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CRANIOMANDIBULAR DISORDERS – ANATOMY, PHYSIOLOGY, PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW
CRANIOMANDIBULAR DISORDERS ANATOMY, PHYSIOLOGY, PATHOLOGY AND TREATMENT MODALITIES – LITERATURE REVIEW * DESORDENS CRÂNIOMANDIBULARES ASPECTOS ANATÔMICOS, FISIOLÓGICOS, PATOLÓGICOS E FORMAS DE TRATAMENTO REVISTA DA LITERATURA
Gissa Alexandra Nuñez BALDERRAMA ** Gustavo Lopes TOLEDO *** Clovis MARZOLA **** Daniel Luiz Gaertner ZORZETTO **** João Lopes TOLEDO-FILHO **** Marcos Maurício CAPELARI **** Cláudio Maldonado PASTORI ****
* Based on a monograph submitted to the Posgraduate Program in Oral and Maxillo Facial Surgery and Traummatolog, São Paulo Association of Dental Surgeons (APCD) - Bauru-São Paulo state, in partial fulfillment of the requirements for a Specialist degree, 2010. ** Specialist in Oral and Maxillo Facial Surgery and TraumMatology. Author of the monograph. *** Professor of the Residency and Specialization in Buco Maxillo Facial Surgery and Traummatology of the Brazilian Oral and Maxillo Facial Surgery and Traummatology School, Base Hospital of São Paulo, Association of Dental Surgeons (APCD)-Bauru-São Paulo State. Supervisor of the monograph. ****Professors of the Residency and Specialization in Bucco Maxillo Facial Surgery and Traummatology of the Brazilian Oral and Maxillo Facial Surgery and Traummatology School, Base Hospital of São Paulo, Association of Dental Surgeons (APCD)-Bauru-São Paulo State
CRANIOMANDIBULAR DISORDERS – ANATOMY, PHYSIOLOGY, PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW
There are countless problems related to the temporomandibular joint known as temporomandibular joint disorders (TMD). Successful treatment of patients with TMD depends mainly on a correct diagnosis which will lead us to the best treatment plan among the many options found in the literature as physical therapy, medication, interoclusal devices and arthroscopy, eminectomy and articular devices, divided into conservative and surgical type of treatment, respectively. Thus, this work aims to describe through literature review some aspects involving the temporomandibular joint disorders most commonly diagnosed, the choice of treatment more appropriate to the type of disorder and mainly to create the ability to discern when conservative or surgical treatment are indicated.
Inúmeros são os problemas relacionados com a Articulação Temporomandibular, as conhecidas Desordens Craniomandibulares (DCM). O sucesso do tratamento dos pacientes portadores de DCM depende, principalmente, da realização de um correto diagnóstico, que quando bem feito, nos conduz a escolha do melhor plano de tratamento dentre as inúmeras opções encontradas na literatura tais como: fisioterapia, tratamento medicamentoso, dispositivos Interoclusais e Artroscopia, Eminectomia e dispositivos articulares, divididos em conservador e cirúrgico, respectivamente. Sendo assim, este trabalho tem como objetivo uma revista da literatura para o conhecimento da anatomia, fisiologia, patologias, DCM mais comumente diagnosticadas, a escolha do melhor tratamento condizente com o tipo de desordem em particular. Sobretudo, obter a capacidade de discernir quando é necessário um tratamento conservador e um tratamento cirúrgico. Uniterms: Temporomandibular joint; Craniomandibular disorder; Mini-anchors. Unitermos: Articulação temporomandibular; Desordens Craniomandibulares; Miniâncora.
The temporomandibular joint (TMJ), part of the stomatognathic system, along with maxilla and mandible, nerves and glands, is one of the most important joints in the human body. Given its complexity, is subject to interference and depends on the anatomical and functional stability of the entire stomatognathic system (MACIEL; TURELL, 2003). The TMJ is a bicondyloid synovial joint, formed by the squamous portion of temporal bone and mandibular condyle. These two elements are surrounded by a bony capsule of fibrous tissue brought by a disc consisting of connective tissue. This disc is fixed to the joint capsule and in the condylar process margin. The joint cavity is divided in superior and inferior compartments (HEFFEZ; MAFEE; ROSENBERG, 1995; OKESON, 2000 and MACIEL; TURELL, 2003). Functionally, it allows the mandible to open, close, protrude, retried, and to perform lateral movements as well as the combination of all. To make this
CRANIOMANDIBULAR DISORDERS – ANATOMY, PHYSIOLOGY, PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW
dynamic mechanism, the condylar process performs rotation and translation on its long axis through the action of muscles and ligaments attached to bone and fibrous structures that surround it (NORMAN; BRAMLEY, 1990; SARNAT; LASKIN, 1992 and DAWSON, 1993). Among the structures responsible for movements of TMJ the articular disc is emphasized. The articular disc has a convex shape in its upper portion and concave in its lower portion dividing the joint into two functionally distinct units. The supradiscal compartment performs the movements of translation since it is more mobile and loose allowing sliding movements, on the other hand, the infradiscal performs rotational movement. It joins the head of the condylar process through collateral ligaments, sometimes called discal ligaments. The lateral discal ligament connects the lateral end to the extreme lateral side of the articular disc. The discal medial ligament connects the medial end of the disc to the medial pole of the condylar process (MANNS; DÍAZ, 1983; DAWSON, 1993 and OKESON, 2003). On many occasions the temporomandibular joint harmony is broken creating temporomandibular disorders (TMD) or Craniomandibular Disorders as well (CMD). In this context, the TMD include a number of diseases whose etiology is mostly multifactorial. Furthermore, the complex anatomy and dynamics of TMJ makes the treatment considerably challenging (GRAY, 1973; SPALTEHOLZ, 1988; GRAY, 1995 and MORAIS; OLIVEIRA; OLIVEIRA, 2001). This study was performed using references on the therapy of Craniomandibular Disorders, through a literature review, in this manner this paper aims to discuss the most important points related to TMJ such as anatomy aspects, normal dynamics of ATM and physiological aspects, craniomandibular disorders and the treatment of craniomandibular disorders.
LITERATURE REVIEW Anatomic Considerations
The TMJ, according to the literature, appears as a set of anatomical structures that aided by a group of muscles develops various movements in mastication (GRAY, 1973; SPALTEHOLZ, 1988; FIGÚN; GARINO, 1989; OLIVEIRA, 1994 and GRAY, 1995). It is classified as a complex biaxial synovial articulation, with its anatomical components such as the articular surfaces, the articular disc, the capsules, ligaments, and synovial membranes (OLIVEIRA, 1994). The joint surfaces are formed by a surface of the condyle and an articular surface of the temporal bone (Figure 1) (FIGÚN; GARINO, 1989). The bony parts of the ATM are the condyle, articular eminence and glenoid fosse of the temporal bone. The articular processes can be defined as two oval-shaped protrusions located in the posterior superior angle of the mandibular ramus, whose major axis oriented obliquely dorso-medially, measuring approximately 20 to 22 mm. They are convex on its sagittal and frontal aspects, wide on its lateral aspect, and narrow medially. His side poles are rough and often sharp, joining the ramus by a narrow, slightly bent forward portion of the neck of the mandible, which holds a depression called the pterygoid fovea where the lateral pterygoid muscle is inserted. The TMJ is surrounded by a fibrous capsule rather weak, which allows large movements of the joint. It is attached above the articular portion of the temporal bone and below the mandibular neck. This disc is quite
unesp.br/anatomia/atm/ATM11. (3) Articular disc. posterior deep temporal and masseteric nerves (Figures 2 and 3) (SICHER. PHYSIOLOGY. Source Figure taken from site: www. (5) temporal muscle tendon. DU BRUL.jpg&imgrefurl=http://www.unesp.jpg&imgrefurl website: www. sensory. (1) Mandibular condyle. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW innervated.711 CRANIOMANDIBULAR DISORDERS – ANATOMY. (4) lateral pterygoid muscle. 1991). Figure 1 .fosjc. Source Figure taken from the trigemeo/mandibular01.fosjc. (6) Auditory Canal. proprioceptive that relates to the auriculotemporal.Skeletal components of the TMJ.fosjc.unesp.htm Figure 2 – TMJ inervation. (2) Articular Eminence of the Temporal bone.br/anatomia/atm/ATM1.br/anatomia/quiz- .
br/anatomia/atm/ATM6. sphenomandibular ligament.Guanabara Koogan. contribute to its irrigation (Figures 4 and 5).unesp. the posterior temporal artery.Articular capsule. J. Figure 4 – Maxillary artery and its branches: anterior tympanic. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW Figure 3 .fosjc. deep auricular and middle meningeal artery. Source . Source . the masseter and lateral pterygoid.jpg Its blood supply is accomplished through the superficial temporal artery branches and later branches of the maxillary artery posteriorly. . 1990. Previously. PHYSIOLOGY. 18ª ed.Figure taken from the website: http://www. Rio de Janeiro: Ed. Atlas de anatomia humana.Figure taken from the book: SOBOTTA.712 CRANIOMANDIBULAR DISORDERS – ANATOMY. temporomandibular ligament.
its anatomic deviation determines the trajectory of condylar movements (GRAY.Venous supply: Pterygoid plexus. 1973. dependent on the movement and in cases of restriction there may occur degeneration of this tissue.Guanabara Koogan. The mandibular fosse is situated below and in front of the external acoustic meatus and is limited medially by the squamo tympanic fissure and posteriorly by the temporal bone that forms the posterior border of the glenoid fossa. It is noted here that as active elements in the process of the dynamics of the joint. PHYSIOLOGY. The articular eminence of the temporal is the transverse root of the zygomatic arch. J. allowing concluding that it is not a part of functional pressure. The articular eminence would also be defined as the articular tubercle (GRAY. superficial temporal and maxillary. which in ventral-dorsal direction. SPALTEHOLZ. descends from the base of the zygomatic arch to the spine of the sphenoid. Source . It is a depression of varying depth. but only the anterior portion is articular. 1991. GARINO. DAWSON. The articular surface of the temporal bone is also covered by fibrous tissue with few cartilage cells. 1995). The coverage of the mandibular fossa. In the transverse direction. 1988. 1993 and GRAY. Rio de Janeiro: Ed. however some authors are unanimous in considering that the articular tubercle is a protrusion on the external end of the anterior root of the zygomatic process of the temporal bone and therefore not articulated. Prior to the articular fossa. 1989 and GRAY. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW Figure 5 . while the posterior part forms the anterior wall of external auditory canal.Figure taken from the book: SOBOTTA. separating it from the middle cranial fossa. FIGÚN. SICHER. however. DU BRUL. 1973 SPALTEHOLZ. serving for insertion of the capsular ligaments. the articular eminence and the mandible are convex in their sagittal and lateral plane. 1990. Their nutrition occurs by soaking of synovial fluids. 1988.713 CRANIOMANDIBULAR DISORDERS – ANATOMY. extends from the articular eminence until the anterior segment of the external acoustic meatus. is always thin and translucent. 1995). making sure that the functional pressure is between the condyle. 18ª ed. Atlas de anatomia humana. free of vessels and nerves that make it impossible to develop inflammation and scarring. the articular disc and .
