Temporomandibular disorders /certified fixed orthodontic courses by Indian dental academy

TEMPOROMANDIBULAR
DISORDERS
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

3/5/2014


1

Introduction
The Temporomandibular joint is a unique joint present in
the body and is different than other joints of the body for two
reasons –

First it is not a single joint but a pair of joints working in
tandem and in a well coordinated manner to meet functional
demands.
Second, unlike other joints of the body where
movements of the joint are determined by functional demands
and anatomy of the joint, the path of movements and position of
the Temporomandibular joint at rest are determined by the teeth
of either jaw which the joint helps to keep in an occluded
position.
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2

Components of
Temporomandibular joint function

• Occlusion
• Muscles of Mastication
• Temporomandibular joint

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Occlusion
TOOTH TO TOOTH OCCLUSION

STATIC / ANATOMIC OCCLUSION:

TOOTH TO TWO TEETH OCCLUSION

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Occlusion
FUNCTIONAL OCCLUSION:

AN OCCLUSION THAT IS IN HARMONY
WITH THE JOINT AND ASSOCIATED MUSCULATURE.
ROTH’S CRITERIA FOR FUNCTIONAL OCCLUSION: - MUTUALLY
PROTECTED OCCLUSION.
• TEETH IN MAXIMUM INTERCUSPATION WHEN THE CONDYLE IS IN A IDEAL
POSITION.
• IN OCCLUSION FORCES SHOULD BE TRANSMITTED THROUGH THE LONG
AXIS OF THE POSTERIOR TEETH.
• WHEN POSTERIORS OCCLUDE AN INTER OCCLUSAL SPACE OF 0.0005
INCH SHOULD BE PRESENT IN THE ANTERIOR REGION.

• MINIMAL OVERJET AND SUFFICIENT OVERBITE TO ALLOW
DISOCCLUSION OF THE POSTERIORS IN LATERAL MOVEMENTS.
•OCCLUSAL PATTERNS SUCH AS CUSP POSITION, CUSP HEIGHT AND
FOSSA DEPTH, RIDGE AND GROOVE POSITIONS SHOULD BE IN HARMONY
WITH THE JOINT MOVEMENTS.
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Occlusion
FACTORS CONTROLLING POSTERIOR DISCLUSION ON FUNCTIONAL
MOVEMENTS:

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Occlusion
MOVEMENTS:
INCISOR ANGULATIONS:

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Occlusion
MOVEMENTS:

Upper Front Tooth Analyzer
- WhipMix Corp
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Occlusion
MOVEMENTS:

Lower Front Tooth Analyzer
- WhipMix Corp

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Occlusion
MOVEMENTS:
INTER INCISAL ANGLE OF 125 DEG
(STUART)
INTER CUSPID ANGLE OF 135 DEG
(RICKETTS)

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Occlusion
MOVEMENTS:
OVERBITE AND OVERJET CONSIDERATIONS: CUSP HEIGHT AND FOSSA
DEPTH

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Occlusion
MOVEMENTS:
OVERBITE AND OVERJET CONSIDERATIONS: CANT OF THE OCCLUSAL
PLANE

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Occlusion
MOVEMENTS:
CANINE GUIDED OCCLUSION:

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Neuromuscular Adaptation

ACCEPTABLE NEUROMUSCULAR
ADAPTATION OR CR – CO
DISCREPANCY:
1.

1 mm Antero posterior

2.

1mm Vertical

3.

Less than 0.5mm transverse

- According to Utt and Wong.

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Functional Anatomy of the
TMJ

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TMJ

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TMJ
FACTORS CONTROLLING NORMAL DISC – CONDYLE POSITION:
1.

NORMAL MORPHOLOGY OF THE DISC

2.

LIGAMENTS

3.

INTERARTICULAR PRESSURE

NORMAL MORPHOLOGY OF THE DISC AND LIGAMENTS:

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TMJ
FACTORS CONTROLLING NORMAL DISC – CONDYLE POSITION:
1.

LIGAMENTS

2.

INTERARTICULAR PRESSURE

INTER ARTICULAR PRESSURE:

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Etiology of TMD
Etiology of TMD is multifactorial

•
•
•
•

Trauma.
Psychosocial factors.
Systemic factors.
Etiology in relation to Orthodontic
treatment planning and execution.

