This document discusses the diagnosis and management of temporomandibular joint disorders (TMD). It defines TMD and covers the functional anatomy, etiology, epidemiology, classification, diagnosis, and treatment. For diagnosis, it describes various tests including screening history, load testing, range of motion testing, Doppler analysis, and various radiographic imaging techniques. Treatment involves identifying and addressing the underlying causes, which may include occlusal factors corrected through appliances, selective grinding, or orthodontics, as well as non-occlusal approaches like education, relaxation therapy, and avoidance of micro/macrotrauma.

1. TEMPOROMANDIBULAR JOINT DISORDERS
DIAGNOSIS AND MANAGEMENT
Dr.SHARI.S.R
JUNIOR RESIDENT, DEPT. OF PROSTHODONTICS AND CROWN & BRIDGE
GOVT. DENTAL COLLEGE, THIRUVANANTHAPURAM

2. 2
Contents
1
2
3
4
5
6
7
Definition
Functional anatomy
Etiology
Epidemiology
Classification
Diagnosis
Treatment
8 Literature review
9 Conclusion

3. TMD

4. Unilateral dull pain in the ear or pre auricular region that is
commonly worse on awakening
Tenderness of one or more muscles of mastication on palpation
Clicking or popping noise in the TMJ
Limitation or deviation of the mandible on opening
4
Signs and symptoms of TMD by Laskin

5. Diagnosis
5

6. HOW TO DETERMINE IF THE TMJS ARE HEALTHY !
6
6 ways

7. Functional occlusion from TMJ to Smile design-Peter.E. Dawson
7
6 methods
SCREENING HISTORY
LOAD TEST
RANGE AND PATH OF MOVEMENT TEST
DOPPLER ANALYSIS
RADIOGRAPHIC IMAGING
ANTERIOR BITE PLANE FOR MUSCLE DEPROGRAMMING

8. Every patient should be asked key questions about the TMJs
before treating
8
Screening history

9. 9
Sample questionnaire
Diagnostic Criteria for Temporomandibular Disorders Clinical Protocol and Assessment Instruments
International RDC/TMD Consortium Network Version: 20Jan2014

10. 10
Sample questionnaire

11. 11
Load test
For verification of comfort in centric relation or
adapted centric posture. Any sign of tension or
tenderness warrants further evaluation

12. General normal:
Wide mouth opening - 40-60 mm
Lateral - 7-15 mm
Protrusive - 7-15 mm
Maximum rotation only opening 20-25 mm; wider opening requires
translation.
12
Range and path of movement tests

13. 13
Deviation and Deflection(Path of movement)
Deviation : Movement away from the midline during opening followed
by return to centre during movement. Either “c”or “s” pattern.
Deflection: Movement away from midline during opening without
return to centre during the movement.
On opening, the jaw will normally deviate toward the side of
the displacement

14. • An intact healthy joint is quiet on rotation and translation.
• It is a standard diagnostic device for determining the
condition of the intracapsular structures
14
Doppler analysis/ Doppler auscultation.
Mario marini. Duplex-doppler spectral analysis in the physiopathology of the temporomandibular joint:
Computerized medical imaging and graphics,18(1)1994 35-43

15. The coarser the crepitus, the more there is breakdown of the posterior
ligament
Chirping sounds Perforation of the ligament.
Chirping mixed with very coarse crepitus Posterior ligament
severely damaged or lost and bone-to-bone articulation.
Opening and closing clicks at the same protrusive position of the condyle
Ankylosis of the disk
The opening click occuring at a more open relationship than the closing
click Disk is not ankylosed but is still reducible
Crepitus for all jaw movements and no click Disk is not recapturable
15
The character of the amplified sounds

16. Not necessary if other tests and history are negative.
Selection of type of imaging should be based on signs and symptoms.
16
Radiography/imaging

17. 1. Panoramic radiography
2. Transcranial radiography
3. Trans pharyngeal radiography
4. Anterio - Posterior trans maxillary radiography
5. Computed tomography (CT)
6. Arthrotomography
7. Arthrography with videofluoroscopy
8. Magnetic resonance imaging (MRI)
17
TYPES OF TMJ IMAGING
Management of temporomandibular disorders and occlusion- Jeffrey p. Okeson

