Your Paragraph Text PDF

Download as pdf or txt
Download as pdf or txt
You are on page 1of 30

Lecture 3

TEMPOROMANDIBULAR
DISORDERS (TMDs)

5th stage

Dr.Aiser kareem al-kaabi


2024-2025
TMD is often a combination of etiologies rather
than a single anatomical or functional
disharmony. Combination of etiologies often
complicates successful treatment and can
frustrate the clinician and patient. There is no
strong evidence to suggest that TMDs are
either associated with malocclusions or cured
by orthodontic therapy.
Most TMDs fall into one of two broad categories: muscle pain (Myogenic), which
is the most common, or intra-capsular (Arthrogenic) disorders. Despite the
involvement of various factors, certain etiologic factors such as the occlusal
condition, trauma, emotional stress, and parafunctional activity (e.g. bruxism and
clenching) have gained significant research support.
Occlusal Condition

There appears to be two ways the occlusal relationship of the teeth may be
associated with TMD symptoms. The first is related to an acute change in the
occlusal condition, for example: a situation when a crown or filling is placed and it
is left a little high; afterward, the patient reports back to the clinic complaining of
discomfort. Frequently this discomfort is not only around the sore tooth, but
there also is muscle tightness and pain because the muscles protectively co-
contract to minimize any damage Muscle co-contraction refers to the
simultaneous activation of muscles on opposite sides of a joint to maintain joint
stability.
Occlusal Condition

The second is related to loading of the


masticatory structures in the absence of
TMJ stability (Orthopedic Instability).
Every mobile joint is designed to be
loaded, and this loading comes from the
muscles that pull across the joint
Occlusal Condition

Therefore, every joint has a musculo-skeletally


stable position, and in the TMJ this is defined as
the condyles resting on the articular eminences
with the disks correctly positioned between those
articulating surfaces. Orthopedic stability in the
masticatory system is present when the teeth are
in their stable biting position at the same time the
joints are in their stable position. When this is
present, joints and teeth can be loaded without
injury or consequence
Occlusal Condition

However, when the stable joint position is


not in harmony with the stable occlusal
position, the condition is considered
orthopedically unstable. Hence, continued
loading of the teeth by activities such as
heavy biting, chewing or bruxism can result
in changes in the joint structures, e.g.
fibrous connective tissue breakdown, bony
degeneration, clicking, locking, and pain.
Trauma

A sudden blow to the face can immediately change the


structures of the joint; this represents macrotrauma.
However, microtrauma can also be an issue whereby
small but repeated traumas can occur to the joints. The
orthopedic instability coupled with loading (previously
mentioned) is an example of microtrauma.
Emotional Stress

There is ample evidence that increased


levels of emotional stress can be an etiologic
factor associated with TMDs. If the stress is
prolonged the muscles of mastication may
show signs of fatigue, tightness, and pain.
Prolonged stressors can result in an
increase or upregulation of the autonomic
nervous system. When this occurs, the
central nervous system can play an active
role in maintaining the pain condition,
making management more difficult.
Parafunctional Activity

Bruxing and clenching of the teeth can produce


pain. Patients who report that they wake up in
the morning with painful muscle are certainly
likely to be experiencing sleep related bruxism.
However, there are other patients who report no
pain upon awakening but instead their pain is in
the late afternoons or evening. These individuals
may be experiencing daytime clenching, or they
may have a completely different etiologic basis
for their myogenous pain.
Parafunctional Activity

It is very important to remember the fact that more than


one of the abovementioned factors may be involved at
any given time, which is often the case. Furthermore, we
need to recognize the fact that all individuals are
different in their capacity to adapt to less than ideal
circumstances.
Parafunctional Activity

Many people may have less than perfect occlusion, have


received some trauma, have some emotional stress, and
have some parafunction, and yet they do not develop
TMD symptoms. This is likely due to their capacity for
adaptability, which is an important clinical consideration
since it helps us understand the great variability of
patient responses.
TMD from an Orthodontic Perspective

There is consensus that orthodontic treatment cannot


be reliably shown to either “cause” or “cure” TMDs. The
question that really needs to be asked is how can
orthodontic therapy be used to minimize any risk factors
that may relate to TMD? In reviewing the known
etiologies of TMD, orthodontic therapy routinely affects
only one of those factors:
TMD from an Orthodontic Perspective

the occlusion :Since occlusal factors may be a potential source of TMD


in some patients, it would seem logical that the orthodontist should
develop an occlusion condition that will minimize any risk factors that
might be associated with TMD
TMD from an Orthodontic Perspective

However, developing a sound occlusal relationship does


not mean the patient will not develop TMD, because
there are other etiologies that are outside the control of
the orthodontist. It seems logical that since orthodontic
therapy will change the patient’s occlusal relationships,
emphasis should be placed on creating an occlusion
condition that will provide the best opportunity for
successful masticatory function for the lifetime of the
patient; hence, minimizing a dental risk factor.
Patient Evaluation for TMD