(1) Articular disc (2) articular eminence. where there is an extension of soft cushioning with two separate layers of fibers. The disc is slightly compressible. The articular disc is a small fibrocartilaginous plate with a slightly oval and italic "S" aspect in the sagittal section. The peripheral portion is covered by synovial membrane. SPALTEHOLZ. and one that supports the higher pressures. 1995).714 CRANIOMANDIBULAR DISORDERS – ANATOMY. (7) Articular Capsule. large in its posterior perimeter and considerably narrower in its central portion. FIGÚN. SICHER. 1994). 1973. 1988. (10) lateral pterygoid muscle. (4) Condile. The disc divides the TMJ into two parts. PHYSIOLOGY. The anterior portion of the disc is connected to the anterior capsule with a projection of the disc itself.Figure taken from website: www. it is concave anteriorly. 1995). (8) Retrodiscal cushion. thick across its border.fosjc. consequently. The articular disc is attached to the joint capsule and to the lateral and medial poles of the condyle by strong fibrous loops. 1991 and GRAY. (5) Articular Cartilage.htm . (9) External acoustic meatus. in any type of lesion shows the character of irreversibility. Its saddle shape in its upper portion is to adjust to the cranial contour and its concavity in the bottom. (6) Infradiscal compartment. This portion of the disc consists of a dense fibrous tissue completely avascular and aneural and. Figure 6 . placing it among the structure of blood vessels and nerves.unsp. 1989 and GRAY. which does not happen posteriorly. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW between the disc and articular eminence (GRAY. to accommodate with the articular process of mandible (Figure 6) (OLIVEIRA. 1973 SPALTEHOLZ. The intermediate or central portion of the disk is thin at around 1 to 2 mm and is located between the articular surfaces that support pressure. (3) Supradiscal compartment. (11) temporal muscle tendon. in contact with the mandibular fossa of the temporal bone. DU BRUL. and directed downward and forward.br/anatomia/atm/ATM2. richly vascularized (GRAY. Source . 1988. relating to the eminence and convex posteriorly. the central portion of the disc is devoid of vessels. GARINO.
The superior attaches to the post-glenoid process and is secured by elastic fibers that have a retractable effect to the disc. 1995). and of undoubted importance in the pathogenesis of craniomandibular disorders (FIGÚN. SPALTEHOLZ. interposing between them as a "cushion" of relative elasticity. Its function is to supply the anatomical deficiency between the joint surfaces of the condyle and articular eminence of the temporal bone. where the insertion is approximately 5 mm below the fibrocartilage coverage. The posterior portion of the joint. JUNIPER 1997). 3. It is represented by two layers. Laterally. Subsequently. Their lower limits are narrower. DAWSON. 1989). 1973. reaching the neck of the mandible. PHYSIOLOGY. 1988. rich in collagen fibers which do not stretch. FIGÚN. the back of the neck is included in the joint (GRAY. 1993 and GRAY.715 CRANIOMANDIBULAR DISORDERS – ANATOMY. 1973. 1995). 4. GARINO. 2. FIGÚN. The articular capsule or ligament is a thin fibrous membrane that surrounds the joint and unites its parts. 1988. SPALTEHOLZ. the retrodiscal. Due to the characteristics of the joint capsule. standing in the contour of the articular surface except for the posterior part. its medial portion is the true posterior limit of the joint. 1973. This function of limiting movement or medial displacement of the condyle is made by a bony prominence belonging to the temporal bone. being limited to the condyle. GARINO. a fibrous loose and tough membrane that is external and a synovial membrane that forms the inner layer of the capsule. SPALTEHOLZ. which are convex. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW In an important study which intended to emphasize the action of the lateral pterygoid muscle during the dynamics of TMJ via 22 human cadavers concluded that: 1. 1973. 1995). Their upper limit in the temporal bone are on the anterior portion of the articular tubercle anteriorly. 1995). DU BRUL. SICHER. 1988. It consists of connective tissue. SICHER. The bottom blade curves downward to the side of the condyle merging into the capsule at the inferior articular joint space in the mandibular neck. Thus. The two posterior layer bands are called bilaminar zone (GRAY. SPALTEHOLZ. The upper and medial fibers of the superior lateral pterygoid muscle is inserted in the medial portion of the articular disc. Approximately 29. is richly innervated and vascularized. GARINO. The lateral ligament can be considered as the one truly functional in the TMJ (GRAY. a considerable range of motion and even dislocation of the condyle without its rupture is allowed. 1989 and GRAY. 1991 and GRAY. determining the existence of the supra and infradiscal articulations. laterally in the articular tubercle and zygomatic arch and medially at the base of the spine of the sphenoid. The proportion of muscle fibers embedded in the articular disc and articular process are not influenced by age (NAIDOO. the disc fuses with the deep fibers of the masseter muscle (GRAY. The deepest is inserted within the limit of the articular disc.5% of the fibers of the superior portion of the muscle were inserted into the articular disc. DU BRUL. in the medial . The portion of fibers that are inserted in the disc can be interpreted as a tendon insertion in the articular disc and. the disk interface with the capsule is made by a spongy pad called retrodiscal cushion that curves inferiorly and laterally from the head of the mandible. in the squamous tympanic suture posteriorly. 1989 and GRAY. 1988. 1991.
716 CRANIOMANDIBULAR DISORDERS – ANATOMY. Although it is believed that this ligament limits the retrusive movements of the mandible. covering the outer surface of the styloid process. 1993). spreading anteriorly as a broad fascial layer covering the inner surface of the medial pterygoid muscle (SICHER. SPALTEHOLZ. The combination of ligaments works as a valuable protection considering that the effects of trauma which should be directed to the articular structure against the tympanic plate or on the roof of the middle cranial fossa reaches initially the anterior portion of the mandible producing fractures in the symphysis and / or in the mandibular angle (DAWSON. This ligament is passive during jaw movement. 1995). because the angle of the mandible swings up and back. 1989 and GRAY. 1973. GARINO. 1993 and GRAY. The stylomandibular ligament is loose when the jaws are closed or when the mandible is at rest and relax remarkably when the mouth is open. keeping on the same stress intensity during the opening and closing of the mouth (GRAY. 1995). 1988. FIGÚN. while the condyle slides down and forward (Figure 7) (SICHER. The posterior ligament is represented by elastic fibers that connect the squamous tympanic fissure to the neck of the condyle and the posterior edge of the disc. SPALTEHOLZ. SPALTEHOLZ. The stylomandibular ligament is a dense concentration located in the cervical fascia. 1988. 1993). Rises from the angular spine of the sphenoid bone and petrotympanic fissure and then run backwards and externally to insert in the mandibular lingula. GARINO. 1991 and DAWSON. 1989 and GRAY. The medial ligament is described as small in volume and of dubious or questionable function. 1973. In addition to the described ligaments there are accessory ligaments (DAWSON. Described as a group of fibrous elements in an apparent anatomical and functional relation to the structures of the TMJ (GRAY. 1973. The temporomandibular ligament has its fibers oriented in such a way that during movements of the articulation these fibers are not distended or relaxed indicating that the TMJ ligaments do not restrict the funcitonal movement of the jaw and are not necessary for the functioning of the joint. DU BRUL. DU BRUL. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW wall of the articular cavity of the temporal glenoid fossa. protecting the tissues of the posterior region of the ATM (DAWSON. 1995). SPALTEHOLZ. PHYSIOLOGY. inserting in the posterior medial part of the neck of the mandible. SICHER. It is responsible for limiting the excursion of the mandibular condyle and disc in the protrusion of the mandible (GRAY. Although it is believed that this ligament limits the retrusive movements of the mandible. 1993). . 10 to 15 mm below the articular line (GRAY. DU BRUL. 1991 and DAWSON. 1993). protecting the tissues of the posterior region of the TMJ (SICHER. lifting off the base of the spine of the sphenoid bone and descending obliquely backward and outward. 1993). 1989 and GRAY. 1991. 1988. Sphenomandibular ligament is a remnant of Meckel's cartilage. extending from the styloid process to the mandibular angle. DAWSON. FIGÚN. DU BRUL. 1995). 1991 and DAWSON. FIGÚN. 1993). 1988. inserting to the bone connecting in the posterior surface of the mandibular angle. 1973. These ligaments would be the sphenomandibular the estilomandibular and the pterigomandibular. GARINO.
