MAXILLOFACIAL PROSTHETICS TEMPOROMANDIBULAR JOINT . DENTAL IMPLANTS SECTION EDITORS

I. KENNETH ADISMAN LOUIS J. BOUCHER

Position paper of the American Academy of Craniomandibular Disorders

Craniomandibular (TMJ) disorders-The state of the art

Charles McNeill, D.D.S.,” William M. Danzig, D.D.S., William B. Farrar, D.D.S., Harold Gelb, D.M.D., Martin D. Lerman, D.D.S., Benjamin C. Moffett, Ph.D., Richard Pertes, D.D.S., William K. Solberg, D.D.S., and Lawrence A. Weinberg, D.D.S., M.S.

Walnut Creek, Calif.

I n dentistry, as in medicine, the diagnosis and treatment of pain syndromes are among the most perplexing problems confronting the clinician. Since a multitude of organic and nonorganic (psycho- physiologic) conditions may contribute to and com- pound facial pain and ‘mandibular dysfunction, temporomandibular joint (TMJ) disorders must be carefully differentiated from other disease entities with similar signs and symptoms.

Craniomandibular disorders are characterized by tenderness in the muscles of jaw, head, and neck; painful TMJs; limited mandibular movements; joint noises; and facial deformities. Headaches, earaches, neckaches, and toothaches are frequently listed as complaints.

ETIOLOGY

The proper management of the patient suffering from a TMJ disorder begins with a thorough diagno- sis followed by the indicated treatment. This should not only be palliative, but an attempt must be made to elimate the etiologic factors. “Snap” diagnosis and “shotgun” therapy often results in unnecessary treat- ment, suffering, and expense. It is an important responsibility of the dentist to differentiate pain of dental origin from pain due to other causes.

The etiologic factors of craniomandibular disor- ders are multicausal and include genetic, develop- mental, physiologic, traumatic, pathologic, environ-

*Chairman, Committee of the Regional Workshops.

Presented at the meeting of the American Academy of Cranio- mandibular Disorders, Chicago, III.

mental, and behavioral factors. Etiology can be divided into predisposing, precipitating, and perpet- uating factors.

Predisposing factors include structural (size and/ or shape) discrepancies with any of the tissues of the masticatory system. In addition, physiologic disor- ders such as neurologic, vascular, nutritional, or metabolic disorders can predispose the patient to craniomandibular problems. Pathologic factors in- clude systemic diseases and infections, neoplasias, and orthopedic imbalances. Behavioral factors relate to the personality profile of the patient and how that patient responds to stress, which can be expressed as noxious habits such as bruxism and tooth clench- ing.

Precipitating (triggering) factors include trauma not only to the masticatory system itself but to the entire head and neck of the patient, an adverse stress response, iatrogenic problems, infection, and idio- pathic factors.

Perpetuating ,(sustaining) factors are manifested primarily by the myospasm-pain-spasm cycle and can be related to any one or a combination of the above predisposing or precipitating factors.

CLASSIFICATION

The following is a classification of TMJ disorders that was agreed upon by the recently formed Regional Workshop Committees of the American Academy of Craniomandibular Disorders.

I. Craniomandibular disorders of organic ori- gin

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CRANIOMANDIBULAR DISORDERS

II.

A. Articular disturbances 1. Disk derangements

a. Disk dysfunction b. Disk displacement c. Disk dyscrasias

2. Condylar displacement 3. Inflammatory conditions

a. Synovitis b. Diskitis c. Capsulitis d. Contusion e. Rupture

4. Arthritidies a. Osteoarthritis (arthrosis) b. Rheumatoid arthritis c. Polyarthritis (i.e., gout, lupus, Reit-

ers Syndrome) d. Rheumatoid variants (i.e., psoriatic,

juvenile) e. Infectious arthritis

5. Ankylosis a. Fibrous b. Osseos

6. Fractures 7. Neoplasias

a. Chondroma b. Osteoma

8. Developmental abnormalities a. Hyperplasia b. Hypoplasia c. Agenesis

B. Nonarticular disturbances 1. Neuromuscular conditions

a. Myofascitis (muscle tenderness) b. Contracture (mechanical short-

ening) c. Trismus/spasm (reflex splinting) d. Dyskinesia (weakness and incoordi-

nation) 2. Dental occlusal conditions

a. Unstable occlusion (structural im- balance)

