TMJ Disorders and Prosthetic Treatment

2
Temporomandibular
Joint-
DEVELOPMENT,
ANATOMY,
DISORDERS &
PROSTHODONTIC
CONSIDERATIONS

CONTEN
TS
□ INTRODUCTION
□ DEVELOPMENT
□ ANATOMY OF
TMJ
□ CLASSIFICATIO
N
□ TM DISORDERS
□ PROSTHODON 3

4
joint
According to okeson-
The area where craniomandibular
articulation occurs is called the
Temporomandibular Joint.
According to GPT-9:
The articulation between the temporal
bone and the mandible. It is a bilateral
diarthrodial and bilateral ginglymoid

At 10 weeks-
Condylar cartilage of the mandible and
development of temporal bone are
noticed.
6
Orban's oral histology and embryology

7
• Mandible-develops as intramembranous
bone lateral to the meckel’s cartilage
• Temporal bone-develops from
desmocranium

At 12
weeks-
• Two slit-like joint cavities and an intervening
disk appear.
• Fibrous joint capsule begins to form from
the mesenchyme around joint.
• Lateral pterygoid muscle attaches to the
disk.
8
Orban's oral histology and embryology

•TMJ - The area where craniomandibular articulation
occurs.
•
Jeffrey P. Okeson: Management of Temporomandibular disorders and

GINGLYMOARTHROIDIAL
JOINT
MOVEME
NT
MOVEMEN
T
TM
J
O
G
L
I
I
N
D
I
T
N
G
HINGING
COMPOUND J
SYNOVIAL JOINT

TM
J
COMPOUND JOINT
SYNOVIAL JOINT

❖ Condyle
❖ Temporal bone (Squamous part)
❖Articular disc

CONDYLE
•It is the p
Ao
nr
t
ti
eo
rn
ioo
rft
vh
ie
ewm
a
–n
d
2i
b
pl
e
olt
eh
a
starticulates with
the craniMum
e,dairaolupnodlweh
-i
c
ph
rom
mo
iv
ne
em
ne
tn
toccurs.
keson: Management of Temporomandibular disorders usion 4th
Jeffrey P.

TEMPORAL BONE
• The mandibular condyle articulates at the base of the cranium
with the squamous portion of the temporal bone.
• This portion made up of Concave Mandibular Fossa
called as ARTICULAR OR GLENOID FOSSA.
• Articular eminence - ?
Posterior
anagement of Temporomandibular disorders lusion 4th
Jeffrey P. Okeson:
roof

Bones of the joint
Glenoid Fossa
Ext. Auditory Meatus
Condyle
Styloid
Process
Articular
Eminence
Zygomatic
Arch

ARTICULAR DISC
• Composed of dense fibrous connective tissue, most part of it is
devoid of blood vessels and nerves fibers.
• It is divided into 3 regions (according to thickness).

Attachment of Articular
Disc
1. Retrodiscal tissue.
2. Superior retrodiscal
lamina
3. Inferior retrodiscal

• The articular disc is attached to the capsular ligament not
only anteriorly and posteriorly but also medially and
laterally.
• This divides the joint into 2 distinct cavities

JOINT CAVITY
SUPERI
OR
JOINT
CAVITY
INFERI
OR
JOINT
CAVITY

• The internal surfaces of the cavities are surrounded by
specialized endothelial cells that form a synovial lining. –
produces synovial fluid - fills the joint cavities
• TMJ - Synovial joint

• Synovial fluid - 2 purposes :
1. Medium for providing metabolic
requirements
Lubricant between the articular
2.
surfaces during function – minimizes
friction
WEEPING
LUBRICATION
BOUNDARY LUBRICATION

LIGAMENTS
•Made up of collagenous connective tissues - do not
stretch.
•They do not enter actively into joint function, act as
passive restraining devices to limit &restrict
border movements.
FUNCTIONAL
• Collateral
• Capsular
• Temporomandibul
ar
ACCESSORY
• Sphenomandibular
• Stylomandibular

