HOL I S T I C A P P R OA C H T O PR OB L E M S R E L A T E D T O EQUI L I B R I UM A ND D Y S F UNC T I ON OF T HE TE M P OR O- MA ND I B UL A R J OI NT

Dr. Luka Krusic
Rudnik 1, 1235 Radomlje Slovenia

1

CONTENT

CONTENT .................................................................................................................. 2 INTRODUCTION ........................................................................................................ 3 TEMPORO-MANDIBULAR JOINT ............................................................................. 6 TEMPORO-MANDIBULAR DYSFUNCTION IN HORSES ....................................... 13
GENETIC FACTORS ........................................................................................................................ 17 TRAUMATIC FACTORS ................................................................................................................... 18 MECHANICAL FACTORS................................................................................................................. 18 EMOTIONAL FACTORS ................................................................................................................... 18

TEMPORO-MANDIBULAR JOINT AND ITS INFLUENCE ON LOCOMOTION ....... 19 LOCAL SYMPTOMS OF TMJ DYSUNCTION ......................................................... 22 CONCLUSION ......................................................................................................... 22 SUMMARY ............................................................................................................... 23 LITERATURE: .......................................................................................................... 25

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INTRODUCTION

“The whole is more than the sum of its single parts” Hippocrates 400 B.C.

“Teeth arcades have a deeper meaning than their mechanical function represents” W. Balters

The horse as a supreme athlete has evolved as a grazing herbivore with a specific masticatory system and continuously growing teeth, which play an important role in all functions of the body and even in his psychological behaviour. In exploring the locomotion problems related to TMJ dysfunction, the teeth play an extremely important role. Horses rely on the proper function of their teeth because of the three aspects that may be reflected in their role of: • • • mechanical digestion, important for growth and the maintenance of all biological functions; the normal function of TMJ, i.e. the ability to move the jaw properly affecting the body's balance and equilibrium; and the alteration of behaviour and psychological state.

The role of teeth in mechanical digestion has shown that normal dental occlusion after correction of teeth may have a significant effect on digestibility of organic matter (Table 1, Gatta et al., 1995; Ralston et al., 2001) and minerals (Table 2, Gatta et al., 1997) and consequently on overall health and physical condition. Before
diet 1 mean Dry matter Organic matter Crude protein Crude fibre ADF NDF Cellulose Hemi cellulose N-Free extract Gross energy Nit. ret. 0,75 Nit. ret. mg/Kg/LW 134.2 84.5 128.7 47.0 144.5 15.5 150.5 19.7
Row with different superscripts differ (P<.05)

After
se 2.12 1.95 2.99 3.57 3.84 3.26 3.55 2.35 1.18 1.98 4.9 Diet1 mean 55.26 56.25 50.53b 52.88 48.36 48.59 58.81 54.91ab 62.42ab 53.17 16.57 se 6.7 3.2 4.98 3.47 4.18 3.84 3.32 3.98 2.57 3.25 1.55 diet 2 mean 56.13 57.66 55.25ab 45.72 40.29 45.58 52.36 55.53b 67.87b 53.57 17.51 se 2.27 2.24 3.96 1.87 3.06 2.9 3.19 2.61 1.78 2.34 2.03

se 2.98 2.99 4.18 3.63 4.47 3.41 3.83 2.33 2.49 3.17 12.9

diet2 mean 53.84 55.54 54.35ab 44.21 36.13 41.8 48.41 52.47b 65.04b 52.95 14.21

47.37 48.01 44.39a 38.47 32.84 38.55 45.96 53.4a 57.59a 44.19 14.99

g/d

Table1: Apparent digestibility coefficients and nitrogen retention of hay (diet 1) and hay and oats (diet 2) prior to and after dental correction (means ± se) (Gatta

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Diet 1-0 Retained 2-0 1+ 2+ 1-0 Apparent Digestibility 2-0 1+ 2+

Ca-g 58.89±8.92a 35.38±6.01b 87.91±13.10c 43.99±7b 0.48±0.05 0.51±0.05 0.61±0.09 0.60±0.08

Mg-g 0.69±2.71a -0.56±1.38a 5.34±2.06b 1.52±2.84a 0.22±0.11 0.22±0.04a 0.37±0.08b 0.36±0.09b

Na-g 1.92±0.99a -1.89±1.76b 1.44±1.20a -0.73±1.09b 0.47±0.13a -0.32±0.50bc 0.40±0.27ac -0.12±0.23b

P-g -0.37±3.23a 5.14t2.86ab 6.73±2.09b 6.04±0.71b -0.02±0.17a 0.26±0.15ab 0.37±0.12b 0.31±0.04b

Mn/mg -83.06±77.72 237.31±109.52ab 421.20±167.91b -233.24±80.00a -0.15±0.11 -0.53±0.25ab -0.77±0.31b -0.52±0.18b

Se/mg 0.45±0.02 0.37±0.11a 0.63±0.04b 0.34±0.16a 0.69±0.03 0.75±0.05ab 0.80±0.04b 0.80±0.01b

*0, before dental correction; +, after dental correction; a, b, P < 0.05.

Table 2: Apparent digestibility and retention of macro- and micro-minerals prior to and after dental correction (Gatta et al., 1997)

Proper function of the TMJ is of vital importance for a horse’s health and biomechanical functions of the whole body. In the modern management of horses, regardless of horse disciplines, all horses are exposed to a number of contributing factors that affect the proper mastication and normal wear of teeth. Some of these factors include the unnatural feeding of a high proportion of mechanically and thermally treated grain feeds, wearing of certain types of bit and noseband, undergoing various kinds of dental work, and a lack of professional standardised dental care. Due to the above-mentioned factors horses are prone to the condition known as Temporo-Mandibular Dysfunction (TMD) as a consequence of TMJ problems. TMJ refers to an area of the cranium where the mandibular bone contacts and articulates with the temporal bone. An important principle in a holistic approach to biomechanical or locomotion problems related to TMD in horses is the interrelation between structure and function as in osteopathy and between a single part and the rest of the body. The mandibular movement during mastication is controlled by the form and consummation of molar and incisor teeth. The normal function of a mandible depends on the correct position and functional balance of temporal bones and normal contact of dental tables producing normal occlusion. The dental occlusion refers to the coming together of the upper and lower teeth, whereas neuromuscular occlusion occurs when the dental occlusion is synchronized with healthy relaxed masticatory muscles. It is known that various dental problems can cause through the function of the upper and lower jaw position a dysfunction of the Cranio-Sacral System (CSS). The basis of cranio-sacral work is the work and research performed by the osteopath Sutherland, who discovered that cranium bones were connected through membranes with flexible bone sutures. The cranio-sacral system is a physiological system that exists in humans as well as in those animals possessing a brain and spinal cord. Its formation begins in the uterus and its function continues until death (Upledger, 1983). The cranio-sacral system derives its name from the bones involved: the skull, face and mouth which make up the “cranium” and extend down the spinal cord to the “sacrum”. The cranio-sacral system is a functional unit including the cranium and sacrum with all meningeal layers, bone structures, ligaments, cerebrospinal fluid and other additional systems such as nerves, vessels, lymph vessels, endocrine glands, respiratory system and the muscle-skeletal system. The cranio-sacral system is connected by membranes enclosing a semi-closed hydraulic system and has a palpable rhythm separate from either heartbeat or respiration rate. The craniosacral rhythm (cranial rhythmic impulse) is created by the formation and absorption of cerebrospinal fluid within the ventricles of the brain. Due to the faster formation of cerebrospinal fluid than occurs at its outflow the increased hydrostatic pressure causes a very fine rhythmic dilatation of cranium bones. One of the essential parts of the CSS in man and horse is the body fascia or soft tissue layer that covers the entire body from the head to the end of the limbs. This layer is in constant movement with the corresponding parts of the CSS in the form of the cranio-sacral movement/rhythm that can easily be disturbed by any tissue pathology (Rossaint, 1996). The proper functioning of the cranio-sacral system is possible under the normal anatomical and physiological state of all its parts (Rossaint et al., 1996).