Because TMD symptoms are common, it is


recommended that every orthodontic
patient be screened for these problems,
regardless of the apparent need or lack of
need for treatment. Because orthodontic
therapy will likely influence the patient’s
occlusal condition, it is important to
identify any dysfunction in the masticatory
system before therapy is ever begun.
Patient Evaluation for TMD

Knowing the functional condition of the masticatory


system in advance helps prepare the patient and the
orthodontist to what can be expected after the therapy
has been completed. This information also helps develop
the most appropriate treatment plan that will minimize
dysfunction in future years
Patient Evaluation for TMD

Nothing is more disheartening to the


orthodontist than to be in the middle
of orthodontic therapy and have the
patient report that a pre-existing TMD
symptom was a result of the
orthodontic therapy.
TMD Screen History

The screening history consists of several


questions that will help alert the
orthodontist to any TMD symptoms.
These can be asked personally by the
clinician or may be included in the
general health and dental questionnaire
that the patient completes before
developing the treatment plan.
TMD Screen History

The following questions are recommended to identify functional disturbances:

-In the last 30 days, how long did any pain last in your jaw or temple area on
either side?
a. No pain
b. Pain comes and goes
c. Pain is always present
-In the last 30 days, have you had pain or stiffness in your jaw on awakening?
a. No
b. Yes
TMD Screen History

-In the last 30 days, did the following activities change any pain (that is, make it
better or make it worse) in your jaw or temple area or either side?

A- Chewing hard or tough food


B- Opening your mouth or moving your jaw forward or to the side
C- Jaw habits such as holding teeth together, clenching, grinding, or chewing
gum D- Other jaw activities such as talking or yawning If a patient reports
positively to 3 or more of these questions, the clinician should request
additional information to clarify the condition.
TMD Screen Examination

It begins with an inspection of the face for


any facial symmetry. The screening
examination should include the palpation
of facial muscle and the TMJs as well as
observations of jaw movement. Several
important muscles of the masticatory
system can be palpated for pain or
tenderness during the screening
examination
TMD Screen Examination

The temporalis and masseter muscles


are palpated bilaterally. Palpation of the
muscle is accomplished mainly by the
palmar surface of the middle finger, with
the index and ring fingers testing the
adjacent areas; the degree of discomfort
is ascertained and recorded.
TMD Screen Examination

Pain or tenderness of the TMJs is determined by


digital palpation of the joints when the mandible
is both stationary and during dynamic
movement. The fingertips are placed over the
lateral aspects of both joint areas
simultaneously and the patient is asked to
report any symptoms
TMD Screen Examination

Once the symptoms are recorded in a static


position, the patient opens and closes, and any
symptoms associated with this movement are
recorded. Joint sounds are recorded as either
clicks or crepitation. A click is a single sound of
short duration. Crepitation is a multiple,
gravel-like sound described as “grating” and
“complicated.” Crepitation is most commonly
associated with osteoarthritic changes of the
articular surfaces of the joint.
TMD Screen Examination

Patients with TMD signs and symptoms may be seen and managed at three
stages:

1- TMD signs and symptoms may be present before the onset of orthodontic
treatment.

2- TMD signs and symptoms may arise during orthodontic treatment.

3- A completed patient may develop TMD after orthodontic treatment.

The orthodontist must be prepared to deal with each type of those patients.
Management of TMD signs and symptoms within an orthodontic practice.

At time of presentation

1. If patient has signs and symptoms of TMD, then the patient should be
informed that orthodontic treatment will not resolve those problems

2. Current TMD signs and symptoms should be noted, and a full TMD history
and clinical examination should be undertaken and recorded

3. If the existing TMD is acute and severe, the commencement of orthodontic


treatment should be postponed until the condition is either resolved or
stabilized
Management of TMD signs and symptoms within an orthodontic practice.

During treatment 1. Acknowledge and recognize the signs and symptoms of TMD
2. Reassure and educate the patient that TMD is not necessarily a progressive
problem and in most cases symptoms will improve over time with conservative
treatment 3. Active orthodontic treatment should be discontinued, and TMD
signs and symptoms should be managed by either the orthodontist or an expert
TMD colleague 4. Once signs and symptoms have been alleviated or controlled,
active orthodontic treatment may be resumed with consideration to
modification of treatment (reduction of forces on headgear, remove or lighten
elastics, use of oral TMD treatment appliance)
Management of TMD signs and symptoms within an orthodontic practice.

After treatment
The patient should be monitored for signs and symptoms throughout the
retention period. If symptoms arise, appropriate management should be
provided

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy