TMJ Presented At Neurosurgery Conference.

1. Trigem
inal Neuralgia
A
Dental Perspective

2. A
Multidisciplinary
Approach
Differential
Diagnosis

3. The Stomatognathic Triad
• Articulation Of The Teeth –
Dominant
• Joints – Accommodate
• Muscles – Accommodate

4. Articulation of
the teeth (Bite)
Bite

5. TMJ Pain
TMJ Noise
Headaches
Cervical Pain
Ear Congestion
Limited Opening
Postural Problems
Parathesia of Finger Tips

6. Dizziness -Vertigo
Ringing in ears - Tinnitis
Swallowing difficulty - Dysphagia
Bell’s Palsy
Trigeminal Neuralgia
Nervousness/ Insomnia
Non-Specific Facial Pain

7. Video Tmj #
9

8. •Video TMJ # 9
•Next

9. No Matter How
Malpositioned
The Occlusion

10. Muscles Will Struggle
to Create a Centric
Occlusion (C.O.)
They Accommodate

11. The
Temporomandibular
Joints Accommodate

12. Disc and Condyle
Rotation Then Translation
• Should move
synchronously
• Maintain spatial
relationship
• Adequate disc space
• Synchronous non-
hypertonic
musculature

13. Asynergy of Disc and Condyle
Rotation And Translation
• Can be the result of
mechanical
impingements
• Or muscle spasms that
result in uncoordinated
disc movement

14. Clinical Range Of Motion
•40 mm or Around Three Fingers
•Lateral About ¼ Of Max Opening
•Symmetrical – No Deviations
•Asymmetrical – Deviates To The
Side Of The Dysfunction
•Clicking Joint
•Non Reducing Disk

15. Smooth Movement
1. Centric (Habitual) Occlusion with posterior teeth in maximum
cuspation.
2. Normal opening free of clicks and dyskinesia.
3. Normal Closing.
4. Maximum speed of opening.
5. Maximum speed of closing.
6. Speed of mandible at moment of tooth contact.
7. Note: Lack of lateral deviation during opening and closing
movements.

16. Uncoordinated function
• Slowing mandibular
movement
• Characteristic of
reciprocal click
• Slower closing
A. Clicks will be more reproducible during “normal”
opening. Patient overrides clicks during “fast”
opening.
B. Click in velocity trace is usually accompanied by a
lateral shift in the jar movement in the frontal plane.
C. Lateral deviation may be anatomic (condyle/disk) or
unilateral muscle spasm.

17. Sonography - Normal disc
• Low frequency sounds
• Amplitude is a factor
• Intact discs can have a
click or pop

19. Sonography - Chronic
impingement with crepitis

20. Severe degeneration

21. The Stomatognathic Triad
• Teeth – Dominant
• Joints – Accommodate
• Muscles – Accommodate

22. Normal

23. Posterior
Displaced
Condyle

24. The Stomatognathic Triad
• Teeth – Dominant
• Joints – Accommodate
• Muscles – Accommodate

25. Muscles
•Function is to Contract
•With the ability to vary
speed, power and extent of
that contraction
•This is how they act as
Mandibular Accommodators

26. The structural units
are Actin And
Myosin With ATP
Being The Energy
Source

27. •The Muscle Motor Unit
consists of the nerve cell body,
a single axon of the motor
nerve, its terminal branches
and the muscle fibers supplied
by these branches
•It’s the occlusion that
determines the amount of joint
compression however this will
not occur until muscle motor
units are called upon to move
the mandible under function
or Parafunction

28. Pain/Spasm Cycle
•Is almost universal in TMD
•As muscles are called upon
to continually accommodate
an occlusion they become
contracted and function at a
decreased working length
•This results in lymphatic
and vascular impingement,
inhibits metabolism with the
resultant build up of
spasmogenic metabolites

29. Hypertonicity
•A condition of excessive tone of the skeletal muscles
•Characterized by increased muscle motor unit firing to
maintain posture at rest
Video
Neuromuscular
Dentistry #5

30. • Neuromuscular
Dentistry #5
• Next

31. A.High postural EMG activity is common in patients
with TMD.
B.The anterior temporalis is usually elevated more
than the masseter since it is a posturing muscle.
The masseter is a force muscle.
C.High posterior temporalis activity is common in
patients with cervical myofacial dysfunction.