The continuous production and absorption of cerebrospinal fluid causes two movements of the cranium bones, membranes and soft tissue as dilatation and contraction, that can be palpated in all parts of the body (Figure 1): 4

Inspiration = Outer rotation = Flexion

Expiration = Inner rotation = Extension

Figure1: Absorption of liquor = dilatation, inspiration, outer rotation or as flexion; Production of liquor = contraction, expiration, inner rotation or extension (according to Bäcker & Solomon, 2003)

Flexion “inspiration” and extension “expiration” are the movements of the unpaired cranium bones: sphenoid, occiput, os ethmoidale and sacrum at the level of the hind limbs.

Figure 2: Flexion movement of inner cranium bones (occiput, sphenoid, ethmoid and vomer)

The outer and inner rotations are synchronous movements of the paired cranium bones occurring with the spheno-basilar joint (Figure 2). During flexion of the symphisis spheno-basilaris, called the inspiration phase, both cranium bones approach and during extension extend in the socalled expiration phase (Figures 3a, b). The spheno-occipital or spheno-basilar joint is moved into the convex position, thus enabling the motion of all head bones.

Figure 3a,b: Flexion and extension movement of inner cranium bones (occiput and sphenoid)

With the flexion of the spheno-basilar joint through the connection of the dura mater the motion of the head and sacrum occurs, contributing to the movement of the occipital bases posteriorly and the sphenoid anteriorly, whereas the sacrum is moved posteriorly (Figure 4).

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Sacrum

Figure 4: Flexion and extension movement of inner cranium bones in connection with the sacrum schematically modified according to Evrard (2003)

With extension the opposite movement occurs. Under normal conditions the intensity and the amplitude of both phases is the same. The measurable amplitude of the cranial wave, felt as a discreet muscular pulsation, is between 40 microns to 1.5 mm in movement according to different authorities. In an abnormal or pathological state, where the occipital bone moves to one side, the same movement of the sacrum is followed (Asche van, 1996). The spheno-basilar joint is not important only as the centre of cranium bone movement, but it plays an important role as the location of the hypophysis in the sella turcica. Therefore any lesion of the symphisis spheno-basilaris may affect, besides the locomotion system, the whole hormonal and immune system.

TEMPORO-MANDIBULAR JOINT
The importance of the normal structure and function of the Temporo-Mandibular Joint (TMJ) is well known in humans, but very poorly studied in horses (Becker and Solomon, 2004; Evrard, 2004; Rosenstein et al., 2003; Maierl et al., 2000; Bonin, 2001; Cooper, 1992, 1993, 1996; Thomas and Cooper, 1989; Schöttl, 1991; Rossaint et al, 1996). The TMJ is an incongruous joint formed by the temporal bone and the mandible. It contains a fibrocartilaginous meniscus, which is interposed between the two articular surfaces in the form of a fixed double cartilaginous layer of the arcus zygomaticus (Figure 5). The articular meniscus divides the equine TMJ into a more special dorsal compartment (discotemporal articulation) with a caudodorsal recess and a ventral compartment (discomandibular articulation) with a rostroventral and a smaller caudoventral recess. Gross dissection may be used for the identity of individual structures and two pouches filled with synovial fluid. The temporal bone contains the entrance to the auditory tube (eustachian tube), the place where balance and equilibrium are registered by the vestibulocochlear nerve. Any abnormal state or function of the inserting head muscles can therefore influence a horse’s balance and equilibrium. It is known that the trigeminal nerve branch lies on the side of the temporal bone; one of the trigeminal nerves contains the motor nerve innervating the muscles for mastication. The second bone of the TMJ is the mandible consisting of two halves fused together at an early age of two to three months. The third important bone of the TMJ mechanism is the hyoid bone lying between two mandibular halves. The hyoid bone is inserted in the tongue muscles rostral and connected to the larynx and articulates with the temporal bones. This bone is connected with eight short and three long muscles to the different parts of the head and the breast and has an important role in mastication and the act of swallowing. One-sided contraction of laryngeal and hyoid bone muscles can cause a rotation, lateral flexion or lateral shift of the hyoid bone, thus affecting the equilibrium. There are several muscles involved in the movement of the upper and lower jaw. The largest muscles are the masseter muscles responsible for closing the upper and lower jaw. The second major muscles acting together with the masseter muscles are the temporal muscles, whose function is to close the mandible. The third important pair of muscles responsible for the lateral excursions of the mandible are the pterygoid muscles, responsible for closing, left and right side protrusion and contra-lateral excursion of the mandible. There are a number of muscles in each ear responsible for the movement of the ears that may affect the normal function of the TMJ. The majority of horses, except those with acquired and genetically disposed anomalies, have a maxillary overbite when the head is held parallel to the ground. In a normal upward position the mandible returns rostrally in the temporo-mandibular joint to its normal position. In a study with 3dimensional cinematic analysis of the equine TMJ a 6 mm rostro-caudal movement of the mandible 6

during the chewing cycle of normal light-breed horses was found (Bonin, 2001). The mandibular mobility and correction of the acquired overbite has always been found after the correction of the last molar tooth even at an age prior to the eruption of the sixth molar (Gatta et al, 1995; Krusic, 2004).

Figure 5a: TMJ left and right meniscus with surrounding tissue

Figure 5c: Lateral view of temporo-mandibular joint

Figure 5b: Rostral pouch with the meniscus of the right TMJ

Figure 5d: Ventral pouch with the meniscus of the right TMJ

The TMJ is supported and reinforced by ligaments and muscles that co-ordinate the movement of the mandible for normal lateral excursions and mastication. Any tightness or contraction in the muscles, tendons or ligaments of the TMJ mechanism will change the normal function of the TMJ. In the event of these muscles tightening and shortening, the body then negatively compensates for the imbalance and equilibrium. Any imbalance of tissue structures resulting from incorrect body static can cause body fascial tightness contributing to TM dysfunction. On the other hand, any dysfunction of the masticatory apparatus such as dental diseases, anomalies, teeth extractions and TMJ problems may affect locomotion problems through fascial and muscle tightness. The proper function of the TMJ mechanism therefore plays an important role in the whole function of the horse including leads, gaits, balance and equilibrium. The TMJ is one of the last joints in the body to develop. In contrast to man, the horse mandible is displaced backwards as the condyles grow in an anterior-superior direction together with the third premolar tooth. Growth and maturation of the TMJ is not completed till the end of the eruption of the last, sixth molar tooth. Due to the abnormal height of the incisive teeth, last molar or irregularity of any other molar tooth, the condyles may be subjected to displacement after unilateral mastication and occlusion and/or functional interference. The excessive consummation of the cartilaginous meniscus on the affected TMJ side may be found in young growing foals or older horses with gross abnormalities of molar teeth (Figures 6a, b).

Figure 6a: Lesion of the left rostral and right ventral side of the meniscus

Figure 6b: Lesion of the left rostral meniscus

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The lesion of the TMJ cartilaginous meniscus can be the consequence of excessive pressure of the masticatory muscles due to the abnormal condylar position in horses with occlusal surface abnormalities in the buccolingual plane as the last molar height difference. The primary lesion of the TMJ meniscus has not been documented as a possible symptom of orthopaedic bone disease. It is known that there is a close relationship between the condylar position and the height of the molar occlusion structure, which may explain the grade of consumption of the occlusal surface of molar teeth (Lotzmann, 1998). It is said that even small changes of the texture of any molar tooth can contribute to the condylar displacement (Figures 7a, b). In horses with disorders of wear, especially with supraeruptions of individual molar teeth (408, 308 or 411, 311 molar teeth) the occlusal surface on the opposite dental arcade tends to be always extremely worn with a loss of surface texture. The difference of the position of occlusal surface to condylar inclination can always be detected in horses with a misalignment of incisors (Figure 7c).

Figure 7a: The position of the occlusal surface to condylar inclination affects the height of occlusal texture (Lotzmann, 1998)

Figure 7b: Condylar displacement – schematically

Figure 7c: Misalignment of incisors and TMJ displacement of a 28-year-old coldblood horse

Excessive wear of the normal occlusal surface of molar teeth and incisors is always found in the “wave mouth” (undulating appearance of the occlusal surface of the molar arcades in the rostrocaudalor mesiodistal plane, combined with the abnormally high sixth molar (311 or 411) in older horses with primary or secondary TMJ dysfunction (Figures 8a, b, c, d).

