CONSERVATIVE TREATMENT OF TMJ DISORDERSDr. Bahjat Abu Hamdan Consultant Prosthodontist .DDS, CES, DSO Paris- France.

Introduction

Diagnosing and treating TMJ disorders can be difficult and confusing task.

Proper diagnosis is the key to successful treatment.

A comprehensive knowledge of. 1.Anatomy and physiology of the

masticatory system. 2.Aetiology of TMJ disorders

(intracapsular and extracapsular)

Introduction

3.Diagnosis of TMDS. 4. Management of TMDs. A. Conservative therapy (Reversible ). B Non conservative therapy (Irreversible). So that these elements are important to be

well known by the practitioner before starting up the diagnosis and Tx of TMJ Disorders.

In this lecture we will expose mainly the conservative therapy and briefly the other aspects in relation.

American Dental Association, 1983 defined TMD as a group of orofacial disorders characterized by:

Pain in the preauricular area, TMJ, and muscles of mastication

Limitations/deviations in mandibular range of motion

TMJ sounds during jaw function The spectrum of TMJ disorders could range from

congenital developmental problems to the commonly degenerative joint disease.

1990Y Craniomandibular Disorders(CMD)

TMD Epidemiology.

The prevalence of signs and symptoms associated with TMD can be best associated by examining epidemiologic studies.

Dorland,s illustrated medical dictionary describes epidemiology as.( the study of the factors determining and influencing the frequency and distribution of disease, injury, and other health-related events and their causes in a defined human population for the purpose of establishing programs to prevent and control their development and spread )

.TMD: EpidemiologyDefining and explaining the interrelationships of factors that determine disease frequency and

distribution Most prevalent between 20-40 years. 50% to 60% of the general population

have a sign of some functional disturbances of the masticatory system

-65-85% in USA experience one or more symptoms of TMD

-12% experience prolonged pain or disability-Only 5-7% have symptoms severe enough

to require treatment. Most cases are self-limiting

epidemiology

Scandanavian study: Most problems are with joint noises and jaw deflection.

Non-patient populations greater than 18 years old 40-75%: one clinical sign is evident

50% of the population will exhibit sounds and/or deviation (much more so than in patients under 18 years of age

Less than 5% have limited opening 33% of the population has one symptom

Approximately 10% of those greater than 18 years of age will exhibit pain

Defining and explaining the interrelationships of factors that

determine disease frequency and distribution

Figure 5 : Presenting sign and symptom of TMJ

Figure 6 : Presenting sign and symptom of the muscles of mastication

Figure 7 : Presenting sign and symptom of mouth opening

33

76

10

38

4 50

10

20

30

40

50

60

70

80

One Two Three +

Symptoms

Signs

Perc

en

tage Inci

dence

Number of Signs & Symptoms

TMD Signs & Symptoms

These are the ones who really need treatment

Age and Sex DistributionThis data is from a Seattle based , patients from 8 years old to

80 years old. The bars are on the

inside. Most seek treatment between 25-40 years old .Childbearing age in females age is

the most likely time. It is NOT progressive over time….it gets better over time, after 35.

1 2

S1S2

S3S4S5S6S7S8S9S10S11S12S13S14S15S16S17S18

0

100

200

300

400

500

600

Pa

ite

nts

Sex

Age

Only irreversible treatments will cause things to progress.

Age distribution of subjects with TMD

Figure 1: Prevalence of TMD according to gender

General Population

33%

41%

26%

Intra-articular

Extra-articular

No sign or symptom

Only 7% of the general population patients need treatment .There may be many signs and symptoms, but few need to be treated.

Pain Clinic Populations

Internal Derangement

31%

Arthritis39%

Myofascial30%

These are relatively equal distributions, overall. This does not take into

account the dominant treatments done by a general practitioner .

It really depends on who is running the clinics and their clinical reputations.

AdaptationAdaptation

Normal

Adaptation

PathologyFlattening of the condyle is exhibited. There is no joint space. No asymmetries are

seen, no pain ,no visible problems, there is no limitation of movement and no deflections of the

mandible .This is a good example of adaptation. All of us are in some state of adaptation .

This is why we don’t see a progression in this disease . Patients should undego treatment first, then have their TM condition evaluated. Dr.

Rigg

Adaptation

Normal

Injury/Pathology

Adaptation

- +

Disability

Death

Impairment(articular disc is out of place,

but the patient is still able to function)

Signs & Symptoms

10 20 30 40 50 60 70

Pain

Dysfunction

Decrease ROM

Noise

TMD appears to benon-progressive

Joint noise will increase with time, but it can be managed. This is looking at a cross section of the population. This follows the

biopsychosocial syndrome.

Reciprocal click

Disc dislocation w/o reduction

Etiology of TMD

Trauma Excessive stress Arthritis of the TMJ Whiplash injury Postural abnormality Ligamentous laxity Psychosocial distress (stresses)

Etiology

Bruxism (teeth grinding) Unaligned teeth Congenital Jaw abnormalities Prolonged mouth breathing Thumb sucking

Risk factors associated with TMD

Etiology of TMD

Assessment History & Examination. The effectiveness and success of treatment

lie in the ability of the clinician to establish the proper diagnosis.

