tmj disorders and its management prof.dr. ahlam el-sharkawy prof.dr. ahlam el-sharkawy head of...

TMJ Disorders and its management

Prof.Dr. Ahlam El-Sharkawy

Head of prosthodontic departement

Pharos University in Alexandria

What is the Temporomandibular Joint?

Temporomandibular joint represents the articulation of the mandible to the temporal bone of the cranium.

Interarticular disc lies between the mandibular condyle and the temporal bone, helping in smooth motion.

This disc absorbs shocks to the jaw joint from chewing and other movements.

What is the Temporomandibular Joint?

TMJ innervation : - Sensory supply through the

auriculotemporal nerve branch from the mandibular nerve branch from the trigeminal nerve.

- Motor supply to the muscles through the mandibular nerve (the main trunk and the anterior division).

Normal closed and opened positions

jaw closed

jaw opened

TMJ Disorders Temporomandibular disorder (TMD)

is a collective term used for a number of clinical problems that involve the masticators muscle, TMJ, and/or associated structures.

The term TMD has been defined as an abnormal, incomplete or impaired function of the TMJs.

Classification

TMD fall into two main categories: Myogenous , which involves muscles.

Arthrogenous , which involves articular bones, or disc inbetween.

Articular disorders “arthrogenous

Degenerative disk disorders Inflammatory; capsulitis, synovitis, polyarthiritides.

Non-inflammatory; osteoarthritis

Articular disorders “arthrogenous”

Disk derangement disorders

Displacement with reduction.

Displacement without reduction [closed lock].

Perforation. Dislocation(open-lock)

Common sign and symptoms

the most common initial symptom is 1- pain, usually localized in

Muscles of mastication The preauricular area TMJ May radiate to head and neck And aggravated by chewing or

other jaw functions.

Common sign and symptoms

2-Limited mandibular movements,

3-joint noises( clicking, creptius )

4-jaw ache, ear ache, headache, and facial pain.

Etiological factors

1- Tensional, emotional ,and physical stress. 2-Occlusal interference, premature contact and occlusal instability. 3-Pain in masticatory system. 4-Abnormal biting habits. 5-loss of posterior teeth. 6-External force or trauma. 7-Pathophysiologic factors.

Examination of TMD

1. History2.Clinical examination3. Radiographic

examination

Examination of TMD1.history

Personal history:

including patient's name, age, sex, occupation, marital status, telephone number and habits such as bruxism.

Medical history:

to exclude systemic diseases affecting bone, joint and /or muscles.


Dental history: To detect any relation

between dental procedures and the onset of the TMJ symptoms, also if there is any history of trauma to jaw .


Chief complaint: The most imp in history the type of

pain(usually dull pain) location, onset, characteristics, aggravating factors

So treatment must be directed toward the source of pain, not to the site where it is felt.

Examination of TMD

II-Clinical examination:The masticatory apparatus

examination consists of evaluating three major structures:

muscles joints teeth.

II.Clinical examination of TMD1. Muscles examination

1.TemporalisThe temporalis muscle is

segmented into anterior, middle, and posterior regions.

1.Temporalis (anterior): Fibers of this region run vertically and were palpated above the zygomatic arch and anterior to the TMJ.


Temporalis (middle):

Fibers of theses region run obliquely and were palpated in the depression above the TMJ about 2cm lateral to the lateral border of the eyebrow


Temporalis (posterior):

Fibers of this region run horizontally and were palpated above and behind the ear.


Masseter: The masseter is

palpated by placing the fingers on the zygomatic arch then they are dropped down slightly just anterior to the joint.


Lateral ptrygoid muscle: palpated by placing the index

finger on the lateral side of the alveolar ridge above the maxillary molars while moving the finger upward and medial to palpate. (the location for the posterior superior alveolar injection)


Medial pterygoid muscle: Slide the index finger a

little posterior to the traditional insertion site for an inferior alveolar injection, until you feel muscle, and press laterally. to where muscle is felt and press laterally.


Sternomastoid: Bilaterally palpate the

sternomastoid muscles by squeezing each between the thumb and index finger along the length of the muscle.

