Conservative management of temporomandibular disorders

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this presentation addresses the TM Joint disorders focusing on the conservative and no-surgical methods of treatment , with special emphasis on the effective role of occlusal splints .

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Conservative management of temporomandibular disorders

  1. 1. ‫‪Conservative Management of‬‬ ‫‪TemporoMandibular Disorders‬‬ ‫التدابير المحافظة لالضطرابات الوظيفية‬ ‫الفكية الصدغية‬ ‫‪Dr . Marwan Mouakeh , Consultant Orthodontist‬‬ ‫د. مروان موقع – استشاري تقويم األسنان‬ ‫المستشار العممي لمجمع عيادات أكاديمية الحقيل‬
  2. 2.  Temporomandibular Disorders ( TMDs )  A Collective term embracing a broad spectrum of clinical Joint & Muscle Problems in the Orofacial Area .  These Disorders are characterized primarily by: - Pain, - Joint Sounds , and - Irregular Limited Jaw Function .  TMDs represent a major cause of nondental pain in the orofacial region .
  3. 3.  Temporomandibular Disorders ( TMDs ) •Because various components of the masicatory system are affected , it is appropriate that dentists take responsibility for diagnosing and treating TMDs .
  4. 4. Classification of TMDs The American Academy of Orofacial Pain ( AAOP) I- TMJ Disorders II- Masticatory Muscle Disorders III- Congenital & Developmental Disorders
  5. 5.  Classification of TMDs the American Academy of Orofacial Pain ( AAOP) I- TMJ Disorders 1- Deviation in form 2- Disc Displacements 3- Displacement of the Disc-Condyle Complex - Hypermobility - Dislocation 4- Inflammatory Disorders - Capsulitis & Synovitis - Retrodiscitis 5 – Degenerative Diseases 6 – Ankylosis - Fibrous - Bony
  6. 6.  Classification of TMDs the American Academy of Orofacial Pain ( AAOP) II- Masticatory Muscle Disorders - Acute 1- Myositis 2- Reflex Muscle Splinting 3- Muscle Spasm - Chronic 1- Myofascial Pain 2 – Muscle Contracture 3 – Hypertrophy 4- Myalgia Secondary to Systemic Disease
  7. 7. Reported TMD Symptoms in 18 Epidemiologic Studies “ Carlsson 1984” Symptoms Mean Value % TMJ Sounds 19 Tiredness,Stiffness of jaw 11 Pain on Mandibular function 6 Limitation of Mandibular movement 8 Locking 4 Frequent Headache 17
  8. 8. Age distribution of 5 samples of patients with TMDS •A Common Peak in the age distribution of the patients , specifically during the period between 20 and 40 years . • A higher prevalence of TMDs signs & symptoms in women than in men .
  9. 9. Physiologic & Functional Considerations
  10. 10. TMJs • From a functional and pathologic point of view , the most important elements are the Articular Disc & the Lateral Pterygoid Muscle .
  11. 11. Posterior Band Sup. Attachment Intermediate Zone Elastic Anterior Band Bilaminar Zone Inf. Attachment Non-Elastic Parts of the Articular Disc - Sagittal view
  12. 12. The Articular Disc Frontal View Medial Lateral Collateral Discal Ligaments ‫األربطة الجانبية للقرص المفصلي‬
  13. 13. Physiologic Position of the Articular Disc ‫خالية من األوعية‬ ‫الدموية واألعصاب‬ 1 12o’clock position 2 3  The Absence of Blood Vessels & Nerves in the Intermediate Zone of the Disc Enables this part of the disc to act as a Pressure-Bearing Area .
  14. 14. Healthy Joint Elastic Collagenous  Tight discal ligaments and self-seating wedges provided by thick posterior and anterior borders of the disc maintain the disc in proper relationship .
  15. 15. Healthy Joint 1 2 3 •Synovial Fluid : ‫السائل الزليلي‬ •Nutrition • Lubrication • Heat absorption
  16. 16. Lateral Pterygoid Muscle Sup. Belly : Elevator Inf. Belly : Depressor
  17. 17.  Functional role of the upper & lower lateral pterygoids Sup. Belly : Elevator Inf. Belly : Depressor Opening Closure
  18. 18. Masticatory Pains Arthrogenous (TMJs ) ‫منشأ مفصلي‬ Myogenous (Masticatory Muscles ) ‫منشأ عضلي‬ Combination of Both Types
  19. 19. • Myalgia Masticatory Muscles Pain  Dull , Deep , and Diffuse pain  Felt in the morning when related to Nocturnal Bruxism .  Influenced by functional demands ( chewing…)  Depressing
  20. 20.  Myofascial Pain  A very common TM disorder , involves discomfort or pain in the muscles that control Jaw function .  Characterized by Referred pain from Trigger Points within the myofascial structures. Pain referral pattern from the masseter muscle
  21. 21.  Myofascial Pain •Trigger points (TrP) are tight, highly irritable spots in a taut band of muscle that can cause referred pain, or pain located away from the trigger point itself.
  22. 22. Masticatory Muscles Palpation
  23. 23. Lateral Pterygoid Palpation
  24. 24. Restricted Mouth Opening : Less than 30 -35 mm
  25. 25.  Arthralgia = Pain originating from the joint  Localized in the TMJ Region  Increased with mandibular movement.
  26. 26. Arthralgia (Articular Pain)  TMJ Pain-sensitive structures : - Collateral discal ligaments - Posterior attachment - Articular capsule .
  27. 27.  Disc Displacement  Commonly referred to as Internal Derangement • A Disorders characterized by abnormal relationship between the articular disc, mandibular condyle, and articular eminence.
  28. 28.  Disc Displacement • Patho-physiology  Muscle ( lat.ptery ) incoordination  Deformation or thinning of the of the posterior band  Elongation of discal attachments . Disc Displacement
  29. 29.  Disc Displacement • Patho-physiology  In this position , excessive pressure on the TMJ can cause thinning of the posterior border of the disc.  These changes lead to loss of disc’s self-seating capacity .
  30. 30. Anatomic Classification  Anterior Disc Displacements
  31. 31. Anatomic Classification  Sideways (Rotational ) Displacements Medial
  32. 32. Anatomic Classification  Sideways (Rotational ) Displacements Lateral
  33. 33. Antero-medial Disc Displacement the most common clinical condition … The medial component occurs because of a compromised lateral discal ligament & the pull of the superior laterl pterygoid .
  34. 34. Anatomic Classification  Posterior Disc Displacements • Very Rare  Known as “ Open Lock “
  35. 35. Anterior Disc Displacement  Functional Classification ‫االنزياح األمامي الردود‬ A.D.D With Reduction ‫االنزياح األمامي غير الردود‬ A.D.D Without Reduction
  36. 36. ‫االنزياح األمامي الردود‬ A.D.D With Reduction The Displaced Disc recaptures its normal relationship with the condyle on opening .
  37. 37. • Disc Displacement With Reduction Closed Partially Open Fully Open
  38. 38. • Disc Displacement With Reduction ‫الطقة المفصلية المتبادلة‬ Opening Major Symptom Closing Reciprocal Click
  39. 39. • Disc Displacement With Reduction • Mandibular midline Deviation ( ipsilateral )
  40. 40. • Disc Displacement With Reduction
  41. 41. ‫االنزياح األمامي غير الردود‬ A.D.D Without Reduction The Displaced Disc can’t recapture its normal relationship with the condyle on opening .
  42. 42. • Disc Displacement Without Reduction •Acute Phase  Closed Lock : Severely restricted opening ( < 25-30 mm ) in the Acute phase .
  43. 43. • Disc Displacement Without Reduction •Acute Phase Closed Major Symptom Open Closed Lock
  44. 44. • Disc Displacement Without Reduction 1 2 3
  45. 45. D.D Without Reduction Chronic Phase • Progressive increase in mouth opening . • Mild pain , if any …
  46. 46.  Disc Perforations  Disc displacements have a high correlation with TMJ osteoarthrosis, which is characterized by degenerative changes in the articular surfaces.  Crepitation ….
  47. 47.  Disc Perforations  it is too late for conservative treatment.