LIGAMENTS
na ement of Temporomandibular d on 4th
Jeffrey P.
FUNCTIONAL
• Collateral
• Capsular
• Temporomandibul
ar
ACCESSORY
• Sphenomandibular
• Stylomandibular

COLLATERAL(DISCAL) LIGAMENTS:-
• They attach the medial & lateral borders of articular disc to the poles
of the condyle.
• 2 TYPES:-
- Medial discal ligament
- Lateral discal ligament

o True ligaments – composed of collagenous fibers – do not
stretch.
o Permits the disc to be rotated anteriorly and posteriorly on
the articular surface of the condyle. – HINGING
MOVEMENT.
o They have a vascular supply and are innervated - Strain -
produces pain

Entire TMJ is
surrounded &
encompassed by the
capsular ligament.
Attachment :-
- Superiorly
- Inferiorly
Functions:-
Prevents
dislocation of the
articular surfaces.
Retaining the
synovial fluid
CAPSULAR
LIGAMENT

TEMPOROMANDIBULAR
LIGAMENT
2 parts –
On the Lateral aspect
1) outer oblique
of the capsular
portion
ligament 2) Inner horizontal
portion

3
1
□ During the initial phase of opening, the condyle can
rotate around a fixed point until it becomes tight as
its point of insertion is on the neck of the condyle
that is rotated posteriorly
□ When it is taut, the neck of the condyle cannot
rotate further
□ If the mouth were to be opened wider, the condyle
would need to move downward & forward across the
articular eminence.

SPHENOMANDIBULAR LIGAMENT
• Accessory ligament
• Arises from

Functi
1) T
2) M
So, dible.
GAMENT
on:
aut - when mandible is protruded
ost relaxed – when mandible is opened.
limits excessive protrusive movement of man
STYLOMANDIBULAR
LI

BIOMECHANICS OF TEMPOROMANDIBULAR
JOINT
□ Compound joint
□ Structure and function can be divided into two distinct
systems:
1.One joint system- tissues that surround the inferior
synovial cavity (i.e., the condyle and the articular disc).
• Disc is tightly bound to the condyle by the lateral and
medial discal ligaments
• Rotation of the disc on the articular surface of the
condyle.
• The disc and its attachment to the condyle are called the
condyle-disc complex.

2.The second system- made up of the condyle-disc
complex functioning against mandibular fossa.
• Disc is not tightly attached to the articular fossa, free
sliding movement- in the superior cavity.
• This movement occurs when the mandible is moved
forward- translation.
• Translation occurs in this superior joint cavity.
• Thus the articular disc acts as a nonossified bone
contributing to both joint systems, and hence the
function of the disc justifies classifying the TMJ as a
true compound joint.

40
During closing of
mouth
1. Mandible is elevated
2. the condyle is pulled backward along
with articular disc
Retrodiscal lamina is
stretched
3.
4. The interarticular pressure and
themorphology of the disc prevent the disc
from being overretracted posteriorly.
Superior retrodiscal lamina is the only structure
which is capable of retracting the disc
posteriorly on the condyle

41
During mouth
opening
1. Mandible is depressed
2. the condyle is pulled forward down
the articular eminence
3. Rotation occurs until 25 mm
4. Translation occurs when the mouth is
widely opened.

What happens during chewing???
Interarticular pressure is
increased on the contralateral
joint while on the ipsilateral it is
decreased.
Jaw works as fulcrum around the
hard joint.
Superior lateral pterygoid
becomes active.
Rotating the disc forward on the
condyle so thicker portion of the
disc contacts the joint.
As the teeth approach
intercuspation , just opposite
occurs
This can
lead to
dislocati
on

43
Position of
disc
• Normally, in the rest position condyle seats
itself in the intermediate portion of disc.
• As the interarticular pressure ↑ses, the condyle
seats itself on the thinner intermediate zone
more positively.
• Pressure ↓ses, the disc space is widened, a
thicker portion of the disc is rotated to fill the
space.