18. Panoramic radiography
• Screening radiograph, they may alert the clinician to a suspected
problem
• Not a dependable modality for assessment of the articular space.
Transcranial radiography
• Readable images can be achieved economically and with minimum
complexity by use of a standard dental x-ray machine.
• Most of the pathologic changes that occur on the articulating
surfaces start at the lateral half of the joint and are visible in the r/g.
• Diagnosis of disk displacement should not be determined solely
from transcranial radiography.
18
TYPES OF TMJ IMAGING

19. Arthrotomography
• Refers to the injection of a radiopaque contrast medium into the lower
joint space followed by radiography.
• Used to diagnose the position and condition of the meniscus in relation
to the condyle.
• Abnormalities that can be observed include anterior dislocation of the
disk, perforation, degenerative changes, and adhesions
Arthrography with videofluoroscopy
• To observe the movement and contour of the disk in relation to the
condyle as the jaw opens, closes, and translates
Computed tomography (CT)
• Tomography provides a better assessment of the medial pole
area of the condyle
• Improved clarity
19
TYPES OF TMJ IMAGING

20. Magnetic resonance imaging
Gold standard
Helps in diagnosis of complete disk derangements, or
when unexplainable pain or dysfunction of the TMJs is present
that does not respond to treatment
MRI shows bone marrow changes, disk morphology, mobility, joint effusion
Anterioposterior transmaxillary projection
This offers a good image of superior subarticular bone of the condyle
aswellas medial and lateral poles.
20
TYPES OF TMJ IMAGING

21. MRI
Trans cranial Trans pharyngeal Computed tomography
21
TYPES OF TMJ IMAGING
CT

22. Can be used to determine :
- if occlusion is a factor
- if an intracapsular disorder is contributing to the pain.
If a flat, permissive anterior bite plane does not
relieve pain or discomfort at the TMJs
intracapsular disorder as a source of pain.
22
Anterior bite plane for muscle deprogramming

23. Separating occluso-muscle pain from TMJ pain
23
Functional Occlusion: From TMJ to Smile Design- PETER E DAWSON

24. Determine whether any masticatory muscle is involved in the
pain. The medial pterygoid muscle is diagnostic – it is almost
always tender to some degree if there is an occluso-muscle
disorder.
24
Separating occluso-muscle pain from TMJ pain
Step 1:

25. • Ask patient to clench.
• Palpation of the masseter muscle at their superior attachment to the
zygomatic arches.
• Palpation of the superficial masseter muscles near the lower border of
the mandible.
25
Masseter muscle.

26. 26
TEMPORALIS MUSCLE
It has some origin behind the lateral wall of the
orbit of the eye sharp pain behind the eye.
Its aponeurosis extends as an innervated sheath
to the top of the head scalp sore to touch.
Temporal headaches and pain are some of the
most common symptoms related to occluso-
muscle imbalance.
Tendon of the temporalis - Ask patient to open
mouth.
Check for pain. Place finger on anterior ridge of
the coronoid process. Palpate on the superior
aspect of the process.

27. • Anterior part of insertion can be palpated by placing the finger 45°
in the floor near the base of the relaxed tongue.
• The opposite hand can be used extraorally to palpate posterior
and inferior portions of insertion.
• Body of the muscle can be palpated by rotating the index finger
upwards against the muscle to near its orgin on the tuberosity
27
Medial pterygoid muscle

28. 28
Inferior and Superior lateral pterygoid muscle
Inferior lateral pterygoid muscle
The muscle that pulls the condyle forward every
time the mandible leaves centric relation.
Superior lateral pterygoid muscle.
The muscle that keeps the disk aligned during function.
Ask patient to open the jaw. Ask patient to move his
or her mandible toward the same side, and place
finger on buccal side of alveolar ridge above the
maxillary molars and move finger posteriorly,
medially, and upward as far as possible, and
palpate.

29. Often involved when deflective occlusal
interferences cause the mandible to be
postured forward to avoid the interferences.
Check for protruded jaw position to achieve
maximum intercuspation.
Muscle involvement If anterior
deprogramming relieves the discomfort
29
The digastric and the hyoid muscles

30. • If this muscle is tender to palpation, evaluate collateral effects from
head posture and/or cervical misalignments.
• Consider referral to a physical therapist for adjunctive evaluation.
30
Sternocleidomastoid (SCM) muscle.