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Trauma
A force that exceeds the normal functional loading of the joint can lead
to injury of the affected structures

Macro trauma
Microtrauma

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Macrotrauma
Macrotrauma is a sudden force to the joint that
causes structural alterations.
Causes: Injury or trauma and Iatrogenic.
Changes:
Macrotrauma
Dislocation or
fracture of the
disc

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Loosening of the
ligaments due to
elongation

Haemarthrosis,
bruising & laceration

Class II disc Class III disc
interference interference
disorder.
disorder.


21

Microtrauma
Microtrauma is any small force to joint structures that
occur repeatedly over a long period.

• Static loading.
• Impact loading.
•Frictional movement.

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Microtrauma
Static Loading: Stationary application of excessive
pressure.
Bruxism / Emotional stress / Hard chewing
Loss of occlusal molar support
Force transmitted to the joint rather than maxilla

Deformation of disc - deepening of central
bearing area
Roughening of articular surfaces
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Perforation of the disc


Class II disc interference disorder

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Microtrauma
Impact loading: occurs during the stage of maximum
intercuspation when a displaced condyle unduly
compresses an anchored disc.

Cause: Occlusal disharmony – CR-CO discrepancy.
•Loss of disc contour.
•Loss of self centering capability of the disc.
• anteromedial pull on the disc
• thinning of the posterior disc border and subsequent
elongation of the inferior retrodiscal lamina
•Grating noise.
•Class I and Class II disc interference disorder.
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Microtrauma
Frictional movement: Occurs due to overloaded movement
that exceeds the ability of weeping lubrication to prevent
damage to the articular surfaces from friction.
Cause: Gross functional disharmony when the teeth are
clenched. Eg: Class II Div II malocclusions.

•Remodeling of articular eminence.
•Loss of disc contour.
•Elongation of disc collateral ligaments.
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Psychosocial factors
• A strong association is present between
emotional stress and TMD.
• Mechanistic model of pain does not apply to
TMD: All pain arises from somatic disease or
structural damage.
• Biopsychosocial model: One cannot separate
the mind from the body when analyzing pain.
Both somatosensory and psycho social input
for pain is present.
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Systemic factors
• Presence of collagen and other
connective tissue disorders predisposes
to TMD.

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Etiology in relation to
Orthodontics
•
•
•
•
•
•
•
•

General statistics
First premolar extractions
Head gear and Class II elastics
Herbst appliance- cause or cure?
RPHG and Class III elastics
Midline switch / Cross elastics
Overbite and anterior axial inclination
Retention phase

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General statistics
• According to Graber’s study on 347 TMD patients…..
– 53% had Class II malocclusions.
– High incidence of Class III malocclusions with
anterior displacements, cross bite and tongue
dysfunction..
– Most had a deep bite and horizontal growth
pattern.
– 68% had abnormal peri oral muscle function.
– 21% showed tongue dysfunction.
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and TMD
“ first premolar extractions was a technique that was never designed
with the face, the stability of the occlusion and the health of the TMJ in
mind” - Witzig and Spahl
First premolar extraction
Over retraction of incisors
Premature contacts

Distally displace the mandible and condyle
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and TMD

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and TMD
• Larsson and Rönnerman studied 23 Swedish adolescent patients who had
been treated orthodontically 10 years previously–18 with fixed appliances and
5 with functional appliances (activators). They concluded that extensive
orthodontic treatment could be performed without fear of creating
complications of TMD
• Janson and Hasund studied 60 patients who were an average of 5 years out of
retention. These patients presented with Class II, division 1, malocclusions and they
were treated as adolescents. Thirty of the patients were treated with the extraction of
first premolars and 30 were treated on a nonextraction basis. These authors also
concluded that there was not a significant risk of developing TMD when undergoing
orthodontic treatment with or without premolar extraction.
•Dibbets and Van der Weele stated: “It is evident that over a 15 year period there exists
no relationship at all between the choice of not to extract or to extract or to extract either
first premolars or any other teeth and the registration of pain, limitation of mouth
opening, crepitation, and radiological signs.
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and TMD
•
•

