TMD's and occlusal splint therapy

Occlusal Splint Therapy
Dr. Marwan Mouakeh , DDS, Doc.Orhto.Sc
Head of Aleppo Orthodontic Residency Center
Director of the National Committee for
Qualification in Orthodontics
Ministry of Health - Syria

Temporo - Mandibular Disorders

Temporomandibular joint and muscle
disorders, commonly called “TMDs,”
are a group of conditions that cause pain
and dysfunction in the jaw joint and the
muscles that control jaw movement.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health

We don’t know for certain how many people
have TMJ disorders, but some estimates
suggest that over 10 million Americans are
affected. The condition appears to be more
common in women than men .
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health

Signs & Symptoms
- Pain in the chewing muscles and / or jaw joint.
- Radiating pain in the face , jaw , or neck
- Jaw muscle stiffness
”- Limited Jaw Movement or “ Locking
- Painful Clicking , Popping or Grating Sounds in
the joint when opening or closing the mouth.
-A Sudden Change in the Bite “ Acute Malocclusion” .
- Ear Pain, Dizziness, Hear Problems …

The Masticatory System:
 TMJs
 Muscles
 Teeth ( Occlusion)

Temporo-Mandibular Joint
 The temporomandibular joint connects the lower jaw,
called the mandible, to the bone at the side of the head—
the temporal bone.
 When we open our mouths, the
rounded ends of the lower jaw,
called condyles, glide along the
joint socket of the temporal bone.
The condyles slide back to their
original position when we close our
mouths.

Because these joints are flexible, the jaw can move
smoothly up and down and side to side, enabling us to
talk, chew and
yawn.

To keep this motion smooth, a soft
disc lies between the condyle and
the temporal bone. This disc absorbs
shocks to the jaw joint from chewing
and other movements.

Sagittal View
The Articular Disc
A Biconcave Oval Structure Dividing the joint
cavity into 2 distinct compartments.

Parts of the Articular Disc
Anterior Band
Intermediate Zone
Posterior Band
Sup. Attachment
Elastic
Inf. Attachment
Non-Elastic

Physiologic Position of the Articular Disc
1
2
3
 The Absence of Blood
Vessels & Nerves in the
Intermediate Zone of the Disc
Enables this part of the disc to
act as a Pressure-Bearing
Area .

Collateral Discal Ligaments
Frontal View
The Articular Disc
Medial
Distal

The temporomandibular joint is different from the
body’s other joints. The combination of hinge and
sliding motions makes this joint among the most
complicated in the body. Also, the tissues that make up
the temporomandibular joint differ from other load-
bearing joints, like the knee or hip. Because of its
complex movement and unique makeup, the jaw joint
and its controlling muscles can pose a tremendous
challenge to both patients and health care providers
when problems arise.

Masticatory Muscles
 The Primary Movers of the Mandible

Lateral Pterygoid Muscle
Inf. Belly : Depressor
Sup. Belly : Elevator

What are TMJ Disorders ?
Myofascial pain Arthritis
Internal Derangement
of the Jaw Joints

 Myofasial Pain
The most common TM
disorder , involves
discomfort or pain in the
muscles that control Jaw
function .

Myalgia ( Muscular Pain)
 A Regional muscle pain disorder
 Characterized by Referred pain from
Trigger Points within the myofascial
structures
Pain referral pattern from the masseter muscle
TrpS

Myalgia ( Muscular Pain)
 Dull , Deep , and Diffuse pain
 Depressing
 Felt in the morning when related
to Nocturnal Bruxism
 Influenced by functional demands
( chewing…)

 Restricted Mouth Opening : Less than 30 -35 mm

 TMJ Internal Derangement
 Involves a Displaced Disc ,
Dislocated Jaw , or Injury to the
Condyle.

• Disc Displacement: Abnormal relationship between the
Articular Disc , the Mandibular Condyle, and the Articular
Eminence .
Antero-Medial Displacement

• Disc Displacement With Reduction
Closed Partially Open Fully Open

• Disc Displacement With Reduction
Reciprocal Click

• Disc Displacement Without Reduction
Closed Lock : Severe limited mandibular movement …
Closed Open

• Disc Displacement Without Reduction
 Closed Lock : Severe limited mandibular movement …
Closed Open

Arthralgia (Articular Pain)
 Loclized in the TMJ Region
 Increased with mandibular
movement.
Origin of pain :
posterior attachment - collateral
ligaments -articular capsule.