  48. 48. What causes TMJ disorders? The Exact Causes Are Not Clear Yet …
  49. 49.  Contributing Factors  Predisposing Factors : increase the risk of TMDs. ( systemic conditions- skeletal deformities-postural imbalances …)  Initiating Factors : cause the onset of the disorders. ( Acute or Chronic Trauma )  Perpetuating Factors : interfere with healing and complicate treatment . ( emotional stress - anxiety- sleep disorders )
  50. 50.  Initiating or Precipitating Factors  Macrotrauma : as a result of a single event - Extrinsic ( blow , sport accidents … ) - Intrinsic ( hard foods, prolonged mouth opening… ) Whiplash
  51. 51.  Initiating or Precipitating Factors  Microtrauma : repetitive adverse loading of the masticatory system - Parafunctional activities ( Bruxism & Clenching )
  52. 52.  Bruxism • Clenching or grinding the teeth during nonfunctional movements of the mandible. - Nocturnal Bruxism , related to sleep disorders and may be influenced by stress . - Diurnal Bruxism , a learned behavior .
  53. 53. What causes TMJ disorders? Stress: Emotional & Physical  Stress frequently leads to unreleased nervous energy. It is very common for people under stress to release this nervous energy by grinding and clenching their teeth.
  54. 54. What causes TMJ disorders ? •Specific Forms of Malocclusion Anterior open bite Forced bite Class II-2 Anterior crossbite
  55. 55. Evolution How joint and muscles disorders progress is not clear . Symptoms worsen and ease over time, but what causes these changes is not known. ‫تكيف‬ ‫وظيفة طبيعية‬ ‫فرط وظيفة‬ ‫خلل وظيفي‬
  56. 56. Conservative Management of TMDs
  57. 57.  The Management Goals  Reduction of Pain and Anxiety .  Reduction of Functional or Parafunctional Activities Leading to Adverse Loading .  Restoration of Acceptable Function .  Resumption of Normal Daily Activities .
  58. 58. Conservative Treatment of TMDs • Reversible •Not just a “Symptomatic “ treatment
  59. 59. The Management Program 1 Emergency Therapy 2 3 Initial Therapy Long-Term Management
  60. 60. • Conservative Treatment of TMDs  Emergency Therapy • Patient Education & Reassurance . • Medication to relieve pain (Analgesics – Anti - inflammatory) • Injecting active trigger points with local anesthetic agents . • Short – term of soft vinyl splint to relieve pressure on joint structures .
  61. 61. • Conservative Treatment of TMDs  Emergency Therapy • Analgesics  NSAIDs  Muscle Relaxants
  62. 62.  Emergency Therapy Articular & Masticatory Muscle Injections - only in severe pain cases …
  63. 63.  Emergency Therapy • Soft Resilient Splint for 2-3 days at maximum …..
  64. 64. • Conservative Treatment of TMDs • after the Emergency Treatment  Initial Therapy : Should Be • Reversible • Palliative • A Mean to Promote Healing
  65. 65. Initial Therapy • Patient Education • Home - care Instructions • Intra - oral Appliance Therapy (occlusal splints) • Physiotherapy • Pharmacotherapy • Behavioral therapy
  66. 66. Initial Therapy - Patient Education Understanding the : • Nature of the Problem • Role of Contributing Factors ( Bruxism ) • Possible Side Effects and Prognosis
  67. 67. Initial Therapy • Home - Care Instructions Aids the healing process and prevents further injury. > Soft diet > Local ice packs / Moist heat > Rest (avoiding extreme jaw movements) > Relaxation and Stress – Reducing Techniques. > Stretching & Relaxing Exercises.
  68. 68. Initial Therapy •Home - Care Instructions  Ice massage (acute pain).  Moist heat (chronic pain). Cara Heating Pad with Select Heat, Moist/Dry
  69. 69. Initial Therapy • Pharmacotherapy  Effective control of Pain and Inflammation .  Most effective when used as an adjunct to other treatment modalities .
