treatment of headaches and temporomandibular joint...

Treatment of Headaches and

Temporomandibular Joint Problems

Soft DietSuitable for Painful

Temporomandibular Join Conditions reducing the Stress on the Joints

CounsellingSome Patients with

Temporomandibular Joint Problemshave varying degrees of Psychological

Problems

CounsellingRanging from Treatment

of Mild Depression to Severe Psychological Problems

PsycotherapySuitable for Patients with More Serious Psychological Problems

• Anti-inflammatory Drugs• Antidepressants• Analgesics

Drug Therapy

Drug Therapy• Muscle Relaxants• Steroid Injections• Cessation of Certain Drugs

Occlusal Therapy• Appliance Therapy• Limited Occlusal Adjustment• Occlusal Equilibration• Removal of Teeth

Occlusal Therapy• Orthodontic Treatment• Occlusal Reconstruction• Prosthetic Treatment

Physical Therapy• Moist Heat• Ice• Vapocoolant and Stretch• Local Anaesthetic and Stretch

Physical Therapy• Muscle Exercises• To Restrain• To Regain Mobility• To increase Muscle Strength

Physical Therapy• Biofeedback• Microwave Therapy• Faradism• Relaxation Therapy

OrthodonticTo correct Occlusaly Related Problems

NeurologicalTo correct Neurologically Related

Problems

Medical

To correct Medically Related Problems

SurgicalShould be the last resort after all other Treatments have been tried and have

failedand where the Patients Symptom are

sufficiently Troublesome

SurgicalIn some Circumstances

Surgical reattachment of an Anteriorly Displaced Disc

is Necessary

No TreatmentIn Some Circumstances

No Treatment is the Best Option

Sometimes TreatmentEither has No Effect

and the Patient eventually gets Betteror stays the Same

or gets worse

Treatment ofNeuromuscular Dysfunction

( Myofascial Pain Dysfunction Syndrome M.P.D.S.)

Lateral Pterygoid Isometric Exercises

to Strengthen the Lateral Pterygoid Muscles

Physical Therapy• Palm of Hand under Chin• Support Elbow with Other Hand• Close Teeth together • Push up and back

Physical Therapy• Separate Teeth Slightly• Open against Palm of Hand • Rotation only No Translation • Push Closed • 30 x 4 x Day for 4 weeks

Appliance Therapy

Uses of Appliances• To alter the Occlusion• To reposition the Jaw Relationship• To reposition Teeth

Types of Appliances• Bite Raisers• Soft Appliances• Anterior Jigs• Posterior De-programmers

Centric Relation Appliances with Posterior Disclusion

Upper or Lower

Anterior Repositioners• Used to recapture Anteriorly

Displaced Discs• Permanent Repositioners

Reasons for using Upper Appliances

• Better Appearance • Better Speech• More Comfortable• “My Guru taught Upper Appliances”

Reasons for using Lower Appliances

• Better Appearance • Better Speech• More Comfortable• “My Guru taught Lower Appliances”

Good Reasons for using Upper Appliances

• More Teeth Lost in Upper Jaw • Looser Teeth in Upper Jaw • Instanding Teeth in Lower Jaw

Good Reasons for using Lower Appliances

• More Teeth Lost in Upper Jaw • Looser Teeth in Lower Jaw• Instanding Teeth in Upper Jaw• Very Uneven Lower Anterior Teeth

