Protective muscle splinting
• Masticatory myospasm
– Elevator muscle spasm
– Lateral pterygoid muscle spasm
• Masticatory myositis

Masticatory muscleMasticatory muscle
disordersdisorders
• Protective muscle splinting
– Functional myalgia without structural restraint.
– Masticatory function is restrained due to inhibitory influence
of pain and weakness.
• Masticatory myospasm:
– Spasms of all muscles
– Functional myalgia
– Muscular dysfunction due to sustained isometric / isotonic
contractions.
• Masticatory myositis:
– Inflammation of the muscles
– Immobilization
– Soreness at rest and severe pain during function

• Class I interference disorders
• Class II interference disorders
• Class III interference disorders
• Class IV interference disorders
• Class V interference disorders
• Abnormal sensations, noises and movements
• Arthralgic type of pain
• Arrested movement (locking)

• Class I interference disorders
– Symptoms occur during clenching of the teeth.
• Class II interference disorder:
– Symptoms occur during the first opening
movements after Max intercuspation.
• Class III interference disorder:
– Numerous symptoms occur during the course of
normal translatory movement.

• Class III interference disorder:
– Due to excessive interarticular pressure.
– Due to structural irregularity.
– Due to non inflammatory degenerative joint
disease.
– Internal derangement

• Internal derangement
– Detached sup retrodiscal lamina:
• Anterior dislocation of the disc.
• Irregular movement during the forward translatory phase of
movement.
– Disc displacement:
• Loss of disc contour and elongation of ligaments.
• Symptoms of clicking, catching and locking.
– Damaged disc:
• Deformation and perforation of the disc
• Grating noise
• Irregular movements
– Adhesions.

• Class IV interference disorder:
– Mouth opening extends beyond the normal
anterior limit of translatory movement of
disc-condyle complex.
• Class V interference disorder:
– Spontaneous anterior dislocation.
– Due to wide opening
– Disc trapped anteriorly preventing closure
–”open lock”.

Inflammatory disordersInflammatory disorders
• Synovitis
• Capsulitis
• Retrodiscitis
• Inflammatory arthritis

Chronic mandibularChronic mandibular
HypomobilityHypomobility
• Pseudoankylosis
• Contractured elevator muscles
• Capsular fibrosis
• Ankylosis

Growth disordersGrowth disorders
• Neoplasia
• Abberant development
• Acquired change

DiagnosisDiagnosis
• Functional examination
• Radiological examination

Functional examinationFunctional examination
• Palpation: Muscles
• Digital palpation is used
• Muscle should be evaluated
through out it’s length –
origin, muscle belly and
insertion.
• Should be evaluated at rest,
stretched and contracted
position.
• Examined bilaterally for
comparison.
• Palpate horizontally and
parallel to their attachments.

• Two methods of
palpation- Flat palpation
and Pincer palpation.
• Flat palpation- use
middle finger to press
the muscle against
underlying bone. Soft
but firm palpation in a
small circular motion.
• Pincer palpation –
palpate muscle
between forefinger and
thumb.

• Temporalis: Flat palpation
when palpating the anterior,
middle and posterior
portions.
• Temporalis tendon: Bidigital
palpation intraorally and
extra orally along the
anterior border of the ramus.
• Masseter: Superficial and
deep masseter – flat
palpation.
• Pincer palpation for anterior
border of superficial fibres.
• Pterygoids: Intra oral
palpation.

• Palpation
• STAND IN FRONT OF THE PATIENT.
• LATERAL POLES OF BOTH CONDYLES SHOULD
BE PALPATED SIMULTANEOUSLY USING DIGITAL
PRESSURE.
•ASK THE PATIENT TO OPEN THE MOUTH
SLIGHTLY AND PALPATE 10 TO 20 mm IN FRONT
OF THE EXTERNAL AUDITORY MEATUS.
•TO CHECK FOR POSTERIOR WALL
TENDERNESS ASK THE PATIENT TO MOVE THE
MENDIBLE TO THE CONTRALATERAL SIDE OR
USE THELITTLE FINGER TO PALPATE FRO
WITHIN THE EAM.

• Auscultation
• Click: A single noise of short
duration that occurs at any point in
the active range of mandibular
motion.
• Crepitus: A grating or gravelly noise
caused by degenerative changes in
the articular joint surfaces.
• A loud popping noise or thud at the
end of mouth opening indicative of
joint hyper mobility when the disc
condyle complex moves over the
articular eminence.

AUSCULTATION:

EARLY
INT
LATE

EARLY OPENING CLICK – 0 TO 15 mm
MIDDLE OPENING CLICK – 16 TO 30 mm
LATE OPENING CLICK – 31 TO 50 mm
EARLY CLOSING CLICK – 31 TO 50 mm
MIDDLE CLOSING CLICK - 16 TO 30 mm
LATE CLOSING CLICK - 0 TO 15 mm

• Functional analysis
– Postural rest position.
– Maximum mouth opening
– Path of mandible on opening and closing.

• Postural rest position
– Command method
– Non command method
– Combined method
• Methods of measurement
– Direct intra oral
– Direct extra oral
– Indirect extra oral

• Deviated mouth
opening
• Deviation always
occurs towards the
side of decreased
mobility.
• Condylar
hyperplasia is an
exception.

• Path of the mandible on opening

Laterotrusive movements
TOWARDS LEFT TOWARDS RIGHT

• Path of closure from
postural rest to
centric occlusion:

• Compares hinge axis
pathways of normal
individuals and patients with
TMD.
• Records hinge axis
movements in three planes.
AXIOGRAPH:

AXIOGRAPH TRACINGS:

FUNCTIONAL MOUNTING OF THE PATIENT’S MODELS:
FACE BOW TRANSFER:

FUNCTIONAL MOUNTING OF THE PATIENT’S MODELS:
BITE REGISTRATION FOR CENTRIC
RELATION: ROTH’S POWER CENTIC
BITE REGISTRATION.

ARTICULATOR MOUNTING:
PANADENT ARTICULATOR CONDYLAR POSITION INDICATOR

CR – CO DISCEPANCY RECORDINGS OF THE CPI:

Radiological examinationRadiological examination
• Hard Tissue
– Panoramic radiograph
– Extra oral Projections
• Transcranial
• Transpharyngeal (Parma)
• Transorbital
– Conventional tomography
– Computed tomography
• Soft tissue
– Arthrography
– MRI

Panoramic RadiographPanoramic Radiograph
• A screening projection
• Gross osseous changes- erosions, osteophytes
• No information about condylar position or function
• Superimposition of the skull base and zygomatic arch

Transcranial projectionTranscranial projection
• Provides a sagittal view of
the lateral aspects of
condyle and temporal
component
• Only lateral joint contours
are visible
• Superimposition of the
petrous ridge may be
present.
• Image is usually distorted
and the position is of the
condyle is not reliable.
• For identifying gross
osseous changes and range
of motion (open views)

TranspharyngealTranspharyngeal
projectionprojection
• Provides a sagittal view
of the medial pole of the
condyle
• The temporal
component is not
imaged well
• Limited diagnostic value
• Only for osseous
changes in the condyle.

Transorbital projectionTransorbital projection
• Provides an anterior
view of the TMJ
• Entire mediolateral
aspect of the
condylar head and
neck is visible.
• Can give a limited
view depending
upon the degree of
mouth opening.

Conventional tomographyConventional tomography
• A radiographic technique
that produce thin image
slices free of
superimpositions of adjacent
structures.
• Produce images at right
angles to the condylar axis –
better view for depicting true
condylar position.
• Corrected sagittal
tomography using the aid of
a SMV projection or a 20
degree head rotation.

Conventional tomographyConventional tomography

Computed tomographyComputed tomography
• Image slices are
made in both
sagittal and coronal
planes.
• 3D images can be
constructed
• Cannot produce
accurate images of
the disc

Computed tomographyComputed tomography

ArthrographyArthrography
• A technique in which an indirect image of the
disk is obtained by injecting a radio opaque
contrast agent into one or both joint spaces
under fluoroscopic guidance.
• Single space and double space tomograms
• Disk position, function, morphology and
integrity of diskal attachments.
• Risks- Pain, infection, iatrogenic damage and
allergy.

Magnetic ResonanceMagnetic Resonance
ImagingImaging
• Excellent images of
soft tissues
• Imaging of the disk
in all three planes
• Contraindications:
ferromagnetic
materials, Non
ferrous metals and
cardiac
pacemakers.

Magnetic ResonanceMagnetic Resonance
ImagingImaging

Management of TMDManagement of TMD
• Corrective treatment
– Splints
– Splints combined with orthodontic
appliances
• Palliative / supportive treatment
– Sedatives
– Analgesics
– Counseling

SplintsSplints
Splints are hard or soft removable acrylic appliances covering
the teeth.
MODE OF ACTION :
• Eliminate occlusal disharmony
• Prevent wear and mobility of teeth
• Reduce bruxism and parafunction
• Treat muscle dysfunction
• Correct internal derangement
• Limiting the extent of potentially harmful movements.

Types of splintsTypes of splints
STABILIZATION SPLINT:
OTHER NAMES: Muscle deprogramming splint, Flat
plane splint, Superior repositioning splint, CR splint,
Tanner splint (Mandibular), Shore splint (Maxillary),
Michigan plane.
DESIGN:

STABILIZATION SPLINT:
MODE OF ACTION:
• Changes tooth contact
• Alters muscle function
USES:
• Treatment of muscle and joint pain from
occlusal contact discrepancy and parafunctional
activity.
• Mandibular position deprogramming.
•Vertical dimension alteration.www.indiandentalacademy.com

ANTERIOR REPOSITIONING SPLINT:
OTHER NAMES: Repositioning splint, LARS ( Ligated
Anterior Repositioning Splint), Orthopedic positioner.
DESIGN:

USE:
• Alter condylar position at occlusal contact
•Meniscus recapture.
ANTERIOR REPOSITIONING SPLINT:
MODE OF ACTION:
• Change in tooth contact
•Change in muscle function
•Alters the stress and loading of the joint
• Disc recapture

BITE PLANE SPLINT:
OTHER NAMES: Anterior jig, Luca jig, Hawley with ABP,
Anterior deprogrammer, Six point splint.
DESIGN:

BITE PLANE SPLINT:
USES:
• When premature contacts are present in the
posterior segments.
• Reduce muscle activity.
MODE OF ACTION:
• Interrupts mandibular position sense
• Eliminates propioceptive feedback from posterior
teeth.
•Reduces muscle activity.

PIVOT SPLINT: Based on the principle of joint traction.
DESIGN:

PIVOT SPLINT:
MODE OF ACTION:
• Unloading of the joint in cases of inflammation and internal
derangement.
USES:
• Internal derangement.
• Intracapsular inflammation.
DISADVANTAGE:
• Changes in tooth position occur due to the limited areas of
tooth contact.
• No control over condylar position.

SOFT SPLINT: An emergency appliance.
OTHER NAMES: Positioner, mouth guard, night guard.
DESIGN:

SOFT SPLINT:
USES:
• Athletics.
• For reducing parafunctional activity (not
substantiated).
• On a temporary basis for relief of symptoms.
DISADVANTAGES:
• Incapable of causing occlusal adjustments due to
the resilient nature.
•Can cause tooth movements.

MORA: Mandibular Orthopedic Repositioning Appliance.
OTHER NAMES: Gelb Splint.
USES:
• Change posterior occlusion.
• Eliminate anterior tooth contact.
DESIGN:

HYDROSTATIC SPLINT:
USE: Equalizes biting pressure over all teeth.
DESIGN:

Management of TMDManagement of TMD
• Type I disorder
– Mainly a muscle problem
• Type II disorder
– Mainly a disc problem
– Functional damage to the joint
• Type III disorder
– Major bone damage
– Structural damage to the joint components

Management of Type IManagement of Type I
disorderdisorder
PATIENT COMPLAINS OF…..
• Pain from different areas in the head, neck and shoulders but not in the
joint area.
ON CLINICAL EXAMINATION……
• Presence of a dual bite. (occlusal precontact)
•Tension in the masticatory muscles
• Tenderness on palpation of the muscles. Esp Lateral Pterygoid.
• Abnormal mandibular movements.
AIM OFTREATMENT………
• To eliminate muscular tension and pain.
• Correct alignment of teeth in both arches.

disorderdisorder

disorderdisorder
TREATMENT:
• Splints
• Six point splint/ / Bite plane splint
• Stabilization splint
• Orthodontics
• Selective grinding
• Medication
• Counseling

Management of Type IIManagement of Type II
disordersdisorders
PATIENT COMPLAINS OF……..
• Increase in myogenic type of pain
• Onset of arthrogenic type of pain
• Clicking noise
• Occasional acute locking
•Limited movement on one side
ON EXAMINATION:
• Pain on palpation
• Clicking, grating
• Deviation in path of mandible
AIM OF TREATMENT:
• Restore normal condyle – disc – fossa relationship (DISC RECAPTURE)

Management of Type IIManagement of Type II
disordersdisorders
TREATMENT:
• Splint
• Michigan plane / Stabilization splint
• Antero superior repositioning splint
• Orthodontics with splint

Management of Type IIIManagement of Type III
disordersdisorders
PATIENT COMPLAINS OF…..
• No pain
• Impossible to eat
• Limited mouth opening
AIM OF TREATMENT:
• Treat for ‘ BEST ANATOMIC COMPROMISE’

Management of Type IIIManagement of Type III
disordersdisorders
TREATMENT:
• PHASE I:
• Immediately free the joint
• Type III splint
• PHASE II:
• Sectional orthodontics with splint
•Achieving normal dental relationships
•Prosthetic replacements.
•surgery

ConclusionConclusion
The TMJ is a very complex joint to deal with as
a whole. As people who move teeth and change
occlusion, the orthodontist may be the one who alters
joint function the most.
The importance of treating from a centric
relation position to a centric relation position cannot be
stressed any more.
A thorough knowledge of TMJ function and
disorders and functional occlusion is essential to
establish long term goals for the occlusion and the
joint.

REFERENCESREFERENCES
• Extraction-non extraction dilemma as it relates to TMD –
Mclaughlin, Bennet; AO 1995, No 3
• The physiology of splint therapy – Roger A Boero; AO 1989 No
3
• Occlusion with particular emphasis on the functional and
parafunctional role of anterior teeth: Part 1 - JCO 1979 Sep
(606-620): William H McHorris
• Concepts in functional occlusion and management of functional
disorder of TMJ- Dr. N.R. Krishnaswamy. 7th IOS PG students
convention.
• Garden of Orthodontics –
• TMD- Weldon E Bell
• TMD a practitioner’s guide – Annika Isberg.

Thank you

Understanding TMDs from an Orthodontic Perspective

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