Tmd in orthodontics /certified fixed orthodontic courses by Indian dental academy

TMD in Orthodontics
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

CONTENTS


TEMPEROMANDIBULAR DISORDER



INTRODUCTION
DEFINITION
HISTORICAL BACKGROUND
SYNDROME Vs DISORDER
CLASSIFICATION
ETIOLOGY
EPIDEMIOLOGY
SYMPTOMS AND SIGNS










 RELATIONSHIP

OF TEMPEROMANDIBULAR DISORDER AND
ORTHODONTICS






INTRODUCTION
TEMPEROMANDIBULAR DISORDER Vs
ORTHODONTIC TREATMENT
REVIEW OF LITERATURE

 EXAMINATION OF TMJ
 DIAGNOSTIC IMAGING OF TMJ
 MANAGEMENT



TWO PHASE THERAPY
DIFFERENT MODES OF TREATMENT

 OVERVIEW
 CONCLUSION

INTRODUCTION


 Orthodontists

are constantly being
challenged with the task of providing
their patients with acceptable
esthetics and masticatory function.
Although esthetics is often the
patient’s immediate and primary
goal, function becomes far more
important over the lifetime. So
developing a sound, functional
masticatory system is the primary
goal of all orthodontic therapy.

 The

frequency of TMJ complaints
has multiplied in the last few years.
This may have been brought about
by the increased stresses of our fast
paced world, or at least we now
recognize that there is a stress strain
tension release syndrome that often
manifests itself with nocturnal
parafunctional activity.



Dentists, through many accepted
dental procedures may
inadvertently exert distal pressure
on the mandibular complex, which
can be the beginning of a TMJ
disorder.




Few examples of such dental
problems and their treatment are :

 Firstly,

Extractions leading to
horizontal or vertical dental changes
can add to distal and elevated
mandibular pressure.

 Secondly,

Crowns, bridges, fillings that
alter physiologic intercuspation can
create adverse functional pressure on
the mandible.

TEMPEROMANDIBULAR
JOINT




The craniomandibular
articulation is a complex synovial
system composed of
temperomandibular joints
together with
their articular
ligaments and masticatory
muscles.

TEMPORAL DISC
BONE

FIBROUSPOSTERIOR
TISSUE LIGAMENT

CARTILAGE
TEETH

CONDYLE

NERVES
ARTERIES

 The

craniomandibular
articulation presents several
features that complicate
diagnosis and treatment.




Unique mechanism for providing
joint stability :
The human craniomandibular articulation is
structurally the most complex synovial system in
the body, consisting of two quiet separate but
functionally interdependent TM joints . It
consists of a double joint within a single capsule.
Each is composed of a lower hinge joint and a
freely movable upper joint capable of both
sliding and pivoting movements.



Impact of Occlusion :
Disharmony between the effect of
occlusion and that of muscle action
may induce masticatory dysfunction
or cause overloading of the articular
tissues.




Lack of Regenerative Capability of
the Disc
The osseous supported articular
surfaces of the TM joint have
capability to undergo active
remodeling in response to the
demands of function. But articular
disc does not display regenerative
or remodeling behaviour.



Importance of Retrodiscal Tissue :

Retrodiscal tissue is essential for
both the normal metabolic activity as
well as functional movements of the
joint.
 It is the major source of synovial fluid
for both compartments of the joint,
which is essential for nutrition and
lubrication of the moving parts.
 Damage to this tissue predisposes to
both masticatory dysfunctions as well
as degenerative changes.



DEFINITION


 Temperomandibular

disorder, in the
broad sense are to be considered a
cluster of joint and muscle disorders
in the orofacial area, characterized
primarily by pain, joint sounds and
irregular or deviating jaw function.


The pain is neither of neurogenic,
psychogenic or visceral origin nor of
periodontal, dental or cutaneous .




According to “American Academy of
Orofacial Pain” – Temperomandibular
disorder is a collective term embracing a
number of clinical problems that involve
the masticatory
musculature,temperomandibular joint and
associated structures or both.


Therefore, TMD includes disorders
related to the joint itself and of the
masticatory cervical muscle
complex.


OF TMD


A notion has persisted for half a
century that dysfunction’s of the
masticatory apparatus comprises
syndrome initially referred to as
Costen's syndrome or TM syndrome.
In 1956 Schwartz introduced the TM
pain dysfunction syndrome. Then came
the myofacial pain dysfunction (MPD)
syndrome in 1969.

A partial list of the attempts to
label TMJ related conditions
Costen Syndrome ( Costen,1934 )
 TMJ Syndrome ( Schwartz,1956 )
 TMJ Dysfunction Syndrome ( Shore
1959 , Lupton 1969 )
 TMJ Pain Dysfunction Syndrome
(Schwartz1959)
 Pain Dysfunction Syndrome ( Voss ,
1964 )



 Arthrosis

Deformatus ( Boering ,

1966 )
 Oto Dental Syndrome ( Myrhaug ,
1969 )
 Autodestruction (Drum , 1969 )
 Functional Temperomandibular Joint
Disturbances and Disorders ( Olson
1969 , Ramjford 1971 )
 Occluso Mandibular Disturbances

 Mandibular

Dysfunction (Hickimo ,

1974 )
 Myoarthropathy of TMJ ( Graber ,
1972 )
 Craniocervical Mandibular Syndrome
( Geeb 1975 )
 Mandibular Stress Syndrome ( Ogus
and Teller , 1981 )
 Craniomandibular Disorders

 Temperomandibular

PainDysfunction Syndrome ( Mersken ,
1986 )
 Temperomandibular Disorders ( Bele
1982 , Mcneil 1990 )


SYNDROME Vs
DISORDER


It is interesting to note that in the
medical dictionary the only joint
disorder listed as a syndrome is
Costen’s. This syndrome concept has
no doubt contributed to the one
disease – one treatment myth.