31. • Occipital headaches are commonly associated with occlusal interferences.
• May result in combination with head posture and cervical misalignments,
or it may be unrelated to occlusal factors.
• Consider referral to a physical therapist for adjunctive therapy.
31
Occipital area

32. Occlusal disharmony
Head posture
Muscle pain.
32
Trapezius muscle
Cervical misalignment must always be a consideration.
Consider referral to a physical therapist.

33. Step 2:
Rule out intracapsular problems.
Verify that centric relation or adapted centric posture can
be achieved.
Load testing must be negative.
33
Separating occluso-muscle pain from TMJ pain

34. Step 3:
Verify the general acceptability of condyle position and condition
with TMJ radiographs if warranted.
34
Separating occluso-muscle pain from TMJ pain
Step 4:
Rule out pathologic factors as a source of pain.
a. Pulpal
b. Periodontal
c. Soft-tissue
d. Bone
e. Sympathetic and/or referred pain

35. Step 6:
Correct the cause of the problem.
a. Reversibly with permissive occlusal splint, or
b. Directly with occlusal correction.
Options for treatment:
• Equilibration
• Restorative
• Orthodontics
• Surgery
35
Separating occluso-muscle pain from TMJ pain

36. Test 1: Clench test
If a patient can clench the teeth together and feel tenderness
in any tooth when the mouth is empty -Positive
Test 2: Anterior deprogramming test
Firmly clench against a cotton roll laid across the arch at
the premolars - If pain is relieved occluso-muscle problem
If clenching on the cotton roll produces discomfort in either
TMJ intracapsular disorder .
Flat anterior deprogramming device [discluder splint] overnight
36
Confirmation of diagnosis of occlusomuscular pain

37. Treatment
37
Management of temporomandibular disorders and occlusion-
Jeffrey p. Okeson

38. 38
Definitive therapy( for etiologic factors)
• Occlusal appliance(Reversible)
• Selective grinding (irreversible)
• Orthodontic treatment
• Surgical procedures
• Education and cognitive awareness training
• Restrictive use
• Voluntary avoidance
• Relaxation therapy
• Macrotrauma: Mouth guard
• Microtrauma:Occlusal appliance.
For occlusal factors
For emotional stress
For trauma
For deep pain input • Referral to physical therapist.
For parafunctional
activity
• Diurnal activity: Patient education and cognitive
awareness
• Nocturnal activity: Patient education ,Relaxation therapy,
Occlusal appliance therapy ,Clonazepam,Amitryptyline.

39. PHARMACOLOGIC THERAPY PHYSICAL THERAPY
Analgesics
Anti Inflamatory
Anxiolytics
Muscle Relaxants
Anti-depressants
Anti-convulsants
Injectables
Topicals
MODALITIES
MANUAL
TECHNIQUES
Soft tissue mobilisation
Joint mobilisation
Muscle conditioning
Passive muscle stretching
Active muscle stretching
Resistance exercises
Postural training
39
Supportive therapy
Thermotherapy
Coolant therapy
Ultrasound therapy
Phonophoresis
Iontophoresis
Electro galvanic
stimulation
TENS
Cold laser

40. Assisted stretching Resisted exercises.
Accupuncture Physical self regulation
40
Supportive therapy

41. Definitive management is usually based on etiology
Supportive management:
• Restrict the use of the mandible within painless limits
• Soft diet
• Short term analgesics
• Physical self regulation techniques
41
TREATMENT OF MASTICATORY MUSCLE DISORDERS
Myofascial pain
Trigger points management:
• Spray and stretch –Simon and Travel
• Injection and stretch
• Pressure and massage
• Ultrasound and electrogalvanic stimulation
• Muscle relaxants
• Muscle conditioning techniques

42. 42
Disk displacement with reduction:
An Anterior repositioning appliance should be
fabricated to wear at night during sleep and during the
day when needed to reduce symptoms. These adaptive
changes can take 8 to 10 weeks or even longer.
1. Softer foods, slower chewing, smaller bites.
2. If inflammation - NSAID’s , moist heat or ice.
3. Passive jaw movements may be helpful.
4. Distraction manipulation by physical therapist.
Definitive
treatment
01 02 03 04
Supportive therapy:

