This case appears to involve myofascial pain originating from a whiplash injury rather than a TMJ disorder. Conservative treatments like physical therapy, massage, injections and occlusal splint may help relieve symptoms.

1. CONSERVATIVE TREATMENT OF
TMJ DISORDERS
Dr. Bahjat Abu Hamdan Consultant Prosthodontist.
DDS,CES, DSO Paris- France.

2. Introduction
 Diagnosing and treatingTMJ disorders can be
difficult and confusing task.
 Proper diagnosis is the key to successful
treatment.
 A comprehensive knowledge of.
 1.Anatomy and physiology of the masticatory
system.
 2.Aetiology ofTMJ disorders (intracapsular
and extracapsular)

3. Introduction
 3.Diagnosis ofTMDS.
 4. Management ofTMDs.
 A. Conservative therapy (Reversible ).
 B Non conservative therapy (Irreversible).
 So that these elements are important to be well
known by the practitioner before starting up the
diagnosis andTx ofTMJ Disorders.
In this lecture we will expose mainly the
conservative therapy and briefly the other
aspects in relation.

4. American Dental Association, 1983 definedTMD as a
group of orofacial disorders characterized by:
 Pain in the preauricular area,TMJ, and muscles of
mastication
 Limitations/deviations in mandibular range of
motion
 TMJ sounds during jaw function
 The spectrum ofTMJ disorders could range from
congenital developmental problems to the
commonly degenerative joint disease.
1990YCraniomandibular Disorders(CMD)

5. TMD Epidemiology.
 The prevalence of signs and symptoms associated with
TMD can be best associatedby examining
epidemiologic studies.
 Dorland,s illustrated medical dictionary
describes epidemiology as.( the study of
the factors determining and influencing
the frequency and distribution of disease,
injury, and other health-related events and
their causes in a defined human population
for the purpose of establishing programs
to prevent and control their development
and spread )

6. TMD: Epidemiology
Defining and explaining the interrelationships of
factors that determine disease frequency and distribution
 Most prevalent between 20-40 years.
 50% to 60% of the general population have a sign of
some functional disturbances of the masticatory
system
-65-85% in USA experience one or more symptoms of
TMD
-12% experience prolonged pain or disability
-Only 5-7% have symptoms severe enough to require
treatment. Most cases are self-limiting

7. epidemiology
 Scandanavian study: Most problems are with
joint noises and jaw deflection.
 Non-patient populations greater than 18 years
old
 40-75%: one clinical sign is evident
 50% of the population will exhibit sounds and/or deviation
(much more so than in patients under 18 years of age
 Less than 5% have limited opening
 33% of the population has one symptom
 Approximately 10% of those greater than 18 years of age will
exhibit pain
Defining and explaining the interrelationships of factors that
determine disease frequency and distribution

8. Figure 5 : Presenting sign and symptom of TMJ

9. Figure 6 : Presenting sign and symptom of
the muscles of mastication

10. Figure 7 : Presenting sign and symptom
of mouth opening

11. 33
76
10
38
4 5
0
10
20
30
40
50
60
70
80
One Two Three +
Symptoms
Signs
PercentageIncidence
Number of Signs & Symptoms
TMD Signs & Symptoms
These are the ones who really
need treatment

12. Age and Sex Distribution
This data is from a Seattle based , patients from 8 years old to 80 years old.
The bars are on the
inside. Most seek treatment between 25-40 years old.
Childbearing age in females age is
progressive over time….it gets better over time,NOTthe most likely time. It is
after 35.
1 2
S 1
S 2
S 3
S 4
S 5
S 6
S 7
S 8
S 9
S 1 0
S 1 1
S 1 2
S 1 3
S 1 4
S 1 5
S 1 6
S 1 7
S 1 8
0
1 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
Paitents
S e x
A g e
Only irreversible treatments will cause things to progress.

13. Age distribution of subjects with TMD

14. Figure 1: Prevalence of TMD according
to gender

15. General Population
33%
41%
26%
Intra-articular
Extra-articular
No sign or symptom
Only 7% of the general population patients need treatment.
There may be many signs and symptoms, but few need to be treated.