The clinical signs and symptoms
displayed by masticatory disorders are
much too varied to be classified as a
“Syndrome”.



 According to a medical definition, a
SYNDROME is a set of symptoms
which occur together as a symptom
complex. This term is meant to apply
to symptoms as such.


A

DISORDER is a derangement or
abnormality of function, a morbid
physical or mental state. This term
applies not to symptoms but to
conditions.


CLASSIFICATION




The American Academy of Orofacial
Pain has published a TMD classification
system that is integrated with an
existing medical diagnostic
classification used by the International
Headache Society. Although no
classification has been accepted by all
the practitioners, the AAOP
classification has received general
acceptance.

1.

Temperomandibular joint disorder

2.

Masticatory muscle disorders

3.

Congenital and developmental
disorders

1.

Temperomandibular joint disorder

A

Deviation in form

Articular surface defects

Disc thinning and perforation.
B Disc displacement

Disc displacement with reduction

Disc displacement without reduction
C Displacement of disc condyle complex

Hypermobility

Dislocation
D Inflammatory conditions

Capsulitis and synovitis

Retrodiscitis

E Degenerative disease

Osteoarthrosis

Polyarthritis

Osteoarthritis
F Ankylosis

Fibrous

Bony

Masticatory muscle disorders
A Acute
2.





Myositis
Reflex muscle splinting
Muscle spasm

B Chronic



Myofacial pain
Muscle contracture
Hypertrophy
Myalgia

3.

Congenital and developmental disorders



Condylar hyperplasia
Condylar hypoplasia
Aplasia
Neoplasms
Fractures











 SECOND

CLASSIFICATION OF TMJ
DISORDERS (E.W.William, AJO 1987,
91):
 A) Systemic :
These are disorders that have direct
manifestations in the joint, but the
cause is systemic disease (e.g.
arthritis).
 B) Acquired :
These are disorders induced from a
variety of causative factors. Trauma,
stress, any dental procedure which
may inadvertently exert distal pressure
on the mandibular complex.

ETIOLOGY
OF
TEMPEROMANDIBULAR
DISORDER




The etiology of TMD remains
mired in controversy. It is
generally agreed that the etiology
of symptoms of TMD is
multifactorial. That is several
different factors acting alone, or in
varying combinations may be
responsible.

The etiological factors sometimes
be called as contributing factors
that can be defined as factors that
initiate, perpetuate or result in a
disorder .


Predisposing factor – factors that
increase the risk of developing TMD
or orofacial pain.
 Initiating factors – factors that
cause the onset of disorder.
 Perpetuating factors – factors that
interfere with healing and
complicate management .





Predisposing factors can be subdivided
into :
Systemic factors – medical conditions such as
rheumatic infections, nutritional and metabolic
disorders can influence masticatory system to
an extent that TMD may emerge.
Psychologic factors - Personality,behaviour
can affect masticatory system.


Structural factors – All types of occlusal
discrepancies, improper dental treatment,
postural abnormalities ,skeletal
deformation, past injuries etc.
Genetic factors.




Initiating factors :
Trauma – Microtrauma or
Macrotrauma
Overloading of joint structures
Parafunctional habits etc.




Perpetuating factors :
Mechanical and Muscular stress.
Metabolic problems.




All the above factors can be
broadly grouped into three major
factors.
Anatomical
Psychological
Neuromuscular

 The

three main groups anatomic,
neuromuscular and psychologic
factors will influence each other and
act together.

Depending on the type of disorder
and depending on the pathology in
individual patient, the three can act
as predisposing initiating or
perpetuating factor.

EPIDEMIOLOGY


 Epidemiological

studies in many
parts of the world confirms a very
high prevalence of signs and
symptoms of TMJ dysfunction.

 Most

of the studies report at least
50% of individuals having at least
one sign (e.g. muscle tenderness or
joint clicking) although only 30% of
subjects may be aware of such
symptoms.

Symptoms of TM disorders
are common in all age groups.
Older age groups have slightly
more symptoms than the
young.
 At the same time there is
higher frequency of symptoms
of dysfunction in females as
compared to males.



SYMPTOMS AND SIGNS




Pain :
Pain may arise from TM Joint and muscles
of mastication. It is the most common
symptom causing patients to seek
treatment. Pain may be present as a
constant or periodic dull ache over the
joint, the ear and the temporal fossa. Pain
is usually elicited by mandibular
movement or by palpation of the affected
regions.

 Pain

can be :
 Myogenic pain :
Mechanical trauma and muscle
fatigue.

Articular pain :
Arises as a result of inflammation of
articular and periarticular tissues
caused by :
 Overloading or trauma
 Degenerative changes such as
occurring
in osteoarthrosis



Joint Sounds :

Crepitus : This is a grating or
scraping noise that occurs on
movement. It is caused by the
roughened, irregular articular
surfaces of the osteoarthritic joint.
Clicking: It is caused by
uncoordinated movement of
condylar head and articular disc.

