tmj presentation

7/21/2019 TMJ Presentation

1/135

Differential Diagnosis of TMD,Head, & Facial Pain

Leonard B. Goldstein, D.D.S., Ph.D.

Director, Clerkship Education

New York College of Osteopathic Medicine

EROC 2009


2/135

Diseases that mimicTemporomandibular Disorders

Differential Diagnosis

1. Comprehensive Medical History

2. Thorough Physical Examination


3/135

Clinicians must develop a plannedsystematic approach to patients withcomplaints of TMJ pain, or risk overlookingmore serious conditions, which carry

increased morbidity, and in someinstances, mortality.


4/135

Referred PainPain is considered referred if the origin of the

irritative lesion is some distance from the siteat which the pain is perceived. The anatomicbasis for this phenomenon is that pain isreferred from one region to another by

sensory nerves that share a commonsegment within the gray matter of the spinalcord.


5/135

The sensory innervation of the region

surrounding the TMJ is supplied by fourcranial nerves (V, VII, IX, X), and twocervical nerves (C1, C2). Trigeminal pain isreferred to the region anterior to the tragusby way of the auriculotemporal branch ofthe third division.


6/135

Lesions involving the floor of the mouth,

teeth, mandible, anterior 2/3 of thetongue, palate, paranasal sinuses andinfratemporal fossa can result in pain

directed to the same region by thetrigeminal nerve.


7/135

Pain felt in the external auditory canal

and postauricular region can betransmitted by the sensory branch of thefacial nerve by way of the nervusintermedius.


8/135

Patients with lesions involving the

geniculate ganglion (Ramsay HuntSyndrome), as well as tumors of the 7th

nerve have reported pain in the TMJregion.


9/135

GlossopharyngealReferred pain travels from the tonsils,

eustacian tube, posterior base of thetongue and nasopharynx to the petrosalganglion and down the nerve of Jacobsonto the middle ear.


10/135

Pain can also be referred in regions ofthe head and neck, which areinnervated by branches of the Vagusnerve (to the external auditory canal).


11/135


12/135

Differential Diagnosis

TMJ Pain may be due to Pathology in a

contiguous site or may be referred from aremote site. The patient can onlyidentify the site where the pain is feltnot the location of its source. Therefore,a comprehensive and careful search ofthe head and neck is necessary toascertain the correct diagnosis.


13/135

Vascular Syndromes1. Carotidynia

a) a variant of migraineb) long-lasting throbbing neck and facial pain

c) Pain is reproduced by palpation of the

carotid

d) Usually, self-limiting, and responds tosteroids and salycilates


14/135

Temporal Arteritis

(Also Called Giant Cell and Cranial Arteritis)

1. Vascular inflammatory disease ofunknown origin

2. Predeliction for Whites over 55 yearsof age

3. Female over male predominance 2:1

4. Headache is most common complaint*

5. Painful Mastication *


15/135

Temporal Arteritis

(Also Called Giant Cell and Cranial Arteritis)

6. Often, an elevated SED Rate (ESR)

7. Biopsy of the Temporal artery is

confirmatory

8. Prominent, Tender Temporal Artery

9. Prednisone 40-60 mg daily alleviatessymptoms and avoids ocularcomplications (blindness)


16/135

Eagles Syndrome

Caused by inflammation of an elongated

styloid process. Pain can be elicited bypalpation of the tonsillar fossa.Treatment is by excision of the styloid

process. Symptomatic improvement hasbeen reported with Steroid and Lidocaineinjections in the Tonsillar Fossa.


17/135

Neuralgic Pain

1. A trigger area or region where lightstimulation produces severe pain in thesensory distribution of that nerve

2.