The Tanner ApplianceA Lower Centric Relation Appliance

with Posterior Disclusion in Excursive Movements

A Centric Relation Appliance

Discluding Posteriorly in Excursive Movements

If an Occlusal Appliance is fitted and adjusted to occlude in Centric Relation

Patients tend to tap their teeth together in Centric Relation

This can be Verified by• Tapping the Patient in Centric

Relation on Articulating Paper• Then having the Patient tap rapidly

on a Different Coloured Paper

Case 1

Note the Red and Blue Dots coincide

Case 1

Case 2

Case 3

Given the OpportunityWhen Interferences are covered up with

an Appliance or if the Interferences are removed by

EquilibrationMost Patients will tap together

in Centric Relation

Tanner Appliance Construction

Beading Wax place just below the Occlusal Surface

Undercuts blocked out

Tin Foil adapted to the Lower Model

Cold Cure Acrylic

The Acrylic Template Former

Apply Vaseline to the Acrylic Template Former as a Separator

The Acrylic Pressed onto the Template Former

Roller used to flatten the Acrylic

The Acrylic Tanner Sheet

The Acrylic Tanner Sheet pressed over the Lower Model

Trim back some of the Excess before the Acrylic is set

The Acrylic Tanner Sheet pressed over the Lower Model

The Centric Markings

The Excess Acrylic Trimmed away

The Cold Cure Acrylic applied to the under-surfaced of the Tanner

Appliance

This is best done in Three SegmentsNot All in one go

There is Less Likelihood of the Appliance becoming Stuck

Start with the Right Side• Apply Soft Acrylic to the Under

Surface of the Right Side • Fit the Appliance in the Mouth• Press down Firmly into Place• Repeatedly lift the Left Side until the

Acrylic is set

Do Not allow the Acrylic to set in the Mouth

to remove the Appliance if it becomes Set in Place

would require cutting out This is a Difficult Procedure

Remove and trim away Excess Acrylic

Continue with the Lower Front• Apply Soft Acrylic to the Under

Surface of the Lower Front• Insert into the Mouth• Press down Firmly into Place• Repeatedly lift the Left Side until the

Acrylic is set

Continue with the Lower Front• Remove and trim away Excess Acrylic

Continue with the Lower Left Side• Apply Soft Acrylic to the Under

Surface of the Lower Left Side• Insert into the Mouth• Press down Firmly into Place• Repeatedly lift the Left Side until the

Acrylic is set

Continue with the Lower Front• Remove and trim away Excess Acrylic

Equilibrate the Appliance in Centric Relation

Then remove All Posterior Excursive Contacts

Centric Stops

Lack of Centric Stops

In Some Cases it is Necessary to add Soft Acrylic to the Occlusal

Surface

The Acrylic added to the Occlusal Surface of the Tanner Appliance

The Final Centric Stops

Centric Stops

If the Patient taps their Teeth together

The Marking Ink may be cleared from the Centre of a Marking

This is known as a “Halo”

A Halo indicates a Definite Contact rather than a False Marking

Lateral Excursions

Protrusive Excursions

Posterior Lateral Excursion Movements marked in Red

All Posterior Excursive Markings should be removed

All Posterior Lateral Excursion Movements removed

Grooves added to aid eating

The Patient experienced Pain when chewing

The Appliance relieved the Symptoms

The Appliance may cause Sores on Soft Tissues

Apply Zinc Oxide Impression Pasteto the Fitting Surface

to indicate the Tight Area

Ease the Tight Surface

An Alternative Lower Appliance

Occlude used to detect the Tight Fit

Occlude used to detect tight Fit

Upper Appliances

Upper Appliance

Anterior Guidance

Centric Contacts

Lingually placed First Premolar

A Lower Appliance would impinge on the Tongue

An Upper Appliance was fitted

An Upper Appliance

Anterior Jigs

Place some Soft Acrylic behind the

Anterior Teeth

Overlap the Incisal Edges

Have the Patient bite into the Soft Acrylic

Remove the Some of the Palatal Surface

Flatten the Biting Surface

Treatment of Anterior Displaced Discs

At Rest the Disc is displaced Anteriorly

The Closed Position

Opening

The Disc bunches up in Front of the Head of the Condyle

The Disc clicks into Place

There is a Late Click on Opening

Closing

The Disc has clicked off Anteriorly again

There is a Late Click on Closing

Diagnosing Anterior Displaced Disc

A Late Click on Openingfollowed by a Late Click on Closing This is known as a Reciprocal Click