Figure 8a,b,c,d: Stepped mouth with abnormally high inferior M3 right and left teeth and excessively worn occlusal surface prior to and after correction of longitudinal grooves of maxillary teeth and the occlusal surface of mandibular teeth, serrated in a way that presents a mirror image of the serrations of the upper arcade

TMJ is considered from the standpoint of traditional Chinese medicine as the energy centre (Figure 9). Both joints are located in the network of energy vessels (Gb, Bl, 3-E, St, Si); which may often be subjected to energy blockades or imbalances. The imbalances of energy vessels may result from local mechanical displacement of the TMJ or from peripheral disorders of the hind limbs due to abnormal static or poor conformation.

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Figure 9: The temporo-mandibular joint is located in the network of energy waves

The most evident imbalance may be seen on the SI meridian passing the TMJ and descending the neck laterally on the front leg down to the hoof. The energy imbalance of this meridian may be one of the main causes of lower joint lesions after the compensation phase. The most important energy meridian connecting the head and the hind legs is the Bladder meridian (Bl), responsible for muscles and a majority of back problems. Any imbalance of energy flows in this meridian may cause a sore back, asymmetric gate and imbalanced movement of the entire body. In TMJ dysfunction several diagnostic acupuncture points are indicators of the energy imbalance on the contra-lateral side of the TMJ lesion (Bl 10, 20,22,23,25, Bl 30). The Gall bladder meridian (Gb), that connects the head and the hind legs, is responsible for projecting and pushing the hind limbs forward. In the case of one-sided TMJ displacement this meridian may be blocked at the level of the head (Gb 20), lumbar or hind limb region (Gb 26, 30, 34) on the opposite side of the trunk. The TMJ plays the role of a regulator of lateral excursions during mastication, which enables the horse to have mechanical digestion in the mouth and proper wear of growing teeth. In horses with dental problems the mandibular bone in connection with the maxilla represent the primary cause for dysfunction of the cranio-sacral system through temporal bones and the tentorium cerebelli, which divides the small and big brain and has the function of maintenance of tension around the basilar cranium bones. Numerous muscles inserted in the mandibular bone can be contracted due to cranium bone imbalances resulting from abnormal occlusion. Mandibular movement is directly connected to the cranio-sacral rhythm (primary rhythmic impulse). The normal occlusion depends on the balance between the cranio-sacral system and the mandibular system. The occlusion is the result of the dynamic of several cranium bones and the dynamic of the sphenobasilar joint. The cranio-sacral and mandibular system are built up from two main systems: a dynamic, functional and adaptive system, represented by the TMJ, which is connected with the first cervical vertebra atlas by myofascial tissues and the hyoidal bone, and a gravitational system representing the osteo-articular Axis-Atlas-Occiput-Sphenoid-Complex (Evrard, 2003). In holistic dentistry the TMJ is not an independent functional unit, but is interconnected with the rest of the body through the stomatognathic system. The stomatognathic system includes the parts of the head, the neck and the upper thorax representing the muscular, osseus, ligamentous, fascial and nervous system. The stomatognathic system is responsible for the control of biting, chewing and swallowing (Figure 10).

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Figure 10: The Stomatognathic system consisting of the mandible, temporal bone, condyle, occiput, and atlantoaxial joint

According to the causes of clinical symptoms found during a holistic examination, two kinds of pathological changes may be diagnosed: primary or secondary lesions. The primary occlusive lesion may be manifested as descending pathological changes, that can be initially compensated by the TMJ and later by the hyoidal bone (os hyoideum) and by C1,C2,-C4, where the local muscle tightness occurs due to the energy imbalance of four main meridians (Gb, Si, Bl, St).

Secondary occlusive lesion

C0 C1
Descending lesions

Primary occlusive lesion

C2

C3

Descending

lesions C4

Ascending

lesions Figure 11: Primary and secondary occlusive lesions

The secondary occlusive lesion may be manifested as the ascending lesion of the occiput-atlas C0/C1 axis. The ascending pathological lesions (deriving from diverse peripheral trauma or visceral lesions) are compensated at the level of C1 and transformed into caudo-rostral forces causing the rostral pression on the mandibular bone and compression of the TMJ. In horses with dental problems the mandibular bone in connection with the maxilla represents the primary cause for dysfunction of the cranio-sacral system through temporal bones and the tentorium cerebelli, which divides the brain from the cerebellum and acts as a spanner to the sphenobasilar symphisis (Bäcker and Solomon, 2004). Numerous muscles inserted in the mandibular bone can be contracted due to cranium bone imbalances resulting from abnormal occlusion. In an abnormal dental occlusion due to a variety of dental problems the mandibular movement may influence the stability of head bones and cause even its deformation, recognised in the form of head asymmetry in young horses with retained deciduous caps or in older horses with chronic changes of the cranio-sacral system (Figures 12a, b).

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Figure 12a: Head asymmetry in a 4-year-old Standardbred

Figure 12b: Head asymmetry schematically

Figure 12c: Head asymmetry of 17 years old dressage horse

The TMJ joint is very sensitive and unstable in conjunction with both temporal bones. The onesided shift or displacement of the mandible and consequent muscle tension may occur always in the case of gross abnormalities of molar teeth (shear mouth, wave mouth and step mouth with a high inferior sixth molar tooth (411 or 311 according to the Triadan system for numbering the cheek teeth) or in the case of superior brachignatism (Figures 13a, b)

Figure 13a: Superior brachignatism in a foal

Figure 13b: Superior brachignatism in an adult horse

The mandibular bone is a paired cranium bone making lateral excursions in the form of outer and inner rotation together with the extension and flexion of the sphenobasilar joint. The outer rotation is influenced by temporal bones (Figures 14a, b), whereas the sphenobasilar symphisis (SBS) is in flexion and the TMJ moves in a medial, caudal and ventral direction. Since the proportion of vertical and horizontal mandibular parts in horses is 2:1 (in a human 1:1), TMJ anomalies are consequently greater in horses than in man.

Figure 14a: Outer end rotation of the temporal bone (right excursion of mandible)

Figure 14b: Inner rotation of the temporal bone (left excursion of mandible)

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Figure 14c: Outer rotation of the temporal bone and mandible (Evrard, 2003)

Figure 14d: Inner rotation of the temporal bone and mandible (Evrard, 2003)

The inner rotation is influenced by temporal bones, whereas the sphenobasilar symphisis (SBS) is in extension – the TMJ moves in a lateral, rostral and dorsal direction (Figures 14b, d). The correction of the inner and outer mandibular rotation may be performed by osteopathic treatment (local temporal bone and correction of peripheral lesions), correction of mandibular CSR mobility (by the indirect or the direct method, or by compression or decompression of the TMJ) and by correction of the dental occlusion. In most horses and even foals after the eruption of the third premolar tooth the restricted mandibular rotation may be due to one-sided or both-sided occlusal change, i.e. excessive >15° angulation of the molar occlusal surface in the buccolingual plane, termed shear mouth and formed by irregular wear of molar teeth. The movement of the upper and lower jaw has not been described and evaluated during the past few decades, except in a recently performed 3-dimensional cinematic analysis of the equine TMJ during the chewing cycle of normal light- and heavy-breed horses (Bonin, 2001; Carmalt et al., 2003). The systematic study of the movement of the upper and lower jaw during the chewing cycle was conducted by German researchers in the early forties (Leue, 1939, 1941). According to Leue (1938, 1939) the mandibular movement can be monitored and described as a 4-phase movement corresponding to the outer and inner rotation of the temporal bone and mandible. During abnormal wear of the molar teeth the occlusal surface formed in the textured surface is reduced to such an extent that the mandibular movement tends to be changed from the 4phase movement to a 3- or even 2-phase movement. It should be mentioned that too many worn dental surfaces are not efficient enough for chewing properly because the dental arcades slide rather than grind and turn the food. These changes were described by monitoring the mollograms of horses showing different colic symptoms (Leue, 1941). During normal chewing the grinding tables of the molar teeth should have a slight angle of 10-14 degrees, depending on the breed, in order to slide over and maintain the textured surface. The normal movement of the mandible during the chewing cycle is graphically presented in Diagram 1.
TOP VIEW AB – closing and posterior movement of mandible BC – cutting and pressing movement CD – rostro-anterior movement DA – end sliding of dental surfaces SIDE VIEW AB – closing and retrusion CD – cutting and pressing rostro-lateral movement + rostro-anterior movement FRONT VIEW AB – closing and retrusion BC – cutting and pressing movement CD – rostro-anterior movement DA – end sliding of dental surfaces
Diagram 1: 4-phase movement of upper and lower jaw during mastication (modified according to Leue, 1939).

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TEMPORO-MANDIBULAR DYSFUNCTION IN HORSES
Temporo-mandibular dysfunction is a term used in the field of dentistry meaning a group of conditions, often painful, that affect the TMJ and the muscles that control chewing. TMD can affect general health and does not cause only local changes. It is known from human literature that TMD may be divided into three categories: myofascial pain, manifested in discomfort and pain in the muscles that control jaw function, neck and shoulder muscles; internal derangement of the joint, meaning a dislocated jaw or displaced articular meniscus, or injury to the condyle; and degenerative joint disease which is a form of osteoarthritis rheumatoid arthritis in the TMJ (Metha et al, 1984). Despite its recognised importance in human medicine, TMJ disorders and dental abnormalities have been poorly studied. Some early studies on pathological changes of the TMJ in gross abnormalities of molar teeth were performed in the systematic work of Hollatz (1910). During recent decades only limited studies of TMJ function and anatomical structure were performed (Meierl et al., 2000; Bonin, 2001; Rosenstein et al., 2003). The TMJ is one of the most important joints in the horse skeleton. In the horse the TMJ dysfunction is specific to the TM joint and consists of pain in and around the joint, abnormal movement of the mandible and even degenerative changes within the joint. Determination of the range of movement of the mandible is a simple and objective method of assessing the TMJ function and occlusion. A reduced range of movement to the left or right side may be a sign of disorder of the musculature and/or of the TMJ mechanism. The lateral inter-incisal opening may be measured by the opposite incisor movement (three incisors left or right), observing the maximum opening (Figures 14a, b). The determination of occlusion is based on the fact of pushing laterally as far as possible without using undue force, to determine the lateral excursion. The contact surfaces of the central incisors are used as pointers for determination (Rucker, 1995). Incisor movement (or opening) laterally may indicate an estimation of reduced occlusion to 30%, 2 incisors 66% and 3 incisors with movement laterally may indicate 100% occlusion. Restricted lateral excursions of the mandible to one or the other side may often reflect the first disharmonies of the contra-lateral TM joint due to abnormal wear of the occlusal surface or overgrowth of any mandibular molar teeth on one side and consequently an abnormally high sixth molar tooth (311 or 411) of the opposite arcade. The TMJ dysfunction may be reflected in any part of the body. The TMJ dysfunction and consequent changes of other structures may be caused by dental problems, genetic factors, traumatic factors, mechanical factors and emotional stress.

DENTAL PROBLEMS The teeth are a part of the mandibular cranio-sacral system and may have a significant effect on the function of TMJ. They are connected by nerves and energy vessels to the head and other parts of the body as different organs. According to the detection of corresponding human acupuncture points to the teeth, corresponding acupuncture points can be found in horses and dogs by controlled acupuncture (Petermann, 2004). The teeth, identified according to the Triadan system, correspond to different acupuncture points on the energy vessels of horses and are summarized in Table 2 and presented in Figure 15. In human dentistry this method is used for the detection of teeth disorder centres.

Figure 15: The triadan system of dental identification (Dixon at al., 1999)

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Upper jaw:
Tooth Point 11 1 Kd 3 11 0 Lu 1 10 9 Gb 41 10 8 Hr 4 107 Kd 7 10 6 Gb 34 10 5 10 4 Gb 30 103 Lu 7 10 2 Gb 43 10 1 St 4 20 1 St 4 20 2 Gb 43 203 Lu 7 20 4 Gb 30 20 5 20 6 Gb 34 207 Kd 7 20 8 Hr 4 20 9 Gb 41 21 0 Lu 1 211 Kd 3

Lower jaw:
Tooth Point 411
Yin Tang

41 0 Bl 11

40 9 Li 15

40 8 Kd 6

40 7 B l26

40 6 Bl 67

40 5

40 4 Cv 6

40 3 Li 4

40 2 ?

40 1 Bl 62

30 1 Bl 62

30 2 ?

30 3 Li 4

30 4 Cv 6

30 5

30 6 Bl 67

30 7 Bl2 6

30 8 Kd 6

30 9 Li 15

31 0 Bl 11

311
Yin Tang

Table 2: Corresponding acupuncture points on teeth of the upper and lower jaw of the horse

Dental disease is related to the age and dental development of the horse. It can be basically divided into four categories: developmental, traumatic, infectious and neoplastic. However, the division of dental disease to four categories is difficult because developmental problems of occlusion and tooth growth may predispose to different traumatic and infectious problems (Easly, 1991). Dental disease with disorders of development and eruption and variation in the position of cheek teeth, disorders of wear, traumatic damage, idiopathic fractures, periodontal disease, retained deciduous incisors with subsequent crowding and rostral displacement of the retained incisor, less common incisor displacement by overcrowding of the permanent incisors in the absence of retained or supernumerary teeth, dental or bone tumours, supernumerary permanent incisors and miscellaneous dental abnormalities have been evaluated by Dixon et al. (1999 a, b, c; 2000) on a large number of horses of different breeds and different ages (Table 3). An interesting approach with improved diagnostic criteria and retrospective examination of case records, dental specimens and radiographs was applied in the light of improved knowledge.
No cases Age (years) Median (range No teeth involved Cases involving mandibular incisors Cases involving maxillary incisors Cases involving mandibular & maxillary incisors Quidding Weight loss Bitting problems/ abnormal head carriage Facial swelling Halitosis Periodonta l disease No clinical signs

Traumatic fractures

11 25% 5 11,4% 3 6.8% 4 9.1% 0 4 9.1% 3 6.8% 3 6.8% 3 6.8% 3 6.8% 3 9.1%

2 (1-9) 5 (3-5) 3.5 (0.5-17) 6,5 (2-10) 0 5 (3-6) 14 (1-14) 5 14 (11-21) 11.5 (9-14) 5 (4-10)

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3 27.3% 1 20% 1 31.3% 0

8 72.7% 2 40% 3 100% 0

0 2 40% 1 33.3% 4 100% 0

2 18.2% 1 20% 1 33.3% 1 25% 0

2 18.2% 0 1 33.3% 0

0 1 20% 0 1 25% 0

6 54.5% 1 20% 0

2 18.2% 0

0

3 27.3% 3 60% 1 33.3% 3 75% 0 4 100% 0 3 100% 0 2 66.7% 0

Retained deciduous incisors

13

0 2 66.7% 0

Developmental displacement

12

0

Brachygnathia

0

0

0

Prognathia

0

0 2 50%) 2 66.7% 0

0 2 50% 1 33.3% 1 33.3% 1 33.3% 2 66.7% 2 66.7%

0

0

0

0

Supernumerary incisors

18

0

0

0

0

0 3 100% 0

0

0

Dental tumour

10

0 2 66.75% 2 66.7% 0 0

0

0

0

0

0

Abnormalities of wear

16

0 2 66.7% 0 0

0 2 66.7% 0 0

0

0

0 3 100% 0 1 33.3%

Primary periodontal disease

17

0 1 33.3% 1 33.3%

0

0

0 1 33.3% 0

Idiopathic fractures Apical infection

3 3

0 1

0 1

Table 3: Dental diseases and clinical symptoms of 42 horses with equine incisor disorders (Dixon et al., 1999)

In older literature there are some important studies on equine dental disorders in German literature summarized in the publications of Ostertag, (1903) as inherited dental disorders, abnormal dental number (oligodonty, pleodonty, heterotropic pleodonty, abnormal dental position, jaw anomalies such as gross brachygnathia or “parrot mouth”, prognathia or “undershot”, abnormal structure of hard dental substances, abnormal change of deciduous teeth, abnormal wear of the occlusal surface and individual cheek teeth (“shear mouth”, “wave mouth”, “step mouth”, prominent overgrowth of the lingual aspect of mandibular cheek teeth and the buccal aspect of maxillary teeth, the abnormal early wear of the whole occlusal surface, ruminant occlusal surface and “scissor mouth” as bevelling of the molars, and prolongation of the molar crown (exsuperantia dentium). Further original extensive research work on dental diseases is limited to a few authors in the German language, dealing with the terminological system of Ostertag (1903), Joest et al., (1922), Joest (1926), and Günther and Günther (1859). Relatively detailed scientific research on periodontal 14

disease and its possible aetiology during a period of 14 years on clinic patients and separately on abattoir specimens was performed by Kurtzwig (1912). The most representative source of information on normal anatomy and dental diseases with the numerous citations of original publications are considered to be the original research work of several authors at the beginning of last century (Klingemann, 1906; van der Veen, 1908; Ehlers, 1911; Weiss, 1911; Niklas, 1915; Finger, 1920; Meyer, 1921; Spinner, 1922; Bruder, 1922; Westman, 1922; Chorin, 1922; Bruhns, 1931; Ruprecht, 1936; Schlack, 1938; Obiger, 1939; Leue, 1941). The neglect of equine dental studies can be found in French literature, where only a few authors are known (Magitot, 1873, 1875; Goubeaux et Barrier, 1884). The scarcity of dental studies in past centuries was noted also in English literature (Dixon et al., 1999). In the last century in English literature only a few important dental studies have been performed mainly on horse cadavers from abattoirs (Colyer, 1906; Baker, 1979; Wafa, 1988). Dental disorders are of major clinical importance in the horse with a British survey of equine diseases presented by Anon (1965). In a survey of dental abnormalities found in horses with no signs of dental disease and a group of horses with clinical symptoms of dental disease Uhlinger (1987) found 24% of horses with dental abnormalities, suggesting that proper dental examinations have often been neglected due to the dangers and difficulties associated with such examination. During recent years in the USA equine dental disorders were ranked as the third most common medical problem encountered in large animal practice (Traub-Dargatz et al., 1991). Different dental abnormalities, manifesting in the form of abnormal wear of the occlusal surface, may contribute to abnormal movement of the upper and lower jaw and thus affect the TMJ. Overgrowths due to the disorders of wear are a major cause of dental disorder in hypsodont species, to which belongs the domesticated horse (Becker, 1962). It is still unclear whether these overgrowths of enamel are the result of abnormal chewing activity due to primary periodontal disease or due to TMJ discomfort. It is known that enamel overgrowths regularly develop on the medial or lingual aspects of the mandibular, and on the lateral or buccal aspect of the maxillary molar teeth. From the early studies of Leue (1939) and Leue (1941) measuring the lateral excursion of grinding movements in horses chewing grass, oats or chaff, excursions of 60 mm, 38 mm and 23 mm, respectively, were found. Leue (1941) proposed that fibrous food such as hay or grass could readily be maintained on the occlusal surface of the mandibular teeth as they moved laterally to their full extent, thereby allowing a complete horizontal grinding movement. However, just a limited quantity of particulate food could be retained on the narrow mandibular occlusive surface. Therefore a primary vertical mandibular movement, with minimal latero-medial excursion, was required to maintain particulate food between the occlusal surfaces. Diets high in concentrates, especially flaked or semi-ground, also greatly reduce the length of time horses chew forage and so further predispose to such enamel overgrowths (Dixon, 1999). Diseases of the equine molar tooth crown are considered to be found with increasing frequency (Dixon et al., 1999). These include diasthemata, traumatic or idiopathic fractures of the crown, abnormalities of wear such as transverse ridges, wave-, step-, shearmouth, and supernumerary or missed numbers of molar teeth (polydontia, hypodontia). The inflammation with consequent carries and root inflammation of any molar tooth may cause one-sided overload and different muscle and ligament tightness, contractions and abnormal function of the TMJ. The removal of cheek teeth in mature horses can cause the primary occlusal problem due to the continued dental eruption of the opposing tooth. The extraction of cheek teeth may cause the migration of a caudal tooth to the space left by a removed tooth leaving a diasthema (open space), representing a source of periodontal disease. Further complications after surgical tooth extraction, fractured cheek teeth, sequestration and fistula formation may influence the normal functioning of TMJ. An important cause of the abnormal occlusion and function of TMJ is the retarded deciduous teeth change during the age of two and half and four years. During retained deciduous teeth several observations can be made regarding the function of the TMJ, general health, body weight maintenance, equilibrium or balance problems. In Standardbred horses a change in normal and specially retarded deciduous teeth can cause severe symptoms of exercise intolerance, body weight loss and locomotion problems? In a long-term study performed under a controlled nutrition programme, body weight monitoring, orthopaedic control and exercise testing the majority of horses showed reduced aerobic and anaerobic capacity, significant weight loss and several locomotion problems in the form of asymmetric stride during the period of deciduous teeth change (Graph 1).

15

540
540

520
520

500
500

Body weight [kg]

Body weight [kg]
June 03 July 03 March 03 March 04 June 04 Sept 02 Oct 02 Sept 03 Jan 03 Oct 03 May 03 Jan 04 April 03 Aug 02 Aug 03 May 04 Feb 03 Nov 02 Nov 03 Dec 02 Dec 03 Feb 04

480 460 440 420

480 460 440 420

400
400

380
380
July 03 Jan 04 Feb 03 Sept 03 April 03 Nov 03 Feb 04 Oct 03 March 04 May 03 March 03 May 04 Aug 03 Dec 03 June 03 June 04

M o n th

Month

Graph 1a: Body weight changes during a training period in a group of 3-year-old Standardbreds after dental corrections

Graph 1b: Body weights during a training period in a group of 3-year-old Standardbreds after dental corrections

The results of a clinical examination and dental correction with the treatment of corresponding neck and dorsal muscle soreness showed the normalisation of physical capacity, body weight recovery and normalisation of gait within a 4-week period of time. In contrast, horses with a problem of retarded deciduous teeth change have shown neither performance improvement nor body weight gain during this period. These changes may be found in the form of painful maxillar and mandibular swellings that persist over a period of change in normal deciduous teeth and eruption of permanent teeth (Figures 16a, b, c, d).

Figure 16a: Retained 108 and 408 molar teeth with mandibular swellings (cysts) with a 4-year-old Standardbred

Figure 16b: Retained 108 and 408 molar teeth with maxillar swellings (cysts) with a 4-year-old Standardbred

Figure 16c: Retained 107 and 407 molar teeth with maxillar swellings (cysts) with a 3-year-old Standardbred

Figure 16d: Retained 107 and 407 molar teeth with maxillar swellings (cysts) with a 3-year-old Standardbred

16

Molar tooth alveolitis (tooth root infections, periapical disease or apical infections) is a relatively common but not so easily diagnosed dental condition. In a recent study on the appearance of dental diseases of the horse by Archer et al. (2003) it was revealed that periapical infection is likely to be identified by the scintigraphic method as shown in previous reports (Metcalf et al., 1989; Boswell et al., 1999; Gayle et al., 1999; Semevolos et al., 1999; Weller et al., 2001). In older horses the affected horses may present very large swellings in chronic periapical disease, even with periodically purulent discharge and symptoms of digestive disorders and weight loss (Figures 17a, b, c, d, e). Alveolitis can occur in young horses during the deciduous teeth change, in the case of incomplete removal of milk caps affecting the TMJ mechanism by overloading the opposite TMJ side. In older horses alveolitis may occur after dental damage, consequent feed impaction and periodontal disease.

Figure 17a: Mandibular swelling due to 309M chronic apical infection

Figure17b: Occlusal surface prior to correction and extraction of 309 M

Figure 17c: Occlusal surface after correction and extraction

Figure 17d: X-ray picture of the 309M affected tooth with secondary granulomatous reaction

Figure 17e: X-ray picture of the 309M missing apical part of the tooth root

GENETIC FACTORS Genetic factors such as an inherited abnormal proportion between the upper and lower jaw, too big or too small teeth, supernumerary incisor and molar teeth on one side (Figures 18a,b), occlusion anomalies, brachignatia and prognatia in some horse breeds may contribute to abnormal mastication and prominent overgrowth of molar teeth with signs of TMJ dysfunction. The most frequent occlusal anomaly in the form of brachygnathia of the upper jaw can be found in thoroughbred horses.