TEMPOROMANDIBULAR
DISORDERS AND
PROSTHODONTIC
MANAGEMENT
44

Temporomandibular disorders (TMD) are
recognized
as the most common non tooth-related
chronic oro- facial pain conditions that
confront dentists and other healthcare
providers.
45

Because of the complex and unique nature of
each TMD
case, diagnosis requires a multi
disciplinary , patient-specific and customized
approach to address the
specific characteristics of each patient’s
disease.
46

WHAT IS A
TEMPORO-
MA
NDIBULAR
DISORDER?
48

Temporomandibular disorder is not a
single disease but a
collection of structural and/or
functional disorders resulting clinically
in comparable and
analogue complaints, but the fact that
the symptoms are almost identical
indeed does not justify the diagnosis of
one single disease for all patients. 49

How TMD symptoms
arise???
Normal
function
Event
Physio-l
ogical
tolerance
TMD
symptom
5
1

SIGNS AND SYMPTOMS OF TMJ
DISORDERS
PAIN DYSFUNCTI
ON
Two major
symptoms
5
1

5
6
CLASSIFICATION OF TEMPOROMANDIBULAR
DISORDERS
I. Masticatory Muscle
Disorders
1. Protective Co-
Contraction
2. Local Muscle Soreness
3. Myospasm
4. Myofascial Pain
5. Chronic Centrally
Mediated Myalgia
6. Fibromyalgia
II. Temporomandibular Joint
Disorders
3. Inflammatory Disorders Of The
TMJ
a) Synovitis/Capsulit
is
b) Retrodiscitis
c) Arthritides
1. Derangement Of The Condyle-
Disc Complex
a) Disc displacements
b) Disc Dislocations Without
Reduction.
c) Disc Dislocations With Reduction.
2. Structural Incompatibility Of The
Articular Surfaces
a) Deviation In Form
b) Adhesions
c)Subluxation (Hypermobility)
d) Spontaneous
Dislocation
III. Chronic Mandibular
Hypomobility
1. Ankylosis
2. Muscle Contracture
3. Coronoid Impedance
IV. Growth
Di1s.ordCeornsgenitalAnd
Developmental Bone
Disorders
2. Congenital And
Developmental Muscle
Disorders
Jeffrey P. Okeson: Management of Temporomandibular disorders and occlusion

5
7
L
E
ASTICATORY
MUSC
DISORDERS
1. Protective Co-Contraction
M3.Myospasm
4. Myofascial Pain
5. Chronic Centrally Mediated
Myalgia
6. Fibromyalgia

PROTECTIVE CO-CONTRACTION
(muscle splinting)
□First response to one of the
previously described events.
□It is a C.N.S response to injury
□ Not a pathologic condition
CAUSE:
□ Altered sensory or proprioceptive
input
□ Constant deep pain input
□ Increased emotional stress 5
8

CLINICAL
CHARACTERSTICS:
□Feeling of muscle
weakness
□Limited mouth
opening
□ No pain at rest
□ Increased pain with
function
TREATMENT:
Removal of the causative factor
Key
factor-
Immediatel
y follows
an event
5
8

LOCAL MUSCLE SORENESS/
Non-inflammatory myalgia
□ Non inflammatory myogenous pain
disorder.
□First response of muscle to prolonged
muscle co-contraction.
CAUSE:
□ Protracted co-contraction
□ Trauma
□ Stress 5
8

CLINICAL
FEATURES:
Minimum pain at rest, increases with
function Muscle weakness
Muscle tender when palpated
Patient has great difficulty opening
wide
TREATMEN
T:
DEFINITIVE TREATMENT:
Source of deep pain should be
eliminated Restricted mandibular
movement Occlusal appliance at
night for bruxism SUPPORTIVE
THERAPY:
Mild analgesic , NSAIDs, manual physical therapy and gentle
massage
Respon
ds in 1
to 3
weeks
5
8