SPALTEHOLZ. GARINO. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW Figure 7 . FIGÚN. there is a communication between these two cavities. retrusion and lateral movements as well . 1973. The TMJ receives vascularization from the posterior temporal and masseteric deep arteries. 1989 and GRAY.htm The synovial membranes create internally the articular supradiscal and infradiscal spaces. anterior tympanic artery.auladeanatomia. 1988.717 CRANIOMANDIBULAR DISORDERS – ANATOMY. FIGÚN. superficial temporal and maxillary arteries correspond to the arteries that irrigate it (GRAY. 1995). 1973. FIGÚN. It is abundant in the vascularized and innervated portions of the upper and lower surfaces of the retrodiscal area. 1973.com/artrologia/atm. The posterior and lateral sides of the joint are irrigated by branches of the superficial temporal artery. (4) Styloid apophysis (5) Estilomandibular ligament. In case of perforation of the articular disc. The posterior portion of the TMJ is innervated by branches of the auriculotemporal nerve from the posterior division of the mandibular branch of trigeminal nerve (GRAY. The supradiscal is a cylinder limited superiorly by the insertion of the articular capsule in the temporal bone and inferiorly implants into the upper surface of the articular disc. The supradiscal space is bulkier than the infradiscal. 1989 and GRAY. and middle meningeal. GARINO. 1995). Source: Figure taken from website www. (3) Articular capsule. PHYSIOLOGY. Regarding the innervation was observed that the anterior portion of the TMJ is innervated by the anterior branch of the mandibular nerve (branch of the trigeminal nerve) and branches of the masseteric nerve. The veins that drain the joint arising into the pterygoid plexus. The infradiscal extends from the edge of the articular disc to the mandibular neck. 1988. TMJ DYNAMICS Functionally. the TMJ allows the mandible to be able to make opening and closing movements including protrusion. 1989 and GRAY.(1) Esfenomandibular ligament (2) Temporomandibular ligament. 1995). which is responsible for alleviating the friction of joint surfaces (GRAY. both joint compartments are irrigated by the synovial fluid. SPALTEHOLZ. GARINO. The middle and posterior surfaces of TMJ are irrigated by branches of the maxillary artery.
miologia. 1997). The inferior joint is composed of condyle and articular disc inserted by ligaments that form the disc-condyle complex where the rotation occurs. Some pathological changes observed in the TMJ result from functional overload to the ligaments since they do not have great capacity for dimensional changes. the lateral inferior pterygoid muscles in an anterior and superior position guiding the condiles horizontally on the posterior wall of articular eminence (SARNAT. which guide the condyles superiorly in the fossa. 1995). It is known that the mandible is the only mobile bone of the face being attached to the skull base through a double joint bilaterally. To make this dynamic. 1992 and MACIEL. swallowing. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW as the combination of all. the masseter and medial pterygoid. within acceptable limits for proper function and integrity of the joint capsule. Source . 1996). The major muscles involved in this condition are the temporal muscles. bone and fibrous structures. Its dorsal fibers contract at translation with occlusion and .br/atm2. speech and posture and it is protected by the articular disc and ligaments formed from collagen fibers (CABEZAS. masseter. The articulation assist in several vital processes such as chewing. medial pterygoid and lateral mandibular muscles are essencial in mandibular masticatory movement as others. Figure 8 – Muscles responsible for movement of the joint.Figure extracted from website: http://www. ligaments and muscles (MOLINA.718 CRANIOMANDIBULAR DISORDERS – ANATOMY. as mentioned (Figure 8) (DOUGLAS 1988).jpg The temporal muscle is well known to elevate the jaw when its anterior fibers contract in maximum aperture and subsequent retraction of the mandible by the posterior fibers and acts in the contralateral displacement and elevation of the mandible. LASKIN. Temporal. the condylar process performs rotation and translation due to the presence of muscle.com.hpg. The upper joint is formed by the disc-condyle complex that articulates with the mandibular fossa. PHYSIOLOGY. where the translation occurs (OKESON 1991). According to the literature the presence of ligaments causes restriction of certain functional movements as rotation and translation. The TMJ appears as the most complex articulation of the body capable of performing sophisticated movements.
It is also responsible for retruding the mandible as the digastrics (Figure 9) (SICHER. as does the geniohyoid (Figure 10) (SICHER. The medial pterygoid muscle. SARNAT. LASKIN. . This muscle is crucial in determining muscle tone in the postural position of mandible.com More than a suprahyoid muscle. If the contact between them is lost. DU BRUL. The masseter muscle helps not only in the mandibular anterior projection but also in lateral movements bilaterally. displacement may occur. 1996). lowering the floor of the mouth and making swallowing easier. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW the ventral fibers contract at rotation with occlusion. 1992). 1996). Despite the pressure between the condyle. 1991. 1992 and MACIEL. PHYSIOLOGY. otherwise it helps swallowing pulling the hyoid bone up. disc and glenoid fosse comply with the activity of the elevator muscles some pressure is always maintained to prevent separation of joint surfaces. The other muscles responsible for mouth opening are the following. with unilateral contraction and contralateral loosening. The digastric muscle. as well as masseter muscle lifts the jaw acting in protrusion and lateral movements (SARNAT. Figure 9 – Digastric Muscle.fotosearch. LASKIN. According to this becomes clear the action of the mandibular elevator muscles which assisted by ligaments induce the mandibular condyle to articulate with the glenoid fosse and maintain its movement. LASKIN. the mylohyoid depresses the jaw when hyoid bone is fixed. and also the mylohyoid and geniohyoid muscles. anterior projection and movements of laterality. Source . SARNAT. Another important group is that of the depressor muscles which have the basic function of opening the mouth and also execute other secondary functions. is primarily a depressor.Figure extracted from website: www. It is important to emphasize that mouth opening starts with the lateral pterygoid and followed by the digastrics muscle. This group is divided into lateral pterygoid and digastrics muscles. The geniohyoid muscle which is also suprahyoid and mandible depressor. 1992 and MACIEL. a suprahyoid muscle. like all the suprahyoid muscles.719 CRANIOMANDIBULAR DISORDERS – ANATOMY. When the mouth is closed it pulls the hyoid upward. The lateral pterygoid muscle is responsible for the opening of the mouth. DU BRUL. 1991.
1996). as the irregular. spasmodic movement of the disc-condyle complex on the non articular surfaces. 1991. LASKIN. in each TMJ. During the full mouth opening. It is reported that during closure of the mouth.720 CRANIOMANDIBULAR DISORDERS – ANATOMY. . When the mouth is opened completely. PHYSIOLOGY. 1973. the basic contraction function of the superior lateral pterygoid muscle appears to be to coordinate the return of the articular disc smoothly to its resting position (MACIEL 1996).com/20.transtornostemporomandibulares. the disc-condyle complex is moved down the articular eminence. Source Figure extracted from the website www. by resistance of the capsule and the lack of articular surface available. The posterior ligament tension during half opening of the mouth helps to bring back the disc rotating around the condyle (SOLBERG 1989). SICHER. the soft tissue is sucked into the posterior lateral sides of the joint (BARROS. At the same time. while the disc-condyle complex moves forward and down. characterizing the movement of translation. GRAY. It is believed that the lower portion of the pterygoid is activated along with the depressor muscles of the mandible during mouth opening (CABEZAS 1997). 1995 and MACIEL. slide of the disk is nullified by the stretching limit of the muscle. which rotating around its axis determines the rotational movement. close to the articular eminence. SARNAT. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW Figure 10 – Suprahyoid muscles. with the assistance of the digastric anterior and milohyoid. DU BRUL. leading to a stretch of the superior retrodiscal compartment. the articular disc spins posteriorly near the mandibular condyle. the entire disc-condyle structure slides along the posterior wall of articular eminence. RODE 1995).blogspost. SPALTEHOLZ.htm of Anatomy: During mouth opening. In the first phase of opening there is a small movement of the condyle. Mouth opening or mandibular depression is performed by bilateral contraction of both lateral pterygoid muscles. 1992. Anteriorly to disc-condyle complex is the lateral pterygoid muscle with its upper and lower fibers. The exaggerated movement of mandible opening beyond this point causes subluxation. In the opening sequence. resulting in posterior movement of the articular disc in the mandibular head or condyle (GRAY. 1988.
DU BRUL. Usually. The activity in the upper fibers of the lateral pterygoid muscle along with the mandible elevator muscles produces an anterior component of strain on the disc and causes it to move forward. the lateral excursion is formed in combination with protrusive excursion. disc and condyle move together which is not determined by insertion of the ligaments. producing a anterolateral dislocation of the mandible (SICHER. aided by the posterior and middle fibers of the temporalis muscle on the same side. SARNAT. OKESON. the disc acts as a wedge in motion to ensure full contact between the components of articulation for maximum function (SOLBERG 1989). The superior retrodiscal zone rotates the disc posteriorly and the superior lateral pterygoid muscle moves the disc in an anterior direction (DOUGLAS. Because the mandible is unable to achieve full opening through only a hinge-like movement. the dynamic condyle-disc can be changed and. 1992 and MACIEL. 1991). is the beginning of disc disorder interference (CABEZAS 1997). come to characterize most of the mandibular movements (DOUGLAS. rotational movement between the disc and head of the mandible or condyle and translation between the upper surface of the disc and articular eminence should be carefully studied. assisted by the middle and posterior fibers of the temporalis muscle on the left.721 CRANIOMANDIBULAR DISORDERS – ANATOMY. During movement. the movement of the jaw to the left involves the contraction of the right inferior lateral pterygoid muscle. 1991). As this movement is accomplished. 1991. indeed. the disc-condyle complex is rotated on the left and relocated on the right side of the TMJ. DU BRUL. 1988. a combination of both. To understand the biomechanics of the joint. For example. in which the disc-condyle complex moves down and forward along the eminence and a return phase in which it moves up and returns to its resting position. During the opening and closing of the mandible. The morphology of the disc and intra-articular pressure always present ensure maintenance of the condyle in the intermediate thinner disc zone. LASKIN. If there is any change in morphology of the disc or a change in intra-articular pressure. the stability of the TMJ is provided by anterior and posterior rotation of the disc which keeps its intermediate zone between the articular process of the mandible and the temporal articular eminence. 1988). sudden disruptive forces are created on the condyle. rotation and sliding motion. the thin intermediate zone of the disc is maintained between the articular process of the mandible and the temporal articular eminence. At this point. The translation cycle starts from the rest position. but for two main reasons: morphology of the disc and intra-articular pressure. but as the disc-condyle complex . PHYSIOLOGY. The retrusion of the mandible is accomplished by the middle portion of the middle temporal muscle and suprahyoid. by the resistance of the bolus. The upper retrodiscal structure is relaxed at rest position. The author claims that during closing. especially its relation to dental occlusion. perhaps with some assistance from the deep portion of the masseter and posterior branch of the temporal muscle (SICHER. 1996). The movement of the mandible to the left or right side involves the contraction of the lower lateral pterygoid muscle on the opposite side. consisting of an earlier stage. The protrusion is achieved by simultaneous contraction of the bilateral inferior branches of the lateral pterygoid muscle. In this position. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW During closure the joint receives the maximum tension.