•

Kundinger et al radiographically (with corrected tomography) studied the condyle
positions of 29 upper and lower premolar extraction cases and 29 untreated
patients with no evidence of TMD.
Gianelly evaluated the extraction of upper first premolars only to determine if this
procedure led to posterior condylar displacement. In a study of 12 Class II
patients treated with upper first premolar extractions, he observed that the
condyles were in a similar position, an “anterior position,” when compared with
an untreated control sample.
Årtun et al tested the hypothesis that retraction of maxillary anterior teeth may
lock the mandible in a posterior position and evaluated the relationship between
condylar position and signs and symptoms of internal derangements in the
temporomandibular joints. The authors concluded that they could not rule out
the possibility that some patients acquire a more posterior location of the
condyles during correction of Angle Class II, division 1, malocclusions with
extraction only of maxillary premolars. However, the prevalence of patients with
definitely posterior displacement of the condyles or joint sounds shortly after
therapy was similar to the control group.

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and TMD

“ The literature review shows no scientific basis for the claim that
premolar extraction results in a higher incidence of TMJ disorders.”
- Richard P. McLaughlin, John C. Bennett. AO 1995.

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Headgear and Class II
elastics
Grummons alleged that orthodontic mechanotherapies such as
Class II and III elastics, mandibular headgears, facial masks, chin
cups, and balancing side occlusal interferences, can cause TMD.
Finally, Solberg and Seligman, Thompson and Ricketts
expressed similar viewpoints.
William E Wyatt:

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RPHG and Class III
elastics
RPHG and Class III elastics produce a distal
driving force of the mandible and condyle. This would
produce a reciprocal forward displacement of the disc
and pressure on retrodiscal tissues.
•It is better to have the patient wear lower or reverse headgear and
Class III elastics only during waking hours.
•Muscle tone (tension) positions the mandible forward.
•When worn at night, the muscles are relaxed and there is more distal
pressure on the condyle because compensating muscle activity is not
in play.

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Midline switch / cross
elastics
When cross elastics are used there is a
displacement of the mandible and condyle to one side,
resulting in unilateral distal driving force on the condyle.
Can be used during day alone when the resting
muscle tone can counter act the distal driving force.

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The Herbst appliance
• Pancherz and Pancherz in 1982 studied 20 patients
undergoing Herbst treatment. There was a high
prevalence of muscle and joint tenderness – 45% during
treatment which decreased to 15% after treatment and to
10% 1 year after treatment.
• Hansen et al in 1990 did a follow up study on 19 male
subjects treated with Herbst 7.5 years earlier. TMJ sounds
were detected in 26% and muscle tenderness in 32%. 8%
of the condyles were posteriorly displaced.
• Ruf and Pancherz in 1998 did a follow up study on 20
subjects who had undergone Herbst treatment 4 years
earlier. They found moderate to severe signs of TMD in
25% of the subjects and mild signs and symptoms in 15%
of the patients.
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The Herbst appliance
• Ruf and Pancherz in 2000 studied 62 patients undergoing
Herbst treatment. They observed:
– All condyles were positioned significantly forwards but
returned to the normal position after removal of the
appliance.
– A temporary Capsulitis was present during the course of
treatment.
– Herbst appliance did not have the potential to cause
muscular TMD.
– Reduced the prevalence of structural bony changes of the
TMJ.
– Did not induce disc displacement.
– Resulted in a stable disc position in partial disc displacement
– Could not recapture the disc in cases of total disc
displacement.
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Overbite and anterior
axial inclinations
• Trying to correct Upper anterior spacing
and axial inclination in deep bite cases
without bite opening.
• Correcting lower anterior crowding in
deep bite cases without prior bite
opening.
• Both cause anterior premature contacts.
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Retention phase
Majority of orthodontically treated cases may have dental deep bites at
the beginning and some also have skeletal deep bites
Relapse will cause:
•It separates the upper
anterior teeth.
•It may crowd lower anterior
teeth.
•It tends to move the maxilla
forward.
•Drive the mandible distally.
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Retention phase

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Pathogenesis of TMD

• Changes in the Muscles
• Changes in the Joint

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Changes in the Muscles
EMOTIONAL STRESS
BRUXISM
PREMATURE CONTACT
ALTERED RESTING POSITION OF MANDIBLE

ALTERATION IN SENSORY OR PROPRIOCEPTIVE INPUT TO THE CNS

MUSCLE SPLINTING

MYOSPASM
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Changes in the Muscles
Muscle splinting: is an involuntary CNS induced
hypertonic condition.
• Splinting is normal protective reaction to any
change in the masticatory system that might be
perceived as threat to its integrity.
•A clinically discernible.
•No discomfort in the resting stage.
•Pain only on muscle contraction.
•No increase in EMG activity.
•A hypertonic reaction with resistance to stretch.
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Changes in the muscles
Myospasms: are involuntary CNS induced muscular
contractions. Myospasm causes CNS to recruit motor
unit for continuous contraction.

Causes: emotional stress, deep pain and muscle
splinting can lead to myospasms.
• Muscle is tender on palpation and firm.
•Patient complains of myogenic type of pain.
•Tenderness usually present in areas of insertion of the muscles.
•Patient complains of vague, chronic diffuse pain over head, neck and face.

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Changes in the joint
MICROTRAUMA
THINNING OF DISCAL LIGAMENTS
FUNCTIONAL DISPLACEMENT OF THE
DISC
SINGLE CLICK
RECIPROCAL CLICK
FUNCTIONAL DISLOCATION WITH REDUCTION (OPEN
LOCK)
FUNCTIONAL DISLOCATION WITHOUT
REDUCTION (CLOSED LOCK)
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Normal disc-condyle
relation

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Functional dislocation with
reduction

• PAIN
•CLICKING
•JOINT PAIN AND MUSCLE PAIN,
•DEVIATED PATH OF CLOSURE.
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Functional dislocation
without reduction
FUNCTIONAL DISLOCATION / CLOSED LOCK

• LIMITED MOUTH OPENING
• NO PAIN
•NO CLICKING
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Disc interference disorders

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Classification of
Temporomandibular disorders
•
•
•
•
•

Masticatory muscle disorders
Inflammatory disorders
Chronic mandibular hypomobility
Growth disorders

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Masticatory muscle
disorders
• Protective muscle splinting
• Masticatory myospasm
– Elevator muscle spasm
– Lateral pterygoid muscle spasm

• Masticatory myositis

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Masticatory muscle
disorders
• Protective muscle splinting
– Functional myalgia without structural restraint.
– Masticatory function is restrained due to inhibitory influence
of pain and weakness.

• Masticatory myospasm:
– Spasms of all muscles
– Functional myalgia
– Muscular dysfunction due to sustained isometric / isotonic
contractions.

• Masticatory myositis:
– Inflammation of the muscles
– Immobilization
– Soreness at rest and severe pain during function
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•
•
•
•
•

Class I interference disorders
Class II interference disorders
Class III interference disorders
Class IV interference disorders
Class V interference disorders
• Abnormal sensations, noises and movements
• Arthralgic type of pain
• Arrested movement (locking)

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• Class I interference disorders
– Symptoms occur during clenching of the teeth.

• Class II interference disorder:
– Symptoms occur during the first opening
movements after Max intercuspation.

• Class III interference disorder:
– Numerous symptoms occur during the course of
normal translatory movement.

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• Class III interference disorder:
– Due to excessive interarticular pressure.
– Due to structural irregularity.
– Due to non inflammatory degenerative joint
disease.
– Internal derangement

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• Internal derangement
– Detached sup retrodiscal lamina:
• Anterior dislocation of the disc.
• Irregular movement during the forward translatory phase of
movement.

– Disc displacement:
• Loss of disc contour and elongation of ligaments.
• Symptoms of clicking, catching and locking.

– Damaged disc:
• Deformation and perforation of the disc
• Grating noise
• Irregular movements

– Adhesions.

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• Class IV interference disorder:
– Mouth opening extends beyond the normal
anterior limit of translatory movement of
disc-condyle complex.

• Class V interference disorder:
– Spontaneous anterior dislocation.
– Due to wide opening
– Disc trapped anteriorly preventing closure
–”open lock”.
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Inflammatory disorders
•
•
•
•

Synovitis
Capsulitis
Retrodiscitis
Inflammatory arthritis

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Chronic mandibular
Hypomobility
•
•
•
•

Pseudoankylosis
Contractured elevator muscles
Capsular fibrosis
Ankylosis

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Growth disorders
• Neoplasia
• Abberant development
• Acquired change

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Diagnosis

• Functional examination
• Radiological examination

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Functional examination
• Palpation: Muscles
• Digital palpation is used
• Muscle should be evaluated
through out it’s length –
origin, muscle belly and
insertion.
• Should be evaluated at rest,
stretched and contracted
position.
• Examined bilaterally for
comparison.
• Palpate horizontally and
parallel to their attachments.
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• Two methods of
palpation- Flat palpation
and Pincer palpation.
• Flat palpation- use
middle finger to press
the muscle against
underlying bone. Soft
but firm palpation in a
small circular motion.
• Pincer palpation –
palpate muscle
between forefinger and
thumb.
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• Temporalis: Flat palpation
when palpating the anterior,
middle and posterior
portions.
• Temporalis tendon: Bidigital
palpation intraorally and
extra orally along the
anterior border of the ramus.
• Masseter: Superficial and
deep masseter – flat
palpation.
• Pincer palpation for anterior
border of superficial fibres.
• Pterygoids: Intra oral
palpation.
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• Palpation
• STAND IN FRONT OF THE PATIENT.
• LATERAL POLES OF BOTH CONDYLES SHOULD
BE PALPATED SIMULTANEOUSLY USING DIGITAL
PRESSURE.

•ASK THE PATIENT TO OPEN THE MOUTH
SLIGHTLY AND PALPATE 10 TO 20 mm IN FRONT
OF THE EXTERNAL AUDITORY MEATUS.
•TO CHECK FOR POSTERIOR WALL
TENDERNESS ASK THE PATIENT TO MOVE THE
MENDIBLE TO THE CONTRALATERAL SIDE OR
USE THELITTLE FINGER TO PALPATE FRO WITHIN
THE EAM.

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• Auscultation
• Click: A single noise of short
duration that occurs at any point in
the active range of mandibular
motion.
• Crepitus: A grating or gravelly noise
caused by degenerative changes in
the articular joint surfaces.
• A loud popping noise or thud at the
end of mouth opening indicative of
joint hyper mobility when the disc
condyle complex moves over the
articular eminence.
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AUSCULTATION:

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EARLY
INT

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LATE


70

EARLY OPENING CLICK – 0 TO 15 mm

MIDDLE OPENING CLICK – 16 TO 30 mm
LATE OPENING CLICK – 31 TO 50 mm

EARLY CLOSING CLICK – 31 TO 50 mm
MIDDLE CLOSING CLICK - 16 TO 30 mm
LATE CLOSING CLICK - 0 TO 15 mm
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• Functional analysis
– Postural rest position.
– Maximum mouth opening
– Path of mandible on opening and closing.

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• Postural rest position
– Command method
– Non command method
– Combined method

• Methods of measurement
– Direct intra oral
– Direct extra oral
– Indirect extra oral
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• Deviated mouth
opening
• Deviation always
occurs towards the
side of decreased
mobility.
• Condylar
hyperplasia is an
exception.
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• Path of the mandible on opening

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Laterotrusive movements

TOWARDS LEFT
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TOWARDS RIGHT

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• Path of closure from
postural rest to
centric occlusion:

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AXIOGRAPH:

• Compares hinge axis
pathways of normal
individuals and patients with
TMD.
• Records hinge axis
movements in three planes.

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AXIOGRAPH TRACINGS:

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FUNCTIONAL MOUNTING OF THE PATIENT’S MODELS:

FACE BOW TRANSFER:

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FUNCTIONAL MOUNTING OF THE PATIENT’S MODELS:
BITE REGISTRATION FOR CENTRIC
RELATION: ROTH’S POWER CENTIC
BITE REGISTRATION.

