Management of temporomandibular disorders

Management of Temporomandibular Disorders
Ravi B

Contents
• Introduction
• History and Description
• Etiology
• Signs and symptoms
• History and examination
• Differential Diagnosis
• Classification and management
• Role of occlusion
• Occlusal appliances
• Conclusion
• References

Introduction
• Temporomandibular disorders embrace a wide
spectrum of specific and non-specific disorders that
produce symptoms of pain and dysfunction of the
muscles of mastication and temporomandibular
joints.
• Temporomandibular Joint Dysfunction is applied
in a more restricted sense to smaller cluster of related,
relatively non-specific disorders of TMJ and muscles
of mastication that have many symptoms in common.

History and Description
• 1934 – James Costen – Costen syndrome,
Temporomandibular Joint disturbances.
• 1959 – Shore – Temporomandibular joint dysfunction
syndrome
• 1961 – Ramford and Ash – Functional
temporomandibular joint disturbances
• 1969 – Laskin – Pain dysfunction syndrome
• 1974 – Greene & Laskin – Myofascial pain dysfunction
syndrome
• Other terms – Myoarthropathy of the temporomandibular
joint, occlusomandibular disturbance, craniomandibular
disorders etc.
• 1990s – Bell – Temporomandibular disorders

Etiology
Proper identification of the correct factors is basic for therapeutic
success.
A review of the scientific literature reveals five major factors
associated with TMD.
These factors are the:
 Occlusal condition,
 Trauma,
 Emotional stress,
 Deep pain input, and
 Parafunctional activities.

Etiology
The etiology of the symptoms of TMJ dysfunction are generally
multifactorial.
They have been described as being:
• Predisposing: increase the risk of temporomandibular
disorders
• Precipitating: causing the onset of temporomandibular
disorders
• Perpetuating: interfere with healing or enhance the progression
of temporomandibular disorder
Shalendra sharma et al: Etiological factors of temporomandibular joint disorders: National Journal of
Maxillofacial Surgery; 2011; 2(2); 116-119

Predisposing
• Various anatomical, physiological and biochemical factors
predispose an individual to TMJ dysfunction.
• Genetic or inherited disorders contribute to the anatomical
factors.
• Neurological, psychological, vascular, nutritional or metabolic
fall under the physiological factors.
• The biochemical mediators of pain, neuromuscular interaction
and enzymes diminishing the activity of pain regulatory
mechanisms are examples of the biochemical factors.

Precipitating
• Stress – psychological factors
• Bruxism
• Oral parafunctional habits
• Trauma
• Occlusal abnormalities
• Occlusal deficiencies
• Interferences
• Vertical dimension
• Incisor relationship

Perpetuating factors
• Include any combination of predisposing and precipitating
factors.
• Psychological and immunological changes may also act as
perpetuating factors.

Signs and symptoms
SIGN: Objective clinical finding revealed during an examination.
SYMPTOM: A description or complaint by the patient.
The commonly occurring symptoms are:
• Pain.
• Joint sounds.
• Limitation of mandibular movements.
• Ear symptoms.
• Recurrent headache
Jeffrey P. Okeson: Management of Temporomandibular disorders and Occlusion; 6th edition.

Pain:
Pain:
• Origin Muscles, TMJ, Dentition
Muscle:
– Pain felt in muscle is called myalgia.
– Two main factors of myogenic pain are:
- Mechanical trauma,
- Muscle fatigue.

Pain:
• Mechanical trauma:
– Macrotrauma arises from an external force such as blow to
the face.
– Microtrauma arises in the absence of external force and is
commonly associated with parafunction such as bruxism.

Pain:
• Muscle fatigue:
• Sustained static muscle contraction can cause localized
ischaemic and an alteration in muscle fibre membrane
permeability that results in local oedema.
• Localized tender areas of muscle which may be associated
with firm bands or knots of muscles are known as trigger
points and is termed myofascial pain.

Pain:
Myogenic pain is a type of deep pain and if it becomes constant
can produce central excitatory effects which may present as
referred pain, secondary hyperalgesia or even autonomic
effects.
• Articular pain(joint pain)
– It can arise as a result of inflammation of articular and
periarticular tissues caused by overloading or trauma to
those tissues.

Pain:
• Dentition:
– These are commonly associated with breakdown created by
heavy occlusal forces to the teeth and their supportive
structures.
• Mobility - Due to loss of bone support
A). Heavy occlusal forces.
– Loss of bone support is primarily due to periodontal
disease.
– When heavy horizontal forces are applied to the bone, the
pressure side of the root shows signs of necrosis and
opposite side shows signs of vascular dilation and
elongation of periodontal ligament.

Pain:
Dentition:
- Heavy occlusal forces.
– This increases the width of periodontal space on both sides
of the tooth which is initially filled with granulation tissue
which changes gradually to collagenous and fibrous
connective tissue. This increased width caused increased
mobility.

Joint Sounds
• There are two types of joint sounds:
• Crepitus
• Clicking
Crepitus
• This is a grating or scraping noise that occurs on jaw
movement which can be noticed by the patient and often
can be palpated by the clinician. It is said by the patient to
feel like sand paper rubbing together. It is caused by
roughened, irregular articular surfaces of the osteoarthritic
joint.
Laskin : Temporomandibular Joint: 1st edition

Joint Sounds
Clicking
• This is caused by uncoordinated movement of condylar
head and TMJ disc.
Causes of TMJ Clicking (Klingberg,1991)
Dysfunction:
• Click associated with deviation in form of condyle, disk and
temporal fossa.
• Click associated with neuromuscular dysfunction.
• Eminence click.
• Click (reciprocal) with anterior disc displacement.
• Click associated with hypermobility.
• Teethered disc click.

Joint Sounds
• Cause:
– Remodeling and morphologic changes of the articular
surfaces and disc perforations may provide mechanical
obstruction to condylar translation.
– Uncoordinated movement may be due to dysfunction of
controlling muscles, the lateral pterygoid or masseter
muscles.

Joint Sounds
Cause:
– Eminence click occurs in association with a forced joint
opening with a protrusive opening arc. This can occur
unconsciously for example with Class II occlusion or as a
delibrate movement.

Joint Sounds
• Cause:
– The anterosuperior part of the mandibular condyle is
normally related to central fossa of the disc. The disc in
some cases however may become displaced. Anterior
displacement of the disc in the joint space causes a click to
occur as the condylar head moves across the posterior ridge
of the disc. This takes place both on opening and closing
movements of the mouth

Joint Sounds
• Cause:
– A double click is thus produced and is referred to as
reciprocal clicking. This condition may progress to closed
clock when head of condyle becomes unable to pass across
posterior ridge. This will result in limitation of opening of
mouth.