Figure 18b: Ten permanent supernumerary maxillary incisors

Figure 18a: Supernumerary maxillary molar teeth

17

TRAUMATIC FACTORS Traumatic factors like different traumatic lesions of the upper or lower jaw and mandibular fractures can cause severe abnormal function of the TMJ mechanism, manifested in abnormal wear of molar and incisive teeth. In extreme cases of jaw injuries and poor teeth care the TMJ dysfunction may cause an overgrowth of the upper molars and reduced mechanical function with symptoms of changed body condition and dramatic weight loss (Figures 20a, b, c, d).

Figure 20a: Acquired shear mouth in a 9-year-old stallion (mandibular fracture) prior to first and third correction of the occlusal surface

Figure 20b: Acquired shear mouth in a 9-year-old stallion (mandibular fracture) after first and third correction of the occlusal surface

Figure 20c Misalignment of incisors of a 9-year-old stallion prior to first and second correction

Figure 20d: Misalignment of incisors of a 9-year-old stallion after first and second correction

MECHANICAL FACTORS The most important mechanical factors contributing to TMJ dysfunction may be static changes of the skeleton due to inherited factors such as normal conformation of legs and hooves and due to acquired abnormalities as abnormally high or too low hooves. The most frequent mechanical factor can be considered different shoeing errors that can affect the hip and sacroiliac joints and through the spinal cord the TMJ. Any primary peripheral joint pathology due to genetically acquired orthopaedic bone disease (OCD) or direct trauma of the peripheral joints may cause TMD. The primary peripherallesion can cause, through the unequal distribution of body weight on four legs, a contralateral overload and consequent contraction and compression of the TMJ. The abnormal position of the hyoid bone, which is connected with eight principle muscles to the mandible and breast and thus with the whole static and locomotion system, can affect the function of the TMJ. The hyoid bone is considered in osteopathy as a mediator between body and head facial tissues acting as a neutralising mechanism during extreme forces (Bäcker and Solomon, 2004). Therefore the hyoid bone may be frequently involved in restrictions of different parts of the body manifesting in asymmetric stride and equilibrium problems.

EMOTIONAL FACTORS Since the horse is an animal with a very strong emotional body constant emotional stress caused by painful situations or mishandling can provoke myofascial contractions causing compression on the TMJ and contraction of the hyoid bone and its abnormal position. Trauma within the mouth can often create painful physical conditions locally and possibly in any other parts of the horse’s body. Unfortunately, the horse has an enormous ability to compensate for his dental problems because they arise so slowly and they adapt to the painful situation. The physical pain that extends beyond the time of the actual dental problem may be compensated for to a certain stage, as emotional discomfort becomes predominant and the horse changes his behaviour. This is often the reason why emotional pain as a consequence of long-lasting physical pain is not recognised by the owner. If the horse has been compensating for his painful situation over several years, the memory of the pain can last much longer than the pain itself. During the long-term experience of proper dental treatment of horses it has been shown that younger horses improve their function of the TMJ and their locomotion problems within a short period of time. The improvement of gait asymmetry may be 18

supported by acupuncture, acupressure, chiropractic and cranio-sacral therapy. In older horses that have been compensating for more than six years by abnormal carriage of the head, holding their neck and vertebral column in a position of minor discomfort, their emotional state and behaviour have remained abnormal for a longer period of time, whereas their locomotion problems have improved significantly in a relatively short period of time.

Symptoms indicating a blockade of C1

-

Headshaking, uncontrolled head movements Head/bit problems Stiff, sore neck muscles Abnormal head carriage, Problems in turning and/or stretching the neck Abnormal chewing of the feed – Quidding, dropping of food from the mouth Horse masticates very slowly (less than 20 circles per min.), mostly due to dental problems The faeces contains undigested feeds and forage particles longer than 5 mm (Gatta et al., 1995) Increased salivation with dense saliva during mastication In all occlusion problems the TMJ is overloaded All kinds of irregularly consumed or deformed teeth may be the consequence of TMJ problems Stretching of the tongue out of the mouth Balance and equilibrium problems Pulling the bit; excessive salivation The horse tends to hold the head upwards or sideways rigidly according to the affected TMJ side Rigid reaction of the back tending to take an abnormal position in order to avoid the painful situation Unwilling to take a bit The horse will not turn the neck to the left or right; the side which is easier to handle or to turn to is affected by sternocleidomastoideus muscle contraction; the horse can turn to the affected side due to painful muscles The muscle over the C1 on one or both sides may be stiff or even swollen; stiff and sore muscles on the contra lateral side from the last breast or lumbal vertebra; painful reaction on Shu acupuncture points (Bl30); reduced extension of the contra-lateral hind leg muscles and shorter stride – asymmetric stride

Mastication problems and unknown weight loss

Abnormal position of upper and/or lower jaw Abnormal wear of teeth (incisor and molars) Problems occurring during riding or driving the horse

-

-

-

Table 4: Summary of symptoms indicating TMJ dysfunction in the horse.

TEMPORO-MANDIBULAR JOINT AND ITS INFLUENCE ON LOCOMOTION
Head and neck movements are one of the most obvious and reliable diagnostic signs in detecting mandible position changes and TMJ dysfunction. Traditionally it has been assumed that lowering the head moves the centre of gravity forward and vice versa. Through computer modelling, it has been shown that these static effects on the centre of gravity are minimal. It is the dynamic effect of pivoting the head and neck around a rotational point at the base of the neck, resulting in an inertial interaction between the trunk and the head/neck segments, that shifts weight from a lame limb to the diagonal and contra-lateral limbs (Vorstenbosch et al., 1997). This reaction of the body balance may be clinically detected in every horse with a TMJ dysfunction and mandibular posture change. The mastication system with perfect occlusion and central regulatory TM joints play an important role in maintaining the body balance and proper locomotion. The influence of abnormal occlusion regarding the height and eruption state of the 311 or 411 molars during the period of deciduous teeth change and later on after eruption of the inferior sixth molar teeth may be manifested by problems of locomotion and maintenance of body balance. The incidence of temporo-mandibular joint (TMJ) dysfunction after uneven wear of the last molar teeth can be manifested in a series of biomechanical problems such as stride asymmetry or as different lameness symptoms. 19

The first important atlanto-occipital joint, constructed from two ellipsoid joints that enable the movement of the head in vertical directions (stretched and lower position), is exposed to numerous abnormal blockades, manifested in different symptoms of head reactions. It also represents the initial symptom of TMJ derangements and dysfunction in the horse. The second head joint, the atlantoepistrophicus or axial vertebral joint, which supports the atlas, is connected with three joint surfaces, partly concave and partly convex, and enables the axial movement of atlas and head (Nickel et al., 1961). Since all three joint surfaces remain in constant contact, only a small deviation of the normal position suffices to affect the joint integrities. These two cranio-cervical joints are responsible for all head movements and maintenance of the forward head position and body equilibrium. In one-sided TMJ imbalance (dislocation, compression) a side inclination of the atlas C1 and consequent tension of atlanto-occipital joint muscles and ligaments occurs (Figures 21a, b).

Figure 21a: Dislocation of C1 vertebra

Figure 21b: C1 muscle swelling

The neck muscles (sternocleidomastoideus and sternocleidotransversarius) of the affected side tend to be contracted due to the decreased energy flow in the Bl, Gb, St, Si and 3-E meridians (the diagnostic points Bl10,Gb20 are painful). The upper and lower neck muscles are painful on the affected side and cannot be extended or stretched to the opposite side during work or manual manipulation. The front leg of the affected side has a shorter stance and lower swing phase during the adaptation phase, whereas during the compensation phase lameness may appear. Regardless of the type of horse’s activity (dressage, spring or race horses), abnormal head carriage and locomotion problems occur as the laterality disorders always cause the dysfunction of TMJ, affected by the prominent overgrowth of 311 or 411 molar teeth. The symptoms of head carriage and locomotion problems can be interpreted as energy imbalance in meridians or changes at the level of the nervous system as shown in the reflex block of the ganglion in laterality disorder. During a clinical examination, the horse with the laterality problem demonstrates a painful reaction in the affected TMJ with the contraction of the sternocleidomastoideus and the sternocleidotransversarius muscle. In veterinary medicine the symptom of inversion is well known in horses and dogs. It represents the reflex block of the ganglion stelatum or a mechanical block of the first rip, causing a change in the reflective reaction between the sympathetic and the parasympathetic nervous system (Roesti, 1997). The horse, standing on four limbs, with a consequently horizontal position of the spine and lacking clavicular bone, is predisposed to relatively frequent inversion. The incidence of inversion is predisposed also by a heavy head and long neck ligament on the upper side and clavicular band, which is bound with pars cleidomastoidea to the mastoid and with pars cleidotransversaria to the atlas. There is a clear evidence of the manifestation of the inversion of ganglion stelatum and diagnostic acupuncture points Gb20/Bl10, which represent the sympathic and parasympathic basis (Zeitler and Bahr, 1987). In order to maintain the body balance the contra-lateral hind leg is subjected to take and carry an excessive load during the adaptation phase. The contra-lateral hind leg cannot be stretched completely (100%) due to the blocked energy path (Bl30 positive) and consequent reduced gluteal muscle elasticity. After a longer compensation period of TMJ dysfunction and consequent laterality problem different joint pathologies may develop. It is interesting that pathologic changes of the contra-lateral