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ARTICULATOR MOUNTING:
PANADENT ARTICULATOR

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CONDYLAR POSITION INDICATOR


82

CR – CO DISCEPANCY RECORDINGS OF THE CPI:

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Radiological examination
• Hard Tissue
– Panoramic radiograph
– Extra oral Projections
• Transcranial
• Transpharyngeal (Parma)
• Transorbital

– Conventional tomography
– Computed tomography

• Soft tissue
– Arthrography
– MRI
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Panoramic Radiograph

•
•
•
•

A screening projection
Gross osseous changes- erosions, osteophytes
No information about condylar position or function
Superimposition of the skull base and zygomatic arch

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Transcranial projection
• Provides a sagittal view of
the lateral aspects of
condyle and temporal
component
• Only lateral joint contours
are visible
• Superimposition of the
petrous ridge may be
present.
• Image is usually distorted
and the position is of the
condyle is not reliable.
• For identifying gross
osseous changes and range
of motion (open views)
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Transpharyngeal
projection
• Provides a sagittal view
of the medial pole of the
condyle
• The temporal
component is not
imaged well
• Limited diagnostic value
• Only for osseous
changes in the condyle.

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Transorbital projection
• Provides an anterior
view of the TMJ
• Entire mediolateral
aspect of the
condylar head and
neck is visible.
• Can give a limited
view depending
upon the degree of
mouth opening.
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Conventional tomography
• A radiographic technique
that produce thin image
slices free of
superimpositions of adjacent
structures.
• Produce images at right
angles to the condylar axis –
better view for depicting true
condylar position.
• Corrected sagittal
tomography using the aid of
a SMV projection or a 20
degree head rotation.

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Computed tomography
• Image slices are
made in both
sagittal and coronal
planes.
• 3D images can be
constructed
• Cannot produce
accurate images of
the disc
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Computed tomography

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Computed tomography

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Arthrography
• A technique in which an indirect image of the
disk is obtained by injecting a radio opaque
contrast agent into one or both joint spaces
under fluoroscopic guidance.
• Single space and double space tomograms
• Disk position, function, morphology and
integrity of diskal attachments.
• Risks- Pain, infection, iatrogenic damage and
allergy.
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Magnetic Resonance
Imaging
• Excellent images of
soft tissues
• Imaging of the disk
in all three planes
• Contraindications:
ferromagnetic
materials, Non
ferrous metals and
cardiac
pacemakers.
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Magnetic Resonance
Imaging

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Management of TMD
• Corrective treatment
– Splints
– Splints combined with orthodontic
appliances

• Palliative / supportive treatment
– Sedatives
– Analgesics
– Counseling
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Splints
Splints are hard or soft removable acrylic appliances covering the
teeth.
MODE OF ACTION :
• Eliminate occlusal disharmony
• Prevent wear and mobility of teeth
• Reduce bruxism and parafunction
• Treat muscle dysfunction
• Correct internal derangement
• Limiting the extent of potentially harmful movements.
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99

Types of splints
STABILIZATION SPLINT:
OTHER NAMES: Muscle deprogramming splint, Flat
plane splint, Superior repositioning splint, CR splint,
Tanner splint (Mandibular), Shore splint (Maxillary),
Michigan plane.
DESIGN:

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100

Types of splints
STABILIZATION SPLINT:
MODE OF ACTION:
• Changes tooth contact
• Alters muscle function

USES:
• Treatment of muscle and joint pain from
occlusal contact discrepancy and parafunctional
activity.
• Mandibular position deprogramming.

•Vertical dimension alteration.

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Types of splints
ANTERIOR REPOSITIONING SPLINT:
OTHER NAMES: Repositioning splint, LARS ( Ligated
Anterior Repositioning Splint), Orthopedic positioner.
DESIGN:

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Types of splints
ANTERIOR REPOSITIONING SPLINT:
MODE OF ACTION:
• Change in tooth contact
•Change in muscle function
•Alters the stress and loading of the joint

• Disc recapture

USE:
• Alter condylar position at occlusal contact
•Meniscus recapture.
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Types of splints
BITE PLANE SPLINT:
OTHER NAMES: Anterior jig, Luca jig, Hawley with ABP,
Anterior deprogrammer, Six point splint.
DESIGN:

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Types of splints
BITE PLANE SPLINT:
USES:
• When premature contacts are present in the
posterior segments.
• Reduce muscle activity.
MODE OF ACTION:

• Interrupts mandibular position sense
• Eliminates propioceptive feedback from posterior
teeth.
•Reduces muscle activity.

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Types of splints
PIVOT SPLINT: Based on the principle of joint traction.
DESIGN:

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Types of splints
PIVOT SPLINT:
MODE OF ACTION:
• Unloading of the joint in cases of inflammation and internal
derangement.
USES:
• Internal derangement.
• Intracapsular inflammation.

DISADVANTAGE:
• Changes in tooth position occur due to the limited areas of tooth
contact.
• No control over condylar position.
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Types of splints
SOFT SPLINT: An emergency appliance.
OTHER NAMES: Positioner, mouth guard, night guard.
DESIGN:

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Types of splints
SOFT SPLINT:
USES:
• Athletics.
• For reducing parafunctional activity (not
substantiated).
• On a temporary basis for relief of symptoms.
DISADVANTAGES:
• Incapable of causing occlusal adjustments due to
the resilient nature.
•Can cause tooth movements.
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Types of splints
MORA: Mandibular Orthopedic Repositioning Appliance.
OTHER NAMES: Gelb Splint.
USES:
• Change posterior occlusion.
• Eliminate anterior tooth contact.
DESIGN:

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Types of splints
HYDROSTATIC SPLINT:
USE: Equalizes biting pressure over all teeth.
DESIGN:

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Management of TMD
• Type I disorder
– Mainly a muscle problem

• Type II disorder
– Mainly a disc problem
– Functional damage to the joint

• Type III disorder
– Major bone damage
– Structural damage to the joint components
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Management of Type I
disorder
PATIENT COMPLAINS OF…..
• Pain from different areas in the head, neck and shoulders but not in the
joint area.
ON CLINICAL EXAMINATION……
• Presence of a dual bite. (occlusal precontact)
•Tension in the masticatory muscles
• Tenderness on palpation of the muscles. Esp Lateral Pterygoid.
• Abnormal mandibular movements.
AIM OFTREATMENT………
• To eliminate muscular tension and pain.
• Correct alignment of teeth in both arches.
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disorder

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disorder

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disorder
TREATMENT:
• Splints
• Six point splint/ / Bite plane splint
• Stabilization splint

• Orthodontics
• Selective grinding
• Medication
• Counseling

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Management of Type II
disorders
PATIENT COMPLAINS OF……..

• Increase in myogenic type of pain
• Onset of arthrogenic type of pain
• Clicking noise
• Occasional acute locking
•Limited movement on one side
ON EXAMINATION:
• Pain on palpation
• Clicking, grating
• Deviation in path of mandible
AIM OF TREATMENT:
• Restore normal condyle – disc – fossa relationship (DISC RECAPTURE)
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Management of Type II
disorders
TREATMENT:
• Splint
• Michigan plane / Stabilization splint
• Antero superior repositioning splint
• Orthodontics with splint

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Management of Type III
disorders
PATIENT COMPLAINS OF…..
• No pain
• Impossible to eat
• Limited mouth opening

AIM OF TREATMENT:
• Treat for ‘ BEST ANATOMIC COMPROMISE’

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Management of Type III
disorders
TREATMENT:
• PHASE I:
• Immediately free the joint

• Type III splint
• PHASE II:
• Sectional orthodontics with splint
•Achieving normal dental relationships

•Prosthetic replacements.
•surgery

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Conclusion
The TMJ is a very complex joint to deal with as
a whole. As people who move teeth and change
occlusion, the orthodontist may be the one who alters
joint function the most.

The importance of treating from a centric
relation position to a centric relation position cannot be
stressed any more.
A thorough knowledge of TMJ function and
disorders and functional occlusion is essential to
establish long term goals for the occlusion and the
joint.
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REFERENCES
• Extraction-non extraction dilemma as it relates to TMD –
Mclaughlin, Bennet; AO 1995, No 3
• The physiology of splint therapy – Roger A Boero; AO 1989 No
3
• Occlusion with particular emphasis on the functional and
parafunctional role of anterior teeth: Part 1 - JCO 1979 Sep
(606-620): William H McHorris
• Concepts in functional occlusion and management of functional
disorder of TMJ- Dr. N.R. Krishnaswamy. 7th IOS PG students
convention.
• Garden of Orthodontics –
• TMD- Weldon E Bell
• TMD a practitioner’s guide – Annika Isberg.

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Thank you
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123

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