 Limitation

of Mandibular Movement

a) Muscular restriction:
It is most common reason for limitation
of
mandibular movement. The
restriction is caused by contraction of
group of muscles.
b) Disc displacement:
An anteriorly displaced disc may
prevent the forward translation of the
mandibular condyle. This results in
limitation of opening of the mouth.

c) Ligamentous restriction:
The ligaments normally restrict
the movements of the joint in all
direction and operate when the
muscles are
unable to
stop
the movement and when
there
is a risk
of dislocation of joint.
Eg. Following sudden, voilent
movements .

 Dislocation

:

On wide opening of the mouth the head
of the condyle normally passes over
the articular eminence. Occasionally
patient may be unable to close the
mouth as condyle can not return into
the fossa. The patient may eventually
be able to reduce the dislocation
himself or may present at hospital for
treatment.


 Ear

Symptoms :

Subjective ear symptoms are
commonly associated such as
tinnitus, itching in the ear, vertigo.


 Recurrent

headache :

It is frequently associated with pain
and tenderness in the masticatory
muscles. TM disorder is mostly
associated with temporalis muscle
contraction , headache and
sometimes migraine headaches .

RELATIONSHIP OF
TEMPEROMANDIBULAR
DISORDER
AND
ORTHODONTICS

 The

orthodontist have long been
interested in the problems associated
with diagnosis and management of
Temperomandibular disorders.
 Indeed orthodontic treatment has been
characterized in diverse publications
as both causing and curing
temperomandibular disorder.

 The

interest of the orthodontic
speciality concerning the
association or lack of association
between Orthodontic treatment and
TMD has increased dramatically
during the past decade.



The attention of the orthodontic
community regarding TMD however
was heightened in the late 1980s
after litigation involving the
allegations that orthodontic treatment
was the proximal cause of TMD in
orthodontic patients.

HISTORY OF TMD AND
ORTHODONTIC
TREATMENT


In the 1980’s articles in various
journals and trade magazines
suggested that orthodontic
treatment might play a role in
initiating temperomandibular
disorder.
 On the other hand it was also
claimed that orthodontic treatment
might be effective in alleviating the
signs and symptoms of TMD.



 The

conflict became earnest when
result of the famous Michigan
orthodontic / TMJ law suit was announced.
This litigation turned on the argument
that a form of orthodontic treatment
had been the cause of the patient’s
TMD, the six member jury were in
favour of the patient.

The patient named Susan Brimm, when
she was 16 years began treatment to
correct a Class II Div I malocclusion with
a 7 mm of anterior open bite. Her
treatment included the removal of her
upper first premolars, the use of
headgear and bonding of her upper
and lower teeth.

At the time the treatment was initiated she
exhibited no temperomandibular symptoms.
She complained that when braces were
removed she suffered a severe click with
severe pain and limited opening.
Ultimately the matter was settled by a payment
of a large sum of money to the patient.


This litigious climate stimulated the
American Association of Orthodontics
not only to sponsor a series of risk
management teleconferences and
newsletter, but also to underwrite
research concerning the relationship
of orthodontic treatment to TMD.

TEMPEROMANDIBULAR
DISORDER
Vs
ORTHODONTIC
TREATMENT


 The

benefits of orthodontic treatment
in the management of
Temperomandibular Disorder is
questionable, since the occlusion is
considered as having a limited role in
the cause of TMD.



But the potential detrimental effects
of orthodontic treatment on TMJ has
captured the attention of orthodontic
community.

Some of the examples of Orthodontic
treatment which can lead
to
Temperomandibular Disorders are :




1) Effect of headgear and/or class II elastics in
correction of Class II malocclusions with deep
interlocking cusps.
Headgear or Class II elastics are often used
in an effort to get the patient into a Class I
cuspal relationship.
By the headgear force, as the maxilla is
moved backward the muscles of mastication
will attempt to retract the mandible when the
patient closes into maximum intercuspation.
This compensating movement by the
mandible can put distal pressure on the
condyles and conceivably cause an anterior
dislocation of the disk.

To correct this problem in
orthodontic treatment, a possible
solution is to give flat plane of
acrylic which can be bonded on the
occlusal surface of lower molars and
premolars after the fixed appliance
has been placed or it can be a
removable bite plane.

When the bonded bite planes are
used, then maxillary teeth move
freely distally as there is no cuspal
inter locking hence no effect on the
mandible.


Once cusps get past a point to point
contact, the bite plane is removed.
Now the cuspal inclines tend to guide
the mandible forward and maxillae
backward on maximum closure. This
may aid in the retraction of the maxilla
but at the same time the mandible is
moved forward .



2) Effect of Cross elastics to correct the
midline :
The cross elastics have a little effect on
TMJ. As the jaw is pulled to one side,
distal pressure is put only on one condyle
and chances of anterior dislocation of
disc. If it creates a TMJ problem then
elastics should be worn only during
waking hours so that the muscles can
help to hold the mandible forward because
of muscle tension.



3) Effect of Reverse Headgear or Class III
Elastics for Correction of Class III malocclusion :
This again can put distal pressure on the
mandible. If there is a developing problem,
then patient is asked to wear reverse
headgear or Class III elastics during waking
hours as muscle tension or tone, positions
the mandible forward. Since at night, the
muscles are relaxed and there is more distal
pressure on condyle since compensating
muscle activity is not in play.