Pain is paroxysmal in nature3. Pain does not awaken the patient at

night from sleep

4. The pain is unilateral

Most neuralgias share the following commonfeatures:


18/135

Trigeminal Neuralgia (Tic

Douloureaux)One of the most painful conditions

known to man. A misdiagnosis of dentaldisease is commonly made and isresponsible for many unnecessaryextractions. Periods of spontaneousremission occur which may span monthsor even years. Clinical diagnosis ofTrigeminal Neuralgia can be based on:


19/135

1. Clinically negative neurologic finding

2. Alleviation of pain and abolishment of the

trigger point by administration of a localanesthetic to block the involved trigeminalnerve division

3. The Half Inch Test in which the patient,when asked to demonstrate where the painbegins will avoid touching the trigger zoneby inch in fear of precipitating an attack


20/135

Glossopharyngeal NeuralgiasAn uncommon condition compared to

trigeminal neuralgia.

Characterized by paroxysms of pain thatradiate from the pharynx and tonsillarfauces to the TM region, ear, and

tympanum.


21/135

Pain occurs with swallowing, chewing,talking, or yawning.

Tonsillar and pharyngeal regions aretrigger zones.


22/135

Sphenopalatine NeuralgiaPain radiates to the mandible, zygoma,

and ear. Attacks are associated withedema of the nasal mucosa. Thediagnosis rests on the immediatecessation of pain after cocainization of thesphenopalatine ganglia during an attack(or 4% Lidocaine).


23/135

Herpes Zoster Oticus (Ramsay

Hunt Syndrome)An uncommon acute infectious disease

that affects the sensory and motor

branches of the facial nerve. Starts with pain and burning.

Within 2-3 days, the pain is followed by theonset of isolator facial nerve paralysis.

Within 10-14 days, vesicular eruptionsappear on the skin of the external auditorycanal.


24/135

SinusitisAcute and chronic infections of the

maxillary sinus can refer pain to the TMJas well as the cheeks and teeth.Misdiagnosed as TMJ pain in 20% of thecases.


25/135

Headaches Migraine (Vascular Headache)

Cluster (Vascular Headache)

Muscle Contraction Headache


26/135


27/135

The trigeminal nerve is commonly involved

in acoustic neuromas. Facial hyperesthesiaand occasionally, periauricular pain are themost common symptoms secondary totrigeminal involvement.


28/135

Confirmation of the presence of anacoustic neuroma is by contrast enhancedCT Scanning or Magnetic ResonanceImaging (MRI). Treatment is by surgicalexcision of the tumor.


29/135

Ear DiseasePathologic conditions of the ear maymasquerade as TM Disorders. Patients

with TMJ pain often have symptomssimilar to those of true ear pathology.Therefore, disease within the ear must

be considered and excluded as a sourceof TMJ pain.


30/135

1. Medical History

2. Examination of the ear

a) Inspection of the auricle and externalauditory canal, looking for erythenia, earprotrusion, tenderness, ecchymosis, orvesicular eruptions.

b) Otoscopy with insufflation.1. Perforation of the tympanic membrane

2. Otorrhea

c) Hearing status using a 512Hz tuning fork.


31/135

1. Diffuse External Otitis usually seen duringthe summer with constant high humiditybacterial and/or fungal. Treatment involves

mechanical cleansing of the ear canal,maintenance of a dry environment,applications of topical antibiotic drops.

The following conditions represent the mostcommon ear disorders that may mimic a TMDisorder.


32/135

2. Malignant External Otitis. Malignant ornecrotizing otitis is destructive bacterial infectionof the external auditory canal that is most often

observed in diabetic and immunocompromisedpatients. Treatment involves extensivedebridement of the ear canal with removal of allgranulation tissue and prolonged (6-10 weeks)intravenous antibiotic therapy directed againstpseudomonas aerugenosa, the primary causativepathogen. These include Ticarcillin, thirdgeneration Cephalosporins (e.g. Ceftazedrine,Cefoperazone), and Ceprofoxacin.