 Arthritis
Refers to a Group of Degenerative Inflammatory Joint
Disorders that can affect the Temporomandibular Joint.
Crepitation

Mean Value
%
Symptoms
19TMJ Sounds
11Tiredness,Stiffness of jaw
6Pain on Mandibular function
8Limitation of Mandibular
movement
4Locking
17Frequent Headache
Reported TMD Symptoms in 18 Epidemiologic Studies
“ Carlsson 1984”

Age distribution of 5 samples of patients
with TMDS
A common Peak in the
age distribution of the
patients ,specifically
during the period
between 20 and 40
years .

What causes TMJ disorders?
 The Exact Causes Are Not Clear Yet …
- Trauma to the jaw or TMJ :
> Macrotrauma
> Microtrauma
- Malocclusion (Bad Bite)
- A possible link between Female Hormones and
TMJ disorders ?
- Stress

Acute Trauma to the Neck : Whiplash
What causes TMJ disorders ?
Macrotrauma: Blow, Traumatic extraction ,
Intubation…

Parafunctional Activities : Bruxism
Microtrauma

Stress: Emotional & Physical
 Stress frequently leads to unreleased nervous energy. It is
very common for people under stress to release this nervous
energy by grinding and clenching their teeth.

Specific Forms of Malocclusion
What causes TMJ disorders ?

Balance( in the Masticatory System ) between Destructive
Overloading that leads to CMDs & Homeostatic Adaptability
that promotes normal function .

Diagnosis
- A Detailed Medical & Dental History
- Clinical Examination of the joint and facial
muscles, as well as the occlusion
- Radiographic Examinations of the TMJ
(Panoramic, Transcranial, CT scan, MRI….)

Evolution
How joint and muscles disorders
progress is not clear . Symptoms
worsen and ease over time, but what
causes these changes is not known.

Treatment Methods
- Conservative & Reversible treatments are
strongly recommended .
> Conservative: Do not invade the tissues
of the face, jaw, or joint, or involve surgery.
> Reversible: Do not cause permanent
changes in the structure or position of the jaw
teeth

Conservative Treatment
- Self – care practices
> Soft diet
Moist heat/> Local ice packs
> Rest (avoiding extreme jaw movements)
> Relaxation and Stress – Reducing
Techniques.
> Stretching & Relaxing Exercises.

- Pain Medications :
> Nonsteroidal anti- inflammatory
drugs (NSAIDS) : Ibuprofen
> Corticosteroids Injection??
> Muscle Relaxants
> Anti- Depressants
 Anti- Anxiety Drugs

- Pain Medications :
> Nonsteroidal anti- inflammatory
drugs (NSAIDS) : Ibuprofen
> Anti- Inflammatory Drugs
> Muscle Relaxants
> Anti- depressants

Stabilization Joint Splints
or
Interocclusal Appliances

Irreversible Treatments
- Orthodontics
- Occlusal Adjustment
- Crown & Bridge Works
- Repositioning Splints
-Surgery

A Non – invasive and Reversible? Biomechanical
Method of Managing Pain and Dysfunction of the
TMJ and its Associated Musculatures .

- Stabilization Splints or
interocclusal Appliances

A Non – invasive and Reversible Biomechanical
Method of Managing Pain and Dysfunction of the
TMJ and its Associated Musculatures .

Stabilization Splint
- Removable interocclusal device
- Usually made of hard acrylic resin
- Fits over the teeth in one arch

Purpose of Occlusal Splint Therapy
 Stabilize or improve the function of the TMJs .
 Improve the function of the Masticatory
Muscles & Reduce abnormal muscle activity.
 Protect Teeth from attrition and adverse
traumatic loading .

Occlusal Splints
2 Main Types
Stabilization splint Anterior Repositioning splint
Permissive Directive

Occlusal Splints
2 Main Types
1 -Permissive Splints
 Designed To Unlock the Occlusion & Allow the Condyles
to Return to their Correct Seated Position in CR

Posterior Bite Plane
Full-Coverage” Mandibular”Full-Coverage” Maxillary”
Types of Permissive Occlusal Splints
Anterior Bite Plane

Anterior Maxillary Bite Plane Posterior Maxillary Bite Plane
Anterior Mandibular Bite Plane Posterior Mandibular Bite Plane

Anterior Maxillary Bite Plane Posterior Maxillary Bite Plane
Anterior Mandibular Bite Plane

Occlusal Splints
2- Directive Splints
 Designed To Position the Mandible in a Specific
Relationship to the Maxilla that Enhance the
Alignment of the Condyle - Disc Complex.

Anterior Repositioning Splint
Indication :
 Anterior Disc Displacement
With Reduction

The Stabilization Splint
- Muscle Relaxation S.
- Centric Relation S.
-Michigan S.
- Bruxism Appliance
 Synonyms
 The most commonly used appliance , which is a
hard acrylic splint that provides a temporary & ideal
occlusion .