this contact is achieved by muscular action. 1988. heads or condyles are stabilized by muscle tone. 1995). OKESON. This is the best alignment to prevent injury to the articular structures. During translation. Since the TMJ articular surfaces are not directly connected. In the return phase. active and passive. 1988. lying along the slope or posterior inclination of articular eminence. Another important factor is the intra-articular pressure between the condyle and eminence. 1998). intra-articular pressure is insignificant. the superior lateral pterygoid muscle is inactive. fatigue. 1991 and GRAY. SPALTEHOLZ. as well as in the antero-posterior motion of the disc. 1991). the superior lateral pterygoid muscle also exerts some control over the movement of the disc-condyle complex at the return stage (GRAY. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW moves forward towards the articular eminence. is also influenced by emotional stress. Only when the teeth are tightly occluded. 1991 and GRAY. the disk space is reduced and the lower portion of the disc thickness twists between the condyle and eminence. In the rest position. 1973. When teeth are occluded. Occlusion of the teeth provides the necessary stability in maximum intercuspal position. this position is similar to the currently most accepted definitions for centric relation (OKESON. then retracting the disc posteriorly to the head or condyle. The temporomandibular ligament does not contribute actively to stabilize the joint. occlusion does not appear to directly influence the function of the joint. this pressure is increased. it becomes active. At rest. The closure also does not play an important role when the jaw is at rest because the teeth are not in touch. Perhaps the most important element in maintaining stability of the joint is the position of the articular disc in relation to the articular process of the mandible. Since most of the mandibular movement does not involve dental contact. The optimal stable musculoskeletal joint position can be defined as "one in which the head or condyles are in their most superior and anterior position in the glenoid fossa. the upper retrodiscal blade becomes inactive and the superior lateral pterygoid muscle contracts to spin the disc above the condyle. With their integration into the neck of the articular process of the mandible. The passive intra-articular pressure is the result of contraction of skeletal muscles during function and is due to muscle tone that can be modified by gravity. This action prevents the disc from being displaced anteriorly during the full opening of the mouth. illness and age (OKESON. The intra-articular pressure can be divided into two types. joint stability is achieved by the muscle tone in the elevator muscles. . the opposite occurs. SPALTEHOLZ. This position depends in the contour of the central zone of the disc. with the articular disc properly superposed". During the previous phase. serving rather passively to limit the posterior and inferior condylar displacement (GRAY. No discussion involving the biomechanics of the TMJ could be complete without addressing the role of occlusion. The articular surfaces of the synovial joint require continuous contact at all times to maintain stability. the relationship between the teeth of the maxilla and mandible in fact occurs.722 CRANIOMANDIBULAR DISORDERS – ANATOMY. 1973. when forces of great intensity are applied. OKESON. PHYSIOLOGY. interposed between the posterior temporal and inferior portion of the lateral pterygoid the disc-condyle complex and the temporal articular eminence remain in firm contact. 1995). the disk space is wide and the slightly thicker portion of the disc spins to occupy or fill the space between the condyle and eminence.
bruxism and others ) can be harmful and lead to imbalance and disharmony of the TMJ and the entire stomatognathic system. There are also noises. RAMFJOR. tooth wear. GREENE. TURELL et al. but also includes the functional disturbances of the masticatory system (OKESON. The etiology of TMD is multifactorial. The main signs and / or symptoms of TMD are pain in the masticatory muscles or temporomandibular joint or in surrounding areas. HYLANDER. Based on the literature. 1990). being often submitted to dental treatments. then going to the term Craniomandibular Disorders (PAIVA. consequently. the rate of symptoms in both is only slightly different. but it does not always happen. Population studies have reported that about 70% of the population has one or more symptoms of temporomandibular and muscular disorders. GREENE. COSTA et al. YUNUS et al. caries. hand in support of mandible. untimely dental extractions. SMYTHE. For the appropriate function of the temporomandibular joint. 2003 e LASKIN. B – Disc-condyle complex disorders. C . unsatisfactory prosthetic devices. 1993). WESTESSON. inappropriate restorations among others). The term includes not only problems related to the temporomandibular joint (TMJ). myositis). producing. 1982) and gained wide acceptance and popularity.Acute muscle disorders (muscle spasm. SCHMIDSEDER 1998). psychological factors (cause tension and increase muscle activity. VIEIRA. smoking. such as disc displacement. thumb sucking or pacifier. PHYSIOLOGY. loose or illfitting dentures. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW CRANIOMANDIBULAR DISORDERS The temporomandibular joint (TMJ). E . limitation of opening. which divides temporomandibular disorders in: A . biting objects.Changes in growth and development. some authors believe that a more collective term should be used. inadequate posture of mandible.Changes in mandibular mobility. HYLANDER. degenerative joint disease (osteoarthritis).. 2006).Inflammatory disorders of TMJ. 2006). 1990 e LASKIN. 1990. Similarly to terminology and etiology.723 CRANIOMANDIBULAR DISORDERS – ANATOMY.. MACIEL. deficient anatomical restorations. traumatic or degenerative alterations of the TMJ. among others. the classification that seems to be most accepted is that proposed (BELL. The temporomandibular disorders (TMD) was suggested (BELL. ranked as the most complex of the human body can be affected by the same diseases and disorders that affect other joints of the musculoskeletal system. causing occlusal maladjustments. the individual can not always maintain its stable stomatognathic system. damage to the entire masticatory apparatus (JUNQUEIRA.. Most patients seeking treatment are women between 20 and 40 years old (ASH. . skeletal problems . where various aspects such as: changes in occlusion (tooth loss. generate spasm and fatigue) and deleterious habits (nail biting. the very temporomandibular joint. Although most patients are women (5:1) when compared to men. D . inflammatory arthritis and synovitis (WOLFE. classification of temporomandibular disorders has also been very diverse. has no single cause. dental occlusion and neuromuscular balance must relate harmoniously. The pain is spontaneous or during chewing. During life. 1997). Since the symptoms are not always restricted to the temporomandibular joint.
. cease the related painful symptoms. Other authors argue that the main symptoms are pain in the preauricular area. there is a spasm of the elevator muscles although the lateral movements may be perfectly normal. Muscle spasm: It is a tonic prolonged contraction induced by central nervous system. The stimulus may be temporary or may cease with time simply displaying the etiologic agent and limiting jaw movements (VALMASEDA. marked mandibular dental abrasions or frequent fractures of teeth and / or restorations (TAKAHASHI. constant emotional tension. ARAÚJO 1995). SCHOUTEN. Other symptoms include earaches. shoulders and neck. PHYSIOLOGY. SORDI et al. 1997). intubation. pterygoid and masseter muscles sensitivity. although not presenting defined etiology. The authors classified it as (VALMASEDA. eccentric movement limitations of mandible. ABREU. featuring the multifactorial origin of this dysfunction (SOVIEIRO. Protective muscle contraction: In some situations. CASTRO et al. EVALUATION OF CLINICAL SYMPTOMS There are several diseases which can settle in the TMJ. small cracks to open and close the mouth. asymmetry of the mandible. 1997). PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW uncoordinated movements. micrognathia and macrognathia. 1999). modification in dental occlusion. facial asymmetry. some related to noxious stimuli that when disappear. 2007). sensitivity to all cervical muscles and stomatognathic system (RHODEN. although there are others who tend to follow a chronic course for which treatment can be very complex (STEGENGA. 1992). Other signs include tightness of the masticatory muscles and jaw locking or dislocation (AGUIAR. often exacerbated during chewing or during mandible movements (SOVIEIRO. temporal. 2. CASTRO et al. ESCOBA 2002): 1. pain in joint. face . it is believed that functional. 1984). Does not fit as an inflammatory disorder caused by prolonged muscle contraction or myofascial pain. Noises in the joint and limitations in mandibular movements represent the clinical signs most frequently observed. NICOLINI. structural and psychological factors aspects are combined. . The contraction may cause a malocclusion and limitation of mandible movement. popping in the temporomandibular joint. 2002). The restriction is extracapsular.. The most common initial symptom is localized pain in the masticatory muscles or TMJ region.724 CRANIOMANDIBULAR DISORDERS – ANATOMY. ABREU. Masticatory muscle disorders: The disorders related to masticatory muscles are most often found on temporomandibular disorders. 3. sensation of locking of the jaw. the muscle tone increases in response to central nervous system in defense of certain sensory stimuli such as bruxism. 1988). as a central excitatory effect produced by a painful stimulus. GAY ESCODA. and others (OKESON. data of extreme importance in the final diagnosis of a craniomandibular disorder (RAMFJORD. or an extrapyramidal effect originated from the use of phenothiazine. headaches and pain in the face as well as difficulty in swallowing. deviation of the mandible during opening..
DEVELOPMENTAL. masticatory muscles and facial nerve. 1993 e BROWNE. parotid gland. Laboratory tests may also be useful to exclude systemic diseases such as. It usually affects the elevator muscles of the mandible producing limited mouth opening with lateral and protrusion movement preserved (WOLFE. rheumatoid arthritis. One way to diagnose this condition is by means of a radiographic examination of the mandible (condyles projection) and TMJ showing the level of involvement of associated bones. YUNUS et al. systemic changes and deleterious postural habits. DAWSON. . often resulting in a noise and without reduction and with limited opening. SMYTHE. EDMONDSON. Disc displacements are caused by ligamentous disruption between the intra-articular disc and condyle with consequent displacement of the lateral pterygoid muscle with reduction in which the disc is moved anteriorly and medially or laterally from its position. characterized by areas of hypersensitivity presenting muscular trigger points on which increased pain appears when stimulation occurs. 1990 and OKESON. transpharingeal or panoramic radiographs. 5. 1990. YUNUS et al. 6.725 CRANIOMANDIBULAR DISORDERS – ANATOMY. chewing hard foods. Diagnosis is difficult since it must first rule out all possible organic causes. temporal bone. ROUT. Disorders caused by interference of the articular disc: Due to an overload in TMJ there is a decrease in joint space leading to a collapse of the disc in relation to the articular space. This condition is defined by the American College of Rheumatology as a muscular-skeletal disorder in which there is widespread pain in more than 3 months at many points (18 or more) in 3 or 4 body quadrants being one of the muscle-related disorders most commonly found in the TMJ. Myofascial pain: It is a prolonged painful disorder. in which the disc is displaced from its normal position to a position anterior and medial or lateral. 2008). There is a slight deficit of mandibular movements as well as in their velocity. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW 4. It is characterized by signs of inflammation with pain at rest that increases as there is movement. 1992). The causes of adhesions are dental clenching. with limited mandibular opening (OKESON. TRAUMATIC AND CONGENITAL ANOMALIES Condylar agenesis In condylar agenesis concomitant problems may be present in other parts of the mandible. 1997 and GARCIA. with reduction in total openness. PAIVA et al. infection or excessive physical activity. SMYTHE. Transcranial. computed tomography and magnetic resonance imaging to determine the position of the intra-articular disc can help in diagnosis (WOLFE. for example. PHYSIOLOGY. Some people associate it with the emotional stress. 1997). bruxism. This fact is common in people with a habit of nocturnal bruxism which is likely to be observed as a clear limitation of the mouth opening resulting in a click sound in the joint when trying to open the mouth.... Myositis: It is a muscle inflammation due to local injury either by trauma. MADEIRA. Treatment is often early surgical / orthodontic settling the normal height of the mandible and restoration of growth alteration (CABEZAS. middle and inner ear. 1995).
