The document discusses temporomandibular joint disorders (TMD) and their relationship to orthodontic treatment. Some key points:
- TMD signs and symptoms are common in the general population and usually increase with age, unrelated to orthodontic treatment.
- Orthodontic treatment does not increase or decrease the risk of developing TMD. No specific orthodontic mechanics are linked to higher risk.
- Achieving an ideal occlusion does not prevent TMD, and no method of prevention has been proven effective. TMD is usually alleviated by simple, conservative treatments in most cases.
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Temporo Mandibular joint (TMJ) importance in orthodontic treatment /certifie...Indian dental academy
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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
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Description :
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
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www.indiandentalacademy.com
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Temporo Mandibular joint (TMJ) importance in orthodontic treatment /certifie...Indian dental academy
Welcome to Indian Dental Academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
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Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
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Description :
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
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www.indiandentalacademy.com
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
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Temporomandibular joint disorder (TMD), or TMJ syndrome, is an umbrella term covering acute or chronic inflammation of the temporomandibular joint, which connects the mandible to the skull. The disorder and resultant dysfunction can result in significant pain and impairment. Because the disorder transcends the boundaries between several health-care disciplines — in particular, dentistry, neurology, physical therapy, and psychology — there are a variety of treatment approaches.
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offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
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Esthetic Evaluation of ImplantsPlaced after Orthodontic Treatment in Patients...Abu-Hussein Muhamad
Congenitally missing teeth are frequently presented to the dentist. Interdisciplinary approach may be needed for the
proper treatment plan. Several treatment options exist for the replacement of congenitally missing lateral incisors.
These options include canine substitution, resin bonded fixed partial dentures, cantilevered fixed partial dentures,
conventional fixed partial dentures and single tooth implants. Depending on which treatment option is chosen, a
specific criterion has to be addressed. Interdisciplinary treatment plays a vital role to achieve an excellent, esthetic
result for a most predictable outcome. This article aims to present a case report of replacement of bilaterally
congenitally missing maxillary lateral incisors with dental implants
Key words: congenitally missing lateral incisor, interdisciplinary treatment, dental impla
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TMJ is formed by the mandibular condyle and the mandibular fossa of the temporal bone. The articular disc separates these two bones from direct articulation .
The main components of TMJ
Mandibular condyles
Articular surface of temporal bone
Articular disc
LigamentsSPHENOMANDIBULAR LIGAMENT
morphologically, it is remnant of cephalic end of meckel’s cartilage is attached
superiorly to: spine of sphenoid bone
inferiorly to: lingula of mandibular foramen
laterally related to: lateral pterygoid muscle, auriculotemporal nerve, maxillary artery.
medially related to: chorda tympani nerve.
near its lower end it is pierced by: mylohyoid nerves and vessels
STYLOMANDIBULAR LIGAMENT:
It is thickened part of deep cervical fascia.
Above: lateral surface of styloid process.
Below: angle and adjacent part of posterior part of ramus.
AGE CHANGES
CONDYLE:
Becomes more flattened
Fibrous capsule becomes thicker.
Osteoporosis of underlying bone.
Thinning or absence of cartilaginous zone.
ARTICULAR DISK:
Becomes thinner.
Shows hyalinization and chondroid changes.
BLOOD VESSELS AND NERVES:
Walls of blood vessels thickened.
These age changes lead to:
-Decrease in the synovial fluid formation
-Impairment of motion due to decrease in the disc and capsule extensibility
-Decrease the resilience during mastication due to chondroid changes into collagenous elements
-Dysfunction in older people
TMJ EXAMINATION
Examined both clinically and radiographically.
PALPATION OF TMJ is determined by digital palpation..
CREPITATION This is a grating or scalping noise that occurs on jaw movements. may be an early sign of degenerative joint disease. AUSCULTATION OF THE TMJ can be examined with a stethoscope. Also the timing of clicking during opening and closure can be noted.
CLICKING It occurs due to the uncoordinated movement of condylar head and TMJ disc. Joint clicking is differentiated as:
Initial clicking: it is a sign of retruded condyle.
Intermediate clicking: it is a sign of uneven condyle surfaces and articular disc.
Terminal clicking: it is an effect of the condyle being moved too far anteriorly in relation to the disc on maximum jaw opening. TMJ ARTHROGRAPHY
Norgaard (1940)
Indications:
Position and function of disk -pain and dysfunction-long standing
History of locking-persistent
Perforations of the disk and retrodiskal tissue.
Therapeutic :
To delineate loose bodies in the joint spaces
Diagnostic aspiration of joint fluid.
Intraarticular injections of steroids
Contraindications:
Infections in the preauricular region.
Patients allergic to contrast media.
Patients with bleeding disorders and on anticoagulant therapy
TMJ ARTHROGRAPHY
Norgaard (1940)
Indications:
Position and function of disk -pain and dysfunction-long standing
History of locking-persistent
Perforations of the disk and retrodiskal tissue.
Therapeutic :
To delineate loose bodies in the joint sp
Detailed discussion on diagnosis and management of TMJ ankylosis. Surgical anatomy and applied aspects of TMJ is discussed. Reconstruction of ramus-condyle unit is also discussed. Compications of TMJ surgery are also discussed
The temporomandibular joint is the joint of the jaw and is frequently referred to as TMJ. The TMJ is a bilateral synovial articulation between the mandible and temporal bone. The name of the joint is derived from the two bones which form the joint: the upper temporal bone which is part of the cranium (skull), and the lower jawbone or mandible.
There are six main components of the TMJ.
Mandibular condyles
Articular surface of the temporal bone
Capsule
Articular disc
Ligaments
Lateral pterygoid
3. Take Home Message
•TMJ signs and symptoms appear in healthy individuals.
TMJ i d t i h lth i di id l
•The signs and symptoms usually increase with age.
Thus, symptoms occurring during treatment may not be
related to treatment.
•Orthodontic Tx does not increase / decrease odds of TMD.
•No specific risk is associated with any particular orthodontic
N ifi i k i i d ih i l h d i
mechanics.
Not achieving an ideal gnathological occlusion does not
result in TMD.
•No method of TMD prevention has been demonstrated.
•TMD signs and symptoms usually are alleviated by simple Tx
in most cases.
4. Questions to be answered
• What impact does occlusion have on TMJ disorders ?
• Does orthodontic treatment cure / prevent TMD ?
• Does orthodontic treatment cause TMD ?
• Can serial occlusal adjustment prevent TMD ?
5. Gross Anatomy
•TMJ
–Articulation between
A ti l ti b t
the mandibular condyle
and the mandibular
fossa of the temporal
bone
6. •An articular disc
complete divides the
joint space into upper
and lower compartments
–Posterior attachment of
disc to condyle and
temporal bone
–Loose fibrous connective
tissue
–Vascular and innervated
7. Muscle Insertion
•Primary insertion is
the lateral pterygoid
muscle to the anterior
aspect of the condyle
and a few muscle
fibers inserting into
the anterior band of
the disc
9. Blood Supply
•Blood supply is from
the
th maxillary and
ill d
superficial temporal
branches of the
external carotid artery
10. TMJ – A Synovial Joint
• Load bearing surfaces which are
avascular and not innervated
l d ti t d
• Lubrication by synovial fluid
– Less than 1 cc of synovial fluid per
compartment
• Fibrous capsule contains synovial fluid
and maintains relationship between
p
joint components during function
11. • Difference between TMJ and other
synovial joints
i lj i t
Structure: The TMJ has an articular disc which
completely divides the joint space into
l t l di id th j i t i t
separate upper and lower joint
compartments.
compartments Two joints are connected.
connected
Function : the TMJ is a Hinge-sliding joint
with a hinge action (rotation – lower) and a
sliding action (translation – upper)
Complex structure & complex function
12. Biomechanics
Hinge /sliding joint
•Rotation (hinge)
between the condyle
and the inferior surface
of the disc during early
opening
•Translation ( lidi )
T l ti (sliding)
between the disc-
co dy e complex and
condyle co p e a d
the temporal
component during
wider opening
14. Histological Features
• The osseous tissues of the condyle and
temporal components are covered by
articular “soft tissue” which as the
following layers in young adults
– Articular zone of fibrous connective tissue -
Functional
– Proliferation zone of undifferentiated
mesenchymal cells – Progenitor cells of the
cartilage layer
til l
– Cartilage zone – Hyaline cartilage which is
converted to fibrocartilage
15. TUBERCLE COVERING
Dense BONE
OSSIFICATION
IV
} CALCIFICATION
}FIBROCARTILAGE III
}PROLIFERATIVE II
} ARTICULAR I
(FIBROUS)
16. MATURE CONDYLAR LAYERS
ARTICULAR
} (FIBROUS)
I
PROLIFERATIVE II
} FIBROCARTILAGE III
} CALCIFICATION IV
} OSSIFICATION
new bone on calcified
SUBCHONDRAL cartilage
BONE TRABECULAE
18. • The articular surfaces of the TMJ are
covered with fibrous connective tissue, ,
not hyaline cartilage, as in most other
synovial joints
y j
MANDIBULAR CONDYLE
Condylar cartilage
(not all cartilage)
Spongy bone
19. • The posterior attachment is composed of
loose fibrous ti
l fib tissue with vascularity and
ith l it d
innervation
20. Adaptive variations
– Articular surface irregularities (deviation in
form)
•M
Morphological changes may alter joint
h l i l h lt j i t
biomechanics and/or produce joint
sounds such as ‘ li ki ’ or ‘
d h ‘clicking’ ‘crepitation’
it ti ’
21. Adaptive variations
• The apparent potential of the TMJ for
adaptation supports a biological
rationale for conservative treatment
approaches directed at reducing pain
and disability rather than correcting
p
altered morphologygy
22. Embryology
• TMJ develops between 8 – 14 weeks
compared t 5-8 weeks for other
d to 5 8 k f th
synovial joints
23. Embryology – TMJ
• 10 – 11 weeks
Ossification of the temporal components begins
independently of the events in the mandible
• 12 weeks
– the condylar cartilage is present at the most
superior aspect of the ramus.
– the embryonic connective tissue (mesenchyme)
emb onic connecti e tiss e (mesench me)
between the growing condyle and temporal bone
condenses to form the articular disc
• 13 weeks
– cavitation forms the lower joint compartment and
then the upper compartment
24. • 14 weeks
– Joint development completed
• Persistence of the condylar cartilage as
the cartilage zone of the articular soft
g
tissue is presumed to contribute to the
adaptation capacity of the adult condyle
p p y y
25. Pathologic symptoms and signs-TMD
• Definition:
– Collection of medical and dental conditions
affecting the temporomandibular joint
and/or the muscles of mastication as well
mastication,
as contiguous tissue components.
26. Prevalence of TMD
• 32% of population report at least one
symptom of TMD
– Difficulty opening
– Locking
– Pain on movement
– Joint sounds
– Muscle fatigue
– Stiffness of lower jaw
27. Historical Perspective
• Thompson was the first to note patients with
disturbances in vertical dimension more prone
to TMD
– Advocated the elimination of all interferences in
“freeway space” envelope of movement
“f ” l f
• T. Graber was the first to note the
multifactorial nature of TMD, occlusion being
TMD
only one factor
– Cited stress and nocturnal parafunctional habits as
contributors
– Advocated psychological counseling as part of
therapy
py
28. Questions to be clarified
Occlusal Temporo
p
Disturbances Mandibular
Dysfunction
29. Orthodontic Temporo
p
Treatment Mandibular
Dysfunction
32. In adult patients?
Schmitter et al., J Oral Rehabil. 2005 Jul;32(7):467-73
Fifty-eight geriatric patients VS. 44 young subjects
•Geriatric subjects more often exhibited objective
symptoms of TMD (38% exhibited joint sounds on
opening), but rarely suffered from pain (pain at rest: 0%,
joint pain: 0%, muscle pain: 12%).
•In contrast, young subjects rarely exhibited objective
symptoms (j i t sounds: 7%), but suffered more
t (joint d 7%) b t ff d
frequently from pain (facial: 7%, joint pain: 16%,
muscle pain: 25%).
25%)
33. Q 1: Is there prevalence data which shows that one type
of malocclusion is more likely to be associated with a TMD?
• There is no association between overbite or overjet
and self-reported TMD. N= 3033
John et al., J Dent Res. 2002 Mar;81(3):164-9.