Anterior RepositionersUsed to recapture Anteriorly

Displaced Discs

Add some Greenstick Compound• to the Front of a Flat Occlusal

Appliance• Insert the Appliance• have the Patient open until they click

• Have them move their jaw forwards and start to close

• Before they close onto the Soft Compound

• have the Patient move their jaw backwards until They almost click

• then ask them to close

• Remove the Appliance • Add soft Cold Cure Acrylic to the

Posterior Biting Surface• Insert the Appliance • Have the Patient open until they click• Have them close into the Greenstick

The Anterior Greenstick Compound

The Acrylic

• Remove the Greenstick• Add soft Cold Cure Acrylic to the

Anterior Biting Surface• Insert the Appliance • Have the Patient open until they click• Have them close into the Posterior

Acrylic

• Remove the Appliance• Remove any Sharp Projections • Insert the Appliance • Have the Patient open until they click• Then have them Open and Close

Their Disc has been recaptured with the Appliance in

They will not click on opening and closing

On removing the Appliance On closing the Patient will click

The Disc has fallen off the Head of the Condyle

The Reciprocal Click now has returned

The Anterior Appliance with Grooves for chewing

Making an Anterior Repositioning

Appliance using a Relined Tanner Shell

The Tanner Shell

Add some Greenstick Compound• to the Appliance• Insert the Appliance• have the Patient open until they click• Have them move their jaw forwards • and start to close

Before they close onto the Soft Compound

• have the Patient move their jaw backwards until They almost click

• then ask them to close

• Remove the Appliance • Add soft Cold Cure Acrylic to the

Posterior Biting Surface• Insert the Appliance • Have the Patient open until they click• Have them close into the Greenstick

• Remove the Greenstick• Add More Soft Cold Cure• Insert the Appliance • Have the Patient open until they click• Have them close into the Posterior

Acrylic

• Remove the Appliance• Remove any Sharp Projections • Insert the Appliance • Have the Patient open until they click• Then have them Open and Close

The Final Repositioner

Converting Complete Dentures into

an Anterior Repositioning Appliance

The Original Dentures

HistoryThis Patient’s Wife complained about his Loud Clicking Joints

when He was eating

On ExaminationThe Patient had a Late Click on Opening

and a Late Click on Click on ClosingThis is known as a Reciprocal Click

This a Diagnostic of an Anterior Displaced Disc

The Back of the Second Molar flattened Vertically

Greenstick Compound was added• to the Premolar Area of a Flat Occlusal

Appliance• The Appliance was fitted• The Patient opened until he clicked• moved his Jaw Forwards

and started to close

Before closing onto the Soft Compound

• The Patient move his jaw backwards until he almost clicked

• He was then asked to close• Remove the Appliance

Soft Cold Cure Acrylic was added to the Posterior Biting Surface

The Soft Cold Cure Acrylic added

• The Appliance was inserted• The Patient opened until he clicked• Then closed into the Greenstick

• The Greenstick was removed• Soft Cold Cure Acrylic was added

to the Gap• The Appliance inserted• The Patient opened until He clicked• Then closed into the First Set Acrylic

• The Appliance was removed• The Added Acrylic Flattened • A Wedge Posteriorly to keep

the Mandible Forward• This stops the Disc slipping of the

Head of the Condyle

The Posterior Wedge

The Repositioning Appliance

The Patient’s Clicking during eating was eliminated

Gelb AppliancesThe Use of Gelb Appliance Therapy

is Controversial It involves the Use of Kinesthesiology

Treatment of a Patient with a Posterior Open Bite

after wearing a Tanner Appliance

Posterior Open Bite

Tanner Appliance was cut back Posteriorly

To allow the Second Molars to erupt

Tanner Appliance was then cut back Posteriorly

To allow the First Molars to erupt

The Back Teeth were then in Occlusion

The EndThe End

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