An important factor in diagnosis is the condylar deformity. Surgical treatment is mandatory (BARROS. Traumatic: causes increase in intra-articular space or bleeding. followed by narrowing and irregularity of the intra-articular space or obliteration of the normal morphology of the bone. infections and cancers. Traumatic injuries The articular fosse is rarely affected by condylar trauma due to the absortion of the impact by the articular disc. physical and radiographic evaluation. Luxation Obvious feature here is the inability to close the mouth. possibly congenital abnormalities. The first requires manual reduction under local anesthesia and sedation or general anesthesia.726 CRANIOMANDIBULAR DISORDERS – ANATOMY. 1997). the condylar head is angled forward over the neck of the mandibular ramus. 1997). being much thinner than the ramus or the condyle tends to fracture first. The diagnosis is made by anamnesis. 1997). Treatment is . Arthritis Among the malignancies most commonly found in association with TMJ arthritis is largely found due to some major origins such as: 1. The diagnosis is based on physical and radiological findings. followed by orthodontic treatment. deviation of the mandible on the affected side. PHYSIOLOGY. 1997). Chronic recurrent dislocation and chronic permanent dislocation require surgical treatment (BARROS. In the case of children. Chronic recurrent dislocation. RODE 1995 and CABEZAS. trismus. thus protecting the thin roof and the middle cranial fosse. Ankylosis The most common etiologic factor in TMJ ankylosis is possibly trauma and / or rheumatoid arthritis. to establish a normal occlusion (CABEZAS. One consequence of this anomaly is the facial deformity as a result of the reduction of the mandibular body deviating towards the affected side and enlargement of the contralateral side. and usually anterior open bite. Permanent chronic dislocation. parents should be counseled about the possible delay of mandibular growth. 3. 2. the neck of the condyle. The treatment consisted of maxillomandibular fixation and sometimes open reduction (BARROS. The most common signs and symptoms observed are preauricular pain. RODE 1995 and CABEZAS. Simple acute episode. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW Condylar hypoplasia The condylar hypoplasia may be in the majority of cases of infectious origin or also congenital. RODE 1995 and CABEZAS. The surgical treatment is based on lengthening of the hypoplastic portion or shortening of the normal side in the adult. Three forms can be defined: 1. and the two most frequent types of joint involvement found are the involvement of the joint alone or involving extra-articular structures. or caused by trauma or irradiation during growth.
The rarest benign tumors are: myxoma. Clinically is represented by bilateral pain. Rheumatoid arthritis: it might not always be the first symptom. 1993). limited movement of the mandible and difficulty of dental occlusion. MEHRA. The occlusal splint stabilizer also called conventional occlusal splint or Michigan is the most widely used because it causes less risk of irreversible occlusal changes: as anterior open-bite. Structural. The splints are made of rigid or resilient . giant cell granuloma. 1997 and WOLFORD. 2. medications. It is characterized by signs of inflammation and trismus. 2009). as they have a variety of symptoms and have a multifactorial etiology.. Occlusal splints: The occlusal splints have gained noticeable importance in the treatment of TMD explained by the low-cost treatment and the achievement of a high success rate. sinovialoma. determining a multifactorial origin. May be associated with systemic infections such as syphilis. KUSMA et al. fibrous dysplasia. HYLANDER. occlusal stabilizing plates. GREENE. The treatment modalities include: patient education and self-care. osteoblastoma and synovial hemangioma. FERES. ASH 1984). Infections: these are rare in the TMJ. 2006). It is vital to understand that patients respond differently to different therapies. stiffness and joint swelling and limitation of movement. 1. KERN. 2001). derived from local infection or through hematogenic route. Signs and symptoms are pain. physical therapy. functional and psychological aspects seem to be related. The x-ray shows bone destruction with images of apposition and resorption. Neoplasias Chondromas.727 CRANIOMANDIBULAR DISORDERS – ANATOMY. PHYSIOLOGY. There may be invasion of TMJ by the cheek or parotid tumors. osteomas and osteochondromas are quite unusual but might be found. gonorrhea or tuberculosis. The use of occlusal splints is an effective therapy for various types of structural disturbances of the masticatory system (RAMJORD. Treatment is with antibiotics and anti-inflammatories. Treatment is with NSAIDs. corticosteroids and eventually hydroxychloroquine and penicilamide. STECHMAN NETO et al. Malignant tumors are even more unusual fibrosarcoma. occlusal therapy (orthodontics. pathologic extrusions and tooth migration (PORTERO. There are actually several types of treatment for TMD. PITTA. 1999. surgical drainage may eventually be required. behavior modification (including relaxation techniques). 3. chondrosarcoma and multiple myeloma. In order to promote a correct treatment plan a proper diagnosis is required. Surgical treatment is indicated (CZLUSNIAK. to obtain the best possible results. chondroblastoma. oral rehabilitation) and surgery (FAVERO. SAAMANEN. and the practitioner must adequate the treatment to the patient. TREATMENT OF CRANIOMANDIBULAR DISORDERS The treatment of TMD requires a thorough knowledge of the etiology of the problem. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW symptomatic with restricted mobility of TMJ. METSARANTA. Surgery may be necessary in the presence of ankylosis (RINTALA. 2001 e LASKIN.
in different parts of the body (FARELLA. IZAWA et al. but the hard acrylic reduce symptoms more quickly and better. Physical therapy: The main goal here is to guide the patient. 1999). relax muscles in hyperactivity and working those into disuse. exercise and postural reeducation. and can be used both in acute and chronic pain. . Thermotherapy the heat causes an impaired vasodilatation in tissues and leads to reduction of symptoms. increases blood flow in deep tissues and improves flexibility and extensibility of connective tissues. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW materials. cryotherapy. in these types of disorders. Between the physiological and therapeutic effects: increased metabolism. and postural reeducation (FÁVERO. PHYSIOLOGY. muscle strengthening. it is a resource that produces rapid response to treatment. antiedematous effect and healing effect. The ultrasound produces a temperature increase in the tissue interface and affects the tissue more deeply than hot surfaces. being easy to handle. 2. and decrease pain (BASSANTA. but they are not the only treatment option and should never be considered that way. restore muscle tone. TANIMOTO. It is important to observe that occlusal splints or so-called miorrelaxant splints have an important role in the treatment of TMD. MORAES. 1999). The cooling therapy promotes relaxation of the contracted muscle and so relieving the associated pain (OKESON. The cold laser speeds up the synthesis of collagen. Injection of local anesthetic in trigger points and physiotherapy treatment modalities are used recently. 2009). 1997). effects on inflammatory process. STUGINSKI-BARBOSA. electrotherapy. the first step of treatment is to relieve pain... GARGANO et al. decreases the number of microorganisms and decreases pain (OKESON. but as part of or even as an adjunct to other therapies as medication or physical therapy and it is necessary that the etiology of the disorder be well established. it also promotes analgesy (LASKIN. The use of laser as a physical therapy resource in the treatment of TMJ dysfunction is being increasingly used. anti-inflammatory. 2000). the effect being sought by the therapist (FAVERO.728 CRANIOMANDIBULAR DISORDERS – ANATOMY. in addition to the correction of dental occlusion. This is because these approaches have a long history of success in treating problems similar to those of TMJ. authors have concluded that the recommended treatments for craniomandibular disorders are the use of drugs. 2007). increased blood supply. MICHELOTTI. The therapeutic effects are: analgesic. even in the absence of medication. so the resilient splints are mainly indicated for protection against injuries to the teeth (OKESON 2000). as well as acting as a healing factor and supporting tissue reorganization. due to several advantages. 2009). effects on muscle tissue. 2000). orthopedic and neurological nature (KURODA. the resilient splints can reduce the symptoms of TMD. muscle relaxation. physical therapy procedures. increases vascular tissue. using or not splints. A variety of techniques is responsible for the physical treatment among these are thermotherapy and the use of ultrasound. Each one provides physiological effects that will assist in reducing pain. eliminate pain and inflammation. After a literature review. 2000 and MURAYAMA. The TMJ disorders are basically composed of musculoskeletal.
FAVERO. NSAIDs are indicated to relieve moderate inflammatory conditions and acute postoperative pain. and cryotherapy is indicated in cases of joint limitations. it is expected that the definitive treatment improves the symptoms and is not necessary to extend the use of medication (FAVERO.Anti-inflammatory drugs suppress the body's overall response to the irritation. with the principle of breath and is directly related to the proprioceptive activity. This therapy is assisted by heat especially in chronic cases where there is increased muscle tension.Anxiolytics are indicated for supportive therapy (diazepam). 1979. as well as in cases of neurological alterations. . As described the indicated pharmacological treatment for TMD is: analgesics. Its effect is relaxing and analgesic however to the same authors.Analgesics are indicated when the profound pain leads to the disorder. 2009). KUSMA et al. 1999). and also during function (FÁVERO. the occurrence of inflammatory processes. 1999). 4. 1999 e SZUMINSKI. Corticosteroids are not prescribed by their side effects. 1997.729 CRANIOMANDIBULAR DISORDERS – ANATOMY. and tricyclic antidepressants for chronic pain (OKESON 2000). flexeril). Among the palliative drugs used to control pain and anxiety caused by it are the anxiolytics that produce an calming and mild muscle relaxation effect. SANTOS. when anxiety and muscle spasms are prominent. Exercises are essential to the maintenance of muscle function without pain and producing muscle relief. corticosteroids. massage therapy and functional myotherapy. especially musculoskeletal pain. but the patient must be warned that prolonged use can cause side effects (FAVERO. promote symptomatic relief and does not stop the progression of pathological tissue injury (ibuprofen). 1999 e PORTERO. the drugs should be prescribed at regular intervals for a specific period. Medication dynamics: . . the application of heat is contraindicated in acute cases. Muscle relaxants are given to prevent the increase in muscle activity associated with TMD (mephesin. spasms relaxation and acute pain processes. 3. and anxiolytics. It is indicated as a short term therapy. Speech therapy: After physical therapy it is important to adequate the muscle tone and mobility in order to relieve muscle pain. KERN. The ultimate goal of the myofunctional therapy is the adequacy of the stomatognathic function and relieve pain by better blood supply afforded by the workouts (ANELLI. 1999). Pharmacological therapy: The primary goal of pharmacological therapy is to control pain but without eliminating it. thermotherapy to enable changes in oxygenation and muscle relaxation. NSAIDs. KROENING. . 5. QUINTO. BIANCHINI. 1999). to treat acute pain. PHYSIOLOGY. local anesthetics for acute and chronic condition. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW As medication NSAIDs can be prescrit and is generally the most suitable for the treatment of TMJ internal derangement and myofascial pain. especially during inactivity. muscle relaxants. and at the end of this time. 1998 e SZUMINSKI. and sometimes administered with benzodiazepine (DONALDSON. For the TMD.. Speech therapy consists in advising the patient on what he can or can not do in certain phases of the proposed therapy.
