Diagnosis & Clinical Features

Temporomandibular Disorders (TMD)

y TMJ Pathologies & disorders (intra-capsular) y Masticatory muscle Pain & Dysfunction (MPD) {extra-

capsular}

TMJ Pathologies
aka Intracapsular Pathologies y Congenital Anomalies y Developmental Anomalies y Arthritides

y Internal Derangements y Avascular necrosis

Internal Derangements

Internal Derangements
y Abnormal Relationship between the Intra-articular

disc and the Condyle when the teeth are in occlusion

Immobility of the disc to move as the condyle moves 2. Abnormal Disc Condyle relationship.
1.

y Internal derrangement can be divided into four

stages
Joint pain 2. Limited mouth opening 3. Anteromedial Displacement with Reduction 4. Anteromedial Displacement Without Reduction
1.

Immobility
1. Joint Pain or

noise & Catching or binding sensation on opening of mouth 2. Limited mouth opening (Disc Adhesion)

3. Anteromedial Displacement with Reduction

Clicking or

popping Sound

4. Anteromedial Derangement Without Reduction

Crepitations Limited

mouth opening of 2530 mm with hard end feel

Diagnosis
y Clinical Features y MRI y Arthrography ( for Tears & Separations) y Double click or reciprocal click has no clinical

significance

MPD
y It is very difficult to distinguish between the MPD and

TMJ disorders y TMJ disorders can lead to MPD and MPD can lead to TMJ Disorders y It is very important to determine the source and eliminate the cause.

MPD
y TMJ pathology causes pain and leads to muscle co-

contraction or Muscle splinting which leads to pain in the facial tissues = TMD. y TMD due to bruxism can lead to TMJ patholgies.

Signs & Symptoms

MPD symptoms
y Pain y Masticatory Muscle Tenderness y Limitation of Mandibular Movement y Clicking y Absence of clinical or Radiographical evidence of TMJ

Pathologies

MPD Symptoms
Pain
Very important to determine the source of pain. The source should always become more painful when provoked. y Unilateral y Deep seated y Diffused ( patient cant place a finger on the region in in pain)

MPD Symptoms
Pain
y Masseter y Jaw ache y Temporalis y Headache y Lateral Pterygoid y Pain behind the eye y Medial Pterygoid y Swallowing difficulty y Feeling of Painful swollen gland y Stuffiness of the ear

MPD Symptoms
Masticatory Muscle Tenderness y Clinical Examination Limited Mouth Opening y 8-10 mm of mouth opening with Soft End feel. y Mandible deviates to the effected side when the mouth is opened y Reduced excursion to the uneffected side

MPD Symptoms
Clicking Patient will give a history of Clicking or popping sound which started after there was muscle tenderness and pain Absence of clinical or Radiogaphical TMJ pathologies Local Anesthetic differential Diagnosis

MPD & TMJ pathologies

Differential Diagnosis
1. 2. 3. 4. 5. 6. 7.

History Mandibular restriction Mandibular interference Acute malocclusion Loading of the joint Functional manipulation Diagnostic anesthetic

Management of Temporomadibular disorders

Treatment

Reversible (conservative)

Irreversible (non-conservative)

Treatment approach

Definitive

Supportive

y Definitive treatment

Those methods intended to directly eliminate or alter the cause of the disorder y Supportive treatment Treatment methods directed towards altering the symptoms

Definitive treatment
Cause . Any event disrupting the normal masticatory activity can lead to TMDs Common events may be 1. Occlusal instability 2. Emotional stress 3. Trauma 4. Deep pain input 5. Parafunctional activity

1) Definitive treatment for occlusal factors

y

Occlusal condition can become the cause of TMDs in one or both of the following conditions:


acutely disturbed occlusion and/or orthopedic instability

Therapy can be:

a) b)

