GNATOLOGI

- anatomi, fisiologi, histologi, patologi of stomagtognatic system

- Occlusion and movement of mandible
- TMJ
- TMD and orofacial pain
- Sleep disorders

Anatomi TMJ
Temporalis (anterior, middel dan posterior)
Pterygoid (lateral superior, lateral inferior dan medial)

OKLUSI

- there is no escape, dentists cannot repair, move or remove teeth without being
involved in occlusion
 - Dynamic biological relationships of component of the masticatory system that control
tooth contacts during function and dysfunction

-
- Occlusion - contacts between teeth yang bersifat dinamis
- Centric occlusion
- The occlusion the patient makes when they fit their teeth together in
maximum interccuspation
- Common synonyms for this are intercuspation position (ICP)
- Centric relation (CR) - not in occlusion
- Has nothing to do with the teeth because it is the only centric that is
reproducible with or without teeth present
- CR is a jaw relationship

MUSCOSKELETALLY STABLE POSITION

- condyles are in their most superoanterior position in the articular fossae, resting
against the posterior slopes of the articular with the disc properly interposed
- This is the position the condyles assume when the elevator muscles are activated
with no occlusal contact

OKLUSI DINAMIS: BILATERALLY BALANCED OCCLUSION (sering untuk pembuatan GTL)

- Pd pembuatan GTL, konsep ini digunakan agar mendapatkan stabilitas GT yg
adekuat dan optimal
- Pada perawatan GTC ternyata sangat sulit diaplikasikan dan didapat tingkat
kegagalan yg sangat tinggi
- Occlusal wear meningkat, kerusakan periodontal meningkat atau lbh progresif dan
munculnya nyeri neuromuscular
 - Muncul konsep unilaterally balanced occlusion
UNILATERAL BALANCED OCCLUSION
- aka group function
- All teeth on the working side to be in contact during lateral excursion
- Teeth on the nonworking side are contoured to be free of contact
- Teeth on the working side distributes the occlusal load favorably
- Absence of contact on the nonworking side prevents teeth from being subjected to
destructive, obliquely directed forces
MUTUALLY PROTECTED OCCLUSION
- aka canine protected occlusion
- The anterior teeth bear all the load and the posterior teeth are disoccluded in any
excursive position of the mandible
- In the intercuspal position, the posterior teeth contact and relieve the anterior teeth

KRITERIA OKLUSI FUNGSIONAL YANG OPTIMAL

- kontak gigi secara merata dan serentak
- Tidak ada hambatan saat gerak ke lateral
- Saat gerak protrusif terdapat kontak yang adekuat di gigi anterior dan semua gigi
posterior tidak berkontak
- Saat upright hear position and alert feeding position, gigi posterior berkontak lebih
berat dibandingkan gigi anterior
- Tidak ada sliding saat berkontak maksimum

CURVE OF SPEE AND CURVE OF WILSON

- Peran curve of spee sangat penting

- Curve of spee terlalu concave - anterior deep bite, perawatan ortho cenderung
relapse dan dapat menyebabkan TMD
Gerakan dari arah sagital
- tidak bisa melihat pergerakan lateral

Gerakan dari arah frontal

Gerakan dari arah horizontal

REQUIREMENTS FOR SUCESSFUL OCCLUSAL THERAPY
- comfortable and stable TMJ
- Anterior teeth in harmony with the envelope functions
- Non interfering posterior teeth

NORMAL JOINT MOTION

- Pergerakan sendi rotasi lalu translasi
- Tidak ada hambatan
- Diskus mengikutin gerakan kondil

