Temporomandibular Joint & Orthodontics-Seminar

8/4/2019 Temporomandibular Joint & Orthodontics-Seminar

http://slidepdf.com/reader/full/temporomandibular-joint-orthodontics-seminar 1/59

& Orthodontics



Take Home Message

• s gns an symp oms appear n ea y n v ua s.•The signs and symptoms usually increase with age.

related to treatment.•Orthodontic Tx does not increase / decrease odds of TMD.• o spec c r s s assoc ate w t any part cu ar ort o ont c

mechanics.

result in TMD.•No method of TMD prevention has been demonstrated.

• MD signs and symptoms usually are alleviated by simple Txin most cases.



Questions to be answered

• What impact does occlusion have on TMJ disorders ?

• Does orthodontic treatment cause TMD ?•



Gross Anatomy

•TMJ

– r cu a on e ween

the mandibular condyleand the mandibularfossa of the temporal

bone



• An articular disc

joint space into upper

–Posterior attachment of

disc to condyle andtemporal bone

–Loose fibrous connective

– Vascular and innervated



Muscle Insertion

•Primary insertion is

muscle to the anterior

and a few muscle

fibers inserting intothe anterior band of the disc



Innervation

Mandibular division of the trigeminal nervew ith some primary

auricuotemporalnerve and the

r rv



Blood Supply

•Blood supply is fromt e maxi ary an

superficial temporal

external carotid artery



TMJ – A Synovial Joint

• Load bearing surfaces which are

avascu ar an no nnerva e• Lubrication by synovial fluid

– Less than 1 cc of synovial fluid per

compartment• Fibrous capsule contains synovial fluid

and maintains relationship between

joint components during function



• Difference between TMJ and other

synov a o n sStructure: The TMJ has an articular disc whichcomp ete y v es t e o nt space nto

separate upper and lower joint. .

Function : the TMJ is a Hinge-sliding joint

– sliding action (translation – upper)

Complex structure & complex function



Biomechanics

Hinge / sliding joint

between the condyleand the inferior surfaceof the disc during early

opening• rans a on s ngbetween the disc-cond le com lex andthe temporalcomponent during



Biomechanics

•During opening the

on the condyle

between the condyle

and the temporalcomponent



Histological Features

• The osseous tissues of the condyle and

articular “soft tissue” which as the

– Articular zone of fibrous connective tissue -

Functional – Proliferation zone of undifferentiated

mesenchymal cells – Progenitor cells of the

car age ayer – Cartilage zone – Hyaline cartilage which is



TUBERCLE COVERING

OSSIFICATION

CALCIFICATION

PROLIFERATIVE II}

(FIBROUS) I



MATURE CONDYLAR LAYERS

ARTICULAR I

PROLIFERATIVE II

FIBROCARTILAGE III

OSSIFICATION

new bone on calcifiedcartilageSUBCHONDRAL

BONE TRABECULAE



ARTICULAR

TUBERCLE/u er s novial cavit

TMJ

GLENOID FOSSA PROTUBERANCE/ EMINENCE

lower synovial cavitylower synovial cavity



• The articular surfaces of the TMJ arecovered w ith fibrous connective tissue

not hyaline cartilage, as in most others novial oints

MANDIBULAR CONDYLE

Condylar cartilage(not all cartilage)

Spongy bone



• The posterior attachment is composed of oose rous ssue w vascu ar y aninnervation



Adaptive variations

– Articular surface irregularities (deviation in

• orp o og ca c anges may a er o n

biomechanics and/ or produce jointsoun s suc as c c ng or crep a on



Adaptive variations

• The apparent potent ial of the TMJ for

rationale for conservative treatment

and disability rather than correcting

altered mor holo



Embryology

• TMJ develops between 8 – 14 weekscompare o - wee s or o ersynovial joints



Embryology – TMJ

• 10 – 11 weeksOssification of the temporal components begins

• 12 w k – the condylar cartilage is present at the most

superior aspect of the ramus. – e em ryon c connec ve ssue mesenc ymebetween the grow ing condyle and temporal bonecondenses to form the articular disc

• 13 weeks –

then the upper compartment



• 14 weeks

– Joint development completed

• Persistence of the condylar cartilage as

the cartilage zone of the articular softtissue is presumed to contribute to theadaptation capacity of the adult condyle



Pathologic symptoms and signs-TMD

• Definition:

– Collection of medical and dental conditionsaffecting the temporomandibular joint

r u , was contiguous tissue components.