• 82 asymptomatic volunteers vs. 263 symptomatic
TMD patients
p
Literature does not suggest that replacement of
missing posterior teeth prevents the development of
TMDs. However, missing mandibular posterior teeth
i i dib l i h
may accelerate the development of degenerative
joint disease
disease.
Talents et al., J Prosthet Dent. 2002 Jan;87(1):45-50.
34. • Few malocclusions except socioeconomic parameters
were associated with TMD signs, and these associations
i t d ith i d th i ti
were mostly weak.
• Only bilateral open bite up to 3 mm appeared to be
clinically relevant and was associated with TMD signs
(
(odds ratio [OR] = 4.0). This malocclusion, however,
[ ] ) , ,
was of rare occurrence, with a prevalence of 0.3% (n =
9).
Sample size of 4310 men and women aged 20 to 81 years
(response 68.8%) was investigated for TMD signs, malocclusions,
functional occlusion factors, and sociodemographic parameters
using multiple logistic regression analysis
Gesch et al., Angle Orthod. 2004 Aug;74(4):512-20
35. Occlusal Temporo
p
Disturbances Mandibular
Dysfunction
36. Q2: Is there any prevalence data which shows that one
type of occlusion (for instance, canine guidance) is
more likely associated with TMD?
Pullinger and Seligman (2000)
Looked at predictive values of occlusal variables in TMD
By comparing patients with TMD from asymptomatic
normals.
The predictive power of the occlusal values was low
p p
(odds ratio of 2:1)
Patients with disc displacement were characterized by
Unilateral
U il t l crossbite and l
bit d long CO-CR slides.
CO CR lid
Patients with osteoarthritis were related with very long
CO-CR slides
No variable was associated with canine guidance
37. Q 2-1 Are canine guidance (CG) and joint clicking related?
Donegan et al J Oral Rehabilitation 1996 23: 799-804
al., 799 804
In non-patients (n=46) and patients (n=46,with clicking),
In non-Pts, 70% without CG and 30% with CG
In Pts, 78% without CG and 22% with CG
Pts CG.
,
In both Pts and non-Pts,
61% with non-CG and 38% with CG.
No-evidence that both distal (retrusive) and mesial
(protrusive) CG was associated with ipsilateral
clicking.
clicking
38. Q3, Is there a relationship between disc derangement
and occlusion?
Kahn et al., J Prosthetic Dent 1999, 82: 410-5
82 asymptomatics vs. 263 with symptomatic TMDs
vs
39. Q. 4: How often do post-orthodontic cases show
balancing interferences?
Non-working side contacts occurred in 30% of subjects.
And
A d posterior contacts on protrusion i 20%.
t i t t t i in 20%
40. Is there a correlation between
orthodontic treatment
and increased likelihood of getting a
TMD?
41.
42.
43. Questions
addressed by the NIH technology assessment
conference, 1996
1. What clinical conditions are classified
as TMD and what occurs if these are
untreated?
2. What signs and symptoms provide a
basis for initiating intervention?
g
3. What are effective initial therapies?
4. What are effective therapies for
persistent TMD?
44. 1. What clinical conditions are classified as TMD and what
occu s
occurs if these are u ea ed ?
ese a e untreated
• Specific etiology of TMD lacking; therefore, diagnosis
depends on signs and symptoms
d d i d t
• Conditions affecting muscles of mastication:
– Polymyositis
y y
– Dermatomyositis
• Conditions affecting the TMJ:
– Arthritis
– Ankylosis
– Growth disorders
–RRecurrent dislocation
t di l ti
– Neoplasias
– Condylar fracture
y
– Systemic illness
45. What are classified as TMD and what occurs if these
are untreated?
• TMD can be either muscle or joint pain or a
combination of both
• Peak prevalence in young adults (20-40)
• S
Some studies show equal gender predilection,
t di h l d dil ti
but others show higher number of females
• Usually self-limiting if left untreated
self limiting
• Few data to assess long term course in
absence of treatment
46. 2. What signs and symptoms provide a basis for
initiating intervention?
• Physical examination:
–P i
Pain
– Limited range of motion
– Parafunctional habits
– Muscle tenderness
– Psychosocial factors
• Conservative non-invasive treatment
– Patient education/awareness
47. 3. What are effective initial therapies?