Joint Sounds
• Cause:
– Hypermobility click occurs when the head of the condyle
clicks over the anterior ridge of the disc when the mouth is
wide open.

Joint Sounds
• Cause:
– Teethered disc click. A posterior disc attachment that has
been damaged as a result of trauma may prevent the
translation of TMJ disc that should occur on opening the
mouth. Reciprocal clicking may occur as the head of the
condyle passes over the anterior band of the meniscus on
opening and closing the mouth.

Limitation of mandibular movement
Causes of this limitation can be –
• Muscular restriction
• Disk displacement: closed lock
• Ligamentous restriction
• Dislocation

– Muscular restriction:
• The restriction is caused by contraction in a group of
muscles and can be produced by forceful stretching of muscle
or its synergists or as a response to pain, either in the muscle
or its synergists, or around the joint.

– Muscular restriction:
• Difficulties in opening the mouth after complicated tooth
extractions and mandibular nerve blocks might be caused by
reflex muscular inhibition or intramuscular haemorrhage.

– Disc displacement : closed lock:
• An anteriorly displaced disc may prevent the forward
translation of the mandibular condyle which results in
limitation of opening of the mouth, i.e. closed lock.
• Clinical signs are reduced opening capacity, mandibular
deviation on opening and tenderness to palpation of the
affected TMJ.

The early or acute closed lock may result in interincisal
opening of less than 35mm.
Ligamentous Restrictions:

Sometimes ligaments become stretched and thus
hypermobility results with possible sequele i.e. dislocation
of the joint rather than restriction of movement.
the sphenomandibular ligament can sometimes be too
short to permit a normal mouth opening capacity.

Dislocation:
On wide opening of the mouth the head of the condyle
normally passes over the articular eminence, occasionally a
patient may be unable to close the mouth because the condyle
cannot return into the fossa. The mouth will be wide open and
a feeling of panic is observed.

– Ear symptoms:
• Subjective ear symptoms are commonly associated with
TMJ dysfunction. Symptoms include tinnitus, itching in the
ear, a blocked feeling and vertigo. The symptoms are probably
due to functional disturbance of the Eustachian tube. The
masseter hyperfunction may lead to vibration and clones of
tensor tympani muscle which is also innervated by trigeminal
nerve.

– Recurrent headache
• It frequently accompanies pain and tenderness in the
masticatory muscles. Bruxism can produce temporal headache
in the absence of other subjective symptoms but the temporal
muscle is then usually tender to palpation and is often a
symptom of generalized tension related to an associated
anxiety state.

History and examination
– Occlusal sounds during sleep.
– Functional tooth surface wear.
– Periodontal changes.
– Masticatory muscle fatigue /
pain specially on waking.
– Masticatory muscle tenderness.
– Recurrent head aches.
– Fractured fillings or split teeth.
– Soreness of oral mucosa below dentures.
– Tenderness upon percussion of teeth.
– Mucosal ridging of tongue and cheek.

Effect on masticatory muscles:
• Masticatory muscle pain and fatigue.
Effect on teeth:
• An early sign is the presence of shiny facets on the
functional surfaces of teeth or restorations. Further bruxism
leads to greater attrition of enamel, which occasionally flakes
off. Cupping of exposed dentine occurs and in excessive tooth
wear pulpal exposure may take place.

Effect on periodontal tissues:
• Protective reaction by periodontal tissues to compensate
for heavy occlusal forces results in hypertrophy of periodontal
tissues. Thickening of alveolar bone, exostosis formation,
increased trabeculation of alveolar process, a thickened
periodontal membrane consisting of heavy collagenous fibres
and increased periodontal fibre attachment to the cementum
are observed.

– Oral Habits –parafunction
• A common finding in patients with TMJ dysfunction is
that they unconsciously perform purposeless jaw movements
which results in increased physical load on the masticatory
muscles. The habits involved are nailbiting, cheek biting,
pencil biting, chewing gum and occupational conditions like
biting thread in textile factories.

Trauma
– Trauma, such as blow to the jaw may lead to inflammation
and tissue damage perpetuating factors like bruxism may
delay healing.
– Microtrauma may be caused by repetitive strain type
injuries that also might damage the TMJ or muscles of
mastication.

Trauma
– Some patients who have suffered cervical hyperextension /
hyperflexion (whiplash) injury may complain of the onset
symptoms of TMJ dysfunction.
– Symptoms of dysfunction are particularly common after
unilateral subcondylar fracture with significant fracture
displacement.

Occlusal abnormalities:
• Occlusal deficiencies:
– A common finding is that TMJ dysfunction occurs when
there is loss of molar support, which forces the patient to
chew on the anterior teeth rather than to use them purely
for incision which results in consequent risk of overuse and
pain.

Occlusal abnormalities:
• Occlusal deficiencies:
– Unilateral loss of natural teeth will result in unilateral
mastication. This will require increased action by ipsilateral
lateral pterygoid and contralateral masseter muscle.

Interferences:
– Introduction of an occlusal interference e.g. by an
inadequately contoured restoration may lead to TMJ
dysfunction.
– Following extraction of teeth, drifting and tilting of
remaining teeth in the arch can take place.
– Occlusal interferences can be created which cause
deviation of the lower jaw into an eccentric position
leading to tension and pain in the musculature.

Vertical dimension
• Alteration of occlusal vertical dimension may produce
symptoms of TMJ dysfunction.
• Over closure for long periods and sudden increase in vertical
dimension may also be a etiological factor in TMJ
dysfunction.

Incisor relationship:
• Increased overjet / overbite and open bite may also be
initiating factors in production of symptoms of TMJ
dysfunction.
Perpetuating factors
• They may be related to any combination of predisposing
or precipitating factors. Psychoimmunological changes may
also act as perpetuating factor.

Keys in making a differential diagnosis
• History
• Mandibular restriction
• Mandibular interference
• Acute malocclusion
• Loading the joint
• Functional manipulation
• Diagnostic anesthetic blockades

1).Articular
• Developmental
a) Deviation of form.
b) Disc displacement
- With reduction.
- Without reduction.
c)Hypermobility.
d)Dislocation.
e)Inflammatory
- Synovitis.
- Capsulitis.
CLASSIFICATION
[American Academy of Orofacial Pain] – McNeil
Charles Mcneill: Management of Temporomandibular disorders: Concepts and controversies; J Prosthet Dent;
1997; 77(5); 510-522.

1)Articular
Developmental
f)Arthritides
- Osteoarthrosis.
- Osteoarthritis.
- Polyarthritides.
g)Ankylosis
- Fibrous / bony
CLASSIFICATION
1997; 77(5); 510-522.

2)Non-Articular
a) Masticatory muscle disorders.
- Myofascial pain.
- Myositis.
- Spasm.
- Protective splinting.
- Contracture.
- Neoplasia.
CLASSIFICATION
1997; 77(5); 510-522.