33/135

3. Bullows Myringitis

4. Acute Otitis Media. Bacterial infection of the middleear that often accompanies an upper respiratory

infection. Deep-seated, throbbing pain oftenassociated with hearing loss. The conductivehearing loss is secondary to the accumulation ofpurulent fluid in the middle ear space. Otoscopyreveals a dull and erythematous tympanic

membrane that has lost its normal landmarks andhas limited mobility. Treatment includes analgesicsand oral antibiotics. The antibiotics of choice areCeclor, Septra, and Augmentin.


34/135

*Note: The diagnosis of nasopharyngealcarcinoma must always be considered in any

adult who develops otitis media notprecipitated by a URI and is refractory tomedical treatment. Such cases of recurrent

or refractory serious otitis media requirenasopharyngoscopy and CT scanning of thenasopharynx to rule out a mass lesion.


35/135

MalignanciesMalignancies, both regional and metastic,can manifest themselves as TMJ pain andmust always be considered in everydifferential diagnosis of TMJ pain.


36/135

Although most malignant tumors thatinvolve the TMJ are usually secondary tocontiguous spread from the skin, parotidgland, ear, and nasopharynx, somemetastasis from the breast, lung,

prostate, and colon have been reported.


37/135

Pre-auricular mass in a patient with

symptoms of TMJ pain should alert theclinician to consider the parotid gland asthe primary focus.


38/135

The majority of parotid tumors (80%)are benign. The most common

presentation of a benign tumor is that ofa firm, mobile, and non-tender mass.


39/135

Clinical features of a malignant

parotid tumor:1. Pain is often associated with a higher

incidence of malignancy. Additionally,

pain is often an indicator of poorprognosis.

2. Facial nerve paralysis.

3.

Hardness and fixation of the mass areassociated with 30% to 50% incidenceof malignancy.


40/135

Examination and DiagnosisMedical History:

1. Baseline information

2. Alert practitioner to pertinent medicalhistory or to complications that may beencountered.

3. Help establish etiology of problem.

4. Establish and maintain a legal record.

5. Help establish a database for research.


41/135

Organization of Medical History

1. Personal data.

2. Chief complaint.

3. History of present illness.

4. Past medical history.

5. Past dental history.


42/135

ExaminationExamination for T.M. disorders differsfrom the examination for general

dentistry. The teeth and periodontiumreceive less attention than the state ofthe muscles and joints and the

mandibular movement.


43/135

The examination is made up of:1. Observation.

2. Masticatory muscle examination

(palpation and resistance testing).

3. T.M. joint examination. (Palpation,range of motion, selective joint

loading, assessment of joint sounds).4. Head and neck examination.


44/135

5. Occlusal analysis.

6. Diagnostic anesthetic blocks.

7. Cervical spine examination.

8. T.M. joint imaging.

9. Specialist consultation.


45/135

Masticatory Muscle

Examination: This is the most important part of the

examination.

The recommended technique issimultaneous palpation of the left and

right sides using approximately 3pounds of pressure.


46/135

1. Temporalis Muscles.

2. Zygomatic arch.

3. Masseter muscles.

4. Anterior Digastric Muscles.

5. Cervical Spine.


47/135

6. Trapezius Muscles.

7. Sternocleidomastoid Muscles.

8. Medial Pterygoid Muscles.

9. Lateral Pterygoid Muscle Area.

10. Coronoid Process.


48/135

Temporomandibular Joint

Examination1. Palpation of the lateral aspect of each

joint (anterior to the external Auditory

meatus).2. Palpation of the condyle through the

external Auditory Meatus.


49/135

3. Range of motion:

a) Maximal Interincisal opening/active range ofmotion.

b) Lateral movement.

c) Protrusive movement.

d) Patterns of mandibular opening.

e) Selective Temporomandibular joint loading.1) If clenching elicits joint tenderness capsulitis or

Retrodiscitis is suspected.


50/135

Head and Neck Exam:1. Thorough exam for palpable nodes,

Salivary gland pathology, and

Neoplastic disease.2. Evidence of habitual cheek biting or

tongue thrusting.

3. Joint sounds clicking or crepitus.


51/135

Clicking has been shown throughCadaver Studies, arthrography, and open

joint surgery to be indicative of discdisplacement.