b. Premature posterior tooth contacts (posterior fulcruming)

c. Lack of posterior occlusal support d. Distal thrust to mandible

3. Disturbances involving referral of sec- ondary symptoms a. Latent myofascial tenderness b. Active myofascial trigger points

Craniomandibular disorders of nonorganic (functional) origin

A. Myofascial pain-dysfunction (MPD) syn- drome

B. Phantom pains C. Positive occlusal sense D. Conversion hysteria

III. Craniomandibular disorders of nonorganic origin combined with secondary organic tis- sue changes A. Articular B. Nonarticular

1. Neuromuscular 2. Oral

a. Teeth b. Periodontium c. Soft Tissues

DIAGNOSIS

The following baseline records should normally be made for patients suspected of having a TMJ disor- der: medical and dental histories, clinical examina- tion, radiographic examination of the teeth and TMJ, and diagnostic casts. In addition, newer tech- niques of soft tissue radiation or sonics, arthrogra- phy, and mandibular’motion data can prove to be of important diagnostic value.

A thorough history may be the most important means of diagnosing TMJ disorders, and the dentist must be willing to spend the necessary time to make a comprehensive history. This may take as much as an hour or more of in-depth questioning and prob- ing.

A thorough clinical examination should include the TMJ region and mandibular function, the mus- cles of the head and neck, the oral cavity, and an analysis of the octilusion. This analysis should be performed intraorally and, when possible, with prop- erly mounted casts. Also, the newer electronic man- dibular movement recording techniques may well prove to be of invaluable diagnostic importance. Ra’diographic examination can include transcranial radiographs, tomograms or laminograms, corrected cephalometric tomography, xerography, or the new- er nuclear tracer techniques.

Injection of local anesthetics or surface application of refrigerated sprays can be effective as a diagnostic tool and sometimes as a treatment for muscle spasms. This diagnostic tool is especially useful since there can be referred pain from muscles in spasm.

ACCEPTED TREATMENT MODALITIES

The first step in treatment is symptomatic care which usually consists of (1) a soft diet, (2) mild

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McNElLL ET AL

anti-inflammatory agents, (,3) moist heat packs and/ or ice, and (4) voluntary self-disengagement of the teeth. For some patients this may be the only treatment necessary to relieve their symptoms.

It is unfortunate that many patients suffering with head pain symptoms from TMJ disorders go from one type of specialist to the next seeking relief but ending up only more and more confused. Because these patients may have been suffering for a number of years without receiving help, they become con- vinced they have a serious life-threatening disease or that they are truly becoming neurotic. The counsel- ing of such patients may be the most important aspect of the total treatment regimen.

OCCLUSAL SPLINTS

Occlusal splints are usually a reversible form of treatment and, thus, a true diagnostic aid. If the occlusal interferences are not the cause of the patient’s problem, the splint can be discarded. How- ever, in certain extreme jaw discrepancy patients, the patient may be unable to return to his original maximum intercuspated position.

Articulation treatments or adjustments are per- formed on the splints to correlate the continous changes in the maxillomandibular relationship that usually occur with splint therapy as neuromuscular conditions and articular disturbances improve. Occlusal corrections are performed on the splint until the maxillomandibular relationship becomes relatively stable (reproducible) and the patient becomes less symptomatic. With the occlusion (mal- occlusionj being masked by an occlusal splint, the muscle and intraarticular structures are allowed to reposition the mandible to a more physiologicall) normal position.

BEHAVIOR MODIFICATION

Behavior modification can be attempted through (1) a biofeedback technique, (2) acupuncture, (3) hypnosis, and (4) psychotherapy. Even occlusal splints are a form of behavior modification.

Biofeedback is a method of giving a person immediate information about their internal func- tioning which would not otherwise be available. Once this information is available, direct control of particular variables is possible. There is good evi- dence both from controlled studies and from wide- spread clinical use by many practitioners that bio- feedback is effective in the treatment of many stress syndromes, including tension headaches.

Acupuncture does work, although its parameters have not yet been clearly defined. Acupuncture provides important clues about one way of promol- ing the body’s own suppressive mechanisms in the relief of pain, such as the production of brta-

endorphins. Hypnosis is being used successfully in a variety of

conditions by many physicians and dentists. Scirn- tific interest in the field of hypnosis is involved with clinical and experimental investigations being con- ducted by numerous researchers in nearly all the health disciplines.

Psychotherapy from allied health professionals with expertise in that field will be required for some patients. and referral is essential for proper patient management.

REPAIR AND REGENERATION

Forms of physical medicine are a very useful adjunct in TMJ treatment. A combination of moist heat and ice is probably the most practical treatment of muscle pain and spasm. Massage and therapeutic. exercises can be helpful after the acute symptoms have been relieved. Mandibular manipulation is extremely helpful in early disk displacetnent. Myo- functional therapy is also a useful form of treatment to allow for proper function of the orofacial muscu- loskeletal complex.

Ultrasound (or high-frequency sound) and dia- thermy are particularly helpful when increased vas- cularity and elasticity of the tissues is desired deep in the articular and periarticular tissues. Transdermal nerve stimulation is a newer modality used in conjunction with acupuncture points, and it appears very successful in modifying pain sensations.

Recent applications of applied kinesiolou and osteopathy are proving clinically helpful to some investigators. They are related to and used with other forms of physical medicine and behavior modification. Again, occlusal splints can be a useful form of physical rehabilitation in that they allow for more symmetric mandibular movements in many patients.

Analgesics, muscle relaxants, tranquilizers, seda- tive-hypnotics, antiinflammatory agents, and anti- biotics can be integrated with other methods of treatment. Injection of corticosteroids can also be beneficial in reducing the inflammation in an acute- ly inflamed joint. Because repeated injections may induce degenerative joint changes, this treatment must be used with caution.

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CIUNIOMAND~BULAR DISORDERS

DEFINITIVE TREATMENT

Definitive treatment of the occlusion is considered only after the patient’s acute symptoms have been relieved and the maxillomandibular relationship has become as stable as possible.

One of the following may be the treatment of choice: (lj occlusal adjustment of the teeth (equili- bration), (2) restorative treatment, (3) prosthodontic treatment, (4) full-mouth rehabilitation, (5) ortho- dontic treatment, (6) orthognathic surgery, and (7) a combination of any or all of these treatments.

The occlusal correction of a duplicate set of diagnostic mounted casts is extremely important as it is often impossible to achieve an optimum maxillo- mandibular relationship without surgical or ortho- dontic intervention. Because of the complexity of these forms of treatments, especially for elderly patients, the decision may be made to continue the use of the splint indefinitely. After the acute phases

of the symptoms are relieved, sometimes wearing an occlusal splint at night only is sufficient to prevent the patient from having an exacerbation of his symptoms. This is especially true if the patient has learned to control his parafunctional habits during the day.

Certain diseases of the TMJ can be treated only through surgery. Surgery is a primary consideration when there is disk displacement, bony ankylosis of the joint, a fractured displacement, a tumor, or gross developmental abnormalities. Surgery may also be considered when osteoarthritic degenerative changes are continuing to increase and/or concomitant pain becomes unmanageable.

Reprint requests to

DR. CHARLES MCNEII.L

1802 SAN MIGUEL DR.

WALNUT CREEK, CALIF. 94596

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