TMD
- gangguan yang melibatkan otot-otot pengunyahan, TMJ dan struktur2 yang
berhubungan
- TMD comprises a variety of conditions affectgin the anatomy and functional
characteristics of TMJ
- Tanda dan gejala klinis
- Sign: penemuan klinis secara objektif saat dilakukannya pemeriksaan
- Symptoms: deskripsi atau keluhan yg dilaporkan oleh pasien. Pasien sangat
aware terhadap symptom namun tidak menyadari clinical signs
- Common signs and symptoms
 - Tenderness or pain around the jaw joints, face, ears and scalp
- Pain when tring to chew, speak, yawn, or during open-close mouth movement
- Loss of range of motiong in the jaw of the inability to open wide
- Jaws that lock or stick in an open or closed position
- Headahces
- Earaches
- Neck pain
- Toothaches
- Tinnitus (tringing int he ear)
- Dizziness or vertigo
- Swelling around the jaw joint on either side of the face
- Popping, grating, clicking, or grinding sounds from the TMJ (not necessarily
painful
- Mengenai >10% populasi, 80% yg mencari penangannan adalah wanitea
- Etiologi; multifaktorial and complex
- Faktor yg mempengaruhi
- Predisposing factors - factor that increase the risk of TMD
- Systemic factors
- Psychological factor
- Structural factors
- Genetic factors
- Initiating factors - factor that cause the onset of disorder
- Trauma
- Macro - direct/indirect
- Micro - parafunctional activity (nocturnal/malam dan
diurnal/sepanjang hari)
- Perpetuating factors - factors that interfere with the healing and
complicate management
- Stress
- Emotional stress mechanism - stress activate the
hypothalamus —> prepares the body to respond —>
increase activity —> cause the inttrafusal fibers of the
muscle spindles to contract —> increase tonicity of
muscles
- Metabolic problem
- Presence of estrogen receptors in womens TMJ
changes metabolic function increasing ligament laxity
- Estrogen increases susceptibility to painful stimuli by
modulating the limbic system
- Painful symptoms increase by 30% among patients on
menopause treatment with estrogen replacement
therapy and by 20% in women using oral
contraceptives
- Contributing.factors - factors that initiate, perpetuate or result in
disorder
- Influences factor
- Biological factors
- [psychological
 - Behavioral
- Trauma
- Genetic
- Sensory processing
- Patient adaptability
- Each patient has a biologic system that can tolerate a certain degree
of variation from ideal (contoh: the human muscoloskeletal system is
adaptable and therefore can tolerate considerable variation without
showing signs of pathology or dysfunction
- Dengan adanya kemampuan adaptasi pasien maka
- Pasien yg memiliki salah satu faktor dari etiologi TMD —>
tetapi tidak memiliki gejala TMD
- Tingkat keparahan TMD bisa berbeda2 pd tiap orang
-
Etiologic considerations of TMD

Screening history and examination

- tujuan: identifikasi pasien dgn tanda dan gejala klinis dimana pasien tersebut
memiliki keterkaitan dengan gangguan fungsional sistem mastikasi
- Screening history ttd
- Beberapa pertanyaan pendek yang membantu klinisi mendeteksi adanya
TMD
- Do you hv difficulty and/or pain opening your mouth, for instance when
yawning?
- Does your jaw get “stuck”, “locked”, or “go out”?
- Do you have difficulty and/or pain when you are chewing, talking or
using your jaws?
- Are you aware of noises in the jaw joints?
- Do your jaws regularly feel stiff, tight, or tired?
- Do you have pain in or about the ears, temples or cheeks?
- Do you have frequent headache, neckaches or tootheaches?
- Have you had a recent injury to your head, neck or jaw?
- Have you been aware of any recent changes in your bite?
- Have you previously been treated for any unexplained facial pain or a
jaw joint problem?
 -
Tanda dan gejala klinis
- pemeriksaan scr klinis dibagi menjadi 3 kategori menurut struktur
- Otot
- TMJ
- Gigi geligi
- Mengevaluasi pasien sangat penting

MASTICATORY MUSCLES DISORDER

- paling sering dialami
- Rasa nyeri saat aktivitas fungsional seperti mengunyah atau bicara
- Rasa nyeri berasal dari EXTRACAPSULAR (dari otot) (kl dari sendi
INTRACAPSULAR)
- Keterbatasan pergerakan rahang
- Kadang disertai acute malocclusion —> patient will report that their bite has changed
- Dapat dibedakan lagi menjadi kelainan yg akut ataupun kronik
DERANGEMENTS OF THE CONDYLE DISC COMPLEX (disc displacement with reduction)
 - Breakdown of the normal rotational function of the disc on the condyle
- Elongation of the discal collateral ligaments and inferior retrodiscal lamina
- Predispose —> thinning of the posterior border of the disc
- Etiologi:
- Macrotrauma —> blow to the jaw
- Microtrauma —> chronic muscle hyperactivity and orthopedic instability
- gejala; adanya clicking
- Reprocical clicking — clicking saat buka dan tutup mulut

DISC DISPLACEMENT WITHOUT REDUCTION

- Kepala kondil tidak bisa balik ke kepala kondilus. Diskus tetap berada di anterior dari
kondil
- Pembukaan mulut pasien jadi terbatas
- Tidak ada bunyi clicking.
- Biasanya lanjutan dari disc displacement wirh reduction

PENANGANAN AWAL
- definitive treatment - mengontrol dan mengeliminasi faktor2 etiologi
- Menghilangkan kebiasaan buruk
- Faktor oklusal
- Reversible
 - Irreversible
- Stress emotional
- Edukasi dan cognitive awareness training
- Relaxation therapy
- Supportive therapy - menghilangkan symptoms dan gejala yg ada (anageltik /
kompres)
- Farmakologis
- Analgesic
- Analgesic kombinasi
- Antiinflammatory drugs
- Muscle relaxant
- Anxiolytic agents
- Antidepressants
- Anticonvulsant medications
- Injectable medications: anastesi lokal, botox
- Topical medication
- Physical therapy
- Thermotherapy
- Physical therapy
- Passive muscle stretching
- Assisted muscle stretching
- Resistance exercise

OROFACIAL PAIN
- definisi menurut IASP (international association for the study of pain)
- An unpleasant sensory and emotional experience associated with actual or
potential tissue damage or described in terms of such damage

Classification of OFP (menurut IASP-SIG international association for the study of pain -
special interest group)
 - dental pain
- Orofacial neuropathic pain
- Neurovascular headache and facial pain
- Muscle and TMJ pain
- Idiopathic pain
- OFP, TMDs, headache and comorbidities

Pain
- odontogenic toothache
- Caries, pulpitis, gingivitis, periodontitis, pericoronitis
- Nonodontogenic toothache
- Toothache of non dental origin
- Is a painful condition that occurs in the basence of a clinically evident cause
in the teeth or periodontal tissue
- Category - 8 groups
- Myofacial pain referred to tooth or teeth
- Neuropathic toothache (trigeminal neuralgia)
- Idiopathic toothache
- Neurovascular toothache
- Sinus pain referred to tooth or teeth
- Cardiac pain referred to tooth or teeth
- Psychogenic toothache or of psychological origin
- Toothache caused by various other disorders

SLEEP DISORDERS
Stages of sleep and bruxing events
- menurut berbagai sumber dpt terjadi dari semua lapisan proses tidur (non rem dan
rem sleep)
- (NREM) non rapid eye movement sleep followed by a period of (REM) rapid eye
movement sleep
The sleep cycle
- 4 stages of NREM sleep followed by a period of REM sleep
- Stages 1 and 2 represent the early phases of light sleep
- Stages 3 and 4 sleep represents the deeper stages of sleep —> during REM sleep
that dreaming most commonly occurs
- The cycle repeats itself throughout the night. Each complete cycle sleep takes from
60-90 minutes resulting in an average of between 4-6 cycles per night
Bruxing events and masticatory symptoms
- penelitian ware and Rugh
- 2 tipe pasien bruxism dimana 1 group tdk memiliki gejala dan grup memiliki
gejala
- Ditemukan >> grup dgn gejala sakit melakukan lbh banyak bruxing selama
kondisi REM saat tidur
- Ada 2 tipe bruxing yaitu bruxing selama REM dan bruxing selama non-REM
- Penelitian Rompre
- Pasien bruxing dgn gejala sakit justru memiliki bruxing events lbh banyak
drpd yg tdk ada gejala sakit —> otot beradaptasi —> tdk menimbulkan gejala
sakit
The sleep cycle
- approx 80% of the sleep period of an adult is made up of nonREM sleep with only
20% REM sleep
- NonREM sleep in thought to be important in restoring function of the body system
—> physical rest —> skeletal tenderness, aching and stiffness
- REM sleep seem to be important in restoring function of the cortex and brainstem
activities —> psychological rest —> difficulty concentrating, greater anxiety and
irritability
Most common sleep disorder
- insomnia
- Difficulty getting to sleep or staying asleep
- Sleep apnea
- Potentially serious sleep disorder which breathing repeatedly stops and starts
- If you snore loudly and feel tired even after a full nights sleep, you might have
sleep apnea
- Ciri-ciri
- Mendengkur yg keras
- Episode dmn berhenti bernafas saat tidur (tidk disadari sendiri tp
orang lain)
- Terangah2 saat tidur
- Terbangun dgn mulut kering
- Insomnia
- Bangun pagi dengan sakit kepala
- Kantuk siang hari yg berlebihan (hipersomnia)
- Faktor yang meningkatkan
- Kelebihan berat bada (lingkar leher meningkat —> Sal udara yang
sempit)
- Jenis kelamin (laki2 2-3x lipat lbh mungkin)
- Usia bertambah (sering pd orang dewasa)
- Sejarah keluarga
- Penggunaan alkohol atau obat penenang (mengundurkan otot di
tenggorokan yg dpt memperburuk sleep apnea)
- Merokok (meningkatkan jumlah peradangan dan retensi cairan di sal
nafas bag atas
- Hidung tersumbat
- Perawatan - Mild (AHI 5-10) - moderate (AHI 10-30) OSA (apne hyponea
index / AHI<30)
- MAD mandibular advancement device
- Tongue retaining device
- Narcolepsy
- Rare long term brain condition that causes a person to suddenly fall asleep at
inappropriate times
- Excessive daytime sleepiness — feeling very drowsy throughout the day and
finding it difficult to concentrate and stay awake
- Sleep attacks - falling asleep suddenly and without warning
- Restless legs syndrome
- Aka Willis-Ekbom Disease
 - Causes unpleasant or uncomfortable sensations in the legs and an irresistible
urge to move them
- Symptoms: commonly occur in the late afternoon or evening hours, and are
often most severe at night when a person is resting, such as sitting or lying in
bed
- REM sleep behavior disorders
- You physically act out vivid, often unpleasant dreams with vocal sounds and
sudden, often violent arm and leg movements during REM sleep
- Sometimes called dream-enacting behavior