One must be suspicious of the pt who reports the location of the pain to be TMJ or masticatory muscles, yet those whose history and Exam. Reveals no alteration in range of jaw movement or increase in pain during function. So that its useless to direct the treatment of the MS, the examiner must find the true source of pain.

History

1. Pain2. Joint Sounds3. Restriction of Opening4. Swelling

Over the maxilla In the area of parotid gland

CLINICAL EXAMINATION

1. The symmetry of the mandible and the face

2. TMJ & muscles tenderness

3. Lateral deviation on opening and

closing

4. Inter-incisal opening (normal=35-

45mm)

5. Joint sounds

6. Dentition

Muscular tenderness

Lateral deviation

Normal=35-

45mm

Inter-incisal opening

Joint sounds

Dentition

In an ideal occlusion, protrusive movement is guided by anterior teeth.

Early lateral movements are ideally canine-guided.

1. Tempromandibular Pain Dysfunction Syndrome (TMPDS) / Deviation in Form

2. Internal Derangement / Articular disorders

1. Disc displacement with reduction2. Disc displacement without reduction

3. Pathological Disorders

TMJ Disorders Classification

TMD

Extra-articular (all muscle) Intra-articular (within the joint)

Synovitis DDWR (disc displacement with

reduction) DDWOR (disc displacement without

reduction) Osteoarthrosis Rheumatoid arthritis Condylar subluxation

Arthrosis: non-painful osseous remodelling of tissues

Temporomandibular DisordersTemporomandibular Disorders

The determination of one of two or

more conditions a patient is suffering

from by systematically comparing

and contrasting their historical and

clinical findings.

History gathering is the most important thing to do .

Differential Diagnosis Differential Diagnosis

Intracranial Pain Disorders Primary Headache Disorders Neurogenic Pain Disorders Intraoral Pain Disorders Temporomandibular Disorders (our

focus in this presentation) Associated Structures Axis II, Mental Disorders

Sources of Orofacial PainSources of Orofacial Pain

Initial (conservative) Further (specialist)

Management

Reassurance. Education . Habit management. Rest. NSAID, analgesic and

muscle relaxants. Removable occlusal

splints. Physio –therapy/ jaw

exercises

Psychologycal intervention.

Antidepressant. Occlusal adjustment. Intra-articular

injection. Manipulation under

GA. Arthroscopy. Surgery.

Indication for surgical treatment About 10% of the chronic TMD

cases are indicated for surgical treatment.

Degenerative joint disease. Condyle fracture. Joint intra capsular pathology

(osteochondroma, chondromatosis ). Tumor involvement of condylar head.

Treatment should begin with conservative, reversible therapies and progress to non-reversible therapies, if needed.

Treatment of TMD

TMD can be difficult to treat because of its multifactorial origin.

Primary goal is to allow the muscles to relax and restore a normal range of motion; pain usually decreases when this happens.

Before any treatment therapies are initiated, the patient should be educated and counseled on the nature and causes of TMD. Educating the patient may relieve the stress enough to alleviate symptoms.

Treatment of TMD

1)NSAIDS - are non-steroidal anti - inflammatory drugs like ibuprofen.

2)Muscle relaxants.

3) Narcotics - should be prescribed in regular doses over a short period of time.

4) Tricyclic antidepressants - may be used to reduce bruxism.

5) Corticosteroids - may be injected into the joint for arthritis.

TMD Treatments: Medications

Reversible procedures should be tried before irreversible procedures.

Goal is to reduce muscle activity and parafunctional habits by correcting occlusal scheme.

Occlusal splint provides orthopedic stability.

Correcting occlusal interferences with selective grinding or construction of new restorations are irreversible procedures.

Occlusal Therapy

Occlusal thrapy Occlusal appliance is useful in reducing symptoms, literature

revealed that its effectiveness is between 70 to 90%. Because the splint provide more orthopedic stable joint

position, optimum occlusal position that reorganizes the neuromuscular activity to the normal limits

Protect the teeth and supportive structures from abnormal forces.

The success or failure of occlusal appliance depend on the selection, fabrication and adjustment, as well as patient cooperation.

If the occlusal appliance does not affect the symptoms, the malocclusion is probably not a cause and certainly the need for irreversible occlusal therapy should be questioned.

Increase patient awareness of muscular activity and incidence of parafunctional habits.

Psychotherapy - referral may be indicated to help patient deal with stress.

Relaxation therapy – exercise and yoga.

Hypnosis for relaxation.

Stress Therapy

Other physical therapy techniques:

1) Thermal or coolant therapy

2) Ultrasound

3) Electrical stimulation of muscles

4) Acupuncture

5) Massage

Patients may improve range of opening through exercises designed to stretch

the muscles.

Physical Therapy6

Hard acrylic

Technically demanding

Maxillary splint is easier to adjust

Worn at night

Long-term use

must provide ideal occlusion

at rest & function (CR =CO)

Stabilization splint

stabilization appliance

Soft or resilience appliance , treatment gaol is to achieve an even simultaneous contact with the opposing teeth.

Its well supported use is as protective device for athletes .

Soft appliances have not been shown to decrease bruxing activity. Scientific evidence support the use of hard appliances for reduction of symptoms related to clenching and bruxing activity.

Soft appliances have been advocated for Pts who suffer from repeated or chronic sinusitis resulting in extremely sensitive posterior teeth.

Clear the occlusion to allow the condyles to be fully seated superiorly/anteriorly

Elimination of discrepancies between seated joints and seated occlusion (CR = CO)

A large surface area of shared biting force

Reduce joint loading by decreasing muscle activity also by consequence myogenous pain decreases.

Idealized functional occlusion SS decrease parafunctional activity that accompanies periods

of stress, local muscle soreness or chronic centrally mediated myalgia also its helpful in cases of retrodiscitis due to trauma.

Stabilization splintHow it works!

Maxillary or mandibular

Hard acrylic, full coverage

Occlusal record with mandible

protruded

Indicated for disc displacement with

reduction

Ideally used 24hrs/day for 12 weeks

Avoid in adolescents

Anterior positioning splint

Occlusal appliance

No more pain

Occlusion is the cause

Pain continues

look for another cause

Irreversible Occlusal

Treatment

It positions the condyle anteriorly away from the fully seated

joint position

Used in case of trauma inducing retrodiscal edema Guide

the mandibular condyles away from retrodiscal tissues.

Used in case of anterior disc displacement Help aligning

the disc over the condyle (back to normal position) hoping that

it will keep this relation with time.

Posterior pivoting appliance is advocated for the treatment

of symptoms related to osteoarthritis of the TMJs, its the

only appliance that can routinely distract a condyle from

the fossa by a unilateral pivot . Its use should be limited to

one week. Otherwise the second molar will be intuded.

Anterior positioning splint When & How it Works!

Case 1.

A 21 yrs old female came to the dental office with left TMJ pain and sounds associated with muscle pain.

The symptoms started 10 month ago, no specific event relating to the onset of the symptoms, yawning increase the pain for several hours.

Examination revealed reciprocal clicking on the left TMJ with pain to palpation specially during opening that accentuate the sounds muscle tenderness L,R mass. and temp. LL pterygoid was painfull to function manipulation.

Diagnosis, pt was diagnosed with DD with reduction. Tx. An APA was fabricated that positioned the mandible forward

enough to eliminate the reciprocal clicking. Pt instructed to wear the appliance day and night for 7 days. Limit the movements to painful limits, mild analgseic prescribed for 10 days. In 1 w pain and popping subsided, 9 w later pain subsided completely but not the clicking , pt is asked to carry the appliance at night for 8-12 w at night . pt. told that joint sound would likely be permanent but pain may not return.

Case 2

50 yrs old female. C/c TMJ pain, headache and neck pain.

Pt has a history of car accident which still hanged in her mind.

She started suffering of neck pain at the right u/ region underneath her skull , with pain radiation to jaw ,face and eyes.

She sought Tx from massage chiropractor and dentist but she has been suffering for about 5 years.

Chiropractic exam. Reveals upper neck injury radiating to jaw face and neck. Treatment done, 2 month later pain is over.

The injury stemmed to the car accident 5 yrs ago.

Case 3

20 yrs old female pt. She arrived complaining of TMJ pain in the left side with

clicking when she opens widly. Exam/ pt has mandibular prognathy with anterior cross

bite, left TMJ is painful to palpation which increase while opening.

OPG revealed deep glenoid fossa which indicates dominant open close movement with limited gliding, guiding the mandible CR position and during closing revealed premature contact between 21,31 shifting the mandible into anterior cross bite.

Case referred to orthodontic clinic for cross bite and anterior shift correction as main cause in displacing the TMJ anterior to its stable position.

Case 4

20 yrs old female pt arrived complaining of pain in the left TMJ area 5 month ago.

Examination :Pt has pain in the left side more sensitive to palpation in front of the left ear, also temporal and masseter muscle were painful to palpation on the same side, looking at the OPG revealed supraerupted 18, 28 with missing opposed third molars.

After muscle relaxation, the mandible is guided into CR position and during closing a severe premature contact in both sides is found between the mesial of 18 and the distal of 47, the mesial of28 and the distal of 37 causing capsular ligament extention resulting in that severe pain.

Adjustment is done, 1 week later pt feels signifigant improvement.

Case 5

A 48 yrs old male pt reported to dental office complaining of R /TMJ sounds. The popping had been present for 15 yrs ago and had never caused any pain or discomfort.

Exam/ revealed a single click at 31 mm of opening the click can not be eliminated by 2 tongue depressor placed bilaterally between the post. Clinical muscle exam was negative, his teeth were in good repair.

The pt was diagnosed with chronic adapted disc displacement with reduction.

Tx. The history and exam revealed that this disc displacement was chronic and asymptomatic. There was no evidence that it was a progressive disorder. In fact, more evidence suggested that the joint tissue had physiologically adapted to the condition. Therefore no definitive treatment instituted.

Thanks For your Attention.