• ARTICULAR
• Developmental:
• The embryonic development of TMJ is frequently
disturbed, leading to many kinds of abnormalities. Common
growth disturbances of the bones are agenesis (no growth),
hypoplasia (insufficient growth), hyperplasia (too much
growth) or neoplasia (uncontrolled, destructive growth).
CLASSIFICATION & MANAGEMENT
1997; 77(5); 510-522.

Etiology
• Trauma affecting condylar head
• Genetic determination
• Disease of adjacent structures, such as middle ear.
• - Trauma may be a contributing factor especially in young
joint, can lead to hypoplasia of the condyle resulting in asymmetric
shift or growth pattern. This ultimately causes an asymmetric shift
of the mandible with an associated malocclusion
1997; 77(5); 510-522.

– Trauma can cause hyperplastic reaction resulting in
overgrowth of bone commonly seen at the site of old
fracture.
– Some hypoplastic and hyperplastic activities relate to
inherent growth activities and hormonal body imbalances
(e.g. acromegaly).
1997; 77(5); 510-522.

• History:
• The clinical symptoms reported by patient are directly
related to structural changes present. Since these disorders
usually produce slow changes, pain is not present and patients
commonly alter function to accommodate the changes.
• Clinical characteristics:
– Clinical asymmetry.
– Pain is secondary to structural changes.
1997; 77(5); 510-522.

Definitive treatment:
• It must be tailored specifically to the patients condition.
Generally treatment is provided to restore function while
minimizing any trauma to associated structures.
Supportive therapy:
• Since most bone growth disorders are not associated with
pain or dysfunction, supportive therapy is not indicated. If pain or
dysfunction arises, then treatment is rendered according to the
problem identified.
1997; 77(5); 510-522.

• Deviation of form:
• Etiology: It is caused by actual changes in the shape of
articular surfaces i.e. either condyle, fossa and / or the disc.
Alterations in form of bony surface may be a flattening of the
condyle or fossa or even a bony protuberance on the condyle.
Changes in the form of the disc include both thinning of the
borders and perforations.
1997; 77(5); 510-522.

History:
• It is usually a long term dysfunction that may not present
as a painful condition. Often the patient has learned a pattern
of mandibular movement (altered muscle engrams) that avoids
the deviation in form and therefore avoids painful symptoms.
1997; 77(5); 510-522.

Clinical characteristics:
• Most deviations in form cause dysfunction at a particular point
of movement when a click or deviation in opening is noted, it
will always occur at the same position of opening and closing.
It may / may not be painful.
1997; 77(5); 510-522.

• Definitive treatment:
• The definitive approach is to return the altered structure to
normal form which is often accomplished by a surgical
procedure. In case of bony incompatibility the structures are
smoothened and recorded. If the disc is perforated or
misshaped, it is repaired (discoplasty). Since surgery is a
relatively aggressive procedure it should be considered only
when pain and dysfunction are unmanageable. Most deviations
in form can be managed by supportive therapies.
1997; 77(5); 510-522.

Supportive therapy:
– The patient should be encouraged, when possible, to learn a
manner of opening and chewing that avoids or minimizes the
dysfunction.
– In case of increased interarticular pressure associated with
bruxism/muscle relaxation appliance is indicated to decrease
muscle hyperactivity.
– If pain is associated, analgesics may be necessary to prevent
development of secondary central excretory effects.
1997; 77(5); 510-522.

Disc Displacement:
• Rotational and sideways displacements of the disk are most
typically found with the mouth closed, rotational disc displacement
is characterized by an anterior, and medial or lateral position of the
disc with respect to an ideal position between condyle and the
eminence. The sideways displacement consists of either a medial or
lateral displacement.
1997; 77(5); 510-522.

• Classification
Disk displacement with reduction:
•
–
1997; 77(5); 510-522.

• Classification
Disk displacement with reduction:
• The disk is displaced from its position between the
condyle and the eminence to an anterior and medial or lateral
position, but reduces on full opening, usually resulting in a
noise.
1997; 77(5); 510-522.

• Classification
• Disk displacement without reduction:
1997; 77(5); 510-522.

• Classification
Disk displacement without reduction:
• A condition in which the disk is displaced from normal
position between the condyle and the fossa to an anterior and
medial or lateral position, associated with limited mandibular
opening.
1997; 77(5); 510-522.

– Disk displacement without reduction without
limited opening:
• A condition in which the disk is displaced from its
position between the condyle and the eminence to an anterior
and medial or lateral position, not associated with limited
opening.
1997; 77(5); 510-522.

Classification and management
– Disk displacement with reduction:
Etiology: It results from elongation of the capsular and discal
ligaments coupled with thinning of the articular disc which
commonly results from macro/microtrauma. The other causes
are orthopedic instability plus joint loading.
History:
• When macrotrauma is the etiology the patient will often
relate an event that precipitated the disorder
1997; 77(5); 510-522.

The patient will also report the presence of joint sounds and
catching sensation during mouth opening.
• Clinical examination reveals a relatively normal, range of
movement with restriction only associated with the pain.
Discal movement can be felt by palpation of the joints during
opening and closing. Deviations in the opening pathway are
common.
1997; 77(5); 510-522.

• Definitive approach is to reestablish a normal condyle-
disc relationship. The treatment goal is to reduce intracapsular
pain and not to recapture the disc.
• A muscle relaxation appliance should be used whenever
possible because adverse long term effects are minimal. When
this appliance is not effective, an anterior repositioning
appliance should be fabricated.

• The patient should be initially instructed to wear the
appliance always at night during sleep and during the day
when needed to reduce symptoms.
• This part time use will minimize adverse occlusal changes. As
symptoms resolve the patient is encouraged to decrease the use
of the appliance. These adaptive changes can take 8 to 10
weeks or even longer. After elimination of the appliance if
symptoms return and orthopedic stability is present, dental
therapy to correct this condition is indicated.

• Supportive therapy:
• The patient should be educated to the mechanics of the
disorder and the adaptive process that is essential for
treatment. Softer foods, slower chewing, smaller bites should
be promoted. If inflammation is suspected, NSAID’s should be
prescribed moist heat or ice can be used if the patient finds
either helpful. Passive jaw movements may be helpful and on
occasion destructive manipulation by a physical therapist may
assist in healing.

Disc dislocation without reduction:
Etiology:
• Macrotrauma and microtrauma are the most common cause.
History:
• Patients most often report the exact onset of this disorder. A
sudden change in range of mandibular movement occurs that is very
apparent to the patient. The history may reveal a gradual increase in
intracapsular symptoms (clicking and catching) prior to the
dislocation.

Disc dislocation without reduction:
• Examination reveals limited mandibular opening (25-
30mm) with normal eccentric movement to the ipsilateral side
and restricted eccentric movement to the contralateral side.
1997; 77(5); 510-522.

• Disc dislocation without reduction:
• The initial therapy should include an attempt to reduce or
recapture the disc by manual manipulation. In patients with
longer history, success by manual manipulation decreases
rapidly.
1997; 77(5); 510-522.

Technique for manual manipulation:
• The lateral pterygoid muscle must be relaxed. If it
remains active by pain or dysfunction it should be injected
with local anesthetic prior to any attempt to reduce the disc.
Definitive treatment begins by having the patient attempt to
reduce the dislocation without assistance. The patient is asked
to move the mandible to the contralateral side as far as
possible. From this eccentric position the mouth is opened
maximally.

Technique for manual manipulation:
• If it fails, assistance with manipulating is needed. The
thumb is placed intraorally over the mandibular second molar
on the affected side. The fingers are placed on the inferior
border of the mandible anterior to thumb position.

• Technique for manual manipulation:
•
• Firm but controlled downward force is then exerted on the
molar and at the same time upward force is placed by the
fingers. The opposite hand helps stabilize the cranium above
the joint that is being distracted.

• While the joint is thus being distracted, the condyle is
brought downward and forward which translates it out of the
fossa. It may be helpful also to bring the mandible to the
contralateral side during the distraction procedure since the
disk is likely to be dislocated anteriorly and medially and a
contralateral movement will move the condyle onto it better.
1997; 77(5); 510-522.

• Once the full range of laterotrusive excursion has been
reached, the patients is asked to relax while 20-30 seconds of
constant destructive force is applied to the joint. The patient
then lightly closes to the incisal end to end position on the
anterior teeth and after relaxing for few seconds open wide and
returns to this anterior position.
1997; 77(5); 510-522.

An anterior repositioning appliance is immediately placed
to prevent any clenching on the posterior teeth which would
likely redislocate the disc. If the disc is not successfully
reduced, a second and possibly a third attempt will be needed.
1997; 77(5); 510-522.

Supportive therapy:
• Patients should be encouraged not to open too wide
especially immediately following dislocation. The patient
should also be told to decrease hard biting, no chewing gum,
and generally avoid anything that aggravates the condition. If
pain is present, heat or ice may be used.
• NSAID’s are indicated for pain and inflammation. Joint
distraction and phonophereses around the joint area can be
helpful.

• Surgical considerations for condyle disc derangement
disorders.
• Surgery should be considered only when conservative
therapy fails to resolve adequately the symptoms and or
progression of the disorder.
1997; 77(5); 510-522.

• Imaging of disk displacements can be done by:
– Transcranial radiography.
– Tomography.
– Arthrography.
– Computed tomography.
– Magnetic resonance imaging.
– Arthroscopy.
– Ultrasonography.
1997; 77(5); 510-522.

Hypermobility:
• Hypermobility does not necessarily represent a pathologic
condition. The term hypermobility implies there is
radiographic or clinical evidence that the mid axis of the
mandibular condyle is translating beyond the peak of the
articular eminence.

• Hypermobility:
• It is also preferred to as subluxation. Clinical observations
of affected joints reveal that as the mouth opens to its fullest
extent a momentary pause occurs, followed by a sudden jump
or leap to maximally open position. The jump does not
produce a clicking sound but instead is accompanied by more
of a thud. During maximum opening the lateral poles of the
condyles will jump forward, causing a noticeable preauricular
depression
1997; 77(5); 510-522.

• Hypermobility:
. Subluxation is more likely to occur in a TMJ whose
articular eminence has a short setup posterior shape followed
by a longer flatter anterior slope. During opening the steep
eminence requires a significant amount of discal rotation to
occur before the condyle reaches the crest. As the condyle
reaches the crest, the disc rotates on the condyle to the
posteriorly maximum degree allowed by the anterior capsular
ligament.
1997; 77(5); 510-522.

Hypermobility:
In subluxating joint maximum rotational movement of the
disc is reached before the maximum translation of the condyle.
Therefore as the mouth opens wider the last portion of the
translatory movement occurs with a bodily shift of the condyle
and disc as a unit. This is abnormal and it creates a quick
forward leap and thud of the condyle disc complex.
1997; 77(5); 510-522.

Definitive treatment
– Surgical alteration of the joint.
Eminectomy
• It reduces the steepness of the articular eminence and thus
reduces the amount of posterior rotation of the disc on the
condyle during full translation.

Supportive therapy:
• The patient must learn to restrict opening so as not to
reach the point of translation that initiates the interference. On
occasion, when the interference cannot be voluntarily resolved,
an intraoral device to restrict movement is employed. Wearing
the device develops a myostatic contracture of the elevator
muscles, thus limiting opening to the point of subluxation. The
device is worn for 2 months and removed, allowing the
contracture to limit the opening.
1997; 77(5); 510-522.

DISLOCATION
Spontaneous dislocation:
• This is commonly referred to as an open-lock.
• Etiology:
• When the mouth opens to its fullest extent, the condyle is
translated to its anterior limit.

Etiology:
In this position the disc is rotated to its most posterior extent on
the condyle. If the condyle moves beyond this limit, the disc
can be forced thorough the disc space and trapped in this
anterior position as the disc space collapses as a result of the
condyle moving superiorly against the articular eminence

Etiology:
This same spontaneous dislocation can also occur if the
superior lateral pterygoid contracts during the full limit of
translation pulling the disc through the anterior disc space.
When a spontaneous dislocation occurs the superior retrodiscal
lamina cannot retract the disc space
1997; 77(5); 510-522.

• Etiology:
. Spontaneous reduction is further aggravated when the elevator
muscles contract, since this activity increases the interarticular
pressure and further decreases the disc space.
• The reduction becomes even more unlikely when the superior/
inferior lateral pterygoid experiences myopasms, which pull
the disc and condyle forward.
1997; 77(5); 510-522.

History:
• The patient reports this condition immediately following a
wide opening movement such as a yawn or a dental procedure.
• The patient remains in a wide open mouth condition. Pain
is commonly present secondary to the patients attempts to
close the mouth.
1997; 77(5); 510-522.

• Definitive treatment is directed toward increasing the disc
space, which allows the superior retrodiscal lamina to retract
the disc. When attempts are being made to reduce the
dislocation the patient must open wide as if yawning. This will
activate the mandibular depressors and inhibit the elevators.
1997; 77(5); 510-522.

• At the same time slight posterior pressure applied to the chin
will sometimes reduce a spontaneous dislocation. If this is not
successful, the thumb placed on the mandibular molars and
downward pressure is exerted as the patient yawns. This will
usually provide enough space to recapture normal disc
position.
1997; 77(5); 510-522.

• When spontaneous dislocation becomes chronic or
recurrent, definitive treatment may consist of surgical
procedure directed toward correcting the structures that
contribute to the disorder.
1997; 77(5); 510-522.

Supportive therapy:
• Most effective method is prevention. When spontaneous
dislocation is recurrent the patient is taught the reduction.
Chronic recurrent dislocations is treated by surgical procedure.
1997; 77(5); 510-522.

Inflammatory disorders:
• They are generally characterized by continuous joint area
pain, often accentuated by function. Since the pain is constant,
it can also result in secondary central excilatory effects such as
cyclic muscle pain, hyperalgesia and referred pain.
1997; 77(5); 510-522.

Inflammatory disorders:
• The four categories are:
• Synovitis.
• Capsulitis.
• Retrodiscitis.
• Arthrritides.
1997; 77(5); 510-522.

Synovitis and capsulitis:
• These both can be distinguished only by visualizing
the tissues through arthroscopy or arthrotomy.
•
Etiology:
• Trauma Macro
• Micro
• Infection from adjacent structures.

• History:
• History of macrotrauma such as a blow to the chin.
Trauma is most likely to cause injury to the capsular ligament
when teeth are separated.
• Any movement that tends to elongate the capsular
ligament will accentuate the pain which is reported to be
directly in front of the ear and the lateral aspect of the condyle
is usually tender to palpation.

• Since the etiology is self limiting there is no definitive
treatment indicated when recurrence of trauma is likely, efforts
are made to protect the joint from any further injury.
– The patient is instructed to restrict all mandibular
movements within painless limits-soft diet, slow
movements and small bites are necessary.
1997; 77(5); 510-522.

Supportive therapy:
– Patients with constant pain should receive mild analgesics.
– Moist heat 4-5 times a day for 10-15 minutes.
– Ultrasound therapy – 2-4 times / week.
– Single injection of corticosteriod to the capsular tissues.
Repeated injections are contraindicated.
1997; 77(5); 510-522.

• Retrodiscitis
• It is a inflammatory condition of retrodiscal tissues. It is a
common intracapsular disorder.
• Etiology
• Trauma Extrinsic
• Intrinsic

• Extrinsic trauma:
• Created by a sudden movement of the condyle into the
retrodiscal tissues. These tissues often respond to this type of
trauma with inflammation which leads to swelling and on
occasion trauma to the retrodiscal tissues cause
intercapsularhemarthrosis.
1997; 77(5); 510-522.

Intrinsic trauma: Occurs when an anterior functional
displacement or dislocation of the disc is present.
History
• Patients experiencing retrodiscitis caused by intrinsic trauma
will report a more subtle history with a gradual onset of the
pain problem. They are also likely to report the progressive
onset of the condition (clicking catching).
• Patients experiencing retrodixites caused by extrinsic
trauma will report the incidence in the history.

– Constant periauricular pain that is accentuated with jaw
movement.
– Cleansing the teeth, increases the pain.
– If the tissues swell a loss of posterior occlusal contact can
occur on the ipsilateral side.
1997; 77(5); 510-522.

• Definitive treatment from extrinsic trauma:
• Since etiologic factor of trauma is generally no longer
present there is no definitive treatment. When trauma is likely
to occur, care must be taken to protect the joint.
1997; 77(5); 510-522.

Supportive therapy for retrodiscites from extrinsic trauma:
• If no evidence of acute malocclusion is found, the patient
is given analgesics for pain and instructed to restrict movement
to within painless limits and begin a soft diet. To decrease the
likelihood of ankylosis, movement is encouraged. Ultrasound
and chemotherapy are often helpful in reducing pain.

• Supportive therapy for retrodiscites from extrinsic
trauma:
• If pain persists, a single intracapsular injection of
corticosteroids may be used in isolated cases of trauma, but
repeated injections are contraindicated. A muscle relaxation
appliance should be fabricated to stabilize the occlusal
condition and eliminate further loading of the retrodiscal
tissues
1997; 77(5); 510-522.

Supportive therapy for retrodiscites from extrinsic trauma:
• On occasion when acute malocclusion results from extrinsic
trauma, intermaxillary fixation may be indicated to reestablish
the proper occlusal conditions. If intermaxillary fixation is
used, the mandible should be freed at least twice a day for
atleast 10 minutes of movement.
1997; 77(5); 510-522.

• Definitive treatment for retrodiscites from intrinsic
trauma:
• Definitive treatment is directed towards eliminating
traumatic condition. An anterior repositioning appliance is
used to reposition the condyle off the retrodiscal tissues and
onto the disc.
1997; 77(5); 510-522.

Supportive therapy for retrodiscitis from intrinsic trauma:
• Supportive therapy begins with voluntary restricting use
of the mandible to within painless limits. Analgesics are
prescribed when pain is not resolved with repositioning
appliance. Thermotherapy and ultrasound can be helpful in
controlling symptoms. Since the inflammatory condition is
often chronic intraarticular injection of corticosteroids is
generally not indicated.
1997; 77(5); 510-522.

Arthritis:
• Arthritis means inflammation of the articular surfaces of
the joint. The different types are:
• Osteoarthritis
• Osteoarthrosis
• Polyarthritides
– These are the most common arthrides. They are also
referred to as degenerative joint disease.
1997; 77(5); 510-522.

Etiology
• Overloading of the articular structures of the joint. This
may occur when joint surfaces are compromised by disc
dislocation and retrodiscites.
History:
• Report of unilateral joint pain that is aggravated by
mandibular movement. The pain is usually constant but often
worsens in the late afternoon or evening.
1997; 77(5); 510-522.

– Limited mandibular opening is characterized because of
joint pain.
– A soft end feel is common unless the osteoarthritis is
associated with an anteriorly displaced disc.
– Crepitation can be typically felt.
1997; 77(5); 510-522.

– Clinical characteristics:
– Lateral palpation of the condyle increases the pain as does
manual loading of the joint. The patient may have
symptoms for as long as 6 months before there is enough
demineralization of bone to show up radiographically.
1997; 77(5); 510-522.

– The mechanical loading should be decreased.
– The condyle-disc relationship, anterior repositioning
appliance therapy should be used. When muscle
hyperactivity is suspected, a muscle relaxation appliance is
indicated. Any oral habits that create pain in the joint must
be identified and discouraged.
1997; 77(5); 510-522.

Supportive therapy
• It begins with an explanation of the disease process to the
patient. Along with the fabrication of an appliance in a
comfortable mandibular position. Pain medication and
inflammatory agents are prescribed to decrease the general
inflammatory response. A soft diet is instituted.
Thermotherapy is usually helpful in reducing symptoms.
1997; 77(5); 510-522.

OSTEOARTHROSIS:
Etiology
– Joint overloading.
History
• Since osteoarthrosis represents a stable adaptive phase
symptoms are not reported by the patient.

OSTEOARTHROSIS:
• Ostearthrosis is confirmed when structural changes in the
subarticular bone are seen on radiographs but no clinical
symptoms of pain are reported by the patient.
1997; 77(5); 510-522.

• Since osteoarthrosis represents an adaptive process, no
therapy is indicated for the condition. The only treatment that
may be considered is if bony changes in the condyle have been
significant enough to alter the occlusal condition.
1997; 77(5); 510-522.

Polyarthritides:
• The six categories are:
– Traumatic arthritis.
– Infectious arthritis.
– Rheumatoid arthritis.
– Hyperuricemia.
– Psioratic arthritis.
• Ankylosing spondylitis
1997; 77(5); 510-522.

• Traumatic arthritis
• When the condyle receives sudden macrotrauma a
secondary arthritic condition can develop. This traumatic
arthritic condition can lead to sudden loss of subarticular bone.
• Definitive treatment is not indicated when future trauma
is expected, he should be protected (e.g. a mouth protector for
sports).
1997; 77(5); 510-522.

Supportive therapy:
• It begins with rest, jaw use should be decreased and soft
diet is instituted.
• Non steroidalantiinflamamtory medications are given to
reduce the inflammation. Moist heat is helpful. A muscle
relaxation appliance is indicated if there is increased pain to
occlude the teeth or if bruxism is present. Dental therapy
should not begin until symptoms have been totally resolved.
1997; 77(5); 510-522.

Infectious arthritis:
• The common cause is trauma such as a punctured wound.
A spreading infection from adjacent structures is also possible.
• Initiate appropriate antibiotic medication to eliminate the
invading organism.
1997; 77(5); 510-522.

Supportive therapy
• After the infection has been controlled, supportive therapy
may be considered and should be directed at maintaining or
increasing the normal range of mandibular movement to avoid
postinfection fibrosis or adhesions. Passive exercises and
ultrasound may be helpful.
1997; 77(5); 510-522.

Rheumatoid arthritis
• This condition produces a persistent inflammatory
synovites that leads to the destruction of the articular surface
and subarticular bone.
• There is no definitive treatment
1997; 77(5); 510-522.

Supportive therapy
• It is directed toward pain reduction. Sometimes a muscle
relaxation appliance can decrease forces on the articular
surfaces and thereby decrease pain.
1997; 77(5); 510-522.

Hyperuricemia (gout)
• It is an arthritic condition in which an increase in serum
urate concentrations precipitates urate crystals in certain joints.
• It is directed towards lowering serum urate concentration.
1997; 77(5); 510-522.

• The most effective method may be merely the elimination
of certain foods from the diet. However since this is a systemic
problem, gout is usually best managed on a medical basis by
the patients physician.
1997; 77(5); 510-522.

Supportive therapy
• The patients physician will be treating the patient on a
medical basis.
PSORIATIC ARTHRITIS
• Since etiology is unknown there is no definitive treatment
available.
1997; 77(5); 510-522.

Supportive treatment
• Often NSAID is helpful. Gentle physical therapy to
maintain joint mobility is important since hypermobility is
often a consequence of this disorder. On occasion moist heat
and ultrasound therapy may reduce symptoms and increase
joint mobility.
1997; 77(5); 510-522.

Ankylosing spondylitis
• The clinician should be suspicious of ankylosing
spondylitis when a patient reports with a painful, hypomobile
joint, no history of trauma, and neck or back complaints.
1997; 77(5); 510-522.

• No definitive treatment is available.
Supportive therapy
• Gentle physical therapy to improve joint mobility is
indicated, but care should be taken not to be too aggressive
and increase symptoms. On occasion moist heat and
ultrasound therapy may also be helpful.
1997; 77(5); 510-522.

Ankylosis
• It means abnormal immobility of joint. It may be
• Bony , Fibrous
• A fibrous ankylosis is most common and can occur
between the condyle and the disc and the fossa.
• A bony ankylosis of the TMJ would occur between the
condyle and fossa and therefore the disc would have to have
been lost already from the discal space.
1997; 77(5); 510-522.

Etiology:Common etiology – Haemarthrosis secondary to
macrotrauma. Fibrous ankylosis represents a continued
progression of joint adhesions that gradually create a
significant limitation in joint movement.
History : Patients report limited mouth opening without any
pain. The patient is aware that this condition has been present
for a long time and may not even feel that it poses a significant
problem.
1997; 77(5); 510-522.

Clinical characteristics
• The condyle can still rotate with some degree of
restriction on the inferior surface of the disc. Therefore the
patient is usually able to open approximately 25mm
interincisally, lateral movements are restricted. The clinical
examination discloses a normal range of lateral movement to
the affected side. During mouth opening pathway difficult to
the ipsilateral side. No condylar movement is felt or visualized
on a radiograph.
1997; 77(5); 510-522.

• If function is inadequate or the restriction is intolerable,
surgery is the only definitive treatment available.
Supportive therapy
• Since ankylosis is normally asymptomatic generally no
supportive therapy is indicated. However, if the mandible is
forced beyond its restriction, injury to the tissues can occur.
1997; 77(5); 510-522.

Supportive therapy
If pain and inflammation result, supportive therapy is
called for and consists of voluantarily restricting movement to
either painless limits. Ankylosis along with deep heat therapy
can also be used.
1997; 77(5); 510-522.

MYOFASCIAL PAIN DYSFUNCTION SYMPTOMS
• Myofascial pain dysfunction syndrome (MPDS) is a
stomatognathic system disturbance, which consists of pain,
jaw movement irregularities, and muscle spasm.
• Pain is the most important inducer and therefore must be
managed firstly in order to manage the muscle spasms.
1997; 77(5); 510-522.

• Symptoms may Include
• Headaches (tension)
• Neck, shoulder or back pain
• Pain or soreness in and around the jaw joints
• Dizziness (vertigo)
• Noise in the jaw joint (clicking, popping or grating)
1997; 77(5); 510-522.

• Symptoms may Include
• Limitation of movement of the jaw
• Wear of the teeth (from night time grinding or"bruxism")
• Earaches, stuffy ears, rustling or ringing sounds in the ears
• Numbness or tingling in the fingers and arms
• Difficulty in swallowing
• Various intra-oral (in the mouth) symptoms, including flared
front teeth, brokendental work and fillings, etc.

SUPPORTIVE TREATMENT
Support of M.P.D.S. treatment may include:
Emotional
• Sir William Osier said "it is as important to know the person who
has the disease as to know the disease the person has"
• For many years M.P.D. was assumed to be "psychosomatic"
originating in the mind. Whilst some problems may originate in this
way (i.e. ulcers, high blood pressure) the symptoms are VERY real.
1997; 77(5); 510-522.

• SUPPORTIVE TREATMENT
• Support of M.P.D.S. treatment may include:
• Emotional
• The emotional aspect is another "stressor", so
counselling/stress management may be suggested.
• STRESS = "STRESSOR" + the individual Chronic pain from
M.P.D.S. can also be the cause of emotional stress.
1997; 77(5); 510-522.

Biochemical
• Dr. Hans Selye,the man famous for his studies on "Stress"
suggested a GENERAL ADAPTION SYNDROME, the parts
of which are alarm, resistance, and finally exhaustion, and it is
in the final stage we find symptoms of M.P.D. Better diet and
avoidance of toxic materials may be suggested
1997; 77(5); 510-522.

• Physiotherapy
• Ice, heat, ultrasound, massage and TENS (tens is explained
later) may be of additional help.
• Doctor
• With chronic head pain it's a good idea to visit the Doctor first
to rule out the possibility of another disease such as tumour,
meningitis or high blood pressure.
1997; 77(5); 510-522.

Physiologic Adaptive Range
• The Physiologic Adaptive Range (PAR) is a term coined by
Dr. Gerry Smith to indicate that not only is there a ‘range’
within which we can adapt but also that this range can be
altered by improving general health this range is made “wider”
and the individual benefits accordingly.
1997; 77(5); 510-522.

Diagnosis
• An accurate diagnosis is important
• (a) to rule out other disease
• (b) to obtain OBJECTIVE data
• (c) to confirm the diagnosis (and find the cause)
1997; 77(5); 510-522.

• TENS
• It's a way of relaxing muscles and is used extensively by
physiotherapists and sports medicine specialists. It's an
electrical (torch battery powered) rhythmic massage to pump
oxygen in and waste products out of the muscles "tensed". It is
relaxing and usually comfortable.

• Measuring Muscle Activity
• Muscle activity can be recorded using EMG's
• We can use this (EMG) information to tell if the muscles are
truly relaxed
1997; 77(5); 510-522.

TREATMENT
• 1.Pain Relief. Tensing is one of the most effective ways to
relieve muscle spasm. Other methods include moist heat
packs, muscle massage, anti-spasm sprays, occasionally
medication
1997; 77(5); 510-522.

• 2.Bite Stabilisation. It may have taken years for the situation
to have got to its present state, and it may take a while to get
the muscles completely comfortable. During this phase the bite
can be stabilised using a small oral orthotic.
1997; 77(5); 510-522.

• TREATMENT
• 2.Bite Stabilisation.. A small horseshoe shaped acrylic wafer
fitting over the bottom teeth allowing them to fit the top teeth
so that the muscles are comfortable. It's easy to reversibly
adjust this plastic (not the teeth) to "perfect" the bite. Once
symptoms are relieved and the bite is stabilised, then 'the bite'
can be permanently built to the correct position.
1997; 77(5); 510-522.

• TREATMENT
• 3.LongTerm Correction
• (i) Sometimes the orthotic will only need to be worn at night,
or occasionally the patient can be "weaned" off wear
altogether,
• (ii) Tooth Adjustment - Selectively adjusting and reshaping
the contours of the teeth to correct the bite.This is a fairly
simple procedure which can be used when the bite has minor
discrepancies
1997; 77(5); 510-522.

• TREATMENT
• 3.LongTerm Correction.
• (ii) Using the instrumentation it prevents the problem often
associated with tooth adjustments where the Dentist constantly
"chases the bite".
• 4.Reconstruction
• - Adding height to the natural teeth or their fillings to correct
the bite without the necessity of having "something
removable". This is a quick and "patient friendly" approach.
1997; 77(5); 510-522.

Role of occlusion
• The most common cause of masticatory muscle pain is
displacement of the mandible to a position dictated by
maximum intercuspation of the teeth.
• According to Okeson,
• 35 out of 57 studies conducted between 1979-2000
relating the occlusal factors with Temporomandibular
disorders reported a positive correlation but none proved
of consistent relationship between the duo.
• Occlusal conditions can affect TMDs by introduction of
acute changes and presenting an orthopedic instability.

Role of occlusion
• Clinicians agree on two facts
• Positive correlation between occlusion and TMDs
• Occlusal conditions do not always lead to TMDs

Occlusal appliances :
• The purpose of occlusal aplliance is to provide an indirect method
for altering the occlusion until the correctness of the condylar axis
position can be determined and confirmed.
• Occlusal appliance provide an acceptable surface for reversible
occlusal treatment that can be altered as needed, to conform with
tentative treatment positions for the condylar axis.

• A common fallacy regarding occlusal appliance is that the
relief of symptoms is the result of the increased vertical
dimension.
• The success or failure of occlusal appliance therapy depends
on selection, fabrication & adjustment of the appliance and
patient co-operation.

• Many types of occlusal appliances have
been suggested for treatment of TMDs. Two of the most
frequently used are –
• Stabilization appliance / muscle relaxation appliance
• Anterior positioning appliance / orthopedic repositioning
appliance

Also known as the gnathologic splint, Michigan splint, or
muscle relaxation appliance.
Нis appliance is generally fabricated for the maxillary arch
but, for esthetics and avoid interference with a speech; some
clinicians have recommended that it could be placed for the
mandibular arch.

. Turp et al. concluded that, based on their systematic review,
no diferences in reduction of symptoms whatever the
appliance placed either for maxilla or mandible.

CLASSIFICATION &
MANAGEMENT
Occlusal appliances : Anterior positioning appliance /
orthopedic repositioning appliance
• the intent of this appliance, is to alter the maxillomandibular
relationship so that a more anterior position assumed by the
mandible.
• Acrylic guiding ramp added to the anterior third of the
maxillary appliance that direct the mandible into a more
forward position, upon closing.

Anterior positioning appliance / orthopedic repositioning
appliance
• This type of appliance designed to be used in treating
patients with anterior disk displacement with reduction.
• It was supposed that by altering the mandibular position in
this manner, the anteriorly displaced disks could return back to
its normal position.

classification of occlusal appliances according to Dawson include
1) Permissive splints/ muscle deprogrammer
2) Directive splints/ non-permissive splints
3) Pseudo permissive splints (e.g. soft splints, Hydrostatic splint)

• What Occlusal Splints Can Do
• Occlusal splints can perform one basic function. They can
prevent the existing occlusion from controlling the jaw-to-jaw
relationship at maximum intercuspation.
• Stabilization of weak teeth. An occlusal splint can
effectively stabilize weak or hypermobile teeth by the
adaptation of the splint material around the axial
surfaceces. It can serve, in effect, as a retainer.

• What Occlusal Splints Can Do
• Distribution of occlusal forces. Reduction of stress on
individual teeth can be effected by provision of more
contacts of equal intensity against the corrected occlusal
surface of the splint. This change also affects the
proprioceptive input to the neuromuscular system.
• Reduction of wear. Wear occurs against the splint rather
than against the opposing teeth.

What Occlusal Splints Can Do
• Stabilization of unopposed teeth. Providing occlusal
contacts for unopposed teeth stops them from erupting.
An occlusal splint is often an effective compromise
when a patient is not ready for a more permanent
prosthesis.

What Occlusal Splints Cannot Do
• Occlusal splints cannot cause effects that are in violation of
mechanical laws. Thus an occlusal splints does not unload the
condyles. The popular claim that a posterior occlusal splint
serves as a pivot for distraction of the condyles is in violation
of facts of anatomy, laws of physics and clinical data.

• Some of the claims for occlusal splint therapy that have neither
a verifiable explanation nor an acceptable substantiation are as
follows:
• Occlusal splints increase the wearer’s strength.
• Occlusal splints cause remission of unrelated diseases.

• Occlusal splints can cause a “purging of system positions”.
• Occlusal splints cause a “regulation of multiple bodily
functions”.

• Other types being –
• anterior bite plane
• posterior bite plane
• the pivoting appliance
• soft/ resilient appliance.

Anterior bite plane: Traditional Anterior Bite Plane
• In general, these appliances are designed as a palatal-
coverage horseshoe shape with an occlusal table covering 6 or
8 anterior maxillary teeth.
• Advocates for using such appliances to treat TMDs based on
their ability to prevent clenching, as posterior teeth are not
engaged in functional or in Para-functional activities.
Jeffrey P. Okeson: Management of Temporomandibular disorders and Occlusion; 6th
edition.

Anterior Bite Plane: Mini Anterior Appliances
• It's an oral appliance that engaged only 2-4 maxillary
incisors. Defferent designs of minianterior appliances include
the Nociceptive Trigeminal Inhibition Tension Suppression
System (NTI), the Anterior Midline Point Stop (AMPS)
devices, and the Best Bite.
• All made of hard acrylic resin.
edition.

Anterior Bite Plane: Mini Anterior Appliances
• Нe purpose of this appliance is to disengage the posterior
teeth, thus eliminating the influences of the posterior occlusion
on the masticatory system.
• Нe anterior bite plane thought to be effective in treating
TMDs and headaches
edition.

• Posterior bite plane
• Usually fabricated for mandibular teeth and consists of areas
of hard acrylic located over the posterior teeth and connected
by a cast metal lingual bar.
• To achieve alterations in vertical dimension and mandibular
positioning.
• Indications: in cases of severe loss of vertical dimension or
when there is need to make major changes in anterior
positioning of mandible.
edition.

Pivoting appliance
• Hard acrylic device that covers one arch and usually provides a
singleposterior contact in each quadrant.
• When superior force is applied under the chin, the tendency is to
push the anterior teeth close together and pivot the condyles
downward around the posterior pivoting point.
• Indications: treatment of symptoms related to osteoarthritis of TMJ.

Soft/ resilient appliance
• Device fabricated of resilient material that is usually adapted
to the maxillary teeth.
• Achieve even simultaneous contact with the opposing teeth.
• Indications: parafunctional habits, carriers of bleaching agents,
contact sports.
1997; 77(5); 510-522.

Hydrostatic Appliance
• A bilateral water-filled plastic chamber attached to an
acrylic palatal appliance, and the patient’s posterior teeth
occlude with water filled chambers.
• Нis appliance originally designed by Lerman .
• Latter on a modified design, retained under the upper lip,
was suggested.
1997; 77(5); 510-522.

Hydrostatic Appliance
• The mode of mechanism of this appliance depends on the
concept that the mandible finds its ideal position automatically
as the appliance was not directing where the jaw should be.
• No evidence support this claims till now.
1997; 77(5); 510-522.

Neuromuscular Appliances (NMA)
• Neuromuscular dentistry (NMD) have Advocated that by use of jaw
muscle stimulators with jaw-tracking machines to produce an
occlusal appliance that is at the ideal vertical and horizontal position
of the mandible in relation to the cranium.
• the data regarding this concept are scars in the literature.
• Proponents of this methodology recommended dental reconstruction
at the new jaw relationship aіer using these appliances.
1997; 77(5); 510-522.

Applience Material used Indication
muscle relaxation
appliance
Hard acrylic resins joint stabilization,
bruxism.”
Anterior
positioning
appliance
Hard acrylic resins anterior disk
displacement with
reduction.
Traditional
Anterior Bite Plane
Hard acrylic resins bruxism.
Mini Anterior
Appliances
Hard acrylic resins TMDs and
headaches
Posterior bite plane Hard acrylic resins severe loss of
vertical dimension
Pivoting appliance Hard acrylic resins osteoarthritis
Soft/ resilient
appliance
resilient material parafunctional
habits

Applience Material used Indication
Hydrostatic
Appliance
Hard acrylic resins Occlusal changes
Neuromuscular
Appliances
Hard acrylic resins Occlusal changes

CONCLUSION
• The efforts of the prosthodontist to record the movements of
the TMJ and to reproduce them on the articulator have been
the chief stimulus for studies on the functional structure of this
joint.
• Precision is the key to prosthodontics and it is thus imperative
that restoration are made as accurately as possible. This is best
achieved by the use of hinge axis concept and thus it should be
incorporated into routine clinical practice to achieve optimum
results.

CONCLUSION
• In order to understand fully the nature of this joint, one must begin
with its evolutionary history, for its popular evolution explained its
astonishing embryological development, from which comes its
unique gross and histological structure, all of this reaching final
clinical significance in the various functional and morphologic
disorders seen in this joint.

REFERENCES
• Jeffrey P. Okeson: Management of Temporomandibular
disorders and Occlusion; 6th edition.
• Sateeshsimha Reddy et al: Diagnosis and Treatment Modalities
for Temporomandibular Disorders (Part I): History,
Classification, Anatomy and Patient Evaluation; International
Journal of Prosthodontics and Restorative Dentistry; 2011;
1(3); 186-191.
• Shalendrasharma et al: Etiological factors of
temporomandibular joint disorders: National Journal of
Maxillofacial Surgery; 2011; 2(2); 116-119.
• Laskin :Temporomandibular Joint: 1st edition.

REFERENCES
• Zubietta et al: COMT val 158met genotype affects mu-
opioid neurotransmitter responses to a pain stressor. Science
2003;299:1240-3.
• Cordeiro et al: Profile of patients with temporomandibular
joint disorder: main complaint, signs, symptoms, gender
and age: Rev Gaucha Odontol., Porto Alegre, 2012; 60(2);
143-148.
• Charles Mcneill: Management of Temporomandibular
disorders: Concepts and controversies; J Prosthet Dent;
1997; 77(5); 510-522.
• American Academy of Orofacial Pain guidelines (Internet)
•

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