43. Patient attempt to reduce the dislocation without
assistance - to move the mandible to the
contralateral side as far as possible. From this
eccentric position the mouth is opened maximally.
Anterior repositioning appliance is contraindicated
43
Disk dislocation without reduction:
Definitive treatment:
Self reduction:
Lateral pterygoid muscle – should be relaxed
If active – Local anesthesia

44. 44
Manual manipulation
3. Joint is distracted, ask the patient to protrude
the mandible.
4. Ask patient to move contra lateral side and ask
to relax, 20-30 sec distractive force is applied to
the joint.
5. Ask the patient to close the mouth to the incisal
end to end position
6. Ask to open wide and return to anterior position
7. Anterior positioning appliance is placed
immediately
1. The thumb - intraorally over the mandibular second molar on the affected side. The
fingers - on the inferior border of the mandible anterior to thumb position.
2. Firm but controlled downward force is then exerted on the molar and at the same
time upward force is placed by the fingers

45. Surgery should be considered only when conservative therapy fails to resolve
adequately the symptoms and or progression of the disorder.
Arthrocentesis:
• Most conservative surgical procedures.
• Two needles are placed into the joint .
• Sterile saline solution is passed through lavaging the joint. The lavage is thought
to eliminate much of the algogenic substances and breakdown by products that
produce the pain
Pumping the joint:
In cases of disc dislocation without reduction a single needle can be
introduced to the joint and fluid can be forced into the space in an attempt to free
the articular surfaces.
45
Surgical considerations for condyle disc derangement

46. Arthroscopy:
• An arthroscope is placed into the superior joint space
• Intracapsular structures are visualized on a monitor.
• This procedure appears to be very successful in reducing
symptoms and improving movement. It helps in
improving disc mobility.
Arthrotomy:
• It is a open joint surgery.
• The surgical procedure of choice is plication during
which a portion of the retrodiscal tissue and inferior
lamina is removed
• The disc is retracted posteriorly and secured with
sutures
46
Arthroscopy and Arthrotomy

47. 47
Discectomy
Disc is damaged and can no
longer be maintained for
use. So disc is removed
It leaves a bone to bone
articulation which is likely to
produce some osteoarthritic
changes.
Another choice is to remove the disc
and replace it with a substitute – Discal
implants which include medical silastic,
proplast-Teflon, Dermal and auricular
cartilage grafts.
1
2
3

48. Adhesions:
• Breaking fibrous attachment using arthroscopic surgery.
• Passive stretching.
• Distraction of the joint.
Subluxations:
• Eminectomy
• Intraoral device that limiting the opening before the point of subluxation
Spontaneous dislocation:
Manual manipulation:
• Thumbs are placed on the mandibular molars & downward pressure is
exerted.
• If not reduced inject LA to inferior pterygoid muscle.
• Chronic spontaneous dislocation ----------- Eminectomy
48
Treatment for structural incompatibility of articular surfaces

49. Definitive treatment:
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.
Supportive therapy:
•Restrict all mandibular movements within painless limits-soft diet, slow
movements and small bites.
•Constant pain - 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.
49
Synovitis, Capsulitis

50. Definitive treatment:
The mechanical loading should be decreased.
Stabilization appliance- When muscle hyperactivity is suspected.
Supportive therapy
It begins with an explanation of the disease process to the patient.
Analgesics
Anti-inflammatory agents.
Soft diet.
Thermotherapy is usually helpful in reducing symptoms.
Arthritidis:
Retro discitis:
• Along with clenching: Give stabilization appliance.
• Due to micro trauma/Disc dislocation with reduction : Anterior positioning
appliance.
50
Retro discitis and Arthritidis

51. Definitive treatment:
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. 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.
51
Ankylosis

52. Definition:
An occlusal appliance is a removable device usually made if hard acrylic
that fits over the occlusal and incisal surface of the teeth in one arch,
creating precise occlusal contact with the teeth of the opposing arch.
It is also called as :
1. Bite guard
2. Night guard
3. Interocclusal appliance
4. Orthopedic device
52
Occlusal Splints

53. • Repositioning of condyles and discs
• Increase of vertical dimension
• Elimination of occlusal interference
• Avoidance of excessive occlusal wear
• Relaxation of jaw and neck muscles
• Stabilization of occlusal and neuromuscular features
• Reduction of headaches
53
Rationale for Splints

54. Based on Consistency :
• Hard splints e.g.: acrylic resins (heat cure and chemical cure)
• Soft splints e.g.: polyvinyl sheets
Based on the type of fabrication
• Direct – chairside fabrication
• Indirect – laboratory fabrication
54
Occlusal splint classification.