CARDOSO. a cannula is introduced with a video lens in the superior articular joint space. Figure 11 . some conditions are imposed with respect to the modality in the surgical management: a joint surgery should be performed only when conservative treatment was not effective. forms of pre-surgical treatment should follow rational and appropriate criteria. For these authors. mepivacaine) (OKESON. 1999. E. Arthrotomy can be performed.. A lateral incision can be made to allow introduction of instruments for biopsy. p. n.. and various types of therapy should have been used before referring for surgery. bras. A. TMJ open surgery shall be performed only in much selected cases.Articular eminence osteoplasty. v...1.32-7. Source: Figure extracted from the article: CARDOSO. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW . drug treatment can not by itself be responsible for remission of symptoms and not fully deal with the problem of the patient. myofascial trigger point (lidocaine.730 CRANIOMANDIBULAR DISORDERS – ANATOMY. C.. The decision to surgically treat a patient depends on the degree of pathology he shows (Figure 11) (FAVERO. ./fev. 2005 e CABEZAS. VASCONCELOS et al. remodeling of articular disc and lysis of adhesions.. when anxiety and muscle spasms are prominent. as previously mentioned. 2005. It is indicated as a short term therapy. The TMJ surgery can be open or closed (MOLINA 1995. Local anesthetics are used for localized pain in muscle. open surgery of the TMJ is the last treatment option to be considered. Regarding the surgical treatment of TMD. discoplasty. but the patient must be warned that prolonged use can cause side effects.71. BELMIRO. PHYSIOLOGY. patients who have persistent chronic or acute signs and symptoms. VASCONCELOS et al. BELMIRO. Otorrinolaringol. jan. 2000). So if conservative treatment for TMD is not effective. adhesions of the disc. B. an option to consider is TMJ surgery. FAVERO 1999 and CABEZAS 2006). discectomy. in which pain is the main component and the signs and symptoms are resistant to conventional therapy.. 2006). 6. For some authors in closed TMJ surgery (arthroscopy or arthrocentesis). disc displacement without reduction. Estudo comparativo da eminectomia e do uso de miniplaca na eminência articular para tratamento da luxação recidivante da articulação temporomandibular. Surgical therapy: In some situations.Tricyclic Antidepressants require increased dosage therapy. uncertain diagnosis. and arthralgia. Rev. Among the indications is failure of conservative treatment.
8 mm wide. A cephalometric study was conducted to evaluate changes in longterm positioning of the anchor in the condyle and the effects of the process on the morphology of the condyle... DE BONT. In a study conducted in 63 patients (59 women and 4 men). In group 1. STEGENGA et al. PITTA. (2) restoration of the articular disc. jaw and occlusal stability. It is known as "Minianchor" used years ago as: (1) articulate endosseous stabilizer. (3) condylar restoration. 2002). and (5) genetic predispositions that lead to joint disturbs. with 12 bilateral and 51 unilateral cases. (4) nutritional deficiencies. Positional changes were minimal for the horizontal and vertical movement.5 to . medially and laterally. Absence of inflammation or bone resorption was observed around these devices (FIELDS. Inc. a total of 57 joints (WOLFORD. Two titanium "wings" provide lateral intraosseous locking making suture viable in the region and the formation of artificial ligaments (VAN LOON. As much more inclinated the eminence is. MEHRA et al. the thicker the distal edge of the disc becomes. with a mean follow up of 12.0 points on a 0-to-10 visual analog scale. (4) restoration of the articular fosse and (5) total joint prostheses. WOLFORD. (2) endocrine dysfunction. ENDOSSEOUS IMPLANTS Endosseous implants can be used fixed in the condyle to assist in the positioning of joint structures. The sample consisted of 29 patients (n = 54 joints) with a mean age of 31. Group 2 consisted of 32 patients (30 women and 2 men) followed for a median of 25.) stabilizing the position of the articular disc. The functional position of the articular disc is a key factor in mandibular movements. many disorders may result from its lack of coordination. and a significant reduction in pain. Other factors should also be considered in choosing a articular device: (1) Autoimmune disorders. Several approaches can be used to expose the posterior condylar head to place a device known as minianchor (Mitek Mini Anchor. It was demonstrated osseointegration in two condyles of the anchors in about 3 months after implantation. Some of these devices have been used in the treatment of TMJ disorders although in some situations they lead to functional impairment to patients. it becomes relevant to highlight the actions of the devices used in TMJ.731 CRANIOMANDIBULAR DISORDERS – ANATOMY. and its posterior margin is relatively thick. 29 of 32 patients (91%) had successful results with the same criteria. with an average decrease in pain of 4.01 mm (range.. 57 of 63 patients (90%) had successful results with an incisal opening of 35 mm or more.1 points in a -10 0-visual analog scale.5 months (range 18 to 36 months).2 months (range 8 to 16 months). 7 cases with unilateral and 25 bilateral. with an average change of 0. a total of 114 joints. Mass. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW The articular disc covers the head or condyle until the adhesion points. FRANCO. -1. designated group 1. This mininchor is composed of titanium with 5 mm in length and 1.8 months (between 12 and 29 months). PHYSIOLOGY. Chronic dislocations of the articular disc that could be treated invasively are currently treated with devices used to stabilize it in the posterior aspect of the condyle.3 years (ranging from 15 to 52 years) and a mean follow up of 16. (3) biomechanical problems. with an average of 4. 2001). Norwood. In group 2. 1997). knowing the dynamics of them and how they are responsible for functional improvement of patient’s quality of life. Considering this. Mitek.
P. USE OF MINI-ANCHORS FOR ARTICULAR DISC. p. CONDYLE.02 mm (range -1 to 1 mm). Figure 13A – Cross-sectional image of condyle showing fixed mini-anchor. L. DALLAS. PHYSIOLOGY. M.. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW 1. p. oral Maxillofac. L. WOLFORD. These studies support the use of Mitek mini anchors for the stabilization of the articular disc of TMJ (CARDENAS. M. WOLFORD.. Source . T.Mini-anchor body. Condylar and ramus average height changes were -0... Figure 12. . 143-9..Figure extracted form: WOLFORD. Surg.732 CRANIOMANDIBULAR DISORDERS – ANATOMY. WOLFORD. J.Figure extracted from: MEHRA. Oral Med. v. GONCALVES et al. 1997). 2001). Oral Surg. The Mitek mini anchor for TMJ disc repositioning: surgical technique and results. Temporomandibular joint devices: Treatment factors and Outcomes. Oral Pathol. 83. 2001. Endod. 497–503. A.5 mm). 1997. 30. Fig. Source . Materials such as polimethyl methacrylate. FOSSA. polyethylene of high molecular weight. Oral Radiol. 13B – Coronal section of condyle showing fixed mini-anchor. and a series of metals (Figures 12 and 13) (MEHRA. v. AND COMPLETE ARTICULAR REPOSITIONING Numerous materials are used for either partial or total reconstruction of the TMJ.
). bone resorption. 2000 and DATAMORE. A clinical study was published in which the use of mini-anchors as a treatment for TMD was considered as a well established treatment because it leads to a success rate of about 91% of a total of 43 patients and 78 treated TMJ with clinical follow-up time of over 2 years (COTTRELL. especially by the presence of giant cell lesions. The basis of chromium and cobalt are used for reconstruction of the condylar head and high molecular weight polyethylene to the surface of the glenoid fosse. Houston. pain. and immune dysfunction (WOLFORD. 2001). There are reports of success around 86% with a clinical follow up 16 to 46 months. WOLFORD.. improved function and occlusal stability with a significant decrease in pain in 84% of cases (HENRY. and also cartilage. Numerous metals have been used for that purpose. including temporal fascia and muscle grafts. leading to a better condylar position preventing dislocations. in 49% of cases. MATERIAL AND METHOD This study was performed using references on the therapy of Craniomandibular Disorders. MEHRA. ATHANASIOU. And Silastic (Dow-Corning. Mo. limiting non physiological movement (MEHRA. In 14 patients had had one or no symptoms of pain. STEGENGA et al. WOLFORD. One hundred and seven patients were evaluated with the use of these types of materials when failed in the use of Teflon was observed. particle migration. The reconstruction was performed using autogenous bone grafts. instability and occlusal function and 19% had up to two such nuisance. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW This procedure is widely used in the constant displacement of articular disc that leads to inability to perform normal mandible movements.. Midland. Such articular devices have being used successfully for some years. severe osteoarthritis.). perforation of the fosse. pain. lymphadenopathy. 1993).733 CRANIOMANDIBULAR DISORDERS – ANATOMY. Patients who had previous implants were treated with Teflon denture materials for orthopedic. 1997). through a Literature Review so this paper aims at discuss the very important points regarding the Temporomandibular Joint concerning . 1993). Sixty-six mini-anchors and their action on changes in vertical and horizontal cephalometric tracings were studied and it was observed that this device leads to an excellent joint stability in condylar replacement (CARDENAS. and lesions of giantcell. Two materials were shown to be the first choice as joint implants interpositional discs that were Proplast Teflon (Vitek.dimensions. TMJ models are initially produced on a computer in three . with a follow-up of 4 years a success rate around 8% to 31% was observed. producing a slight lock. In this study the mini-anchors replaced successfully Teflon widely used for several decades. GONÇALVES. Inc. WOLFORD. PHYSIOLOGY. dermis. The replacement of the articular disc for alloplastic materials was popular technique in the 1970s and 1980s. 2002). WOLFORD. Tex. The failures were noticed. costochondral and sternoclavicular grafts. DE BONT. and copied according to the peculiar anatomy of each patient in addition to the essential use of CT scans for the same purpose (VAN LOON. Later it was observed that the formation of microscopic particles of these materials in the human body was unable to degrade and can cause severe foreign body reactions. 2003). of course adapted to the structure to be reproduced. foreign body reaction and ankylosis.