Acute myalgic disorders Chronic myalgic disorders
Myospasm Regional
myalgic
disorders
Systemic
myalgic
disorders
• Myofascial pain
•Chronic
centrally
mediated
myalgia
Fibromyalgi
a
Centrally influenced muscle pain
disorders
5
8

Involuntary CNS induced tonic muscle
contraction often associated with local
metabolic condition within muscle tissue.
CAUSE:
□ Continued deep pain input.
□Local metabolic factors- muscle fatigue and
changes in local electrolyte balance.
MYOSPAS
M
5
8

CLINICAL
FEATURES:
□Structural dysfunction
□Acute malocclusion
□Pain at rest which increases with function
□Very firm muscles on palpation
DEFINITIVE TREATMENT:
1. Reducing pain followed by lengthening the involved
muscle (manual massage or coolent spray reduces
pain)
2. Elimination of cause
SUPPORTIVE
THERAPY:
Physical therapy- deep massage & passive
stretching 5
8

MYOFASCIAL
PAIN
(TRIGGER POINT
MYALGIA)
□First described by TRAVELL & RINZLER in 1952.
□Myofascial pain is a regional myogenous pain
condition characterized by local areas of firm,
hypersensitive bands of muscle tissue known as
trigger points.
□Sometimes referred to as myofascial trigger point
pain.
5
8

□ETIOLOG
Y :
□ Protracted co-contraction
□ Continuous deep pain
□ Emotional stress
□ Local tissue trauma/ unaccustomed
muscle use
□ Systemic factors
□ Idiopathic trigger point
5
8

CHARACTERSTI
CS:
▪ Structural dysfunction
▪ Constant deep pain
▪ Headache
▪ Local temperature rise
▪Co-contraction leading to muscle
soreness
▪ Muscle tender on palpation
▪ Degenerative changes in TMJ if chronic
▪ Unilateral dull pain in ear –worse on
awakening
▪ Unilateral reddening of eye 6
7

TREATME
NT:
□ Eliminate source of deep pain
□ Eliminate cause
□ Sleep disorder- low dose of anti-depressant and
refferal
□ TRIGGER POINT THERAPY :- by stretching the
muscle with trigger points
• Spray and stretch therapy - 3 to 5 weekly sessions
• Pressure and massage
• Injection and stretch
Use of analgesic , NSAIDs, physical
therapy
Definitive therapy:
6
8
Supportive therapy:

Centrally Mediated
Myalgia
(Chronic
Myositis)
Centrally mediated myalgia is a chronic, continuous
muscle pain disorder originating predominantly from
CNS effects that are felt peripherally in the muscle
tissues.
□ more in the CNS than in the muscle tissue
itself
□ Protracted local muscle soreness or
myofascial pain
ETIOLOG
Y
6
8

7
0
□ Continuity of muscle pain rather than
actual duration
□ No periodic episodes
□ Increased pain with function
□ Local tenderness
□ Generalized muscle tightness
CHARACTERIST
ICS:

TREATME
NT:
□ Restrict mandibular movements
□ Avoid exercise and injections
□ Disengage the teeth (using
appliance)
□ Antiinflammatory drug(NSAIDs)
□ Physical
therapy(cautiously)
□ Moist heat/ice
Definitive therapy:
Supportive therapy:
7
1

Fibromyalg
ia
□ Systemic myologic disorder
□ Tenderness in 11-18 joints of
body
□ Not just a masticatory pain
disorder
7
1