  70. 70. Initial Therapy • Pharmacotherapy Drugs frequently used:  Analgesics  NSAIDS  Corticosteroids  Muscle relaxants  Antianxiety agents
  71. 71. • Pharmacotherapy  Skeletal Muscle Relaxants • Centrally or Peripherally acting agents . • Relieve acute musculoskeletal pain by reducing muscle spasm.  Valium : An Antianxiety drug , but very effective in reducing muscle spasm and pain . Diazepam
  72. 72.  Physiotherapy • Objectives : - To relieve pain of musculoskeletal origin . - To improve or restore normal masticatory function . • Adjunctive role
  73. 73.  Physiotherapy •Jaw muscle exercises
  74. 74.  Physiotherapy Home jaw opening stretching: Best after application of moist heat packs to face/jaws/neck
  75. 75.  Physiotherapy  Clicking avoidance opening from a protrusive jaw position to stay on the displaced disc , jaw opening muscle exercises from a protrusive or incisal edge to edge position to avoid the clicking displacement while opening to stretch out the splinting jaw muscles .
  76. 76. Behavioral therapy • Management of noxious habits accompanying the musculoskeletal disorder:  Hypnosis , Acupuncture  Biofeedback  Relaxation exercises
  77. 77. Interocclusal Appliances or Occlusal Splint Therapy ‫المعالجة بالجبيرة اإلطباقية‬ • Joint-stabilization S. • Anterior Repositioning S. • Anterior Bite Plates • Posterior Bite Plates • Soft ( Resilient ) S.
  78. 78. Occlusal Splint Therapy A Non – invasive and Reversible Biomechanical Method of Managing Pain and Dysfunction of the TMJ and its Associated Musculatures .
  79. 79. Purpose of Occlusal Splint Therapy  Stabilize or improve the function of the TMJs .  Improve the function of the Masticatory Muscles & Reduce abnormal muscle activity.  Protect Teeth from attrition and adverse traumatic loading .
  80. 80. Occlusal Splints 2 Main Types Stabilization splint Permissive ‫مثبتة للمفصل ومرخية للعضالت‬ Anterior Repositioning splint Directive ‫معدلة لوضعية الفك السفلي‬
  81. 81. Types of Occlusal Splints Anterior Bite Plane Posterior Bite Plane Full-Coverage” Maxillary” Full-Coverage” Mandibular”
  82. 82. The Joint- Stabilization Splint - Synonyms : - Muscle Relaxation S. - Centric Relation S. -Michigan S. - Bruxism Appliance  The most commonly used appliance , which is a hard acrylic splint that provides a temporary & ideal occlusion .
  83. 83. The joint - stabilization splint • Main purposes :  To stabilize the TMJs by decreasing pressure on joint structures and reducing parafunctional activity such as bruxism .
  84. 84. The Stabilization Splint - Covers the entire dental arch - Occludes with all opposing teeth - The Occlusal surface is flat , with slight indentations for opposing cusp tips
  85. 85.  Placement in the Maxilla or Mandible ? - Most often in the Maxilla for reasons of comfort . - Mandibular placement is recommended for esthetic reasons and in patients with Angle’s Class III malocclusion .
  86. 86.  Joint-Stabilization splints Area to Cover ? - All the teeth as well as areas without teeth if these areas are opposed by teeth in the opposite arch , to achieve optimum stability.
  87. 87. • Stabilization Splint  Retention ? - By having the acrylic pass the prominence line of the teeth by about 1 mm. - In most cases retention by clasps is unnecessary .
  88. 88. The Stabilization Splint Thickness ? - The bite rise in the frontal region should be 3 – 4 mm in most cases , but in patients with severe bruxism it can be made another 1 to 2 mm thicker .
  89. 89. The Stabilization Splint  Occlusal Relationships ? - The teeth in the opposite arch should have point contact against the appliance, and its occlusal surface should be as flat as possible .
  90. 90. Adjustments
  91. 91.  the Stabilization Splint  Occlusal Adjustments ? - It is Very Important to recheck the occlusion at follow-ups since the occlusal relationships may change as a consequence of jaw-muscle relaxation , forcing the mandible in a more backward position .
  92. 92. The Joint- Stabilization Splint  Possible Effects • Decrease loading on the TM joints • Reduce muscle hyperactivity • Distribute the forces created during bruxism • Reposition mandibular condyles
  93. 93. Use of the Stabilization Splint  Primarily at night - Static Pain ( Muscular involvement) : Nocturnal use only . - Dynamic Pain ( Joint involvement) : Full-time use .  Acute Cases : Full-time use initially ,then decreased gradually.  Nocturnal Bruxism : Continued Night-time use
  94. 94. Anterior Repositioning Splint
  95. 95.  Anterior Repositioning Splint •The appliance has a well-defined fossae on the occlusal surface to actively guide the mandible into a more protrusive position to improve the disc-condyle relationship.