If then also patient cannot tolerate, then
orthodontic treatment must be
compromised or surgical line of
treatment should be considered.




4) Effect of Lower Expansion and Upper
Contraction :
In most cases, the crowded lower anterior
teeth are in contact with the lingual of the
upper anterior teeth. There is a spacing in
upper anterior. The common request that the
patient makes is to close the spaces in the
upper anterior teeth. If a orthodontist tries to
close down the anterior (upper) spaces
without opening the bite, it may create a
premature contact with the lower anterior
teeth and exert distal pressure on the
mandible that may result in TMJ pain.

In these deep bite cases one should
first open the bite and carefully plan
the proper interincisal anterior
angulation, so that the maxillary
space closure can be carried without
impinging on the lower anterior
teeth.

 5)

The Retentive Phase :
According to many TMJ observers,
the retentive phase of orthodontic
treatment may cause more TMJ
problems than any other orthodontic
procedure.
Some clinicians believe that it is the
good antero posterior interdigitation in
the retentive phase which is the main
offender for TMJ problems.

The majority of orthodontically treated
cases mostly have dental deep bite at
the beginning. If the deep bite is
treated by extrusion of the posteriors,
there will be increase in the vertical
dimension of the lower face. In most of
the cases vertical dimension of the
lower face will largely tend to revert to
its original height.

So in cases of orthodontically
treated deep bite malocclusions, the
bite will tend to close at varying
speeds, ranging from months to
years.


As the bite deepens four possible
adverse effects can be seen.
Spacing in upper anterior teeth.
 Crowding in lower anterior teeth.
 Tends to move maxilla forward.
 Drives the mandible distally



Since most of the orthodontists
give a 3 to 3 fixed retainer on both
upper and lower anterior teeth after
the active treatment. These
retainers prevent
 Firstly, lower anterior teeth from
crowding or collapsing.
 Secondly, prevent the upper
anterior teeth from rotating,
separating or moving forward.

But at the same time the retainer
cannot prevent other two adverse
effects i.e. forward movement of
maxilla and distal movement of
mandible, which can again lead to
TMJ problems.


Then how to prevent forward
movement of maxilla and distal
movement of mandible ?


 When

the fixed appliances are
debonded, a retainer Begg labial bow
minus a bite plane is placed on the
same day.
 There must be a minimal lapse of
time between debonding and seating
of the retainer.

 The

bite is allowed to deepen with the
retainer in place for 2-3 weeks. The
curve of spee will begin to return to the
occlusal plane.
 When the bite has deepened
sufficiently for anterior guidance (e.g
bite closure of 1-2 mm) the lingual bite
plane is added to retainer.




If the patient continously wears
the retainer 24 hours a day usually
the bite will not deepen dentally and
there will be no distal pressure
exerted on the mandible during
retention unless there are major
increments of upward and forward
rotating mandibular growth
occurring. www.indiandentalacademy.com

 If

there is no distal pressure on the
mandible by giving anterior upper
bite plane, the condyles are not
driven posteriorly and the articular
disks would stay in place, thus TMJ
problems are much less likely to
occur .

REVIEW OF THE
LITERATURE


Ten years prior, very few clinical
studies regarding the relationship
between orthodontic treatment and
TMD were published.


 In

a comprehensive review of the
literature on this subject that was
published between 1966 to 1988 .

 Reynders divided above publications

into three categories :
 View point articles.
 Case reports
 Sample studies




The view point articles were not suitable
for
critical evaluation of association
between two entities, however useful in
identifying questions that may be worthy
of scientific investigation.


1) What is the prevalence of signs and

symptoms of TMD in orthodontically
untreated population ?

Numerous epidemiologic studies
have shown a significant prevalence,
with an average of 32% reporting at
least one symptom of TMD and an
average of 55% demonstrating at least
one clinical sign.
 Several investigators have noted that
signs and symptoms of TMD generally
increase in frequency and severity in
the second decade of life.

2) Does orthodontic treatment lead
to a greater incidence of TMD ?

Two of the first major investigations
sponsored by the National Institute of
Health to consider relationship
between orthodontics and TMD
revealed no statistically significant
differences between the treated and
untreated groups.

 The

results of these studies provide
evidence in support of the concept that
orthodontic treatment performed
during adolescence generally did not
increase or decrease the risk of
developing TMD later in life.

Another study of the long term
effects of orthodontic treatment was
conducted by Larsson and Ronnerman.
They stated that comprehensive
orthodontic treatment can be under
taken without fear of creating TMD
problems.

3) Does the type of appliance (e.g. fixed
functional or orthodontic vs orthopedic) make a
difference ?


In the major longitudinal study conducted by
Dibbets et al consisting of 171 patients, 75 of
whom were treated by Begg
mechanotherapy, 65 were treated by
activator and 30 patients were treated with
chin cups, revealed that at the end of
treatment, fixed appliance group had a
higher percentage of objective symptoms
than did the functional group, but no
differences existed at the 20 year follow up



Another prospective study conducted by
Pancherz examined the effects of functional
mandibular advancement in patients with
Class II div I malocclusion. He used bonded
Herbst appliance. After an initial edge to
edge bite registration , several patients
reported muscles tenderness during first 3
months of treatment. However, at 12 months
following treatment, the number of subjects
with symptoms was the same as that before
treatment.