Local
muscle
soreness
Myospasm Myofacial
pain
Chronic
myositis
Definitive
Treatment
Occlusal
appliance
Passive
lengthening
-Rx sleep
disorder
- Eliminate
trigger
points
-Restrict mand.
use
-Avoid exercise
& Inj.
-disengage teeth
- Eliminate altered sensory input
- Rx of deep pain
- Restricted use + soft diet
- PSR (Physical Self Regulation)
Supportive
therapy
- NSAIDs, Muscle relaxants
- Passive muscle stretching
- Massage
- Relaxation therapy
- Ultrasound therapy
Dx Protective
co-
Rx contraction

7
7
CLASSIFICATION OF TEMPOROMANDIBULAR
DISORDERS
I. Masticatory Muscle
Disorders
1. Protective Co-
Contraction
3. Myospasm
4. Myofascial Pain
5. Chronic Centrally
Mediated Myalgia
6. Fibromyalgia
II. Temporomandibular Joint
Disorders
3. Inflammatory Disorders Of The
TMJ
a) Synovitis/Capsulit
is
b) Retrodiscitis
c) Arthritides
1. Derangement Of The Condyle-
Disc Complex
a) Disc displacements
b) Disc Dislocations Without
Reduction.
c) Disc Dislocations With Reduction.
2. Structural Incompatibility Of The
Articular Surfaces
a) Deviation In Form
b) Adhesions
c)Subluxation (Hypermobility)
d) Spontaneous
Dislocation
III. Chronic Mandibular
Hypomobility
1. Ankylosis
2. Muscle Contracture
3. Coronoid Impedance
IV. Growth
Di1s.ordCeornsgenitalAnd
Developmental Bone
Disorders
2. Congenital And
Developmental Muscle
Disorders
Jeffrey P. Okeson: Management of Temporomandibular disorders and occlusion

TEMPOROMANDIBU
LAR JOINT
DISORDERS
78

INTERNAL DERANGEMENT OF
CONDYLE – DISC
COMPLEX
80

INTERNAL DERANGEMENT OF
CONDYLE – DISC
COMPLEX
Three types :
• Disc displacement
• Disc dislocation with reduction
• Disc dislocation without reduction
Etiology :
Elongation of
discal ligaments
and inf.
retrodiscal
ligament
Thinning of
posterior border
of disc
Due to anterior
pull of lateral
pterygoid
Disc displaced
more
anteriorly
81

Sligh
t
displace
Interarticular
ment pressure low
N
o
click
Slight
displaceme
nt
Interarticula
r pressure
low
RECIPRO
CAL
click
INTERNAL
DERANGEME
NT
82

Disc
Displacement:
Clinical features
□ During opening translatory
shift of condyle over disc-
click
□ Normal range of jaw movement.
□ Restriction of movement associated with pain.
84

□ If ligaments are further elongated- disc slip completely through discal
space.
□ Disc and condyle no longer
articulate- dislocation
□ If patient manipulate jaw
and reposition disc- reducible disc
Clinical Features:
□ Limited range of motion – before reduction
□ Normal range – after reduction
□ Deviation during opening
Disc Dislocation with
Reduction :
85

Definitive
treatment:
86
□ Anterior positioning appliance
Supportive therapy:
Patient Education:
□ Instructed not to open wide
□ Decrease hard biting.
□ NSAID’S- for pain and
inflammation

Disc is dislocated and does not return to
normal position with condylar
movement
Clinical features:
□ Limited mandibular opening (25-30mm)
□ Normal eccentric movement to ipsilateral side
□ Restricted eccentric movement to the contralateral side
NON REDUCIBLE DISK
DISLOCATION (CLOSED
LOCK)
87

• Only one joint affected
• Other functions normally
•So, when patient opens mouth wide mandible
deflected to affected side
• To be noted- condyle on affected side only rotates
If closed
lock
continues
88
• Condyle chronically positioned on retrodiscal
tissue
• Tissue inflammation

Definitive
treatment:
□ Anterior positioning appliance-contraindicated
□ When acute- attempt to recapture the disc by
manual manipulation
□ Surgical correction – disc repositioning and
discoplasty
Supportive therapy:
Patient Education:
□ Instructed not to open wide
□ Decrease hard biting.
□ NSAID’S- for pain and inflammation
89