with symptoms ranging from joint pain. It is vital to understand that patients respond differently to different therapies.. functional and psychological problems that appear to be fulfilled. CAMPELLO OLIVEIRA et al. 1957 and HALE. OLIVEIRA et al. to obtain the best possible results (FAVERO. RODRIGUES.normal dynamics of TMJ. Thus it is evident that the correct diagnosis is the key to successful treatment. TMJ deleterious habits. the use of miniplates in the articular eminence (BUCKLEY. SILVER. 1998 and MEHRA. 2007). Other predisposing factors are cited in literature such as trauma. CAMPELLO. CAMPELLO OLIVEIRA et al. scarification of the tendon of the temporalis muscle by intraoral approach.treatment of craniomandibular disorders. FLYNN.. for any treatment to be successful it is imperative to know the particulars of each treatment. 1963. intermaxillary fixation. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW . 1984. being the nonsurgical treatment based in medication. The multifactorial origin of TMD is characterized as structural. 1962. 2007).anatomy . 2004). malocclusion. SIMON. Therefore. to obtain the best possible results. IRBY. DESPREZ. DISCUSSION Through the literature a large number of Craniomandibular Disorders are verified. 1951. headaches. 2006 and LASKIN. 1988 and PUELACHER. physiological aspects . TOLEDO-FILHO et al.craniomandibular disorders .. 1999 and STECHMAN NETO. 2001). WALDHART. psychological management. There is a consensus in the literature regarding the need for multidisciplinary treatment (FAVERO. In the surgical treatment there are procedures performed in soft tissue. CAMPELLO OLIVEIRA et al. several methods have been described as eminectomy (MYRHAUG. either surgical or nonsurgical (LASKIN. scarification of the articular capsule (VASCONCELOS. intending thereby to limit mandible movements (VASCONCELOS. CAMPELLO OLIVEIRA et al. the oblique osteotomy of the root of the zygomatic bone or Dautrey procedure (VASCONCELOS. . 2000). According to a study of 12% to 87% of the population carries some form of disorder. decreased ability to jaw movements by vertigo (KIEHN. GREENE. ligaments and bilaminar tissue. myofascial pain. PHYSIOLOGY. viral or bacterial infections and systemic or local diseases. creating an obstruction to certain translation movements and mandibular osteotomy (WEINBERG. Thus it is evident that the correct diagnosis is the key to successful treatment. 1990 and LASKIN. Treating cases of TMD requires a thorough knowledge of the etiology of the problem.. For both the range of treatment options is also large and the main indications for treatment of recurrent chronic TMD are pain and dysfunction (MONGINI. It is vital to understand that patients respond differently to different therapies. One can cite the myotomy of the lateral pterygoid muscle via intraoral (VASCONCELOS. 1999 and OKESON. WOLFORD. 1972). physical therapy and the application of sclerosing agents in the articular capsule. 1991 and VASCONCELOS. 2004). ALMEIDA. Regarding surgical treatment.. LAPP et al. and the practitioner must adapt the treatment to the patient. HYLANDER. removal of the structure that is causing some kind of interference.. 2001). 2004). and the practitioner must tailor the treatment to the patient. BROWN..734 CRANIOMANDIBULAR DISORDERS – ANATOMY. 2004). 2004). TERRY. 1993).
not changing the three dimensional conformation of the mandibular condyle (WOLFORD. Translational control of mandibular movements. WOLFORD. 2001). however.735 CRANIOMANDIBULAR DISORDERS – ANATOMY. GONÇALVES. Access to the temporomandibular joint should be as small as possible in order to preserve a greater amount of soft tissue. Specifically regarding the use of mini-anchors the nickel-titanium is used mainly for the purpose of repositioning the disc. provides a stable anchor position. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW the articular eminence augmentation by the use of alloplastic graft and the employment of the use of mini-anchors "Mitek" in the condyle and the posterior root of zygomatic arch (VASCONCELOS. mini-anchors used in 5 patients with control of 4 years in which there were no failures demonstrating excellent clinical results. Also showed that osseointegration occurs in 3 months despite the application of forces in this period. DALLAS.. WOLFORD. 1997): osseointegration. Low mobility is perceived when the placement of mini-anchors. 1997). more studies should be made to that effect. WOLFORD. especially in treatment of recurrent . which is relevant to note is that according to the literature this method overlaps in terms of advantages over other mechanisms with the purposes (WOLFORD. FRANCO. 3. As reported one of the great advantages of using this device. 1997 and FIELDS. 2. Keep at least 2 mm in the bilaminar tissue in the distal portion of the posterior band of articular disc to be sutured to the mini-anchor. Some items should be considered before placing mini-anchors for the treatment of TMD (MEHRA. WOLFORD. KARRAS. PHYSIOLOGY. CAMPELLO OLIVEIRA et al. 2001). 1997 and MEHRA. 2004). This fact is a unique aspect. DALLAS. the force that will be exercised on the TMJ should be minimal. A favorable result was also obtained when a minimal change in the position of mini-anchors in human condyles in long postoperative follow-up was noted (CARDENAS. 1994. This technique shows how you can realize the following advantages: 1. Just as it has been for osseointegration in dental implants. do no injury any joint structure and not change the anatomical site unless necessary. 1997). 6. Excessive force may lead to peri-implantitis and mobility. 1996). The use of mini-anchors for disc repositioning was reported in more than 400 TMJ with successful results (WOLFORD. The same authors also mention. 2001): 1. WOLFORD. The implanted devices must be safe. WOLFORD. surgery here in joints. Based on this it is clear that the use of mini-anchors for treatment of Craniomandibular Disorders is a reality. there is no consensus about the strength and the vector that can focus on the relationship notwithstanding. COTTRELL. 2. FRANCO. An interesting feature of the use of mini-anchors was demonstrated (FIELDS. Effectively prevents the displacement of the condyle without altering the anatomy of the joint (WOLFORD. 4. is the predictability of a good positioning in the joint structure. During surgery the periosteum should be preserved and the bone should be carefully worked and plenty irrigated. with the formation of fibrous tissue at the interface of the implant and bone tissue (ISIDOR. 2007). The positioning of the articular disc should be passive in relation to the condyle. The occlusion should always be checked if necessary an orthodontic treatment followed by orthognathic surgery can be performed. 5.
Proposta de Mioterapia nos casos de DTM: restrição de abertura bucal e desvios na abertura e/ou fechamento bucal. 1998. P.. therefore. abr. What would be made of the numerous articles published in the literature if not to help to increase satisfactory surgical results. J.. we conclude that: 1. n.. 1997./jun.. C. F. TOLEDO-FILHO. M. M. P. ____________________________________________ * According of the ABNT norms. H. A. Temporomandibular disorders. E. B.. 1. P. J.. BASSANTA.. 205-7. 1991. 1998c. RODRIGUES. RODE. E. PHYSIOLOGY. 3-20. 2. 2. A. Existing mini-anchors which have this advantage makes the results more predictable and positive REFERENCES * AGUIAR. v. M. v. Estimulação elétrica neural transcutânea.. G. R. São Paulo: Ed. Oclusão. anatomical knowledge of the temporomandibular joint is of paramount importance. 1. The use of mini-anchors as a treatment of TMD was highly effective and.. Mosby-Wolfe. S. D. M. v. p.998-1002. 4ª ed. Rev. Postgrado.. p.736 CRANIOMANDIBULAR DISORDERS – ANATOMY. SANTOS. v. BARROS. 1988. [Monografia – Aprimoramento – Irmandade da Santa Casa de Misericórdia de São Paulo]. p. J. 1990. but also the complex anatomy of the Temporomandibular Joint.. 107p. Odontol Univ São Paulo. 51-9. C. oral Maxillofac. W. It is imperative for this procedure that the surgeon be aware not only of the surgical technique. J. C. ASH. – A Cefalometria nas Alterações Miofuncionais Orais – Diagnóstico e Tratamento Fonoaudiológico. Santos. J. BELL. n. et al. 1997. EDMONDSON. Odont. 3. Introducción al diagnóstico y terapia miofuncional su integración tratamiento ortopédico maxilofacial. BUCKLEY. 11. C. The study of techniques and new materials should be done constantly. Chicago: Year Book Medical Publishers. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW dislocations of the articular disc in which there is no control in eccentric mandible movements. p. ALMEIDA. L. S. – Tratamento das disfunções crâniomandibulares ATM.. Odonto Ciência. BIANCHINI. S. D. Ed.109-16. ROUT. Use of bone plates to manage chronic mandibular dislocation: report of cases. São Paulo. ANELLI. RAMFJORD. is a technique of choice when properly indicated. London: Ed. São Paulo: Ed. 11. S. one of the most complex and elaborate structures of the human body. J. M.. BROWNE. 3rd ed. SCHMIDSEDER. p. R. Rev. Interventions without an adequate preparation would not be prudent. M. M. Eminectomia articular como tratamento para luxações mandibulares recidivantes. TENS: sua aplicação nas disfunções temporomandibulares. One of the most important aspects of the use of mini-anchors is the possibility of osseointegration when used in condyles. 1988. Santos. TERRY. São Paulo. 1995. G. Pró-Fono Dep. CONCLUSIONS Based on literature review. W. Atlas of dental and maxillofacial radiology and imaging. Surg. 46. . J. 2.. A. A correct diagnosis is the key to successful treatment for this. QUINTO. B. n.. 1995.