4) Does the removal of teeth as part of an
orthodontic protocol lead to a greater
incidence of TMD ?
 View point articles and tests have
strongly associated the extraction of
premolars with the occurrence of TMD
in orthodontic patients.
 But clinical studies that have dealt with
this issue have not shown relationship
between premolar extraction and TMD.

 Sadowsky

and Coworkers conducted a
study on 160 patients and reported that
joint sounds were evident before and
after treatment in 87 extraction patients
and 68 non extraction orthodontic
patients. They reported there is no
increase in the risk of development of
joint sounds regardless of whether
teeth were removed .

 Another

study done by O’Reilly et al
examined 60 treated subjects and 60
untreated subjects. The treated
patients, underwent fixed orthodontic
treatment that included extraction and
the wearing of Class II intermaxillary
elastics. No difference were seen
between the treated and untreated
groups .

 Finally

Pullinger et al noted that the
contribution of the extraction of two
or four teeth per se, as part of an
orthodontic treatment protocol, was
negligible in most cases when other
variables were controlled.


5) Can orthodontic treatment lead to a
posterior displacement of the
mandibular condyle?
 A number of viewpoint articles have
asserted that a wide variety of
traditional orthodontic procedures e.g.
premolar extraction, extraoral traction,
retraction of maxillary anterior teeth
cause TMD signs and symptoms by
producing a distal displacement of
condyle .

 Gianelly

et al did the study collecting
the tomograms to evaluate condylar
position. They took the tomograms
before orthodontic treatment in 37
consecutive patients aged 10 to 18
years and compared them with
tomograms from 30 consecutively
treated patients with fixed
mechanotherapy and removal of four
premolars. No differences in condylar
position were noted between groups .

 Another

study conducted by Luecke
and Johnston evaluated the
pretreatment and post treatment
cephalograms of 42 patients treated
with fixed appliances in conjunction
with the removal of two upper
premolars.
 The result of the study indicated that
the majority of patients about 70%
undergo a forward mandibular
displacement and a slight opening
rotation of mandible. The remainder of
the sample had distal movement of the
condyle.

 Thus

researchers concluded that
posterior condyle position was
not a result of orthodontic
treatment.


6) Should the occlusion of orthodontic

patients be treated to specific gnathologic
standards ?


Several view point articles including those by
Roth et al and Williamson have maintained
that TMDs may result from a failure to treat
orthodontic patients to gnathologic
standards that include the establishment of a
“mutually protected occlusion” and proper
seating of the mandibular condyle within the
glenoid fossa.

 Pullinger

et al reported that small
occlusal slides less then 1 mm are
common in asymptomatic subjects
as well as patients with TMD.


 It

probably is prudent to establish
morphologic treatment goals that
mimic what is observed in untreated
occlusions that have been judged ideal.
The establishment of an occlusion that
meets gnathologic ideals probably is
unnecessary particularly in adolescent
patients and sometimes impossible to
attain in some adult patients .

7. Does orthodontic treatment prevent
TMD ?


One of the few investigations that found
improved TMD health in a treated group was
the sample studied by Magnusson et al,
Egermark and Thilander. The investigators
noted that clicking recorded at the first
examination sometimes disappeared at
subsequent examination. At the same time
the clinical dysfunction index outcome was
lower in those who had undergone
orthodontic treatment in those who had not
undergone orthodontic treatment.

A

trend toward decreased
prevalence of TMD signs and
symptoms in treated patients also
was noted by Sadowsky , Polson and
Dahl et al.


Palpation of T.M.J.
Pain or tenderness of TMJ is determined by
digital palpation when the mandibular is in
both stationary and dynamic movements.
• The examiners finger tips are placed over
the lateral aspect of joint areas
simultaneously on both sides.
•


Lateral palpation
The finger tips should
feel the lateral poles
•
of condyles passing
down towards across
articular eminence.
• Once position is
verified, the medial
force is applied to the
joint area to check for
any pain
•

Posterior palpation:
•

Position the little finger in
the external auditory
meatus and palpate the
posterior surface of
condyle during opening
and closing of the
mandible.

•

Palpation is done in such
a way that the condyle
displaces the little finger
when in full occlusion.

AUSCULATION OF THE T.M.J.
•

Sounds made by the TMJ can be
examined with a stethoscope. Also the
timing of clicking during opening and
closure can be noted .


Crepitation

This is a grating or scalping noise that
occurs on jaw movements . Sound like
when sand paper is rubbed against a
surface.
• Crepitation is very uncommon in
asymptomatic joint and may be an early
sign of degenerative joint disease.

crepitus is caused by roughened,
irregular anterior surface.
•


Clicking
•

It occurs due to the
uncoordinated
movement of condylar
head and T.M.J disc.

•

Joint clicking is
differentiated as:
Initial
Intermediate
Terminal
Reciprocal www.indiandentalacademy.com

Initial clicking : It is a sign of retruded
condyle
• Intermediate clicking : Is a sign of
unevenness of the condylar surfaces and
articular disc
•

•

Terminal clicking : is an effect of the condyle
being moved too far anteriorly in relation to the
disc on maximum jaw opening.

• Reciprocal clicking :

is an
expression of incordination
between displacement
of the condyle & thewww.indiandentalacademy.com
disc.

