Okeson TX of TMD KDA 2016

Classification of Temporomandibular Disorders

Management of
Temporomandibular Disorders I. Masticatory Muscle Disorders
1. Protective Co-Contraction
by 2. Local Muscle Soreness
Jeffrey P Okeson, DMD 3. Myofascial Pain
Professor and Division Chief of Orofacial Pain 4. Myospasm
Department of Oral Health Science 5. Chronic Centrally Mediated Myalgia
Director, Orofacial Pain Center
University of Kentucky College of Dentistry
Lexington, Kentucky 40536-0297 II. Temporomandibular Joint Disorders
okeson@uky.edu 1. Derangements of the Condyle-Disc Complex
www.jeffokeson.com a. Disc Displacement with Reduction
b. Disc Displacement without Reduction
The Kentucky Dental Association 2. Structural Incompatibilities
March 3, 2016
Louisville, Kentucky 3. Inflammatory Disorders

A Mas&catory Muscle Model A Mas&catory Muscle Model

Acute Time Chronic Acute Time Chronic

Normal An CNS Effects Normal An CNS Effects

Function Event on Muscle Pain Function Event on Muscle Pain

Regional Myalgic Disorders 1 2 Regional Myalgic Disorders

Protective Local Protective
Protective Local
Resolution Co- Muscle Myofascial Pain Resolution Co-
Co- Muscle Myofascial Pain Pain
4 Myofascial
contraction Soreness contraction
contraction Soreness
Centrally Mediated Myalgia 5 Centrally
Centrally Mediated
Mediated Myalgia
Myalgia

Systemic Myalgic 3 Systemic Myalgic

Disorder Disorder
Myospasm Fibromyalgia Myospasm Fibromyalgia
6 Fibromyalgia

Managing Muscle Disorders takes some thinking.

Okeson, 2009 Important: They are all managed differently. Okeson, 2009

A Mas&catory Muscle Model

Local Muscle Soreness
Acute Time Chronic

- e?ology -
Normal An
Function Event
1.  Protracted co-contrac?on produces changes in the
Local Muscle Soreness muscle ?ssue, such as fa?gue, ischemia, resul?ng in
1. Descrip?on the produc?on of algogenic substances.
Protective Local 2. E?ology 2.  Deep pain input (may lead to “cyclic muscle pain”)
Resolution Co- Muscle
contraction Soreness 3. History
3. Local ?ssue trauma
4. Examina?on findings
5. Treatment a. local injury (e.g. injec?ons, strain)
b. unaccustomed muscle use (e.g. bruxism, chewing
gum) (Delayed onset local muscle soreness)
4. Increased levels of emo?onal stress

Because of our limited ?me, we can only discuss the most common disorder.

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Okeson TX of TMD KDA 2016

Local Muscle Soreness Local Muscle Soreness

- history - - clinical characteris?cs -

1. The pain began several hours or days following an event 1. Structural dysfunc3on: a decrease in the velocity
associated with protec?ve co-contrac?on. (e.g. and range of mandibular movement. The full range
altered sensory input, high crown) of movement cannot be achieved by the pa?ent.
2. Tissue injury (injec?ons, opening wide, or Passive stretching by the examiner can oTen
unaccustomed muscle use - pain may be delayed). achieve a more normal range of movement (soT
3. Secondary to another source of the pain. end feel).
4. Associated with an increased level of the emo?onal 2. Minimal pain at rest.
stress. 3. Increased pain with func?on.
4. Local tenderness to palpa?on.

Local Muscle Soreness Local Muscle Soreness

- treatment -
The general goal of therapy is to reduce sensory input that can lead to - treatment -
cyclic muscle pain by:
1. Eliminate any ongoing altered sensory or propriocep?ve input. Expect results in 1-3 weeks.
2. Educa?on pa?ent and encourage physical self regula?on. If the therapy is not successful, consider that either:
a. decrease jaw use to within painless limits.
b. s?mulate proprioceptors with normal muscle use. 1. The e?ologic factors are not being controlled
c. promote emo?onal stress awareness / reduc?on. or
d. encourage reduc?on of non-func?onal tooth contacts
(cogni?ve awareness). 2. You have misdiagnosed the disorder.
3. Occlusal appliance therapy.
4. Considered the use of mild analgesics. (ibuprofen 600mg ?d)

Final Criteria for the Stabilization Appliance The Final Stabilization Appliance

1. The appliance is stable and retentive.

2. All the teeth contact evenly on flat surfaces.
3. Eccentric contacts are on the anterior teeth
4. In the upright position, posterior teeth contact
heavier than the anterior teeth.
5. The appliances smooth and polished.

Right lateral movement Left lateral movement

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Okeson TX of TMD KDA 2016

Managing the patient with Local Muscle Soreness

Week VAS Treatment
0 6/10 education, physical self regulation
reduce use to painless limits
reduce non functional tooth contacts
introduce the stabilization appliance, night time use
1 3/10 reinforce physical self regulation
reevaluate the stabilization appliance, adjust PRN
2 1/10 reinforce physical self regulation
reevaluate the stabilization appliance, adjust PRN
3 0/10 reinforce physical self regulation
reevaluate the stabilization appliance, adjust PRN
Reasons that could explain why your
occlusal appliance reduced the muscle pain.
So why did the patient respond?
1.  A change in the occlusal condition
2.  A change in the condylar position
3.  A change in the vertical dimension
4.  A change in cognitive awareness
5.  Altered sensory input to the CNS (bruxism)
6.  Natural musculoskeletal recovery
7.  Placebo effect
8.  Regression to the mean

4 0/10 What do you do next?

Reasons that could explain why your

Management of Temporomandibular Disorders
occlusal appliance reduced the muscle pain.
I. Masticatory Muscle Disorders
So why did the patient respond? 1. Protective Co-Contraction
2. Local Muscle Soreness
1.  A change in the occlusal condition 3. Myofascial Pain
Dental
Etiologies
2.  A change in the condylar position 4. Myospasm
3.  A change in the vertical dimension 5. Chronic Centrally Mediated Myalgia
4.  A change in cognitive awareness
II. Temporomandibular Joint Disorders
5.  Altered sensory input to the CNS (bruxism) 1. Derangements of the Condyle-Disc Complex
Non-
Dental 6.  Natural musculoskeletal recovery a. Disc Displacement with Reduction
Etiologies 7.  Placebo effect b. Disc Dislocation with Reduction
8.  Regression to the mean c. Disc Displacement without Reduction
2. Structural Incompatibilities
3. Inflammatory Disorders

Anatomy and Biomechanics

of the
Temporomandibular Joint
- Function and Dysfunction -

- Tanaka

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Okeson TX of TMD KDA 2016

the superior lateral

articular disc pterygoid

Slightly opened mouth position Full opened mouth position

the directional forces the inferior lateral

Tanaka
of loading pterygoid

thinning of the
continued thinning of the
posterior border of the disc
posterior border of the disc
elongation of the
lateral collateral ligament continued elongation of the
lateral collateral ligament

elongation of the continued elongation of the

inferior retrodiscal lamina inferior retrodiscal lamina

Normal disc position Disc displacement Disc displacement Disc dislocation

Clinical signs of acute dislocation without reduction

1. A positive history
2. Limited mouth opening (25-30 mm) (ipsilateral deflection)
3. Normal lateral movement to the ipsilateral side
4. Restricted lateral movement to the contralateral side
5. A sudden elimination of the click

Before After
(with reduction) (without reduction)
osteoarthritis

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Okeson TX of TMD KDA 2016

Two very important questions Etiology of Disc Derangement Disorders

that influence treatment considerations.

1. Macrotrauma
1. What is the etiology of disc a. Gross trauma
derangement disorders? b. Iatrogenic trauma

2. Are disc derangement disorders always 2. Microtrauma

progressive?
a. Chronic Muscle hyperactivity
b. Orthopedic Instability

Two very important questions - Adaptation -

that influence treatment considerations.
destruction of cells = repair of cells

1. What is the etiology of disc

destruction repair
derangement disorders? of cells of cells

2. Are disc derangement disorders always

progressive?

a callus
a blister

Long-term Outcome of Disc Displacement with reduction

- conclusions from results of long-term studies -

Our goal should be to help the patient adapt

the retrodiscal tissues by reducing loading forces. How should anterior positioning appliances
be used in patients with anterior disc
1.  Educating the patient to the problem
displacement with reduction?
2.  Reduce heavy chewing
3.  Reduce non-functional tooth contacts
4.  Appliance therapy
Anterior positioning appliances may be
helpful but only on a part time basis.

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Okeson TX of TMD KDA 2016

Management of disc displacement with reduction Management of disc displacement with reduction

Time, Reduce use of the

No pain re-evaluate appliance and assess
Stabilization Appliance for orthopedic stability
(always at night and No dental
when needed during the day) Orthopedic therapy
stability indicated
Continued
pain Assess for
Patient Clinical orthopedic stability
evaluation
No further treatment indicated Evaluate for
Orthopedic appropriate
(consider bruxism) instability dental therapy
Anterior Positioning Appliance No pain
(always at night and No pain
when needed during day)
Return to Pain reduction, Convert the APA
Return the APA allow more time to a SA
Reduces pain Time, Decrease use
re-evaluate of the appliance of pain

No change Pain returns

in pain

Management of disc displacement with reduction

Reduce use of the
No pain Time,
appliance and assess Long-term Outcome of Disc Displacement with reduction
re-evaluate for orthopedic stability
Stabilization Appliance
(always at night and
when needed during the day)
- conclusions from results of long-term studies -
Continued
Clinical
pain Our goal should be to help the patient adapt
Patient
evaluation the retrodiscal tissues by reducing loading forces.
1.  Educating the patient to the problem
Anterior Positioning Appliance No pain, 2.  Reduce heavy chewing
(always at night and no further treatment indicated
when needed during day) (consider bruxism) 3.  Reduce non-functional tooth contacts
4.  Appliance therapy
Reduces pain Time, Decrease use Return
re-evaluate of the appliance of pain Anterior positioning appliances may be
Reduction of pain
helpful but only on a part time basis.
No change Begin
in pain 24 hour use Re-evaluate pain, Permanent occlusal changes are seldom indicated.
No reduction of pain consider surgical
evaluation

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