STRUCTURAL
INCOMPATIBILITIES OF
THE ARTICULAR
SURFACES
90

c)
SUBLUXATION
:
• Also known as hypermobility
• Condyle moves anteriorly
to the crest of articular
eminence
• TMJ- articular eminence- steep and short
posterior slope
91

Steep short posterior
slope of articular
eminence + longer flat
anterior slope
jaw “goes out” any time
he or she opens
wide.
Latter stage of opening
the condyle will jump
forward, leaving a small
depression in the face
behind it.
Etiology History
Clinical
feature

93
• The midline pathway of mandibular opening
will be seen to deviate and return as the
condyle moves over the eminence.
• The deviation is much greater and much closer
to the maximally open position than that seen
with a disc derangement disorder.
• Subluxation is a repeatable clinical
phenomenon that does not vary with changes
in speed or force of opening

Patient education-restrict mouth
opening
TREATMENT :
• DEFINITIVE TREATMENT:
Surgical treatment- eminectomy
• SUPPORTIVE THERAPY:
which reduces the steepness of the articular eminence
and thus
decreases the amount of posterior rotation of the
disc on the condyle during full translation.
Orthodontic tubes
94
Orthodontic
elastics

ANKYLO
SIS
❑ STIFF
JOINT
Causes
• Macrotrauma
• Hemarthrosis or bleeding
• TMJ surgery produces
fibrotic changes in the
capsular ligament
• Previous infection.
History
• Patients report limited mouth
opening without any pain.
95

ANKYLOSIS
FIBROUS BONY
occurs between the
condyle and the disc or
between the disc and the
fossa.
occurs between the
condyle and fossa
Therefore disc
absent
ankylosismeans abnormal immobility
of a joint
96

CLINICAL
FEATURES:
□ Facial asymmetry
□ Bird face deformity – bilateral
□ Deviation on affected side- if unilateral
□ Roundness and fullness of face on
affected side
□ Cross bite may be present
97

98
Definitive Treatment
• Because the patient generally has some
movement
-definitive treatment not indicated.
• If function is inadequate or the
restriction is intolerable-surgery
Supportive Therapy
• Because ankylosis is normally
asymptomatic-no supportive therapy
indicated.
• Pain and inflammation-
□ voluntarily restricting movement to within
painless limits.
□ Analgesics
□ Deep heat therapy

DIAGNOSIS OF
TEMPOROMANDIBU
LAR DISORDERS?
99

□ INSPECTION
□ PALPATION
□ AUSCULTATI
ON
CLINICAL
100

INSPECTION
1. Tooth mobility
2. Tooth wear
3. Mandibular
movements
4. Deviation of
mandible
101

Other features
include:
□ Angle’s classification for molar
relationship
□ Posterior crossbite
□ Overjet and overbite
102

▪ MUSCL
ES
▪ JOINTS
PALPATION
103

• Palpation - palmer surface of the middle
finger
VARIOUS MUSCLES ARE TO BE
PALPATED:
□ Temporalis muscle
□ Masseter muscle
□ Lateral pterygoid muscle
□ Medial pterygoid muscle
□ Sternocleidomastoid muscle
□ Anterior digastric muscle
MUSCLE
EXAMINATION
104

Contracting Stretching
Inferior
Lateral Pterygoid
Protruding
against resistance,
↑ pain
Clenching on
teeth, ↑ pain
Clenching on
separator; no pain
Superior
Lateral Pterygoid
Clenching on
teeth, ↑ pain
Clenching on
separator; ↑pain
Clenching on
teeth, ↑ pain
Clenching on
separator; ↑pain
Opening mouth;
no pain
Medial Pterygoid
Clenching on
teeth, ↑ pain
Clenching on
separator; ↑pain
Opening mouth, ↑
pain