MAXIMUM JAW OPENING
The distance between
the incisal edges of the
upper and lower central
incisors is measured
with a Boley gauge.
• Normal value is 4045mm.
• In overbite cases this
amount is added to the
obtained value whereas
•

Diagnostic imaging of T.M.J
HARD TISSUE IMAGING
• to evaluate the osseous contours, the
positional relationship of the condyle and
fossa and range of motion.
• Because T.M. Joint’s proximity to temporal
bone, mastoid air cells and auditory
structures, imaging of the joint can be
problematic, so a combination of imaging
technique may be required.
•


1) Panaromic Projection: this provides an overall view
of the teeth and jaws, it serves as a screening
projection to identify odontogenic diseases and other
disorders that may be a source of T.M.J. Symptoms.
• These are of limited usefulness because the thick
image layers and oblique distorted view of the joint
they provide severely limited image quality.


No information about condylar position
or function is provided because the
mandible is partly opened and
protruded when this radiograph is
exposed.
• Mild osseous changes may be
obscured and only marked changes in
articular eminence morphology can be
seen as a result of superimposition by
skull base and zygomatic arch.
•


2) Transcranial (Lateral Oblique)
projection or imaging
•

•

•

Initial screening for gross
osseous abnormalities can be
seen with transcranial view.
The x-ray tube is placed at a
true vertical angle at 250
(source distance 22” or 56 cm)
from target to film.
Routine transcranial imaging
includes projections of TMJ in
both closed and maximally
opened position


•Condylar position cannot be reliably determined
It provides sagittal view of lateral aspects of the condyle and
temporal component displaced condylar features, range of motion.


New transcranial lateral oblique system.
•

In this, the office x-ray
machine can be used to
take transcranial lateral
oblique view with a
specific film cassette and
a head holding system .


Transpharyngeal (Parma) Projection
•

•

•

It provides a sagittal view
of the medial pole of the
condyle.
It provides for limited
diagnostic information as
temporal component is
not visible.
It is effective in visualizing
erosive changes in
condyle rather than more
subtle ones.

Transorbital projection & Transmaxillary
projection
•
•

•

Both provide an anterior view of the T.M.J.
The projection is done perpendicular to transcranial and
transpharyngeal projection.
Here the source and head position in such that head
forms an angle of 300 to the source.


•

•

Here the mediolateral
dimension of articular
eminence,condylar head
and condylar neck is
visible. So it is useful
for visualizing condylar
neck features.
It is an useful adjunct in
diagnosis of gross
degenerative changes
or other anomalies of
condylar head.

Submento vertex view:
•

•

It provides the view of the skull base and condyles
superimposed on condylar necks and mandibular
rami.
It is particularly useful for evaluating facial
asymmetries, Condylar displacement, rotation of
mandible in horizontal plane associated with
trauma or orthognathic surgery.


Tomography
Basic principle:
•
Both the radiation source and film
are moving simultaneously to blur all
the anatomy anterior and posterior to
the point of plane convergence.
•

Conventional Tomography
Computed tomography


Conventional Tomography:
•

It produces multiple thin image slices permitting
visualization of an anatomic structure free of
superimposition of overlapping structures. Here
the image slices are taken in closed (maximum
intercuspation position) maximal open position.


Computed Tomography (CT)
•

•

Indicated when more information is needed about
the 3 dimensional shape and internal structure of
the osseous components of joint or if information
regarding the surrounding soft tissues is required.
Cannot produce accurate images of the articular
disc.


Soft Tissue Imaging:
Soft tissue imaging is indicated when
T.M.J pain and dysfunction is present.
• Or when the clinical findings suggest
disk displacement along with
symptoms that are unresponsive to
conservative therapy.
•


Arthrography
It is a technique in which an indirect image
of the disk is obtained by injecting a
radiopaque contrast agent under a
fluoroscopic unit.
• Arthrography is indicated when information
about disk position, function and
morphology and integrity of discal
attachment is required.
• Arthrography is superior in diagnosis of
small disk perforation and joint adhesions.
•


•

•

•

•

Arthrography involves
injection of water soluble
iodinated contrast material
About 0.4 – 0.5 cc of
contrast material is injected
into the joint cavities.
Later needle is withdrawn
then images and Video
recordings are done.
These are illuminated with
xenon light which provides
brighter images.


Magnetic Resonance Imaging
MRI uses a magnetic field
radiofrequency rather than ionizing
radiation to produce multiple digital
images to soft tissue.
• In MRI, the operator electronically tunes
an external radiofrequency to match the
magnetic frequency of the tissue sample
.
• When the external RF is tuned to region
of interest and is intensified, the protons
of the tissues rise to a higher energy
•

state upon termination of RF pulse, which
lasts less than one sec, the responding
photons will immediately begin to relax and
release occurred energy
• Faster the relaxation rate stronger is the
signal, brighter is the image and vice versa
• Slice thickness usually varies from 3 and 10
mm thinner sections result in improved
image quality .
•


•

•

•

In MRI of TMJ the position of
the articular disc is of
utmost importance.
The disc is made of
fibrocartilage, so it gives out
a low signal and hence black
in appearance.
This is seen in contrast to
adjunct superior and inferior,
joint spaces, which of
intermediate intensity (grey
in colour)

•

•

A round 3 inch diameter
surface coil, placed with its
central opening directly over
patients T.M.J provides the
best images.
A series of images in
closed open mouth position
as well as coronal images in
closed mouth position are
obtained bilaterally when the
patient is in supine position.