32. A.Lowering rest EMG activity after therapy is the desired
therapeutic objective.
B.Lowered postural EMG activity indicates improved
physiologic status.

33. Posterior Cervical
Muscles

34. “Authors who have reviewed the
TMJ literature generally agree
that muscle hyperfunction is the
principle cause of myogenous
TMJ disorders.”
JADA, 12:283-290, 1990
Hypertonicity:

35. “There is a general agreement
among both clinicians and
investigators that masticatory
muscle activity is greater in
symptomatic patients as
compared to normal subjects.”
McCall, W.D., A Textbook of
Occlusion, Quintessence, 1988
Hypertonicity:

36. T.E.N.S.
NEURAL STIMULATION
TRANSCUTANEOUS ELECTRICAL

38. Group Action
Facial Nerve Mandibular Nerve
Muscle of Nose Masseter
Buccinator Temporalis
Risorius Medial Pterygoid
Orbicularis Oris Lateral Pterygoid
Muscles of Lower Lip Tensor Palati
Platysma Mylohyoid
Stylohyoid Ant Belly Digastric
Post Belly Digastric

39. Low Frequency TENS
1. Pumps waste metabolites and
lactic acid from hypertonic
muscles
2. Increases vascular flow, oxygen,
ATP, Glucose, and Calcium

40. 3. Changes muscle metabolism
from anaerobic (lactic acid) to
aerobic
4. Endorphin effect
Low Frequency TENS

41. A Normal
Bite ??????

42. Do you have a
malpositioned
occlusion?
?????????????????

43. LOOKS
ARE
DECEIVING!!

44. Class II Div II
Posterior Displaced
Mandible And
Condyle

45. If it has been measured,
it is a FACT.
If it has not been measured,
it is an OPINION.

46. Computerized
Jaw Tracking

47. Video
Diagnosing
Problems #7

48. • Diagnosin
g Problems
#7
• Next

51. •

55. EMG
Electromyography

57. Hyper Active

58. •
Relaxed After Tens

59. Central
Nervous
System

60. The Trigeminal Nerve
comprises 60% of all
neural tissue of the 12
cranial nerves and is
associated with the
reticular activating
(awakening) center.
Sensory information
from the occlusion is
carried along the 5th
cranial nerve to the
awakening center.

61. As a noxious stimuli such
as from a bite prematurity
travels to the reticular
activating center the
message is instantly
processed and the mandible
is pulled away from the
prematurity. Significant
accommodation is often
required. This OCCLUSAL
PROPREOCEPTION often
becomes a common cause
of muscle hypertonicty.

62. Myofascial
Triggers And
Referred
Pain

63. Trapezius

64. Sternocleidomastoid

65. Medial
Pterygoid

66. Masseter

67. Therapeutic Objectives
• Restore Normal Blood Flow (aerobic
metabolism)
• Eliminate Sources Of Nerve And Vascular
Entrapments
• Eliminate Neuromuscular Trigger Points
• Restore Postural Integrity At Rest With
Minimal Muscle Activity
• Elimination Of Neuromuscular And
Temporomandibular Joint Compression

68. Neuromuscular Occlusal
Objectives
• Provide An Occlusal Relationship Of
The Mandible To The Maxilla That
Minimizes The Need For Muscle
Accommodation
• Provide An Occlusal Relationship That
Allows Normal Decompression Of
Neural And Vascular Intracapsular
Tissue And Associated Connective
Tissue

69. The individual
will experience
pain and
pathology when
the stress
exceeds their
ability to adapt.

70. NTI Appliance And Migraines
Video A Dental
Perspective #1

71. • Next #1
• NTI and Migraines