JOINT
EXAMINATION
TMJ NEEDS TO BE
PALPATED IN THREE
LOCATIONS
Ask the patient to:
1) open approximately 20 mm and
palpate the condyle’s lateral pole.
2) open as wide as possible palpate the depth of the
depression behind the condyles
3) With the finger in the depression and the mouth
open wide, pull forward to load the posterior aspect 10
9

AUSCULTATIO
3 major d
N
iagnostic
features:
□ Detection (whether a sound is present or
not).
□ Type (click or crepitus).
□ Position of occurrence during the
open/close cycle.
Click:
111
Sharp, discrete and single sound of relatively short
duration
Crepitus:
Multiple grating like sounds or a longer continuous
sound often
described as rubbing, cracking, sand
paper like.

INVESTIGATIO
NS
□ DIAGNOSTIC MOUNTING
□ CENTRIC RELATION and
centric
occlusion EVALUATION
□ RADIOGRAPHS –OPG
IOPA ( in relation to tooth that
causes abnormal mandibular
movement ) ADVANCED CASES
□ Arthrography
□ Computed Tomography
□ Magnetic Resonance Imaging
□ Sonography 112

DEFINITI
VE
TREATME
NT
SUPPORTI
VE
TREATME
114

DEFINITIVE
REATMENT
TAimeddirectly toward elimination or
alteration of etiologic factor responsible
for the disorder
Occlusal therapy –
reversible and
irreversible
Emotional stress
therapy 115

OCCLUSAL
THERAPY
116
Occlusal therapy is any treatment that
alters a patient’s occlusal
condition.
THEY ARE OF TWO TYPES-
REVERSIBLE
THERAPY
IRREVERSIBLE
THERAPY

According to THE GLOSSARY OF PROSTHODONTIC
TERMS [9th ed.],
“ Occlusal splint is defined as any removable artificial
occlusal surface affecting the relationship of mandible
to the maxilla used for diagnosis or therapy; uses of
this device may include for occlusal stabilization , for
treatment of Temporo-mandibular disorders, or to
prevent wear of the dentition.”
118

Occlusal splint therapy can be indicated for the
following purposes:
□To protect oral tissues
□To stabilize unstable occlusion
□To promote jaw muscle relaxation
□To eliminate the effects of occlusal interferences
□To test the effect of changes in occlusion on the TMJ
119

TYPES OF OCCLUSAL
SPLINTS
According to
OKESON
Stabilizatio
n
Appliance
Anterior
Positionin
g
Appliance
120

OTHER
TYPES
Anterior
Bite
Plane
Posterior
Bite
Plane
Pivoting
Applianc
e
Soft/Resilie
nt
Appliance
121

SOFT OR RESILIENT APPLIANCE
POSTERIOR BITE PLANEANTERIOR
BITE PLANE
PIVOTING APPLIANCE
122

HOW DO SPLINTS
WORK?
PREVENTING THE PATIENT TO
CLOSE IN MAXIMAL
INTERCUSPAL POSITION:
□ Mandible-new
position, results in
new muscular and
articular balance
□ Protects teeth and
TMJ
123

PREVENTING THE PATIENT TO CLOSE IN
MAXIMAL INTERCUSPAL
POSITION:
124

DISTRIBUTION OF
FORCES
□ Dissipate forces by
utilizing larger surface
area in arch.
□ Balances the load and
allows for muscle
symmetry.
125

ALLOWING THE CONDYLES TO SEAT IN
CENTRIC RELATION
Occlusion associated
with relaxed
positioning
Elevator muscles
allowing the
articulator disc to
obtain its anterio- 126

INCREASE IN THE VERTICAL
DIMENSION OF
OCCLUSION
□ Temporary increase
in vertical height
does not cause
hyperactivity of jaw
muscles.
□ Causes
neuromuscular 127