Xeroradiography
The xeroradiographic method uses of
selenium coated plate, and charged plastic
powder a toner, producing variation in shades
of blue.
 The bone will appear blue or white, and the
soft tissues will appear more clearly than on
the usual radiography.



MANAGEMENT OF
TEMPEROMANDIBULAR
DISORDER


 It

is extremely important to begin
treatment early so that the condition
may still be reversible and the
tissues can heal without the need for
joint surgery.


 FIRST

PHASE OF TREATMENT
(COMFORT PHASE) :
The primary purpose is to eliminate the
pain, clicking, popping, locking
headaches, neckaches, backaches,
which are frequently related to condyle
that is improperly positioned in the
fossa and disc that is frequently
displaced forward in the fossa.

The TMJ splint repositions the
mandible in such a position that the
condyles are centered in the fossa
and any impingement of the tissues
is reduced.
 The treatment is usually for 6-12
months.



 SECOND

PHASE THERAPY :
The highest priority is to maintain the
condyles in the proper position,
whatever it takes to maintain TMJ
health.

It includes the following steps :

 A)

TMJ Recall :
If the patient feels fine with no
symptoms when the splint is out and
can move the mandible back to their
original bite position, they can be
placed on category of TMJ recall and
further no treatment is planned at that
time.
They can be examined once in a year .




B) TMJ Treatment (Orthopedics /
Orthodontics) :
If the TMJ disorder symptoms
return,whenever the splint is removed and
patient tries to move their lower jaw back to its
pre treatment position, this confirms the
original diagnosis of TMJ disorder .
The patient no longer knows where to bite and
patient finds it necessary to wear splint full
time .


Then additional treatment will be
needed to align the teeth and jaws to
the proper position of the condyles
in the craniomandibular fossa.




Then following treatment methods
can be carried :



1) Orthopedic / Orthodontic
treatment to rearrange the teeth to the
proper condylar position.
It is important to establish a new
occlusion at the position that the
condyles are healthy.

 Orthopedic

Phase : It involves the
development of bones and muscles to
develop arch width, length and vertical
dimension.
 Orthodontic Phase : To align crooked
teeth as needed.


Crown and bridge to build up all
the
teeth to correct the bite.
•
Individual crowns should be done
on all the teeth to build them upto
a right height to protect the
temperomandibular joints.
•
Implants or bridges can be given
to replace missing teeth.
 2)


Overly partial denture to replace
the splint and
any missing
teeth :
This is more durable material it
would not wear down and would
better increase and maintain vertical
dimension. It can be a good choice
if the patient has many missing
permanent teeth .

 3)


 4)

Orthognathic Surgery :
Surgery can also be carried to
rearrange the jaws to the correct
bite position for the
temperomandibular joints. It is the
best choice if there is a major
skeletal imbalance or facial
deformity needing correction that
falls out of standard orthodontic and
orthopedic treatment range .

 If

due to some reason the second phase
of treatment has to be delayed, in that
case patient should continue wearing a
splint to maintain healthy TM joints and
prevent further breakdown.


TMJ TREATMENT
GUIDELINES


 A)

For first 2-3 days the splint can be
removed for a short period of time if facial
muscles get tense to allow these muscles to
adjust to new position of mandible.

The primary purpose of the splint is to allow the
tissues of the
temperomandibular joint to
heal.


After the initial adjustment period, the
splint must be worn full time, including
eating except brushing in order for
damaged ligaments and TM joint space to
heal.
 Eating without the splint is like pulling
apart suture that are helping to heal a bad
cut on the skin.



 B)

Diet : A softer diet is

recommended for
the few first
weeks until many of the symptoms
subside to reduce stress and
pressure on TM joint.


DIFFERENT MODES
OF TREATMENT


SPLINTS
 FUNCTIONAL

APPLIANCE
 PHYSICAL THERAPY
 TMJ SURGERIES


SPLINTS


 These

appliances are necessary for the
maxillary and mandibular arches to ensure
that each dental arch is stabilized for a
given period of time during the day.
 If possible a maxillary full coverage
appliance is used for night time wear.
 Mandibular full coverage appliance are
generally used to day time wear.







There are many types of splints anterior
splints and posterior splints, maxillary splints
and mandibular splints, full coverage splints
and partial coverage splints.
The exact splint to be used for a given patient
depends not only on patients condition but
also on the doctor’s training and preference.
All splints change jaw relationships and as a
consequence change the relationship of condyle in
the glenoid fossa.

Splints basically relieve stress
within the joint and from the
muscles of mastication.

They even prevent the
patients from bruxing and
grinding their
teeth.









LOWER FULL COVERAGE
SPLINT
A lower full coverage splint gives
the best support for healing the
TMJ.
It give the best result only if worn
all the time except brushing.
With it, it is easy to speak or eat
since it has the least amount of
bulk.
The support given to the TMJ is
similar to that given by a cast to a
broken bone and allows the tissues
to heal.



UPPER ANTERIOR BITE PLANE



It can also be used to unload the posterior
teeth thereby unloading the condyle.
The bite plane can be made flat, so that the
mandible can seat its own anterior-posterior
position.
If the patient skids back into dysfunction, an
inclined plane can be used to guide it.






 It

allows for “natural body
correction” in those patients with an
overclosed vertical dimension and a
deep overbite.



This helps in developing the vertical
dimension by allowing posterior
teeth to erupt.

FUNCTIONAL
APPLIANCES


 They

are very useful in jaw repositioning
and stabilization of the mandible to
the
cranium .