55. 55
Classification of Splints
Dawson classification
Okeson classification
Ash & Ramfjord classification

56. 56
Dawson Classification

57.  Stabilization appliance
 Anterior positioning appliance
 Other types of occlusal devices:
1. Anterior bite plane
2.Posterior bite plane
3.Pivoting appliance
4.Soft / resilient appliance
Stabilization appliance:
• Primary use is to reduce muscular pain –Muscle relaxation appliance
• Eliminate ORTHOPEDIC INSTABILITY.
Anterior positioning appliance:
• It position the mandible more anteriorly to provide a better condyle
disc relationship.
57
Okeson classification

58. 58
Indications of stabilizing appliances
• Bruxism
• Local muscle soreness
• Centrally mediated myalgia
• Retrodiscitis secondary to microtrauma.
• Osteoarthritis
• Establishment of optimal condylar position in centric relation prior to
definitive occlusal therapy.

59. • It must accurately fit the maxillary teeth and have
good retention and stability.
• In CR- all mandibular buccal cusps and incisal
edges must contact with even force on flat
surface.
• During protrusive- Mandibular canines must
contact the appliance with even force.
• In lateral movements only canines should exhibit
laterotrusive contact.
• During closure and upright feeding position–
Mandibular posterior teeth must contact the
appliance more heavily than anterior teeth.
59
Final criteria for stabilization appliance

60. • This helps to position the mandible more anteriorly than the
intercuspal position.
• Provide better condyle-disc relationship
• Provide better oppourtunity for tissue repair.
Indications:
• Disc displacement.
• Dislocation with reduction.
• Retrodiscitis ( due to microtrauma).
60
Anterior repositioning appliance

61. • Stability and retention
• In established forward position all the mandibular teeth
should contact with even force.
• The forward position is established by asking the patient to
move forward the jaw till the initial clicking starts.
• Lingual retrusive guidance ramp direct the mandible into
the established therapeutic forward position.
61
Final criteria for the anterior positioning appliance

62. • It provide contact only with mandibular anterior teeth.
• It disengage the posterior teeth & eliminate their influence on
masticatory system.
Indications:
• Muscle disorders related to orthopedic instability
• Accute changes in occlusal condition.
Complications
• Supraeruption of posterior teeth(> 2 weeks)
NTITSS
62
Anterior bite plane

63. • Fabricated by hard acrylic over the mandibular posterior teeth.
• Indications:
• Severe loss of vertical dimensions
• Mandibular anterior positioning.
• Complication :
• Supra eruption of anterior teeth.
63
Posterior bite plane

64. 64
Hydrostatic Appliances/Aqualizer

65. 65
Pivot appliance
• The pivoting is a hard acrylic
device that covers one arch
and usually provides a single
posterior contact in each
quadrant.
• This appliance lessens
intraarticular pressure and
unload the articular surface of
the joint.

66. Made using resilient material on maxillary teeth
Indication:
• Protective device who likely to receive trauma
• Clenching & bruxism
• Repeated sinusitis resulting in extremely sensitive teeth
• Complication:
• Difficult to adjust.
Hard splints are better
than soft splints
66
Soft splints / Resilient splints

67. 67
Indication of various splints

68. 68
Occlusal Equilibration
It is a procedure by which the occlusal surfaces of the teeth are precisely
altered to improve the overall contact pattern.
Procedure includes:
• Reduction of all contacting teeth surfaces that interfere with the terminal
hinge axis closure.
• Selective grinding of tooth structures that interfere with lateral excursion.
• Selective grinding of teeth that interferes with protrusive movement.
• Harmonization of anterior guidance

69. 69
Armamentarium for Occlusal correction
Paste ,Spray,Paint on material

70. 70
Rule of Third
Predict success of selective grinding.