• Supportive patient education
– M t courses of TMD are b i
Most f benign and self-
d lf
limiting
• Pharmacologic pain control
– NSAIDS (ibuprofen, naproxen)
– Opiates (oxy- and hydrocodone)
– Muscle relaxants (amitriptyline)
– Low-dose antidepressants (amitriptyline)
Low dose
48. 3. What are effective initial therapies?
•Physical therapy
•Intraoral appliances
–Stabilization splints
•Occlusal therapy
–Controversial
–Irreversible
–Not demonstrated in randomized clinical trials to
be superior to reversible therapies
49. 4. What are effective therapies for persistent
TMD?
• Pharmacologic therapies
– NSAIDS
– Opiates
• Major concerns include:
j
– Addiction potential
– Analgesic tolerance
– Uncontrolled s de e ects (itching, co st pat o , nausea)
U co t o ed side effects ( tc g, constipation, ausea)
– Anxiolytic/Hypnotic drugs (benzodiazepines)
• Pain disorders can result in sleep disorders
• Anxiolytic/hypnotic drugs can improve sleep patterns
50. Pharmacologic management of TMD
• NSAIDS
– Effective in relieving acute inflammatory
pain
– When prescribed f weeks or months,
h ib d for k h
however, increased risk for GI ulcerations,
bleeding and renal toxicity
51. COX-2 Inhibitors
• Selectively inhibit COX-2 enzymes,
allowing production of cytoprotective
prostanoids
• Celecoxib (Celebrex)
• Rofecoxib (Vioxx)
• I iti ll popular for the management of
Initially l f th t f
osteoarthritis and rheumatoid arthritis
•NNow popular for chronic orofacial pain
l f h i f i l i
52. Side Effects
• Drug interactions
– May decrease the effectiveness of ACE-
inhibitors used to treat hypertension
• May alter kidney function
• Not safe for use during p g
g pregnancy
y
• Drug allergies to NSAIDS or ASA
53. Occlusal stabilization splints
•Used often in clinical practice
for treatment of TMD
•Monoplane, acrylic appliance
•Either maxillary or mandibular
y
•Adjust until point contacts
•Relaxes muscles of
mastication
ti ti
•Constructed to place patient
in centric relation
•Eliminates tooth guided
condylar position
54. What does the literature say?
• Article published in JADA, 2001
• Reviewed 10 studies using placebo and treatment
groups
• Weaknesses in design:
– E h study l
Each t d lumped TMD patients all together, regardless of
d ti t ll t th dl f
symptoms
– Need to evaluate effectiveness of splint therapy for each
subgroup of TMD (clicking muscle pain limited opening, etc)
(clicking, pain, opening
• Overall, concluded that splints work as behavioral
interventions to produce changes in the
position of the mandible
55. TMD can be treated or caused by Orthodontic
Treatment ?
56. – Signs and symptoms may occur in
healthy persons
– Signs and symptoms increase with
age, often start in adolescence
g ,
• Orthodontic treatment and TMD
start in adolescence; difficult to say
if a true relationship
– Orthodontic treatment during
adolescence does not increase or
decrease the likelihood of having TMD
as an adult
57. • Extraction during treatment does not
increase risk of TMD
i i k f
– Certain types of orthodontic mechanics does
not increase risk of TMD
– Little evidence orthodontic treatment prevents
TMD
• The role of unilateral posterior crossbite
correction in the prevention of TMD needs further
investigation
g
• Pullinger noted that patients with unilateral
posterior crossbite in childhood had an odds
ratio for TMD of >2:1 in adulthood
• Hypothesized that, in a small percentage of patients,
a mandibular shift places increased loading on
one TMJ, leading to internal derangement and TMD as
an adult
58. Conclusions
• TMD is multifactorial in nature
– Warrants a multi-faceted approach
• Self-limiting in nature
• Conservative, non-invasive, reversible
initial treatment
t a t eat e t
• Pharmacologic therapy for persistent
TMD
– COX-2 inhibitors important in
armamentarium
59. Litigations
• Common
• Can occur spontaneously
• Record, record, record
, ,
• Be conservative!
• Refer