The later the click occurs during theopening movement, the more severe thedisc displacement.


52/135

Crepitus is evidence of a change inosseous contour. It commonly indicatesosteoarthritis, but other Arthritides mustbe considered as well.


53/135

Occlusal Analysis:Take notes of the patients maxillo-mandibular relationship, both skeletal

and dental.


54/135

Cervical Spine Examination:Many patients presenting for TMJevaluations have cervical symptoms. It

is clinically evident that these problemscan act synergistically with the TMdisorders and can refer pain to the

temporal region. Motor vehicle accidentvictims, in particular, often present withboth cervical sprain and TMJ injury.


55/135

Dental practitioners are not normallytrained to do in-depth analysis of the

upper quarter, but should evaluate thestructures generally. When indicated,(almost always), a referral should be

made to a physical therapist, physiatrist,osteopathic physician, or a neurologist.


56/135

The Practitioner should note:1. Any shoulder asymmetry or deviation of

the neck.

2. Check for forward head or neckposture.

3. Check head rotation (about 80 degrees

in each direction).


57/135

4. Extension and Flexion (about 60degrees in each direction).

5. Side-bending (about 45 degrees ineach direction).

During this exam, all pain and limitationof movement is noted.


58/135

Temporomandibular JointImaging

General Screening:

Panoramic x-ray.

Lateral Transcranial Imaging.

Tomograms produce clear radiographic

slices of the condyle, which canclearly show subtle osseous changes.


59/135

Arthrography requires injection ofradiopaque dye into both joint spaces. Itcan visualize the meniscus duringmovement (Fluroscopic record recordedon videocassette). This invasive

procedure causes tenderness and somepatients are allergic to the dye.


60/135

CT and MRI

CT is superior for visualizing osseousstructures while MRI can visualize discposition.


61/135

Comprehensive treatment ofTemporomandibular Joint disorders

(Craniomandibular) can be brokendown into three areas:

Modalities.

Mobilization. Patient Education.


62/135

Physical Modalities and ManualTechniques Used in the Treatment of

Maxillofacial Pain


63/135

1. Physical modalities are only an adjunctto therapeutic techniques.

2. Physical modalities can be used to:A. Decrease pain.

B. Increase or decrease circulation.

C. Alter nerve conduction velocity.

D. Facilitate soft tissue stretching by alteringthe elastic properties of the connectivetissue.


64/135

E. Decrease swelling.

F. Decrease muscular spasm and trigger

points.G. Prepare the superficial tissue for electrical

modalities, mobilization, posture re-education, or exercise.

H. Speed the repair of connective tissue.


65/135

Application of cold:

Cryotherapy:

Although cold traditionally has been used

therapeutically for acute injury, the sameeffect can be beneficial in the sub-acuteand chronic phase of dysfunction.


66/135

Physiologically, cold will:

1. Cause vasoconstriction.

2. Decrease metabolism.

3. Reduce swelling.4. Reduce muscle spasm.

5. Reduce pain by producing a local

anesthetic effect.


67/135

The cold impedes synaptic transmissionand slows nerve conduction velocity, thus

elevating the pain threshold.


68/135

Cold can be applied easily andinexpensively as ice chips or cubes,

commercial ice packs, or vasocoolantspray. Ice massage can be performed bythe patient to reduce muscle spasm. The

ice cube is stroked over the muscle inspasm, parallel to the direction of themuscle fibers. Application should continueuntil the area becomes numb.


69/135

Flouro-methane spray and stretch wasdeveloped by Dr. Janet Travell in 1985. A

thin spray of vapocoolant is directed overa trigger point zone while the practitionerpassively stretches the involved muscles.

The streams of spray should overlap andbe performed in one direction from triggerpoint toward the referral zone of pain.


70/135

Spray and stretch techniques should onlybe applied to myogenous

craniomandibular disorders, because theeffect of over-opening of the mouth canprogress the displaced disc relationship in

intracapsular disorders.