71. 71
• INTERFERENCES IN THE ARC OF CLOSURE—Anterior slide
• INTERFERENCES IN THE LINE OF CLOSURE----Right or left slide
(Dawson)
According to Okeson CR slide can be 3 types :
• Anterosuperior
• Antereosuperior and to the right
• Antereosuperior and to the left
Eliminating interferences to centric relation position

72. • Due to contact between mesial inclines of maxillary cusps and the
distal inclines of the mandibular cusps
Grinding rule MUDL
72
Interferences in the arc of closure

73. Slide toward cheek:
Due to inner incline of the maxillary lingual cusp against the inner incline
of the mandibular buccal cusp.
Grinding rule: BULL
Slide toward tongue:
Due to lingual incline of the upper or buccal incline of lower.
Grinding rule: LUBL
73
Interferences in the line of closure

74. Mediotrusive contacts Grinding rule: BUCCAL OF UPPER LINGUAL CUSP AND
LINGUAL OF LOWER BUCCAL CUSP (BUL* LLB).
74
Eliminating the interferences in balancing side

75. Laterotrusive contacts: LINGUAL OF UPPER BUCCAL CUSP AND BUCCAL OF LOWER
LINGUAL CUSP (LUB* BLL)----Working side interferences
75
Eliminating lateral interferences – BULL’s Law

76. 76
GRINDING BASIC RULES:
• Narrow stamp cusps before reshaping fossae.
• Don’t shorten a stamp cusp.
• Upper teeth are always adjusted on the inclines that face the same
direction as the slide.
• Lower teeth are adjusted by grinding the inclines that face the opposite
direction from path of the slide.
• Adjust centric interferences first
• Then lateral excursive interferences
• Protrusive interferences.
• It can occur between distal inclines of maxillary lingual cusp and
mesial inclines of mandibular buccal cusp.
Grinding rules: DUML
Eliminating interferences in Protrusive contacts

77. 77
Occlusal equilibration in complete denture
• Incorrect registration of RCP
• Irregularities in setting the teeth
• Tooth movement during deflasking and packing.
• Incomplete flask closure.
Causes of occlusal disharmony:

78. 78
Types of occlusal error in centric occlusion and their
correction.: 3
1)Any pair of opposing teeth can be too long and hold the other teeth out of
contact.
Correction: The fossae of the teeth are deepened by grinding so the teeth will in
effect,telescope into each other.The cusp are not shortened.
2)The upper and lower teeth can be too nearly end to end.
Correction: Grind the outer inclines of the functional cusp.
3) The upper teeth can be too far buccally in relation to lower teeth.
Correction: Grind the inner incline of the functional cusp from fossae.so
broadening the fossae near the inner incline.

79. 79
Types of working side occlusal error and their
correction:- 6
1) Both the upper buccal cusp and the lower lingual cusp are too long .
Correction: The length of cusps are reduced by grinding to change the incline
extending from the central fossae to the cusp tip.,Central fossae is not made
deeper,but the cusps made shorter.
2) The buccal cusp make contact but the lingual cusp donot.
Correction: Buccal cusp of the upper teeth are ground from the central fossa to the
cusp tip to shorten the cusp.
3) The lingual cusp make contact but the buccal cusp donot.
Correction: The lower lingual cusps are shortened by changing the buccal incline of
the lower lingual cusp ,so it is not as steep.

80. 80
Types of working side occlusal error and their
correction:- 6
4) Upper buccal or lingual cusps are mesial to their intercuspative postions
Correction: Grinding is done on the mesial inclines of the upper buccal cusps
and distal inclines of the lower cusps.
5)Upper buccal or lingual cusps are distal to their intercusping positions.
Correction: Grinding is done from the distal of the upper cusps and from
the mesial of the lower cusps.
6) Teeth on the working side may not contact.
Due to excessive contact on balancing side.
Correction: Grind lingual incline of the lower buccal cusp.

81. 81
Types of balancing side occlusal error and their
correction:- 2
1) Balancing side contact is so heavy so that working side teeth are held out
of contact.
Correction: Grind the lingual incline of the lower buccal cusp.
2) There is no contact on the balancing side:
Correction: Grind lingual incline of the upper buccal cusps and buccal
incline of lower lingual cusp.