IRREVERSIBLE
OCCLUSAL
THERA
PY
128

Permanent Occlusal Therapy is only indicated
when
significant evidence exists to support that the
occlusal condition is an etiologic factor.
INDICATIONS
129

TREATMENT PLANNING FOR
OCCLUSAL THERAPY
When skeletal relations cause dental
malocclusion –
ORTHOGNATHIC SURGERIES
13
0
minor changes needed, occlusal surfaces of teeth
can be reshaped to achieve a desired occlusal
contact pattern.- SELECTIVE GRINDING.
When extensive alteration of occlusion needed and cannot
be met by selective grinding then CROWNS AND FIXED
PROSTHETIC PROCEDURES are used.
When inter-arch alignment is poorer and prosthetic
procedures are not able to complete treatment goals then
ORTHODONTIC PROCEDURES are done.

Patients with muscle disorders - higher
levels of
emotional stress.
Treatment is directed towards reduction of
stresTsy.pes of emotional stress
therapy
Patient awareness
Relaxation therapy
Biofeedback
Negative
biofeedback 132

PATIENT
AWARENESS
❑ Parafunctional activity occurs at
subconcious level.
❑ Establishing awareness of muscle
hyperactivity.
❑ Once habits are brought to concious level –
can be controlled voluntarily.
133

RELAXATION
THERAPY
:
Jacobson’s
technique Patient
tenses the muscle
and then relaxes
them until the relax
state is felt and
ACTIVE THERAPY
“Relaxation is the direct negative of
nervous excitement. It is the absence
of nerve-muscle impulse.” - Edmund
Jacobson.
13
4

RELAXATION THERAPY
ACTIVE THERAPY
Reverse approach:
Instead of above procedure
muscles are passively stretched
and then relaxed.
135

BIOFEEDBACK
Assists patient in regulating bodily functions
that are controlled unconsciously.
136

SUPPORTIVE
THERAPY
□ Alters patient’s
symptoms
□ No effect on the
cause.
Pharmacologic
Therapy
Physical
Therapy
137

DRUGS USED IN
TEMPOROMANDIBU 13
8

• Analgesics
• Anti-inflammatory
medications
• Corticosteroids
• Muscle relaxants
• Tricyclic antidepressants
• Nutritional supplements
139

THERMOTHER
APY
141
□Uses heat as primary mechanism
□ Theory-heat increase blood
circulation to applied area.
□ For 10 – 15 mins, not to exceed 30
mins.

COOLANT
THERAPY
□ Cold encourages
relaxation of muscles
in spasm and relieves
pain.
□ Initially feels uncomfortable
and then burning sensation
felt.
□ Continued icing results in
mild aching and
numbness.
□ Remove ice when
numbness starts.
142

ULTRASOUND
T□
HP
r
Eo
d
u
Rc
e
Ai
n
c
Pr
e
a
Ys
ein temperature
at the interface of tissues
143
□ Increase blood flow in deep tissues

Electro-galvanic stimulation
EGS
□ Electrical stimulation of muscle causes it to
contract.
□ A rhythmic electrical impulse is applied to
muscle creating repeated involuntary
contractions and relaxations
144

TENS
Transcutaneous electrical nerve
□ Continuous stimulation of cutaneous nerve fibres
at a subpainful level.
□ Electrical
activity
decreases pain 14
5

ACUPUNCTU
□ Uses body’R
s ow
E
n anti-nociceptive
system to reduce the levels of pain
itself.
□ Stimulation of some areas cause release of
endomorphins which reduce painful
sensations.
□ These effectively block noxious impulses
and reduce pain.
146

CONCLUSION
By understanding the various causes and
presentations of TMJ problems it is possible to
distinguish between dental pain, TMJ disorder
and the more complicated facial pains to
ensure speedy diagnosis and management for
our patients.
147

149
https://www.youtube.com/watch?v=Dd3aT9c_0
8M
Very nice video of tmd---
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TMJ Disorders and Prosthetic Treatment

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