Reversible occlusal therapy Irreversible occlusal therapy

a) Reversible occlusal therapy

y

The occlusal splint is the major form of therapy used during the initial phase of treatment of TMDs favouring the elimination of masticatory muscle hypertonicity, achieving temporary occlusal stability and the appropriate positioning of the condyle in the glenoid fossa Once a favourable position has been achieved, muscles have been relaxed, phase one may be considered sufficient . However if the symptoms have not been relieved permanent solution is given

a) Reversible occlusal therapy

y y

Temporarily alters patient s occlusal condition Accomplished with occlusal appliance An acrylic device worn on the occlusal and incisal surfaces of teeth in one arch, opposing surface of which results in a change in mandibular position and contact pattern

Treatment lasts for only as long as appliance is kept in the mouth by the patient therefore treatment is reversible

Occlusal appliance
y

Aso referred to as .
  

Bite guard, night guard, inter-occlusal appliance,

Examples:
     

anterior bite plane, posterior bite plane, pivoting appliance, soft or resilient appliance, stabilization appliance, orthopedic device

Two types are important

 

Stabilization appliance Orthopedic-repositioning appliance

Reversible occlusal therapy

irreversible occlusal therapy

b) Irreversible occlusal therapy

y y

Any treatment that permanently alters the occlusal condition, so that the original condition cannot be recovered Examples:
    

Selective grinding Restorative procedures Orthodontic procedures Surgical procedures Appliances designed to alter growth or permanently reposition the mandible

For when u are sure that a MS position has been identified. an orthodontist Start treatment only
This prevents development of a dual bite at the end of orthodontic treatment A unilateral cross bite results in deviation of the mandible which poses a difficulty in location of MS position. A stabilization appliance should be fabricated until a MS position is determined irrespective of the cross bite Once this position has been achieved orthodontist has to observe relationship of both the arches with each other. Our goal is to provide maximum intercuspation in this joint posittion. Thus determine the strategies and mechanics which would need to be taken to achieve this

In growing patients: Treatment might finish before maturation of the condyle fossa relationship.. Therefore a slight CO-CR discrepancy is allowed. Once ortho is finihed patient s individual loading during fuction will assist in stabilizing masticatory system In adult patients: Provide a MS position before finishing orthodontics as no growth is left to modify it later

Development of ortho/TMD treatment plan

y

If only ortho is required . Provide orthodontic goals as well as orthopedic stability If TMDs are present with ortho needs cure the TMDs first with occlusal appliances .. Then give ortho in MS position

y if only TMDs are present ortho is helpful only when

orthopedic instability is the only cause of TMDS and this instability is due to occlusal disturbances y To verify .
 If reversible subsides symptoms give irreversible  If it doesn t consider other of the five options

TMDs during orthodontic treament

y

Educate the patient:


  

If symptom is predominently muscle pain educate the patient

awareness, avoidance of those occlusal contacts, emotional stress, bruxism avoidance

y y y y y y y

If not responsive give medication If not responsive give physical therapy If not responsive discontinue active orthodontics for a while Give soft appliances Give bite planes on temporary basis Re-evaluate MS position. Ensure orthodotics is proceeding in the desired direction If all these things are normal and clicking is also present and symptoms are not subsiding discontinue ortho, diagnose the joint pathology and give specific treatment

Supportive treatment
y Directed towards altering patient s symptoms and has no

relation to the cause of the disorder

y Only symptomatic and not a replacement of long-term

definitive treatment

y Two types of supportive treatment can be given

Pharmacological  Physical


Pharmacological . Treatment through drugs

      

Analgesics NSAIDs Corticosteroids Anxiolytic agents Muscle relaxants Antidepressants Local anesthetics

Physical therapy .. Phsical treatments that can be applied to the patients

        

Thermotherapy Coolant therapy Ultrasound therapy Phonophoresis Iontophoresis Electrogalvanic stimulation therapy Transcutaneous electrical nerve stimulation Acupuncture Cold laser

DEC 95 issue of Semin Orthod 2. Management of temporomandibular disorders by OKESON 3. Graber

1.