- Covers the entire dental arch
- Occludes with all opposing teeth

- The Occlusal surface is flat , with slight indentations for
opposing cusp tips
- Occlusal contact should be uniform around the arch , with
solid posterior and somewhat lighter incisal contacts .

 The condyles are free to travel up & down the
eminentiae to the most superior seated position .
 Provided with Anterior Guidance Inclines that
disclude posterior contact in all Eccentric jaw position.

Horse- shoe shape
- Is primarily used in the maxillary arch because of
increased stability & retention

- Another advantage of the
maxillary splint is that all of
the opposing mandibular
incisors can easily contact the
surface of the appliance, even
when an excessive overjet is
present .

- The Maxillary Splint may
be Bulky, quite Visible , and
often Interferes with
Speech.

Rationale for Occlusal splint therapy
- Establish a new occlusal scheme
- Decrease muscle hyperactivity
- Unloading the joint structures
- Improve disc – condyle relationship
- “ Cognitive Awareness “
- Placebo effect

Main Indications for Stabilization Splints
 Symptoms related to a Neuro-Muscular Problem
( muscle spasm or myositis ) .
 Symptoms related to Joint Overloading ( capsulitis or
synovitis ).
 Cases requiring an increase in the vertical dimension .
 Nocturnal Bruxism and Clenching or Grinding Habits .

The Stabilization Splint : Indications
 Symptoms that are related to a Neuro-Muscular
problem ( Elevator Muscle Spasm or Myositis ) .

 Nocturnal Bruxism and Clenching or Grinding Habits .

 Symptoms related to Joint
Overloading ( capsulitis or
synovitis ).

 Cases requiring an Increase in the Vertical Occlusal
Dimension .

• Patients with Anterior Disc Displacement with
Early Reduction of the disc

in the post-surgical management of the TMJ
( Arthroscopy / Open joint surgery )

Clinical & Laboratory Procedures

Bite Registration
Dawson’s Method

Habitual Arc of Closure
Bite Registration

Wax Bite: 2 mm thickness between posterior
teeth Bite opening = 4 -6 mm

Study casts & wax registration are mounted on
a hinge-type articulator …..

Study casts & wax registration are mounted on
a hinge-type articulator

Retention Elements ” Optional”

Application of Isolating Medium

Clinical Adjustments
Remove Gross Interferences

•Intercuspal position:
•- Marking Centric Stops
•- Check : Uniform occlusal contacts of all
•opposing teeth
Adjustments

- Anterior Guidance
- Lateral (Excursive) Guidance
Adjustments

- Anterior Guidance
- Lateral (Excursive) Guidance
Adjustments
Absence of occlusal contacts
on the Non-Working side

- Follow – up Adjustment Appointments
-Full-time Use vs Part-time Use
- Active Treatment Duration: 3 – 6 months
Postinsertion Instructions

 Primarily At Night
 Static Pain ( Muscular involvement) : Nocturnal use
only .
 Dynamic Pain ( Joint involvement) : Full-time use .
 Acute Cases : Full-time use initially ,then decreased
gradually.
 Nocturnal Bruxism : Continued Night-time use
Use of the Stabilization Splint

- When Symptoms Have Been Significantly Reduced
- Patient is Asymptomatic for a Minimum of 3 Months .
- Discontinue the splint use in a GRADUAL Manner :
 Stop Daytime Use , Then
 Stop Nighttime Use .
The Weaning Process

Instructions for wearing TMD appliances
1- Your appliance is designed to promote healing
and help muscles, which are in spasm, to relax. It is
a treatment device not meant for long – term use.
They must only be worn under the supervision and
guidance of a dentist.
2- Wear the appliance according to the following
instructions:
Day:----------
Night:--------------
Eating:----------------

3- You may experience speech difficulties
initially. Practice reading out loud in front
of a mirror with the appliance in your
mouth to improve your speaking.
4- Avoid hard foods and do not chew gum.
5- Keep the appliance clear by soaking it in
a denture cleanser.

6- Avoid carrying, pushing, or lifting heavy
objects which may strain the muscles in your
face, jaws, neck, and back .
7- Never adjust your appliance.
8- Never wrap the appliance in a tissue or
napkin – it may be lost.
Remember- The More You Wear Your
Appliance, The Faster Your Recovery.

Conclusion
 When Treating Patients With TMDS ,The Overriding Objective is
to TREAT THE PATIENT RATHER THAN THE DISORDER.
 So it is Usual to Utilize More Than One Method of Treatment to
Maximize Any Complementary Effects

Hippocrates
Sometimes Cure, Often
Palliate, and Always Comfort

Thanks For Your Attention
Dr. Marwan Mouakeh

TMD's and occlusal splint therapy

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