Prevalence of TMD

• 32% of population report at least one

– Difficulty opening

–

– Pain on movement

–

– Muscle fatigue

–



Historical Perspective

• Thompson was the first to note patients w ith

to TMD – Advocated the elimination of all interferences in

“freeway space” envelope of movement

• T. Graber w as the first to note the,

only one factor – Cited stress and nocturnal parafunctional habits as

contributors – Advocated psychological counseling as part of

thera



Questions to be clarified

emporo

Disturbances Mandibular



emporo

Treatment

Mandibular



Prevalence

,



In primary dentitions,

I d lt ti t ?



Schmit ter et al., J Oral Rehab il. 2005 Jul;32(7):467-73

In adult patients?

Fifty-eight geriatric patients VS. 44 young subjects

•Geriatric subjects more often exhibited objective

opening), but rarely suffered from pain (pain at rest: 0%,

joint pain: 0%, muscle pain: 12%).

•In contrast, young subjects rarely exhibited objective

symp oms o n soun s: , u su ere morefrequently from pain (facial: 7%, joint pain: 16%,.



Q 1: Is there prevalence data which shows that one typeQ 1: Is there prevalence data which shows that one typeof malocclusion is more likely to be associated w ith a TMD?of malocclusion is more likely to be associated w ith a TMD?

• There is no association between overbite or overjet

John et al., J Dent Res. 2002 Mar;81(3):164-9.

and self-reported TMD. N= 3033

• 82 asymptomatic volunteers vs. 263 symptomatic

MD atientsLiterature does not suggest that replacement of missing posterior teeth prevents the development of

MDs. However, missing man i u ar posterior teetmay accelerate the development of degenerative

.

Talents et al., J P rosthet Dent. 2002 Jan;87(1):45-50.



• Few malocclusions except socioeconomic parameters

were assoc a e w s gns, an ese assoc a onswere mostly weak.

clinically relevant and was associated with TMD signsodds ratio OR = 4.0 . This malocclusion however

was of rare occurrence, with a prevalence of 0.3% (n =

9).Sample size of 4310 men and women aged 20 to 81 years(response 68.8%) was investigated for TMD signs, malocclusions,

using multiple logistic regression analysis

Gesch et al., Angle Orthod. 2004 Aug;74(4):512-20



emporo

Disturbances Mandibular



Q2: Is there any prevalence data which shows that onetype of occlusion (for instance, canine guidance) is

more likely associated w ith TMD?

u r

Looked at predictive values of occlusal variables in TMD

normals.

he predictive power of the occlusal values was low(odds ratio of 2:1)Patients with disc displacement were characterized by

n atera cross te an ong - s es.Patients with osteoarthritis were related with very long

No variable was associated w ith canine guidance



Q 2-1 Are canine guidance (CG) and joint clicking related?

., -

In non-patients (n=46) and patients (n=46,with clicking)

In non-Pts, 70% without CG and 30% with CG, .

In both Pts and non-Pts61% with non-CG and 38% with CG.

No-evidence that both distal (retrusive) and mesial(protrusive) CG was associated with ipsilateral

.



Q3, Is there a relationship between disc derangement

Kahn et al., J Prosthetic Dent 1999, 82: 410-5

.

Q 4: How often do post orthodontic cases show



Q. 4: How often do post-orthodontic cases showbalancing interferences?

Non-working side contacts occurred in 30% of subjects.n pos er or con ac s on pro rus on n .



orthodontic treatment

and increased likelihood of getting a



Questions



Questions

addressed by the NIH technology assessment

conference, 1996

as TMD and w hat occurs if these areuntreated?

2. What signs and symptoms provide a

basis for init iat in intervention?3. What are effective initial therapies?

persistent TMD?