71/135

Application of Heat:

Heat should not be used directly over theT.M. joint. Heat can be used over the

muscles of the upper back and neck.


72/135

Heat promotes relaxation:

1. Reduces pain.

2. Increases metabolism.3. Increases connective tissue flexibility.

4. Prepares muscles for the modalities and

exercise.


73/135

Ultrasound is known to increase heatin the deep soft tissue. In addition,

heat:1. Increases circulation.

2. Alters nerve conduction velocity.

3. Increases pain threshold, and4. Modifies skeletal muscle contractile

properties.


74/135

Therefore, ultrasound is used to treatjoint contractures, scar tissue, muscle

spasm, and pain. Ultrasound can also beused for phonophoresis, which propels ahydrocortisone, or dexamethasone

impregnated coupling agent into the softtissue or the T.M. joint.


75/135

Phonophoresis can:

1. Reduce local irritation.

2. Reduce pain.

3. Reduce post-treatment irritation frommobilization and/or exercise.


76/135

Electric High Voltage Stimulation (HVS orEGS) is a form of electric stimulation

applied to reduce pain, alter nerveconduction, increase circulation, anddecrease swelling.


77/135

Transcutaneous Electrical NeuralStimulation, (TENS), is an effective

adjunct to physical therapy in thereduction of pain. If appropriately used,the TENS unit can bridge the gap

therapeutically between office treatmentsessions.

Mobilization Techniques


78/135

Mobilization TechniquesJoint Liberation

After the soft tissue of the maxillofacialregion is prepared by the application of

physical modalities, the OsteopathicPhysician may elect to use mobilizationtechniques.


79/135

Mobilization may be applied to:

1. Stretch the soft tissue of the

maxillofacial region.2. Increase the range of motion of the

temporomandibular joint.

3. Relax the muscle spasm.


80/135

4. Restore the TM joint disc to a morenormal position on the condylar head.

5. Stabilize the joint.6. Prepare the joint for treatment.

7. Restore joint play.


81/135

*The American Academy of Orofacial Pain(AAOP) cited physical therapy as an

important adjunctive treatment in themanagement of TMD.


82/135

*The American Academy ofCraniomandibular Disorders (AACD)

guidelines note that Physical therapyhelps relieve musculoskeletal pain andrestore normal function by altering sensoryinput, reducing inflammation, decreasing,

coordinating, and strengthening muscleactivity, and promoting the repair andregeneration of tissues.


83/135

Manual Therapy

Manual therapy is the application of gentle,passive, sustained and oscillating forces to

joints or soft tissues to assist in theirreadaptation. Readaptation may restore

joint mobility through lengthening of themuscle, capsule, or fascial structure. Once

the tissue is sufficiently flexible andstrengthened, the patient can regain a moreideal head-on-neck orthostatic relationship.

Soft Tissue and Joint


84/135

Soft Tissue and JointMobilization

Soft tissue mobilization techniquesinclude deep pressure point massage,

stretching, myofascial release, strain-counterstrain, and craniosacral therapy.

The masticatory and cervical

musculature is prone to thedevelopment of trigger points whenshortening, lengthening, or loosening ofmuscles occurs.


85/135

1. Myofascial Release is a combination of direct,indirect, and reflex neural release procedures.Abnormalities and mechanical asymmetries

found by palpation of tissue are signals ofaltered structure. The basis of this technique issensing palpable changes of various levels oftissue and manually directing gentle force toassist in releasing tissues. This alteration oftissue is thought to be mechanical andneuroreflexive. This technique can be used forthe muscles of mastication as well as the uppercervical spine.


86/135

2. Joint Mobilization techniques aredivided into four grades:

Grade I - Small amplitude movement atthe beginning of joint range is used forextremely irritable joints(neuromodulation).

Grade II - A larger amplitude oscillationthat is partway into available joint range.


87/135

Grade III Large-amplitude movementsthat move the joint through full availablerange.

Grade IV Small-amplitude movementsthat are performed at the end of jointrange.

The presenting state of the joint dictatesthe grade of mobilization to be performed.


88/135

Causing pain must always be avoided,and a decision to increase mobilization isbased upon re-evaluation as therapyprogresses.


89/135

Manipulation, or grade IV mobilizationemploys a high-velocity, low amplitude

thrust that moves a joint beyond itsrestricted range. This should only be usedby a therapist who has extensive trainingand experience in manual therapy. GradesI through IV are most often used with theTMJ. Grades I through IV are used fortreatment of the cervical spine.


90/135

Specific Joint Mobilization: TMJ

When mandibular movements are severelylimited, severe pain and spasm due torecent trauma are present, extraoral

techniques are useful. They can helpdecrease spasm and pain when done ingrades I and II oscillations in:

1. Lateral glide.

2. Depression.

3. Protrusion.


91/135

After the soft tissue of themaxillofacial region is prepared by theapplication of physical modalities(such as TENS), mobilization may beapplied to:

1. Stretch the soft tissue of the maxillofacial

region.2. Increase the range of motion of TM

joints.


92/135

3. Restore the TM joint disc to a morenormal position on the mandibular head.

4. Stabilize the joint.5. Restore joint play.


93/135

Initially, the practitioner may simply gentlydepress the mandible to take up the slack

in the joint capsule. According to Rocabado,this action will restore play in the joint. Jointplay is the passive, nonvoluntary movementin the joint, which is actually the normal jointlaxity. Although this movement is minimal, itis required for normal joint function and ispresent in all synovial joints.


94/135

Once the joint play is restored, thepractitioner should concentrate on

restoring any motions that the patient islacking. As muscle guarding decreasesand the range of motion increases,

restricted soft-tissue structures are moreeasily assessed and allow the appropriateuse of direct intraoral techniques.


95/135

The desired effect of mobilization techniquesis the deformation of collagen within its elastic

range. Clinicians must develop an acutetissue-sensing ability through practice. Activemandibular opening is helpful in increasingthe effectiveness of these treatment

techniques. If these techniques are used withtoo much force, increased pain and swellingand decreased mobility may result.

Specific Joint Mobilization:


96/135

Specific Joint Mobilization:Upper Cervical Spine

Headache and facial pain can originate fromC1-3. Mobilization of the subcranial jointsshould always be preceded by a vertebralartery test. The test is designed to detectthe presence of vascular insufficiency, whichmay be exacerbated by backward bending,

side-bending, and/or, rotation of the head.Symptoms include pupillary changes,nystagmus, dizziness, visual changes, andgiddiness.


97/135

The first cervical mobilization is transversevertebral pressure. A gentle force is applied

with the thumbs on the lateral tip of thelateral mass of C1. This technique is appliedtoward and away from the symptomatic sideof the upper cervical spine. When done

appropriately, a decrease in pain, spasm, andjoint restriction between the occiput and C1will occur.


98/135

Posteroanterior unilateral vertebral pressure isused when symptoms are bilateral or unilateral.

This should never be done in a way thatproduces radicular symptoms. At the occiput-atlantal joint (0-C1), the primary motions areflexion and extension. When Posteroanterior

unilateral pressures are used, motion will beincreased when the force is directed to theposterior aspect of the lateral mass of the

Atlas.


99/135

If it is used at the C1-2 segment, theprimary motion will be approximately 40

degrees of rotation. The force is applied tothe C2 articular pillar. This movement isfurther enhanced by rotating the patients

head 30 degrees before applying thistechnique, thus taking up the slack at C1-2.


100/135

Patient Education

Education of patients is a key factorduring all phases of physical therapy. Adiscussion of the nature of the pathologyand its relationship to posture, pain, andmechanics is necessary. Patients must

understand that they are responsible forthe problem and its treatment.


101/135

Forward head posture with resultantrounding of the shoulders can produce

dysfunction of the Craniocervical andTemporomandibular systems.


102/135

Postural re-education starts withinstruction in relaxed sitting position.

Patients who sit in FHP over long periodsof time are placing the head in aposteriorly rotated position, leading to

pathologic changes in the soft tissue ofthe TMJ, hyoid, and cervical spine.


103/135

Adaptive FHP strongly influencesmuscle tone and elasticity of the

masticatory system.1. The resting position of the mandible is

altered.

2. Suboccipital impingement forces areincreased.

3. Freeway space is influence.


104/135

4. FHP alters breathing and swallowing as aresult of decreased airway potency andtongue position.

5. May lead to clenching, Bruxisim, and TMJloading.

6. FHP may lead to increased compressive

forces and intervetebral discdegeneration.


105/135

Sitting Posture

1. Chairs with appropriate lumbar support tomaintain lumbar lordosis.

2.

Knees and hips should be in a 90-90 degreeposition with free lateral movement to turnleft and right.

3. When hips are in the 90 degree position,

proper anterior pelvic tilt is maintained,promoting a decrease in lumbar disc pressureand inducing proper cranio cervical posture.


106/135

Sleeping Posture

1. Least easily controlled.

2. Patients should be instructed to avoid

lying in a prone position, whichstresses the cervical spine by rotatingand extending it, and places tension

on the cervical joints, muscles, andligaments. The TMJ also receivescompressive forces in this position.


107/135

Patients with waking pain or increasedstiffness should have their sleeping

posture evaluated.

Appropriate sleeping posture is lying onthe side or back. The head and neckmust be supported by a pillow meetingthe patients Biomechanical need.

Nasal-Diaphragmatic


108/135

Nasal DiaphragmaticBreathing

Mouth breathing (caused by allergies ornasal obstruction) increases activity on the

Scalenes and Sternocleidomastoidmuscles.

Enlargement of the adenoids may lead to

forward and downward position of thetongue.


109/135

Shortening of the Scalenes andSternocleidomastoids leads to increasedposterior cranial rotation.

As the cranium is pulled into FHP, activity of theTemporales and Masseter muscles increasecausing the mandible to elevate and retrude.

These events may ultimately lead to change inocclusion, facial morphology and lead to cervicalspine pathology.


110/135

Self-Mobilization Exercises

A self-mobilization program will helpmaintain joint mobility as well as muscle

strength and length, thus preventingrecurrence of pain.

A stretching program is as important as

a musculoskeletal strengtheningprogram.

Passive Stretching: Cervical


111/135

a g aSpine

Flexibility is a key factor in preventingrepeated injury.


112/135

Passive Stretching: TM Joint

Passive mobilization of the TMJ is done athome after application of ice or heat.


113/135

SPLINT THERAPY


114/135

Occlusal Splints

Removable interocclusal appliances.

Usually fabricated from hard acrylic.

Prescribed for the treatment ofBRUXISM and CRANIOMANDIBULARSYMPTOMS for almost a century.

TMD Treatment Objectives of


115/135

jSplints

Eliminate occlusal interference.

Stabilize tooth and joint relationships.

Provide a passive stretching of themusculature to reduce abnormal muscleactivity.

Decrease parafunctional habits.

Protect against tooth abrasion.

Decrease joint loading.


116/135

Theories of Splint Therapy

Design of Multiple Appliances

Expectations, Limitations, and

Complications of Splint Therapy

The Six Major Theories Covering the


117/135

The Six Major Theories Covering theMechanism of the Action of Splints

Occlusal Disengagement Theory

Vertical Dimension Theory

Maxillo-mandibular Realignment Theory Oral Orthopedics Theory

TMJ Repositioning Theory

Cognitive Awareness Theory

Occlusal Disengagement


118/135

g gTheory

Placement of an appliance with properocclusal relationships replaces

previously faulty occlusal relationships. Eliminates the stimulus causing

muscular hypertrophy.

Allows for proper joint and mandibularfunction.


119/135

Vertical Dimension Theory

The craniomandibular system is adaptiveand can function in the presence of verticalchange.

When the change becomes excessive, andthe adaptive capacity is overcome,pathology and dysfunction may result.

Therefore, placing an appliance to restore amore normal vertical dimension of occlusionmay cause a decrease in dysfunction.

Maxillo-Mandibular


120/135

Realignment Theory

Proposes that the mandible ismalpositioned relative to the maxilla at

the position of maximum intercuspation(centric occlusion).

If the mandible is repositioned, a more

optimum maxillo-mandibularrelationship can be evolved, and thesymptoms eliminated.


121/135

Oral Orthopedics Theory

Malrelationship of the jaw effects the entireneuromuscular system, involving function ofthe head, neck, and shoulders.

Advocates evaluation of head and neckposture as well as jaw relationships.

Reposition the mandible with its condyles to

produce an optimum neuromuscular balanceas well as a bilateral condyle/fossae and jawrelationship.


122/135

MORA

Developed by Dr. Harold Gelb.

Hard acrylic appliance that covers thelower posterior teeth only.

Advantages of the MORA


123/135

ginclude:

Ease of construction.

Hygienic.

Comfortable. Inconspicuous.

Reversible.

Phonetically and aestheticallyacceptable.

The Muscle-Determined


124/135

Position

Treatment involves low frequency TENS tostimulate the 5th and 7th cranial nerves.

Stimulation causes an automatic involuntary

closure. Accomplishes a neuromuscularly controlled

balanced muscle contraction.

Determines a functionally correct occlusalposition, compatible with a continued state ofrelaxation.

TEMPOROMANDIBULAR JOINT


125/135

REPOSITIONING THEORY

Proposes that a change in the condylarposition within the involved TMJ will

improve joint function and relievesymptoms.

Anterior Repositioning for Treatmentof Internal Derangements


126/135

of Internal Derangements(Variation of the Condylar Repositioning Theory)

An internal derangement is an abnormalrelationship of the disc (meniscus) to

the condyle when the teeth are in theintercuspal position.

Disc is placed anteriorly.

Condyle is placed posteriorly.

ANTERIOR REPOSITIONING


127/135

SPLINTS

Move the mandible into an anteriorposition.

Bring the condyle forward. Re-establish the correct condyle/disc

relationship.

Eliminate clicking.

Relieve condylar pressure on the retro-discal tissues.


128/135

Anterior Repositioning Splints

Function to keep the disc in place sothat:

Soft tissue healing can occur. The disc may recontour.

Osseous remodeling may occur.

COGNITIVE AWARENESS


129/135

THEORY

States that the presence of any splint inthe patients mouth is a constant

reminder to alter previous behaviorpatterns.

SPLINT THERAPY


130/135

THE CONCEPT

A treatment that functions within thecontext of other treatment measures

including: Physical therapy.

Medication.

Psychological counseling.

Other branches of dental and medical care.


131/135

The Ideal Splint Should Be:

Comfortable.

Non-invasive.

Reversible.Aesthetic.

Retentive.

Functional.


132/135

Proper Selection of Splint Type

Depends on an individuals needs andrequests.

Depends on an accurate diagnosis.

Muscular disorders without joint involvementhave different requirements from internalderangements.

Muscular derangements differ in extent ofmeniscus displacement, chronicity, and degreeof pathologic tissue change.


133/135

BRUXISM

Is defined as jaw clenching with orwithout forcible excursive movement,

where the intensity of the clenchingdictates the severity of tooth grinding.

Is generally accepted to be one of the

primary contributing factors in TMD.

Traditional Inter-Occlusal


134/135

Splint Methods

Specific design addresses lateralmovement (grinding).

Severity of symptoms is dictated by theintensity of vertical movement(clenching).

NTI


135/135

(Nociceptive Trigeminal Inhibition)

A new method and device thatsuppresses clenching intensity by

exploiting the nociceptive trigeminalinhibition reflex and prevents canine(cuspid) and posterior tooth contact.

tmj presentation

Documents