16. Pain Clinic Populations
Internal
Derangement
31%
Arthritis
39%
Myofascial
30%
These are relatively equal distributions, overall. This does not take into
account the dominant treatments done by a general practitioner.
It really depends on who is running the clinics and their clinical reputations.

17. Adaptation
Normal
Adaptation
Pathology
Flattening of the condyle is exhibited. There is no joint space. No asymmetries are seen, no pain
, no visible problems, there is no limitation of movement and no deflections of the mandible.
This is a good example of adaptation. All of us are in some state of adaptation.
This is why we don’t see a progression in this disease.
Patients should undego treatment first, then have their TM condition evaluated. Dr. Rigg

18. Adaptation
Normal
Injury/Pathology
Adaptation
+ -
Disability
Death
Impairment
(articular disc is out of place, but the
patient is still able to function)

19. Signs & Symptoms
10 20 30 40 50 60 70
Pain
Dysfunction
Decrease ROM
Noise
TMD appears to be
progressive-non
Joint noise will increase with time, but it can be managed. This is looking at a cross
section of the population. This follows the biopsychosocial syndrome.

20. Reciprocal click

21. Disc dislocation w/o
reduction

22. Etiology of TMD
 Trauma
 Excessive stress
 Arthritis of theTMJ
 Whiplash injury
 Postural abnormality
 Ligamentous laxity
 Psychosocial distress (stresses)

23. Etiology
 Bruxism
 (teeth grinding)
 Unaligned teeth
 Congenital
 Jaw abnormalities
 Prolonged mouth breathing
 Thumb sucking

24. RiskfactorsassociatedwithTMD

25. Etiology of TMD

26. Assessment
 History & Examination.
 The effectiveness and success of treatment lie in
the ability of the clinician to establish the proper
diagnosis.
 One must be suspicious of the pt who reports the
location of the pain to beTMJ or masticatory
muscles, yet those whose history and Exam.
Reveals no alteration in range of jaw movement
or increase in pain during function. So that its
useless to direct the treatment of the MS, the
examiner must find the true source of pain.

27. History
1. Pain
2. Joint Sounds
3. Restriction of Opening
4. Swelling
 Over the maxilla
 In the area of parotid gland

28. CLINICAL EXAMINATION
1. The symmetry of the mandible and the face
2. TMJ & muscles tenderness
3. Lateral deviation on opening and closing
4. Inter-incisal opening (normal=35-45mm)
5. Joint sounds
6. Dentition

29. Muscular tenderness

30. Lateral deviation

31. Normal=35-45mm
Inter-incisal opening

32. Joint sounds

33. Dentition

34. In an ideal occlusion, protrusive movement is
guided by anterior teeth.
Early lateral movements are ideally canine-guided.

36. 1. Tempromandibular Pain Dysfunction
Syndrome (TMPDS) / Deviation in Form
2. Internal Derangement / Articular disorders
1. Disc displacement with reduction
2. Disc displacement without reduction
3. Pathological Disorders
TMJ Disorders Classification
TMD

37.  Extra-articular (all muscle)
 Intra-articular (within the joint)
 Synovitis
 DDWR (disc displacement with reduction)
 DDWOR (disc displacement without reduction)
 Osteoarthrosis
 Rheumatoid arthritis
 Condylar subluxation
Arthrosis: non-painful osseous remodelling of tissues
Temporomandibular Disorders

38. one of two or moreThe determination of
a patient is suffering from byconditions
systematically comparing and contrasting
their historical and clinical findings.
History gathering is the most important thing to do.
Differential Diagnosis

39.  Intracranial Pain Disorders
 Primary Headache Disorders
 Neurogenic Pain Disorders
 Intraoral Pain Disorders
 Temporomandibular Disorders (our focus in this
presentation)
 Associated Structures
 Axis II, Mental Disorders
Sources of Orofacial Pain

40. Initial (conservative) Further (specialist)
Management
 Reassurance.
 Education .
 Habit management.
 Rest.
 NSAID, analgesic and
muscle relaxants.
 Removable occlusal splints.
 Physio –therapy/ jaw
exercises
 Psychologycal
intervention.
 Antidepressant.
 Occlusal adjustment.
 Intra-articular injection.
 Manipulation under GA.
 Arthroscopy.
 Surgery.

41. Indication for surgical
treatment
 About 10% of the chronicTMD cases are
indicated for surgical treatment.
 Degenerative joint disease.
 Condyle fracture.
 Joint intra capsular pathology
(osteochondroma, chondromatosis ).
 Tumor involvement of condylar head.

42. Treatment should begin with conservative,
reversible therapies and progress to non-
reversible therapies, if needed.
Treatment of TMD

43.  TMD can be difficult to treat because of its
multifactorial origin.
 Primary goal is to allow the muscles to relax and
restore a normal range of motion; pain usually
decreases when this happens.
 Before any treatment therapies are initiated, the
patient should be educated and counseled on
the nature and causes ofTMD. Educating the
patient may relieve the stress enough to alleviate
symptoms.
Treatment of TMD

44. 1) NSAIDS - are non-steroidal anti -
inflammatory drugs like ibuprofen.
2) Muscle relaxants.
 3) Narcotics - should be prescribed in
regular doses over a short period of time.
 4) Tricyclic antidepressants - may be used
to reduce bruxism.
 5) Corticosteroids - may be injected into
the joint for arthritis.
TMD Treatments: Medications

45.  Reversible procedures should be tried before
irreversible procedures.
 Goal is to reduce muscle activity and
parafunctional habits by correcting occlusal
scheme.
 Occlusal splint provides orthopedic stability.
 Correcting occlusal interferences with selective
grinding or construction of new restorations are
irreversible procedures.
Occlusal Therapy

46. Occlusal thrapy
 Occlusal appliance is useful in reducing symptoms, literature
revealed that its effectiveness is between 70 to 90%.
 Because the splint provide more orthopedic stable joint position,
optimum occlusal position that reorganizes the neuromuscular
activity to the normal limits
 Protect the teeth and supportive structures from abnormal
forces.
 The success or failure of occlusal appliance depend on the
selection, fabrication and adjustment, as well as patient
cooperation.
 If the occlusal appliance does not affect the symptoms, the
malocclusion is probably not a cause and certainly the need for
irreversible occlusal therapy should be questioned.

47.  Increase patient awareness of muscular activity
and incidence of parafunctional habits.
 Psychotherapy - referral may be indicated to
help patient deal with stress.
 Relaxation therapy – exercise and yoga.
 Hypnosis for relaxation.
Stress Therapy

48.  Other physical therapy
techniques:
1) Thermal or coolant therapy
2) Ultrasound
 3) Electrical stimulation of
muscles
 4) Acupuncture
 5) Massage
Patients may improve range of opening through
exercises designed to stretch the muscles.
Physical Therapy6

49.  Hard acrylic
 Technically demanding
 Maxillary splint is easier to adjust
 Worn at night
 Long-term use
 must provide ideal occlusion
at rest & function (CR =CO)
Stabilization splint

50. stabilization appliance
 Soft or resilience appliance , treatment gaol is to
achieve an even simultaneous contact with the
opposing teeth.
 Its well supported use is as protective device for
athletes .
 Soft appliances have not been shown to decrease
bruxing activity. Scientific evidence support the use
of hard appliances for reduction of symptoms
related to clenching and bruxing activity.
 Soft appliances have been advocated for Pts who
suffer from repeated or chronic sinusitis resulting in
extremely sensitive posterior teeth.

51.  Clear the occlusion to allow the condyles to be fully seated
superiorly/anteriorly
 Elimination of discrepancies between seated joints and seated
occlusion (CR = CO)
 A large surface area of shared biting force
 Reduce joint loading by decreasing muscle activity also by
consequence myogenous pain decreases.
 Idealized functional occlusion
 SS decrease parafunctional activity that accompanies periods of
stress, local muscle soreness or chronic centrally mediated myalgia
also its helpful in cases of retrodiscitis due to trauma.
Stabilization splint
How it works!

52.  Maxillary or mandibular
 Hard acrylic, full coverage
 Occlusal record with mandible protruded
 Indicated for disc displacement with reduction
 Ideally used 24hrs/day for 12 weeks
 Avoid in adolescents
Anterior positioning splint

53. Occlusal appliance

No more pain
Occlusion is
the cause
Pain continues
look for
another cause
Irreversible
Occlusal
Treatment

56.  It positions the condyle anteriorly away from the fully seated joint
position
 Used in case of trauma inducing retrodiscal edema Guide the
mandibular condyles away from retrodiscal tissues.
 Used in case of anterior disc displacement Help aligning the
disc over the condyle (back to normal position) hoping that it will
keep this relation with time.
 Posterior pivoting appliance is advocated for the treatment of
symptoms related to osteoarthritis of theTMJs, its the only
appliance that can routinely distract a condyle from the fossa by
a unilateral pivot . Its use should be limited to one week.
Otherwise the second molar will be intuded.
Anterior positioning splint
When & How it Works!

57. Case 1.
 A 21 yrs old female came to the dental office with leftTMJ pain and
sounds associated with muscle pain.
 The symptoms started 10 month ago, no specific event relating to the
onset of the symptoms, yawning increase the pain for several hours.
 Examination revealed reciprocal clicking on the leftTMJ with pain to
palpation specially during opening that accentuate the sounds muscle
tenderness L,R mass. and temp. LL pterygoid was painfull to function
manipulation.
 Diagnosis, pt was diagnosed with DD with reduction.
 Tx.An APA was fabricated that positioned the mandible forward enough
to eliminate the reciprocal clicking. Pt instructed to wear the appliance
day and night for 7 days. Limit the movements to painful limits, mild
analgseic prescribed for 10 days. In 1 w pain and popping subsided, 9 w
later pain subsided completely but not the clicking , pt is asked to carry
the appliance at night for 8-12 w at night . pt. told that joint sound
would likely be permanent but pain may not return.

58. Case 2
 50 yrs old female. C/cTMJ pain, headache and neck pain.
 Pt has a history of car accident which still hanged in her
mind.
 She started suffering of neck pain at the right u/ region
underneath her skull , with pain radiation to jaw ,face and
eyes.
 She soughtTx from massage chiropractor and dentist but
she has been suffering for about 5 years.
 Chiropractic exam. Reveals upper neck injury radiating to
jaw face and neck.Treatment done, 2 month later pain is
over.
 The injury stemmed to the car accident 5 yrs ago.

59. Case 3
 20 yrs old female pt.
 She arrived complaining ofTMJ pain in the left side with
clicking when she opens widly.
 Exam/ pt has mandibular prognathy with anterior cross
bite, left TMJ is painful to palpation which increase while
opening.
 OPG revealed deep glenoid fossa which indicates dominant
open close movement with limited gliding, guiding the
mandible CR position and during closing revealed
premature contact between 21,31 shifting the mandible
into anterior cross bite.
 Case referred to orthodontic clinic for cross bite and
anterior shift correction as main cause in displacing theTMJ
anterior to its stable position.

60. Case 4
 20 yrs old female pt arrived complaining of pain in the left
TMJ area 5 month ago.
 Examination :Pt has pain in the left side more sensitive to
palpation in front of the left ear, also temporal and
masseter muscle were painful to palpation on the same
side, looking at the OPG revealed supraerupted 18, 28 with
missing opposed third molars.
 After muscle relaxation, the mandible is guided into CR
position and during closing a severe premature contact in
both sides is found between the mesial of 18 and the distal
of 47, the mesial of28 and the distal of 37 causing capsular
ligament extention resulting in that severe pain.
 Adjustment is done, 1 week later pt feels signifigant
improvement.

61. Case 5
 A 48 yrs old male pt reported to dental office complaining
of R /TMJ sounds.The popping had been present for 15 yrs
ago and had never caused any pain or discomfort.
 Exam/ revealed a single click at 31 mm of opening the click
can not be eliminated by 2 tongue depressor placed
bilaterally between the post. Clinical muscle exam was
negative, his teeth were in good repair.
 The pt was diagnosed with chronic adapted disc
displacement with reduction.
 Tx.The history and exam revealed that this disc
displacement was chronic and asymptomatic.There was no
evidence that it was a progressive disorder. In fact, more
evidence suggested that the joint tissue had physiologically
adapted to the condition.Therefore no definitive treatment
instituted.

62. Thanks For your
Attention.