20

leg appear after a short compensation period first in the form of hyperextension of knee ligaments and later in the form of degenerative joint disease of the tarsal joint. The asymmetric stride can be detected either in riding horses as well as in trotters during this adaptation period. In Sweden considerable work on trotting Standardbreds has been done. One of the interesting findings in relation to normal gait is that, at the start of training, the majority of Standardbreds already show left/right asymmetries in the lengths and durations of the left and right steps, with individual horses differing in the direction of the asymmetries. These asymmetries become more pronounced as training progresses (Drevemo et al., 1987). In horses, the asymmetrical stride of the hind legs can often be observed during the first “compensatory phase” of body balance problems with evident TMJ dysfunction and last molar teeth irregularities. As the horse teeth continuously grow as permanent teeth almost until the age of twenty years from 4 to 7 mm per year, the unilateral mastication can easily cause a different consumption of the teeth on the working side of the upper and lower jaws. Clinically, the height difference between the left and the right sixth inferior molar tooth, whose eruption occurs earlier than the eruption of the superior tooth, can easily be detected by regular monitoring of the teeth with a digital camera. In young race horses, which have to perform at a higher speed, the irregular stride, asymmetrical extension of the hind legs or even lameness symptoms occur in cases of unequally high last molar teeth and the consequently affected TMJ (Krusic and Marcolini, 2002) Changes in the TMJ position are due to the abnormal appearance of the occlusal surface of molar teeth rows in the rostro-caudal (mesiodistal) plane as in higher ones (311 or 411 molar tooth, which causes the anterior-superior condylar displacement and restricted movement of the mandible). In palpation of the TMJ the intra-articular space will be decreased. If the condition worsens, the posterior attachment will become even more stretched, thinner and weaker, and the condyle will migrate anteriorly. The lateral excursions of the mandible become more reduced and the mastication frequency differs from one side to the other. The evidence of changes in the condylar position are local pains in the joint and subsequent compensatory pains along the vertebral spine causing an abnormal position or even vertebral subluxation. Both side TMJ imbalances may be manifested in a variety of symptoms of altering asymmetric locomotion and abnormal shoulder position. An abnormal conformation or changed body static due to the errors in shoeing or peripheral trauma of the limbs can lead to TMJ problems. Any joint trauma of a hind leg as in traumatic arthritis or joint lunation can cause overloading of the opposite leg, subsequent contraction of pelvic muscles and ligaments, muscles of the vertebral spine, shoulder, neck and compression of the TMJ with symptoms of dysfunction. Several important neck vertebral problems are summarized in Table 6.

Vertebra

Important nerves of the segment
N.cervcalis innervating: m.rectus cap., obliq. cap., M.splenius and longus cap., N.occipitalis innervating the ear N.hypoglosus (tongue) Ganglion cervical des sympaticus N.cervicalis II (sensile asts to M.sternocephal. N.auriculus mag. and caudalis N. facialis N.cervicalis III

Structural symptoms

Manifestations during riding , driving
Neck cannot be turned to the left or right side; cannot hold the head and even tail straight, body balance problems, contra-lateral blocked breast and/or lumbar muscles; asymmetric gate of the hind legs The horse will not take a bit, head shaking and abnormal head carriage during mastication Cannot hold on line during gallop, changing of gallop, trotter can not go straight, The horse is stiff in the mouth, tends to hold the head and neck to one side, cannot be

Changes of organs, behaviour, other disturbances
Behavioural changes Painful neck and head Thyroidal dysfunction (Ram. N.cervical.) Dental problems, retained caps, abnormal occlusion, etc.

C1

C1 block – dislocation TMJ problems CS-lesions L1 block

C2

Hyoid bone block TMJ problems Neck muscles blocked C2 block very often combined with L4 block C3 block is often combined with the L3 block Rigid and painful neck muscles – on one side more, by palpation of lower m.sterno-

Dental problems, occlusion anomalies, retained deciduous caps, very slow or quick mastication Muscle soreness (sternocleido-mastoideus, sternocleido-trnsversarius on the blocked side; Horse is not willing to follow the leads, painful reaction of lower neck muscles (as in C3)

C3 C4

N.cervicalis IV (Mm longus capitis, longus colli, scaleni)

21

cleidomast. Turns the neck to side Table 6: Vertebral problems (blockades) and their

turned to the opposite side

LOCAL SYMPTOMS OF TMJ DYSUNCTION
A painful reaction of the affected TMJ in the intra-articular space and dorsally to the joint can be palpated (Si-19). The palpable joint space between the mandibular condyle and the arcus zygomaticus may be different in the affected joint due to the contracted masseter muscles and displacement of the mandibular condyle (TMJ-block). In some horses a painful reaction of the TMJ can be manifested by panic head-shaking and distressed behaviour. The space between the mandibular bone and the wing of the C1-atlas is significantly reduced or even closed (Figures 22a, b). The swelling of the C1 muscles is almost always present in the case of dislocation of the atlas, accompanied by biting problems and abnormal head carriage and quidding (dropping of food) or masticatory problems.

Figure 22a: Normal distance between vertical part of mandible and lateral wing of atlas

Figure 22b: Reduced distance between vertical part of mandible and lateral wing of atlas on horse with TMJ disorder

CONCLUSION
The TMJ is one of the most relevant parts in the examination of dental problems in horses. In humans it is known that TMJ dysfunctions may often cause the asymmetrical position of the hips and consequent muscle contractions and differences in the length of the legs (Stracham and Robins, 1965). In horses the TMJ function and disorders have only been recently described by two authors of cranio-sacral therapy and osteopathy as the most important joint of the horse skeleton (Bäcker and Solomon, 2004; Evrard, 2003; Evrard, 2004). Successful correction of different restrictions of the TMJ mechanism (occurring after the compensation phase) by proper correction of the occlusal surface has demonstrated the important role of the TMJ in the normalisation of masticatory function and locomotion. In the past, balancing of the horse during a performance has mainly been done by utilising different harness accessories and orthopaedic shoe correction. The limited knowledge of TMJ function, its role in the maintenance of body balance and a lack of proper dental work have been the principle causes for the poor success of balancing horses in all areas of activity. The consequences of the short- or long-term balance problems caused by TMD may be weight-bearing form of lameness after the compensation phase of maintenance of body equilibrium. The clinical symptoms of lameness should be considered as a consequence of insufficient compensation of the locomotion system and not as primary lesions of the affected limbs. Due to the high incidence of locomotion disorders in sport and race horses during the period of intense teeth growth and formation of normal occlusal surfaces, it is necessary to regularly examine the function of TMJ and occlusion of dental arcades. The practical work has shown that a very high 22

percentage of the orthopaedic problems including gait alterations, stride asymmetry and different symptoms of leg lameness are directly related to the TMJ and teeth problems.

SUMMARY
Three aspects of the role of teeth are presented in the holistic approach to TMJ dysfunction in horses: the aspect of mechanical digestion, important for the growth and maintenance of all biological functions; the aspect of the role of teeth in the normal function of TMJ, i.e. the ability to move the jaw properly affecting the body's balance and equilibrium; and the aspect of dental problems affecting the alteration of behaviour and the psychological state. The role of teeth in mechanical digestion after dental correction has shown a significant effect on digestibility of organic matter and some macro- and micro-minerals. Normal function of the TMJ as the central regulator of teeth function during mastication is of vital importance for the horse’s health and biomechanical functions of the whole body. Dental problems and diseases can cause through improper function and position of the upper and lower jaw a dysfunction of the cranio-sacral system. The cranio-sacral system is a functional unit including the cranium and sacrum with all meningeal layers, bone structures, ligaments, cerebrospinal fluid and other additional systems such as nerves, vessels, lymph vessels, endocrine glands, the respiratory system and the muscle-skeletal system. It is housed within the bones of the skull and face down through the spinal column and into the sacrum area, representing a semi-closed hydraulic system with a palpable rhythm separate from either heartbeat or respiration rate. Moreover, it is intimately related to the central nervous system, therefore a restriction within this system can give rise to many sensory, motor or neurological symptoms. The importance of the normal structure and function of the temporo-mandibular joint (TMJ) is described in the light of present and past knowledge. The TMJ is an incongruous joint formed by the temporal bone and the mandible, containing a fibro-cartilaginous meniscus, which is interposed between the two articular surfaces in the form of a fixed double cartilaginous layer of the arcus zygomaticus. When these bones are misaligned and not articulating properly due to primary or secondary occlusal lesions, the TMJ mechanism cannot function optimally. This condition is known as Temporo-mandibular Dysfunction (TMD) and is used in dentistry as a diagnosis for people with tightness and dysfunction of the TMJ mechanism. Any imbalance of tissue structures resulting from incorrect body static can give rise to body fascia tightness and contribute to TM dysfunction. Inversely, any dysfunction of the masticatory apparatus due to dental diseases, anomalies, teeth extractions and TMJ problems may affect locomotion problems through the body fascia and muscle tightness. The proper function of the TMJ mechanism therefore plays an important role in the whole function of the horse including leads, gaits, balance and equilibrium. Due to dental abnormalities and abnormal wear of the occlusal surface an excessive consummation of the cartilaginous meniscus on the affected TMJ side may be found in young growing foals or older horses. There is a close relationship between the condylar position and the height of the molar occlusion structure that may explain the grade of consumption of the occlusal surface of molar teeth. The excessive wear of the normal occlusal surface of molar teeth and incisors is always found in “step mouth” and “wave mouth” in older horses with primary or secondary TMJ dysfunction. TMJ can be considered as the energy centre located in the network of energy vessels (Gb, Bl, 3-E, St, Si), that may be subjected to energy blockades or imbalances in the case of TMD. Locomotion problems such as stride asymmetry, abnormal head carriage and laterality problems can be explained and diagnosed by diagnostic acupuncture points. The cranio-sacral and mandibular system are connected together and built up from two systems: a dynamic, functional and adaptive system, represented by TMJ, connected with the first cervical vertebra atlas by myofascial tissues and the hyoidal bone, and a gravitation system represented by the osteo-articular Axis-Atlas-Occiput-Sphenoid-Complex. TMJ is a functional unit, interconnected with the rest of the body through the stomatognathic system including the head, neck and upper thorax with the muscular, osseus, ligamentous, fascial and nervous system. It is responsible for the control of biting, chewing and swallowing. In horses with TMD two kinds of lesions can be recognised. The primary occlusive lesion may be manifested as descending pathological changes with local muscle soreness and local blockades of C1-C3 vertebrae due to the energy imbalance of four main meridians (Gb, Si, Bl, and St). The secondary occlusive lesion may be manifested as an ascending lesion of the occiput-atlas axis resulting from peripheral trauma or visceral lesions.

23

The mandibular bone is a paired cranium bone making lateral excursions in the form of outer and inner rotation together with the extension and flexion of the sphenobasilar joint. The outer rotation is influenced by temporal bones, whereas sphenobasilar symphisis (SBS) is in flexion and the TMJ moves in a medial, caudal and ventral direction. The inner rotation is influenced by temporal bones, whereas sphenobasilar symphisis (SBS) is in extension – the TMJ moves in a lateral, rostral and dorsal direction. Restricted mandibular rotation may be due to one- or both-sided occlusal change because of abnormal wear of the molar occlusal surface. The systematic study of the movement of the upper and lower jaw during the chewing cycle performed by German researchers during the previous century and recently a 3-dimensional kinematic analysis of the equine TMJ during the chewing cycle of normal light- and heavy-breed horses have shown the influence of normal and abnormal jaw movement on the efficiency of grinding and wearing the occlusal surface. Temporo-mandibular dysfunction is a term used in the field of dentistry meaning a group of conditions, often painful, that affect the TMJ and the muscles that control chewing. TMD can affect not only local changes, but overall health. The condition known as TMD occurs in all horses regardless of discipline and breed. The TMJ dysfunction and consequent changes of other structures may be caused by dental problems, genetic factors, traumatic factors, mechanical factors and emotional stress. The teeth are a part of the mandibular cranio-sacral system. They represent according to controlled acupuncture the electronic valves in energy vessel circuits and may have a significant effect on the function of TMJ and other body regions. Dental disease with disorders of development and eruption, disorders of wear, traumatic damage, idiopathic fractures, periodontal disease, tooth root infections, periapical disease or apical infections, retained deciduous incisors with subsequent crowding and rostral displacement of the retained incisor, incisor displacement by overcrowding of the permanent incisors in the absence of retained or supernumerary teeth, dental or bone tumours, supernumerary permanent incisors and other dental abnormalities may contribute to abnormal movement of the upper and lower jaw and thus affect the TMJ. Genetic factors such as an abnormal proportion between the upper and lower jaw, too big or too small teeth, supernumerary incisor and molar teeth, brachignatia and prognatia may give rise to abnormal wear and prominent overgrowth of molar teeth with signs of TMJ dysfunction. Traumatic factors like different traumatic lesions of the upper or lower jaw and mandibular fractures can cause severe abnormal function of the TMJ mechanism, manifested in abnormal wear of molar and incisor teeth. The mechanical factors contributing to TMJ dysfunction can be static changes of the skeleton due an abnormal conformation of legs and hooves and acquired abnormalities (hoof imbalances) such as shoeing errors that can affect the hip and sacroiliac joints as well the TMJ through the spinal cord. The horse is known as an animal with very strong emotions. Therefore constant emotional stress caused by painful situations or mishandling can provoke the myofascial contractions causing compression on the TMJ and contraction of the hyoid bone and its abnormal position. The trauma within the mouth can often create painful physical conditions locally and possibly in any other part of the body. The physical pain that extends beyond the time of the actual dental problem may be compensated for to a certain extent, as emotional discomfort becomes predominant and the horse changes his behaviour. The proper dental treatment of horses has shown that younger horses improve their behaviour, their function of TMJ and their locomotion problems within a relatively short time. The incidence of temporo-mandibular joint (TMJ) dysfunction after the uneven wear of the last molar teeth can be manifested in a series of biomechanical problems such as stride asymmetry or as different lameness symptoms. In one-sided TMJ imbalance (dislocation, compression) a side inclination of the atlas C1 and consequent tension of atlanto-occipital joint muscles and ligaments occurs. The upper and lower neck muscles are painful on the affected side and cannot be extended or stretched to the opposite side during work or manual manipulation. In order to maintain the body balance the contra-lateral hind leg is overloaded during the adaptation phase and cannot be extended completely due to the blocked energy vessel (Bl30 positive) and reduced gluteal muscle elasticity. After a longer-lasting compensation of TMJ dysfunction and consequent laterality problem different joint pathologies may develop. Initially, pathological changes of the contra-lateral leg appear after a short compensation period first in the form of hyperextension of knee ligaments and later in the form of degenerative joint disease of lower limb joints. Both side TMJ imbalances may be manifested in a variety of symptoms of locomotion disorders and even an abnormal shoulder position. Any peripheral leg trauma can cause the overloading of the opposite leg, subsequent contraction of pelvic muscles and ligaments, of the vertebral column, shoulder, neck and compression of the TMJ with symptoms of dysfunction. 24

Local symptoms of painful reaction of the affected TMJ can be palpated in the intra-articular space and dorsally to the joint. In some horses local pain reactions can be manifested by hyper sensible head-shaking and distressed behaviour.

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