II.Clinical examination of TMD3. joint examination

Palpation of TMJ Range of motion TMJ noise


Palpation of TMJ TMJ needs to be palpated in two

locations. Tenderness in one of these

locations is not necessarily associated with tenderness in another.

Palpate the first location by asking the patient to open approximately 20 mm and palpating the condyle’s lateral pole.


Range of motion The opening measurement

routinely obtained is the distance (in millimeters) between the incisal edge of the maxillary central incisors and the incisal edge of the mandibular central incisors when.

Radiographic examination

I- Imaging of the TMJ:The goal is to obtain the

necessary diagnostic information without unnecessary patient expense or radiation exposure.

Diagnostic Aids and Methods of Investigation

I- Imaging of the TMJ:1-Plain film radiography: This provides a view of all

mineralized tissues “bone”, but can’t show any soft tissue as disc or cartilage.

Limited by superimposition of adjacent structures.


I- Imaging of the TMJ:2-Conventional

tomography: It produces 3D multiple thin

image slices. true condylar position and

reveal osseous changes. Exposure to radiation is the

main disadvantages.


I- Imaging of the TMJ:3-Panoramic radiography: show condylar abnormalities

such as erosions, sclerosis, resorption, ankylosis, and fractures.

It also gives information about the teeth, mandible, and maxilla, which may help with the overall diagnosis.


I- Imaging of the TMJ:4-Arthrography: It involves injection of

radiopaque contrast material into the joint spaces. So it can then be visualized.


I- Imaging of the TMJ:5-Computed

tomography/ Cone beam CT:

Newer and faster technique, with a lower radiation dose than conventional whole-body CT.

It provides 3 dimensional thin-slice images on the axial, coronal, and sagittal planes.


I- Imaging of the TMJ:6-Magnetic resonance

imaging: Detect soft-tissue abnormalities. Joint and disc can be accurately

visualized both at rest and in motion.

Allows for analysis of the blood supply and vascularity of the condyle, detect any pathologic accumulations of fluid within and around the joint.

The main advantage is the complete absence of radiation.


II- Electromyography:

Graphic recording of the electrical potential of muscle.

Used to assess masticatory muscle function in TMD patients.

Shows nocturnal and diurnal parafunctional habits.


III-Ultrasonography: Sonography is a technique

of recording sound waves of high frequency to produce images of the body.

As the sound waves travel through the body, they encounter a boundary between tissues of varying densities.


IV-Mandibular Tracing Devices:

It is used to detect the exact movement of the mandible.

Unfortunately; many disorders create deviations and deflections in mandibular movement pathways.

Therefore, diagnosis should be aided by clinical and radiographic examination.


IIV-Thermography: Thermography is a technique

that records and graphically illustrates surface skin temperatures.

Various temperatures are recorded by different colors, producing a map.

This is not a reliable method, not useful for TMJ diagnosis.

Management of TMJ disorders

The treatment of TMDs must be based on a proper diagnosis, collecting data regarding patient’s history; trauma, accidents, or oral habits.

Management of TMDs can be summarized into supportive and definitive treatments.

Management of TMJ disorders

Supportive therapy; refers to treatment methods that are directed toward altering patient’s symptoms, such as pain and dysfunction. No or little effect on the etiology.

Definitive treatment; directed toward elimination or alteration of the etiologic factors responsible for the disorder.

I) supportive therapy

1- Pharmacological therapy.

2- Physical therapy.

.

II) Definitive treatment:

1- Occlusal therapy; A-Reversible occlusal therapy.

B-Irreversible occlusal therapy 2- Surgery.

I) supportive therapy1- pharmacological therapy

Pharmacologic therapy used to treat symptoms of TMD can be classified into five types:

1) analgesics2) Corticosteroids3) muscle relaxants4) anti-depressants& anti-anxiety

agents5) local anesthetics.

I) supportive therapy2- physical therapy

Can be categorized in physical modalities and manual techniques.

(A) Physical therapy Modalities:1-Thermotherapy:It is the application of hot fomentation

on the symptomatic area for 10 to 15 minutes, not exceeding 30 minutes.

The primary goal, is to increase blood supply through vasodilatation, leading to decrease pain and joint stiffness.


2-Coolant therapy:-It is the application of cold

fomentation such as ethyl chloride and fluoromethane sprays.

-This intend to decrease pain by numbing the symptomatic area.

-Combination of hot and cold

fomentation is helpful.


3-Acupuncture:It is one of the alternative

Medicine techniques. Its action is still unclear,

but was successfully used in treating TMD symptoms.


4-Electromyographic Biofeedback:

some emotional states may be associated to muscle hyperactivity, relaxation training assisted by the use of EMG biofeedback, can reduce diurnal muscle activity; thus reducing pain.


5-Ultrasound therapy:It has the same concept of

thermotherapy, but more effective; because it acts on deeper tissues, not just the surface.

Ultrasound not only increases the blood flow in deep tissues but also seems to separate collagen fibers, which improves the flexibility and extensibility of connective tissues, decrease joint stiffness, provide pain relief, improve mobility, and reduce muscle spasm.


6-Transcutaneous Electrical Nerve Stimulation “TENS”:

Electric stimulation devices for treatment of TMD are claimed to have two main purposes; relief of pain and relief of muscle hyperactivity or spasm.


7-LASER “Light Amplification by Stimulated Emission of Radiation”:

It has wide application in dentistry.

The only physical risk is eye damage; special eye goggles should be worn for protection.


(B) Manual techniques "Hands on therapy":

These include treatment procedures intended to promote motion and relieve pain in musculoskeletal structures. As

1-Soft tissue mobilization.2-Joint mobilization.3-Muscle conditioning.


b) Assisted muscle stretching:

Stretching, to regain muscle length, should be performed with gentle intermittent force that is gradually increased, where pain should not be elicited in this exercise.

Important in management of myofacial pain.


c) Resistance exercises:Resistance exercises use the concept of reflex

relaxation or reciprocal inhibition.These exercises are useful if the restricted opening

is secondary to muscle condition.They should not be used for painful intracapsular

restrictions; it also should not produce pain which could leads to cyclic muscle pain.

II) Definitive Treatment 1- Occlusal Therapy

Types of occlusal splints: Although there are many types of

appliances, two major types of appliances are commonly used for TMD. Stabilization splints and anterior repositioning splints.


a- Stabilization Splint: It is a hard acrylic resin, flat plane splint that

provides a temporary and removable ideal occlusion. Can be made to cover the maxillary or mandibular

dental arches; although the former provides more retention& stability.

patient.


a- Stabilization Splint: Stabilization splints are designed to- provide stabilization of the joint- redistribution of the occlusal forces at the

tooth and/or joint level- relaxation of the elevator muscles - protection of the teeth from the effects of

bruxism.


a- Stabilization Splint: Myogenous pain disorders respond better

to part-time use, so in bruxism it is suggested that patients wear the splint only at night.

Intracapsular disorders are better managed with continuous use.

Successful splint therapy needs about two to three months.


b- Anterior repositioning Splint:

It is a full arch hard acrylic interocclusal device that can be used in either arch to encourage the mandible to assume a position more anterior than intercuspal position.

However the maxillary arch is preferred because a guiding ramp can be more easily fabricated to direct the mandible anteriorly.


e- Soft or Resilient Splints: also known as mouthguard or

nightguard. It is not as effective in reducing

myofacial pain symptoms as is a hard acrylic appliance.

II) Definitive Treatment2- Surgery

Surgery is rarely used in treatment of TMJ. But in some cases, it will be the only choice; as in bony ankylosis, neoplasia, gross TMJ problems.

Sometimes it is used with disc displacement without reduction in order to return the disc to its normal relation with condyle.

tmj disorders and its management prof.dr. ahlam el-sharkawy prof.dr. ahlam el-sharkawy head of...

Documents

history dental history

history personal history

jaw joint

history of trauma

alexandria slide

medical history

temporomandibular joint

radiographic examination