Surg. GARCIA.. R. M. Surg. diagnóstico e tratamento dos problemas oclusais. DAWSON. Ed. Surg. M. Tratado de Fonoaudiología. Cranio. . CZLUSNIAK.. H. v. 61. oral Maxillofac. H.. L. R. 2006. M. A. São Paulo. 494. 35ª ed. p. D. . GONÇALVES. v. A. et al. 1993. Otorrinolaringol. et al. M. A.. Roca. M. n. Pathol. 1997. Oral Maxillofac. 1997. 1989. DONALDSON. 114. C. Osseous-integration of the Mitek anchor in the human condyle. PAIVA. G./fev. 2000. BELMIRO. B. M. n. FIGÚN. Avaliação. 1990. KROENING.. . L. p. 961-6. FLYNN.. 3. A comparative study of temporomandibular symptoms following mandibular advancement by bilateral sagittal split osteotomies: rigid versus non-rigid fixation. COTTRELL. H. et al. F. CARDENAS.. 4. HALE. T. 4. Oral Maxillofac. L. Longman. Mitek anchor in TMJ surgery: positional changes and condylar effects. Surg. J.. 2003. Estudo comparativo da eminectomia e do uso de miniplaca na eminência articular para tratamento da luxação recidivante da articulação temporomandibular..1-8. DATAMORE. 1999. The Mitek mini anchor in maxillofacial surgery...Avaliação radiográfica da posição condílea em pacientes portadores de más-oclusões classe II divisão 1 e classe divisão 2 de Angle. GARINO. Panamericana. Rev. N. 1973. WOLFORD. p. São Paulo: Ed. p. Am. LAPP. p. FRANCO. MADEIRA. 71. 37-45. H. London: Ed. 1995. 2008. T. Oral. Educat. R. São Paulo. MICHELOTTI. 1st ed. Oral. GRAY. p. v. 2a. 1. K.. FIELDS.. MAFEE. . Gray’s anatomy. 372–380. D. n. 2005. M. Joint vibration analysis in patients with articular inflamation. T. Williams & Wilkins. Gray’s anatomy. p. 1993. CARDOSO.. 70. ATHANASIOU. H. Dissertação (Mestrado) . PHYSIOLOGY. D. v.737 CRANIOMANDIBULAR DISORDERS – ANATOMY. 20. A. GARGANO. Treatment of recurrent dislocation of the mandible: review of literature and report of cases. 92. Rio de Janeiro: Ed. ROSENBERG. F. São Paulo: Ed. T. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW CABEZAS. p. CABEZAS. M. GRAY. 32-7.Desordens temporomandibulares.. v. 55.CEFAC: Centro de Especialização em Fonoaudiología Clínica Motricidade Oral.. WOLFORD. R.. 30..506. S. R. 272-9.Fisiologia aplicada à prática odontológica. dent. B.. Artes Médicas. Myofascial pain syndrome misdiagnosed as odontogenic pain: a case report. Edinburgh: Ed. v. C. Structure and function of the temporomandibular joint disc: implications for tissue engineering.. Crânio.. Imaging atlas of the temporomandibular joint. n. J. jan. E. 307–11. Surg. Oral. 1972. J. 18.. bras. Oral Surg. C. Pancast. FERES. 2. WOLFORD. 1995. VASCONCELOS et al.. ed.. Churchil Livingstone. Disfunções da articulação temporomandibular: Uma visão etiológica e terapêutica multidisciplinar. G. n.. J. 38ª ed. n. 1993. 57. J. Philadelphia: Ed. 1988. v. p. 1997. 26. n. E. P. M.. L. T. HEFFEZ. B. Summaries and Outlines. R. v. v. A.. 99.. Ortodontia. FAVERO. S. v. Recognition and treatment of patients with chronic orofacial pain. 150. P. A. L. FARELLA.... UNINCOR. Med. Oral Maxillofac. p. M. N. Anatomia odontológica funcional e aplicada. K. Assoc. 527-30.. BROWN. 1979. 55. DOUGLAS. A. 1997. L. E.. v. Princípios Básicos e Seqüência de Tratamento das Desordens Temporomandibulares.. J.. p.
The Mitek mini anchor for TMJ disc repositioning: surgical technique and results.. p. p. 6. C. N. – A Importância do Trabalho Fonoaudiológico Integrado a Dentistas e Psicólogos nas Disfunções da Articulação Temporomandibular. WESTESSON. J. MIRHAUG. present. p. São Paulo. 1ª ed. v. C. oral Implants Res. Anatomía da ATM. IZAWA. GREENE. Clin.. NAIDOO. MACIEL. 2009. Quintessence Publishers. F.. p. Meniscectomy for internal derangements of the temporomandibular joint. N. and future. C. MEHRA. São Paulo: Santos. 469–81. Temporomandibular disorders: the past. Endod. Br. 2006. F.C. Santos. R. p. São Paulo: Ed. OKESON. n. et al. p. 1957. TANIMOTO. LASKIN. M. 352-8. . 2001. C. N. et al. PHYSIOLOGY. 307-12. H. v. MOLINA. p. LASKIN. São Paulo. p. Dent. Toothache referred from auriculotemporal neuralgia: case report. 4.. J.. p. ATM e dores craniofaciais – Fisiopatologia básica. J.. 1998. v. R. R. v. Maxillofac. 1. J. J. 59-66. J. 10–15. L. 2009. 1990. DESPREZ.. M. Treatment outcomes of temporomandibular joint reconstruction after Proplast-Teflon implant failure. T.. KURODA. P.. J. England: Wolf Medical Publications. J. MONGINI. R. NORMAN. L. v. In: MACIEL. Surg. oral Maxillofac. Loss of osseointegration caused by oclusal load of oral implants.. Int. 15. WOLFORD. 1951. HYLANDER. ISIDOR.143. J. v. M. KIEHN. M. Clin. OLIVEIRA. TURELL. WESTESSON. B. 1983. MANNS. 2001. Acta Odontol.Pontifícia Universidade Católica de São Paulo]. Oral Surg. MACIEL. Santos. E. 2007. P. Osteoarthritis Cartilage. n. 9. 4.. ATM e dores craniofaciais–Fisiopatologia básica. BRAMLEY. p. p. oral Surg. 199–204. P. Surg.. JUNQUEIRA. 1990. A. STUGINSKI-BARBOSA. Article in press. Amer. . E. N. Temporomandibular disorders: an evidenced-based approach to diagnosis and treatment.738 CRANIOMANDIBULAR DISORDERS – ANATOMY. F. R. 441-6. 497–503.Fisiopatologia crâniomandibular: oclusão e ATM. L. L. n. S. Sistema Estomatognático. Empigraf.. 35. P. Odontology. 1991. 83. C. São Paulo: Ed. M. Passo Fundo. WOLFORD. 63-90. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW HENRY. TURELL. G. K. G. D. JUNIPER R. 7.. Morphometric analysis of the insertion of the upper head of the lateral pterygoid muscle. MURAYAMA. H. W... P. L. Scand. Santos. 1599...Oclusão e ATM: procedimentos clínicos. v. v. F. 15. MORAES. W. S. O. D.. MORAIS.. P. MACIEL.. 1ª ed.247-61. Surg. p. TURELL. Santiago: Ed. 25. 2003.. DÍAZ. v. [ Monografia . J. . 95. 1996. J. 1-7. OLIVEIRA. A clinical and radiographic study in monkeys.. N.Nonsurgical management of disc interference disorders. L. v. oral. p. S. F. A. Biomechanical and biochemical characteristics of the mandibular condylar cartilage.. 1995. F. D. p. Surgical correction of chronic dislocation of the temporomandibular joint not responsive to conservative therapy. 1962. et al. L. 1996.. P. 30. A new method of operation for habitual dislocation of the mandible – review of former methods of treatment. C. A textbook and colour atlas of the temporomandibular joint. Análise da articulação temporomandibular de pacientes adultos com artrite reumatóide por tomografia computadorizada de alta resolução.. v.. . 1993. et al. N. 51. J.. 2003. J. 1997. n. ATM e músculos craniocervicofaciais: fisiopatologia e tratamento. H. 63-90. São Paulo: Pancast. P.. 29-51. Plast. L. IRBY.. W.
A. 1. 2001. P. K.. 15-18. p. n. 9. Saunders Co. 3. P. J. F. Ned. 176-8. 4ª ed.6. Ed. L. Anat. S. KUSMA. P.61-4. STEGENGA.. SPALTEHOLZ. 1993. COSTA. SICHER. p. Artes Médicas. Tandheelkd.mandibular. J. Ortod. SOLBERG. Artes Medicas. 1. 114. Tijdschr. S. São Paulo: Ed..1997. Bone Joint Surg. I. PHYSIOLOGY.. Disfunções e desordens temporomandibulares. B. M. M. J. p. Madrid: Harcourt. Oral Radiol. CASTRO. v. S. 2 ª. Porto Alegre: Edipucrs. Surg. N. 5 a ed. focusing on the temporomandibular joint. M. 2ª ed. Gestão Saúde. G. OKESON.. Disfunções do sistema mastigatório e da articulação temporomandibular: uma cartilha para o paciente. METSARANTA. Santos. Tratamento das desordens temporomandibulares e oclusão. Rio de Janeiro: Ed. Rev. 2. v. 2000. V. J. P. 190. Current terminology and diagnostic classification schemes. 1990. M. J. São Paulo: Ed. E. 16ª ed. Oral Pathol. Médica HSVP. 8. W. W. Fundamentos da oclusão e desordens temporomandibulares. SOBOTTA. H. Craniomaxillofac. v. SARNAT. 1992.. A.. P. J. SCHOUTEN.. H. D. et al. N. 18ª ed. Period.. J. V. 36-40. 2003.83. 1999. W. R. 2a ed. 8 a ed. 2009.Guanabara Koogan. Protocolo para diagnóstico e tratamento das disfunções temporomandibulares (DTM). M. L. J. 2. SILVER. v. 83. 1994. São Paulo: Ed. v.. Endod.739 CRANIOMANDIBULAR DISORDERS – ANATOMY. 49-52. n. PAIVA. OKESON. Oral Med. OLIVEIRA. n. Meniscus injuries of the temporomandibular joint: further experiences. Interamericana. Rev.. J. OKESON. p. ABREU.. Elsevier. OKESON. KERN. 2. Manual de anatomia da cabeça e do pescoço para estudantes de odontologia. n.. p.317. v. Disfunção da articulação têmporo-mandibular em crianças: revisão de literatura. JBO. 1998.. Oclusão. v. 1989. p. