7. Temporomandibular disorders (TMD) are recognized
as the most common non tooth-related chronic oro
facial pain conditions that confront dentists and other
healthcare providers.
7
8. Because of the complex and unique nature of each TMD
case, diagnosis requires a multi disciplinary , patient-
specific and customized approach to address the specific
characteristics of each patient’s disease.
8
12. Temporomandibular disorder is not a single
disease but a collection of structural and/or
functional disorders resulting clinically in
comparable and analogue complaints, but the
fact that the symptoms are almost identical
indeed does not justify the diagnosis of one
single disease for all patients.
We are here to discuss about the occlusal factors
related to Temporo mandibular disorders
12
13. 13
THEORIES (OCCLUSION AND TM DISORDERS)
•Lack molar support caused a direct
eccentric position of condyle in fossa
pain, dysfunction and ear symptoms
MECHANICAL
DISPLACEMENT
THEORY
•Occlusal interferences able to
provoke muscle spasm and muscle
hyperactivity.
NEUROMUSCULAR
THEORY
•muscle is a etiologic factor and tension in
muscles is increased due to
overstimulation leading to muscle spasm.
Denied any influence of occlusion.
MUSCLE
THEORY
•Primary factor was spasm of masticatory
muscles, caused by overextension, over-
contraction or muscle fatigue due to
parafunctions
PSYCHO-
PHYSIOLOGICAL
THEORY
•Emotional disturbances, initiating centrally
induced muscular hyperactivity, led to
parafunction and indirectly to occlusal
abnormalities.
PSYCHOLOGICAL
THEORY
18. 18
CLASSIFICATION OF TEMPOROMANDIBULAR DISORDERS
I. Masticatory Muscle Disorders
1. Protective Co-Contraction
2. Local Muscle Soreness
3. Myofascial Pain
4. Myospasm
5. Chronic Centrally Mediated
Myalgia
II. Temporomandibular Joint Disorders
3. Inflammatory Disorders Of The TMJ
a) Synovitis/Capsulitis
b) Retrodiscitis
c) Arthritides
1. Derangement Of The Condyle-Disc
Complex
a) Disc displacements
b) Disc Dislocations Without Reduction.
c) Disc Dislocations With Reduction.
2. Structural Incompatibility Of The Articular
Surfaces
a) Deviation In Form
b) Adhesions
c) Subluxation (Hypermobility)
d) Spontaneous Dislocation
III. Chronic Mandibular Hypomobility
1. Ankylosis
2. Muscle Contracture
3. Coronoid Impedance
IV. Growth Disorders
1. Congenital And Developmental
Bone Disorders
2. Congenital And Developmental
Muscle Disorders
20. PROTECTIVE CO-CONTRACTION
It is a C.N.S response to injury
Protective muscle splinting
Not a pathologic condition
CAUSES:
Altered sensory or proprioceptive input
Constant deep pain input
Increased emotional stress 20
21. CLINICAL CHARACTERSTICS:
Structural dysfunction
No pain at rest
Increased pain with function
Feeling of muscle weakness
TREATMENT:
Removal of the causative factor
21
22. LOCAL MUSCLE SORENESS
Non inflammatory myogenous pain disorder.
First response of muscle to continued co-
contraction.
CAUSES:
Protective co-contraction
Trauma
Stress
22
23. CLINICAL FEATURES:
Minimum pain at rest, increases with function
Muscle weakness
Muscle tender when palpated
TREATMENT:
DEFINITIVE TREATMENT:
Source of deep pain should be eliminated
Restricted mandibular movement
Occlusal appliance at night for bruxism
SUPPORTIVE THERAPY:
NSAIDs, manual physical therapy and gentle massage 23
24. Involuntary CNS induced tonic muscle contraction often
associated with local metabolic condition within muscle
tissue.
CAUSE:
Continued deep pain input.
Local metabolic factors
Idiopathic
MYOSPASM
24
25. CLINICAL FEATURES:
Restricted movement
Acute malocclusion
Pain at rest which increases with function
Affected muscle is painful to palpation
DEFINITIVE TREATMENT:
Reduction of pain with manual massage or coolent spray
SUPPORTIVE THERAPY:
Physical therapy
25
26. MYOFASCIAL PAIN
First described by TRAVELL & RINZLER in 1952.
In 1969 LASKIN described Myofascial Pain Dysfunction Syndrome.
ETIOLOGY :
Protracted local muscle soreness
Increased emotional stress
Sleep disturbances
Local factors (posture, habits)
Idiopathic
26
27. CHARACTERSTICS:
Structural dysfunction
Pain at rest
Increased pain with function
Presence of trigger point
SIGNS AND SYMPTOMS:
Unilateral dull pain in ear –worse on awakening
Muscle tender on palpation
Degenerative changes in TMJ if chronic
27
28. TREATMENT:
EDUCATION :- Explanation of diagnosis and treatment
and reassurance about good prognosis
SELF CARE :- Eliminate oral habits
PHYSICAL THERAPY :- Heat and cold therapy, exercises
INTRAORAL APPLIANCE :- Avoid long term use
PHARMACOTHERAPY :- NSAID’s, muscle relaxants
RELAXATION TECHNIQUES :- Relaxation therapy, hypnosis
TRIGGER POINT THERAPY :- Spray and stretch therapy - 3 to 5
weekly sessions
28
30. 30
INTERNAL DERANGEMENT OF CONDYLE –
DISC COMPLEX
Three types :
• Disc displacement
• Disc dislocation with reduction
• Disc dislocation without reduction
Etiology :
Elongation of discal collateral ligaments
and the inferior retrodiscal lamina
Thinning of posterior border of the disc
Trauma
31. 31
Disc Displacement:
Inferior retrodiscal lamina
and discal ligaments becomes
elongated.
Due to anterior pull of lateral pterygoid and
thinning of posterior border of disc – disc
displaced anteriorly.
32. 32
Disc Displacement:
During opening translatory
shift of condyle over disc -
click
Normal range of jaw movement.
Restriction of movement associated with pain.
33. If ligaments are further elongated- disc slip completely through discal
space.
Disc and condyle no longer
articulate- dislocation
If patient manipulate jaw
and reposition disc- reducible disc
Clinical Features:
Limited range of motion – before reduction
Normal range – after reduction
Deviation during opening
Reducible Disc Dislocation :
33
34. Disc is dislocated and does not return to normal
position with condylar movement
Clinical features:
Limited mandibular opening (25-30mm)
Normal eccentric movement to ipsilateral side
Restricted eccentric movement to the contralateral side
NON REDUCIBLE DISK DISLOCATION
34
35. Definitive treatment:
Anterior positioning appliance-contraindicated
When acute- attempt to recapture the disc by manual
manipulation
Surgical correction – disk repositioning and discoplasty
Supportive therapy:
Patient Education:
Instructed not to open wide
Decrease hard biting.
NSAID’S- for pain and inflammation
35
36. a) ADHERENCES AND ADHESIONS:
• Temporary sticking.
• Adhesions - more permanent, fibrotic attachment
• In superior joint cavity - restrict movement of rotation
• In inferior joint cavity - jerky movement during opening
TREATMENT-
ARTHROCENTOSIS
STRUCTURAL INCOMPATIBILITIES
OF THE ARTICULAR SURFACES
36
37. b) DEVIATION IN FORM:
Altered pathway of condylar movement
Click or deviation occurs at the same
position of opening and closing
May or may not be painful
TREATMENT:
Surgical procedure
If disc perforated- discoplasty
Patient encouraged to learn a manner of opening and
chewing that minimizes dysfunction
37
38. c) SUBLUXATION :
• Also known as hypermobility
• Condyle moves anteriorly to the
crest of articular eminence
• Not pathologic
TREATMENT :
• Patient education-restrict mouth opening
• Surgical treatment- eminectomy
38
39. d) SPONTANEOUS DISLOCATION:
• Also known as open lock
• occurs -wide mouth opening
• Patient remains in wide open
mouth condition
• Pain while attempting to close
the mouth
TREATMENT:
• Patient is taught the reduction technique if it is recurrent.
• Chronic dislocation:- surgical procedure
39
41. SYNOVITIS AND CAPSULITIS:
• Inflammation of synovial tissue or capsular ligament
• Cause- Macro trauma / Micro trauma
• Pain in front of ear, lateral aspect of the condyle
• Differentiated only by Arthroscopy
• Capsular ligament palpable over lateral pole
• Limited mandibular opening
INFLAMMATORY JOINT DISORDERS
41
42. RETRODISCITIS:
• cause - macro trauma
• Constant pain accentuated by movement
• Limited opening
• Swelling of retrodiscal tissue-condyle moves forward and
downward, causes malocclusion
ARTHRITIS:
• Inflammation of articular surface
• Osteoarthritis: Destructive process, bony articular
surfaces of condyle and fossa becomes altered
42
43. • Joint pain, increases with function
• Crepitation
• Dislocation and ankylosis may be present
• Signs of displacement and perforations
ETIOLOGY:
• Overloading producing degenerative changes in joint.
• Bruxism
• Absence of posterior occlusal contact
43
44. RHEUMATOID ARTHRITIS:
• Cause- unknown
• Inflammation of synovial membrane, extends into
surrounding connective tissue and articular surfaces,
becomes thick and tender
• Always bilateral.
• Malocclusion with heavy posterior contacts and
anterior open bite.
MANAGEMENT OF INFLAMMATORY DISORDERS –
DISCUSSED AT THE END
44
47. CLINICAL FEATURES:
Facial asymmetry
Bird face deformity – bilateral
Deviation on affected side- if unilateral
Roundness and fullness of face on affected side
Cross bite may be present
47
48. TREATMENT PLANNING:
First aim:
Restoration of function as mandible grows in response to
functional stimulation
Child without mandibular retardation- restoration of function
Child with mandibular retardation- restoration of function +
costochondral graft
Adult with mandibular retardation- restoration+reconstruction
48
50. Goals – establishing the accurate primary diagnosis ; find
contributing factors and relate symptom patterns.
The primary diagnosis is the diagnosis for the disorder most
responsible for a patient’s chief complaint.
Contributing factors are elements that perpetuate the
disorder e.g. nighttime parafunctional habits
INITIAL EVALUATION
50
51. 1. Do you have difficulty and/ or pain opening your mouth?
2. Does your jaws ever get stuck, lock or go out ?
3. Do you have difficulty and/ or pain while chewing talking or using your jaws?
4. Are you aware of the noises in the jaw joints ?
5. Do your jaws regularly feel stiff, tight or tired ?
6. Do you have pain in or about the ear, temple or cheeks ?
7. Have you had a recent injury to your head, neck or jaw?
8. Have you been aware of any recent changes in your bite?
9. Have you previously been treated for any unexplained facial pain or a jaw joint problem?
10. Do you have frequent headache or neck ache or toothaches?
QUESTIONNAIRE
51
53. INSPECTION
1. Tooth mobility: can be due to loss of bony support and
unusually heavy occlusal forces.
2. Tooth wear : most common sign of breakdown in the dentition.
Majority is due to direct result of parafunctional activity.
Functional wear occur near to fossa areas and centric cusp tips.
Wear found during eccentric movements is almost always due
to parafunctional activity.
53
54. INSPECTION
54
3. Mandibular movements:
Maximum mouth opening:
Protrusive movement:
Lateral movements:
4. Deviation of mandible:
Patient is asked to open and close the mouth and
deviation is noted if present.
55. Other features include:
Angle’s classification for molar relationship
Posterior crossbite
Overjet and overbite
55
57. • Palpation - palmer surface of the middle finger
• Small circular motion
• Single firm thrust of 1-2 sec
VARIOUS MUSCLES ARE TO BE PALPATED:
Temporalis muscle
Masseter muscle
Lateral pterygoid muscle
Medial pterygoid muscle
Sternocleidomastoid muscle
Anterior diagastric muscle
Posterior diagastric muscle
MUSCLE EXAMINATION
57
58. JOINT EXAMINATION
TMJ NEEDS TO BE PALPATED IN
THREE LOCATIONS
Ask the patient to:
1) open approximately 20 mm and palpate the
condyle’s lateral pole.
2) open as wide as possible palpate the depth of the depression
behind the condyles
3) With the finger in the depression and the mouth open wide,
pull forward to load the posterior aspect of the condyle
58
59. AUSCULTATION
3 major diagnostic features:
Detection (whether a sound is present or not).
Type (click or crepitus).
Position of occurrence during the open/close cycle.
Click:
Sharp, discrete and single sound of relatively short duration
Crepitus:
Multiple grating like sounds or a longer continuous sound often
described as rubbing, cracking, sand paper like.
59
60. INVESTIGATIONS
DIAGNOSTIC MOUNTING
CENTRIC RELATION and centric
occlusion EVALUATION
RADIOGRAPHS –OPG
IOPA ( in relation to tooth that causes
abnormal mandibular movement )
ADVANCED CASES
Arthrography
Computed Tomography
Magnetic Resonance Imaging
Sonography 60
62. How can so many different types of therapies
be successful in managing Temporomandibular
Disorders?
62
63. Lack of adequate scientific evidence for relating
therapy to treatment effects.
Significant research for specific diagnostic
categories of TMD.
Some etiologic factors are difficult to control or
eliminate.
Still there are unidentified factors which are
uninfluenced by present treatment methods.
63
68. According to THE GLOSSARY OF PROSTHODONTIC TERMS [8th ed.],
“ Occlusal splint is defined as any removable artificial occlusal
surface used for diagnosis or therapy affecting the relationship of
the mandible to the maxilla. It may be used for occlusal
stabilization , for treatment of Temporo-mandibular disorders, or
to prevent wear of the dentition.”
68
69. Occlusal splint therapy can be recommended for the
following purposes:
To protect oral tissues
To stabilize unstable occlusion
To promote jaw muscle relaxation
To eliminate the effects of occlusal interferences
To test the effect of changes in occlusion on the TMJ
69
70. TYPES OF OCCLUSAL SPLINTS
According to OKESON
Stabilization
Appliance
Anterior
Positioning
Appliance
70
74. HOW DO SPLINTS WORK?
PREVENTING THE PATIENT TO CLOSE IN MAXIMAL
INTERCUSPAL POSITION:
Mandible-new position,
results in new muscular
and articular balance
Protects teeth and TMJ
74
76. DISTRIBUTION OF FORCES
Dissipate forces by utilizing
larger surface area in arch.
Balances the load and allows
for muscle symmetry.
76
77. ALLOWING THE CONDYLES TO SEAT IN CENTRIC
RELATION
Occlusion associated with
relaxed positioning
Elevator muscles allowing
the articulator disc to
obtain its anterio-superior
position over the condylar head.
77
78. INCREASE IN THE VERTICAL DIMENSION OF
OCCLUSION
Temporary increase in
vertical height does not
cause hyperactivity of
jaw muscles.
Causes neuromuscular
relaxation.
78
80. Permanent Occlusal Therapy is only indicated when
significant evidence exists to support that the occlusal
condition is an etiologic factor.
Treatment of Temporomandibular disorders.
Treatment in conjunction with other necessary measures.
INDICATIONS
80
81. TREATMENT PLANNING FOR
OCCLUSAL THERAPY
minor changes needed, occlusal surfaces of teeth can be
reshaped to achieve a desired occlusal contact pattern.-
SELECTIVE GRINDING.
When extensive alteration of occlusion needed and cannot be
met by selective grinding then CROWNS AND FIXED PROSTHETIC
PROCEDURES are used.
When skeletal relations cause dental malocclusion –
ORTHOGNATHIC SURGERIES 81
When inter-arch alignment is poorer and prosthetic procedures
are not able to complete treatment goals then ORTHODONTIC
PROCEDURES are done.
82. SELECTIVE GRINDING OF TEETH
Occlusal surface precisely altered to improve
overall contact pattern
INDICATIONS -
Occlusal appliance has eliminated the TMD
Occlusal contact or jaw position is identified as the
feature of appliance that affects the symptoms
Only when alteration is minimal, can be made within
enamel structure
82
84. Patients with muscle disorders - higher levels of
emotional stress.
Treatment is directed towards reduction of stress.
Types of emotional stress therapy
Patient awareness
Relaxation therapy
Biofeedback
Negative biofeedback
84
85. PATIENT AWARENESS
Parafunctional activity occurs at subconcious level.
Establishing awareness of muscle hyperactivity.
Once habits are brought to concious level – can be
controlled voluntarily.
85
86. RELAXATION THERAPY
ACTIVE THERAPY
Jacobson’s technique:
Patient tenses the
muscle and then
relaxes them until the
relax state is felt and
maintained.
“Relaxation is the direct negative of nervous
excitement. It is the absence of nerve-muscle
impulse.” - Edmund Jacobson.
86
95. THERMOTHERAPY
Uses heat as primary mechanism
Theory-heat increase blood circulation to
applied area.
For 10 – 15 mins, not to exceed 30 mins.
95
96. COOLANT THERAPY
Cold encourages relaxation
of muscles in spasm and
relieves pain.
Initially feels uncomfortable
and then burning sensation felt.
Continued icing results in mild
aching and numbness.
Remove ice when numbness
starts.
96
97. Should not be used for more than 5 – 7 mins.
During warming , increase blood flow leading to tissue
repair.
Vapour spray also used ( fluoromethane , ethyl
chloride).
Pain relief associated with stimulation of
cutaneous nerve fibres that in turn shut
down the smaller pain fibres.
97
98. ULTRASOUND THERAPY
Produce increase in temperature at the
interface of tissues
Increase blood flow in deep tissues
98
100. Electro-galvanic stimulation therapy.
EGS
Electrical stimulation of muscle causes it to contract.
A rhythmic electrical impulse is applied to muscle
creating repeated involuntary contractions and
relaxations
100
101. TENS
Transcutaneous electrical nerve stimulation.
Continuous stimulation of cutaneous nerve fibres at a
subpainful level.
Electrical activity
decreases pain
perception 101
102. ACUPUNCTURE
Uses body’s own antinociceptive system to reduce
the levels of pain itself.
Stimulation of some areas cause release of
endomorphins which reduce painful sensations.
These effectively block noxious impulses and
reduce pain.
102
103. CONCLUSION
The dental team has a role to play in the diagnosis,
conservative management and referral of patients
with TMJ pain. By understanding the various causes
and presentations of TMJ problems it is possible to
distinguish between dental pain, TMJ disorder and the
more complicated facial pains to ensure speedy
diagnosis and management for our patients.
103
104. 104
DR. S. P. SINGH
(HEAD OF THE DEPARTMENT)
AND
ALL FACULTY MEMBERS
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110
Editor's Notes
-therefore temporomandibular joint disorders is not an acceptable diagnosis but that for each patient a subtype of TMD must be identified
OCCLUSAL SPLINT THERAPY may be defined as “the art and science of establishing neuromuscular harmony in the masticatory system by creating a mechanical disadvantage for parafunctional forces with removable appliances”