 They

can treat the cause rather than the
symptoms of temperomandibular joint


 The

action of functional appliance is
to bring the condyle forward and
downward e.g. in the centre of
glenoid fossa that result in
unloading the condyle .
 So they are effective for pain relief
by repositioning the condyle. Eg.
Twin block, Occlusal splint.

PHYSICAL THERAPIES


 It can be administered to break the

pain spasm cycle of the craniofacial
muscles .

 Practicing

correct ,erect posture during
walking ,sitting can be of great value .

Applying pressure and massaging
the muscles of mastication and
oro-facial musculature produces
relaxation which then permits a
greater range of movement of the
mandible.


 Vaso-coolant

spray applied to the
affected fatigued and painful muscles
brings about muscle relaxation and
result in decrease or loss of pain .
 Muscle pain and spasm can be
controlled by regulating the electrical
impulses in the affected muscles by
Transcutaneous Electrical Nerve
Stimulation (TENS)

TMJ SURGERY




TMJ Surgery should be reserved for
clearly diagnosed conditions known to
be amenable to surgical improvement .

 It

is necessary in cases of degenerative
bone disease , adhesions , ankylosis etc


 Arthroscopic

surgery and TMJ irrigation
procedures may be helpful in some
cases with internal joint disk mobility .



The injection of corticosteroids into the
TMJ may be useful in rheumatoid
arthritis cases.


 It

is always a good practice to treat
TMJ problems with a conservative
way first and only when approach is
unsuccessful should go for surgery .


ALTERNATIVE TO PHASE
SECOND THERAPY :
WALTER NEWMANN


 The

addition of composite to the
occlusal surfaces in order to alter
condyle / fossa relationships is an
alternative to phase II therapy.
 Because of the non-compliance of
patients, fixed splints in the form of
selective composite addition to the
occlusal surfaces of teeth can be
placed .

BICUSPID BUILDUP


 The

bicuspid buildup technique is
simply the application of self curing
resin to the etched buccal, lingual
and occlusal surfaces of upper first
bicuspids.
 This enables the clinician to bring
about changes in occlusal
relationship in vertical, transverse
and saggitalwww.indiandentalacademy.com
positions.

 Bicuspid

buildup is as an alternative
or aid of doing orthodontics Phase II
treatment of temperomandibular
disorder.
 The major part of primary therapy
consist of creating patient
awareness of his problem and at the
same time wearing a splint

 Sometimes

orthodontic treatment is
essential as phase II treatment and
this idea may often be rejected by
the patient because of cost, timing,
age etc.
 In these case the bicuspid buildup
has the greatest effectiveness.

OVERVIEW




Orthodontic treatment has been a favourite
“whipping boy” of TMJ specialists.



Orthodontic treatment can be one of the
most conservative and permanent ways of
contributing to the correction of TMJ
problems.



It is imperative that during active
orthodontic treatment and in retention of
treated cases, persistent distal pressure
should not be exerted on the mandibular
condyle complex. When this is prevented
orthodontic correction can be used as an aid
not a hindrance, of TMJ function

 The

intention of this seminar is to
illustrate an equally fascinating side
associated with research about
temperomandibular disorders. It
should be obvious from the above
literature that conducting research is
no guarantee for an unambiguous
interpretation of findings. On the
contrary, opposing and often
conflicting views make it very difficult
to take a position on these issues.

CONCLUSION


 My

comments may seem an over
statement, but it is not unfair to say
that orthodontists are in good position
to organize the research and
collaborate to solve the important
problems of TMJ dysfunction.
 What is needed is a research team
comprising knowledge and skills of
(1) Craniofacial biometry, (2) TMJ
function, (3) Statistical modelling and
(4)Craniofacial growth.



The role of occlusion in the origin of TMJ
disorders is a problem in craniofacial
development. Craniofacial development is

what orthodontics is all about. We
orthodontists owe it to our colleagues and our
patients to intensify the research in this field,
for only through research will the answers be
found.

 It

is the mission of the researcher to

unravel the Gordian knot of TMD. To
blunty cut it would not yield an solution
and it would only deny our patients.


BIBLIOGRAPHY



joint and

masticatory muscle
disorders.George A.Zarb , Barry J.
Sessle , Gunnar E.Carlson .
disorder,classification,
diagnosis and management ,-Weldon
E.Bell.
 Clinical management of


disorders and orofacial pain. DCNA,Jan 1991
 TMJ Dysfunction and Treatment –
DNCA,July 1983
 Adult Orthodontics-DNCA
 Tempero-Mandibular disorders – Fonesca,
4th Volume .
 Fundamentals of occlusion and
Temperomandibular disorders – Jeffrey
P.Okeson

 William E. Wyatt. Preventing adverse effects on

TMJ through orthodontic treatment . AJO 1987; 91:
493 –499
 Reint M. Reynders Orthodontics and
temporomandibular disorders: A review of the
literature (1966-1988) AJO 1990; 97: 463-471
 Sadowsky C, BeGole EA. Long-term status of

temporomandibular joint function and functional
occlusion after orthodontic treatment. AM J
ORTHOD 1980;78:201-12.

 James

A.McNamara,Jr., Orthodontic
treatment and temperomandibular
disorders.OOO 1997;83 : 107-117
 Burton H.Goldstein . Temperomandibular
disorders .OOO 1999 ;88:379-383


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