1 What clinical conditions are classified as TMD and what



1. What clinical conditions are classified as TMD and what

occurs if these are untreated ?

• Specific etiology of TMD lack ing; therefore, diagnosisepen s on s gns an symptoms

• Conditions affecting muscles of mastication: – Pol m ositis – Dermatomyositis

• Conditions affecting the TMJ:

– – Ankylosis – Growth disorders

– ecurren s oca on – Neoplasias – Cond lar fracture – Systemic il lness

What are classified as TMD and what occurs if these



What are classified as TMD and what occurs if these

• TMD can be either muscle or joint pain or a

• Peak prevalence in young adults (20-40)

• ome s u es s ow equa gen er pre ec on,but others show higher number of females

• -

• Few data to assess long term course in

2 What signs and symptoms provide a basis for



2. What signs and symptoms provide a basis for

• Physical examination: – a n

– Limited range of motion –

– Muscle tenderness

–

• Conservative non-invasive treatment –



3 What are effective initial therapies?



3. What are effective initial therapies?

•Physical therapy

–Stabilization splints•

–Controversial

–Irreversible –Not demonstrated in randomized clinical trials tobe superior to reversible therapies



4. What are effective therapies for persistentTMD?

• Pharmacologic therapies

–

– Opiates• Ma or concerns include:

– Addiction potential

– Analgesic tolerance

– Uncontrolled side effects i tch in const i at ion nausea

– Anx iolytic/ Hypnotic drugs (benzodiazepines)• Pain disorders can result in sleep disorders

•

Pharmacologic management of TMD



Pharmacologic management of TMD

• NSAIDS

– Effective in relieving acute inflammatory

pain

– When prescribed for weeks or months,how ever, increased risk for GI ulcerations,

COX-2 Inhibitors



COX 2 Inhibitors

• Selectively inhibit COX-2 enzymes,

prostanoids

• Rofecoxib (Vioxx)

• n a y popu ar or e managemen oosteoarthritis and rheumatoid arthritis

• ow popu ar or c ron c oro ac a pa n

Side Effects



Side Effects

• Drug interactions

– May decrease the effectiveness of ACE-

inhibitors used to treat hypertension

• May alter k idney function

• Not safe for use durin re nanc• Drug allergies to NSAIDS or ASA

Occlusal stabilization splints



Occlusal stabilization splints

•Used often in clinical practice

•Monoplane, acrylic appliance•Either maxi llar or mandibular

• Adjust until point contacts

•Relaxes muscles of mastication

•Constructed to place patient

•Eliminates tooth guidedcondylar position

What does the literature say?



What does the literature say?

• Article published in JADA, 2001

• groups

• Weaknesses in design: – ac s u y umpe pa en s a oge er, regar ess o

symptoms

– Need to evaluate effectiveness of splint therapy for each

, , ,

• Overall, concluded that splints work as behavioralinterventions to produce changes in the

position of the mandible



TMD can be treated or caused by Orthodontic

Treatment ?



– Signs and symptoms may occur inhealthy persons

– Signs and symptoms increase w itha e often start in adolescence

•Orthodontic treatment and TMD

if a true relationship

– adolescence does not increase or

as an adult

• Extraction during treatment does not



• Extraction during treatment does not

ncrease r s o – Certain types of orthodontic mechanics does

– Little evidence orthodontic treatment preventsTMD

• The role of unilateral posterior crossbitecorrection in the prevention of TMD needs further

investi ation• Pullinger noted that patients w ith unilateral

posterior crossbite in childhood had an odds

• Hypothesized that, in a small percentage of patients,

a mandibular shift places increased loading on

one TMJ, leading to internal derangement and TMD asan adult

Conclusions



• TMD is multifactorial in nature

– Warrants a multi-faceted approach

• Self-limiting in nature

• Conservat ive, non-invasive, reversible

initial treatment• Pharmacologic therapy for persistent

– COX-2 inhibitors important in

Litigations



Litigations

• Common

• Can occur spontaneously

• Record record record

• Be conservative!

Temporomandibular Joint & Orthodontics-Seminar

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