  96. 96.  Anterior Repositioning Splint •The Goal is to advance the mandible forward into a “ therapeutic position” to maintain the disc in proper alignment and thus eliminate pain and joint noise.
  97. 97. The Anterior Repositioning Splint The Therapeutic Position •The Therapeutic Position of the mandible : 2-3 mm forward of the IC Position. • Represents the smallest anterior change from the patient’s habitual IC position that will maintain the disc between the condyle and eminence .
  98. 98. The Anterior Repositioning Splint Indication : • Anterior Disc Displacement With Reduction when the disc displacement is thought to be the source of pain. - the disc can be reduced by moving the mandible only 2-3 mm forward of the IC position - the use of stabilization splint has not reduced pain symptoms .  For patients with Retrodiscitis .
  99. 99. Anterior Repositioning Splint Drawbacks : •Creation of a posterior or lateral open bite .
  100. 100. Anterior Bite Plates  A hard acrylic – resin appliance placed in the maxillary arch and has a bite platform that provides contact only with the mandibular anterior teeth .
  101. 101. Anterior Bite Plates • Aim : - To disengage the posterior teeth in order to eliminate their role in masticatory function . • To alleviate Masticatory Muscle Pain .
  102. 102. Posterior Bite Plates • Used to decompress the TM joint and reduce overloading .
  103. 103. •Posterior Bite Plates - Decompression splint • Indicated in cases of Articular pain & symptoms related to an inflammation localized in the TMJ area. • Very effective in Acute ADD Without Reduction .
  104. 104. •Posterior Bite Plates •Drawbacks • Long-term use of this partial coverage splints may encourage the development of posterior open bite .
  105. 105. • Soft Resilient Splints • For temporary relief for patients in acute distress due to injury or severe muscle spasm . • To protect dental and TMJ structures against traumatic injury during contact sports . Aqua Splint
  106. 106. •Soft Resilient Splints - Disadvantages • Difficulty in adjusting and polishing the appliance . • Can be easily perforated . • Ineffective in treating bruxism because the resiliency of the material stimulated the patient to clench on the appliance. Aqua Splint
  107. 107. The Weaning Process - When Symptoms Have Been Significantly Reduced - Patient is Asymptomatic for a Minimum of 3 Months . - Discontinue the splint use in a GRADUAL Manner :  Stop Daytime Use , Then  Stop Nighttime Use .
  108. 108.  TM Disorders  Long - term Management  Reevaluation of patients responding well to conservative measures at the conclusion of initial therapy .
  109. 109.  TM Disorders  Long - term Management • A trial period of weaning the patient from an occlusal appliance is often employed with periodic monitoring . • Determining whether a change in the present occlusal scheme is necessary . • Evaluating the role of Perpetuating Factors .
  110. 110. Conclusions
  111. 111. Conclusions  Current research has reinforced the view that patients with TMD suffer from a musculoskeletal condition and that their problems are heterogeneous in nature & multifactorial in etiology.
  112. 112. Conclusions  Signs & Symptoms of TMDs often fluctuate , may be transient and self-limiting , and can be resolved without serious long-term effects.  Therefore , it is recommended that irreversible treatments be avoided in the early phase of TMD management , such treatment is rarely necessary in TMD patients .
  113. 113. Conclusions  Interocclusal appliance therapy is the most commonly used treatment modality for managing symptoms of TMD.  Many different interocclusal appliances , each with its own unique indications , have been used clinically . Because of its broad range of indication , the most common is the stabilization splint .  Its effectiveness in reducing symptoms of TMD has been estimated at between 70% & 90% when used in conjunction with other conservative treatment methods .
  114. 114. Conclusions  The majority of patients suffering from TMDs respond well to conservative therapy that is based on simple principles.  Numerous follow-up studies of TMD patients covering periods of 6 months to 7 years have shown that between 60% & 90% of the patients have either no symptoms or greatly diminished symptoms following simple treatment . G.E .Carlsson & T. Magnusson
  115. 115. Thank you … Dr.Marwan Mouakeh Aleppo – Public Park

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