82. 82
LiteratureReview

83. Ware and Rugh studied a group of bruxism patients without pain and another
group with pain
• Bruxers with pain had a significantly higher number of bruxing events during
REM sleep than did the former.
• Bothgroups, however, bruxed more than a control group.
This study suggests that there might be two types of bruxism patients: one bruxing
more during REM sleep and one bruxing more during the non-REM phases.
• Other studies by these authors showed that the amount of sustained
contraction occurring in bruxism was commonly much higher during the REM
than the non-REM phases of sleep.
• These findings help to explain the conflicting literature on sleep stages and
bruxism and may also explain why some patients awaken with pain but others
with clinical evidence of bruxism report no pain.
83
Literature Review

84. Study by Rompre et al in 2007 investigated the number of bruxing events per
night in a group of bruxing patients with pain and compared them with
another group of bruxing patients without pain.
The bruxing group without pain actually had more bruxing events per night
than the ones with pain
Logic
• Patients who regularly brux during sleep condition their muscles and adapt
to this activity. Regular exercise leads to stronger, larger, more efficient
muscles.
• This may explain why dentists often observe middle-aged male patients
with major tooth wear secondary to bruxing, yet they have no pain
• Patients who awaken with muscle pain are more likely to be those who do
not frequently brux; therefore their muscles are not conditioned to this
activity. This unconditioned activity is more likely to be associated with pain.
84
Literature Review

85. Anna Colonna et.al,(2018) Comparative analysis of jaw morphology and
temporomandibular disorders: A three-dimension imaging
study, CRANIO®, DOI: 10.1080/08869634.2018.1507094
• (CT) scans of 20 individuals aged 18 to 40 with (TMD group) or without
TMJ pain (control group) . Three-dimensional reconstructions were
performed to evaluate the gonial angle, condylar volume, and the
distance between the posterior edge of the condyle and the sigmoid
notch.
• There is an association between the presence of TMJ pain and some
features of craniofacial morphology. Individuals with TMJ pain have a
lower condylar volume and a tendency towards hyperdivergent growth.
85
Literature Review

86. Tissue engineering of the mandibular condyle have been trying to regenerate both
bone and cartilage with distinct structural and functional differences. The
scaffolds fabricated for this purpose must fulfill the biological and mechanical
requirements for cartilage and bone regeneration --- surface chemistry, high
porosity, mechanical compliance, biodegradability and biocompatibility for cell
growth and extracellular matrix deposition
Temporomandibular Joint Replacement—Past, Present and Future: A
Bioengineering Perspective T. Vo Van et al. (eds.), 6th International Conference on
the Development of Biomedical Engineering in Vietnam (BME6), IFMBE
Proceedings 63
Prosthesis Fossa Condyle Ramus
Biomet UHMWPE Cobalt chrome /Ti Cobaltchrome/Titanium
TMJ concepts Titanium Cobalt chrome Titanium
TMJ implants Cobalt chrome Cobalt chrome Cobalt chrome
86
Literature Review

87. 87
LiteratureReview
Biomet Christensen prosthesis
TMJ concepts prosthesis

88. Temporomandibular disorders (TMD) is an umbrella
term for pain and dysfunction involving the masticatory muscles
and the TMJs. Chronic pain is the overwhelming reason that
patients with TMD seek treatment.
TMD can associate with impaired general health,
depression, and other psychological disabilities, and may affect
the quality of life of the patient The clinician should be able to
differentiate the various clinical symptoms associated with the
disorders and do the treatment accordingly.
88
Conclusion

89. 89
References
1. Functional Occlusion: From TMJ to Smile Design- PETER E DAWSON
2. Management of temporomandibular disorders and occlusion / Jeffrey P. Okeson. --
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3. Diagnostic Criteria for Temporomandibular Disorders Clinical Protocol and
Assessment Instruments International RDC/TMD Consortium Network Version:
20Jan2014
4. Ware JC, Rugh JD: Destructive bruxism: sleep stage relationship, Sleep 11(2):172–
181, 1988.
5. Rompre PH, Daigle-Landry D, Guitard F, et al: Identification of a sleep bruxism
subgroup with a higher risk of pain, J Dent Res 86(9):837–842, 2007.
6. Temporomandibular Joint Replacement—Past, Present and Future: A
Bioengineering Perspective T. Vo Van et al. (eds.), 6th International Conference on
the Development of Biomedical Engineering in Vietnam (BME6), IFMBE
Proceedings 63, https://doi.org/10.1007/978-981-10-4361-1_93
7. Anna Colonna et.al,(2018) Comparative analysis of jaw morphology and
temporomandibular disorders: A three-dimension imaging study, CRANIO®, DOI:
10.1080/08869634.2018.1507094

90. Thank You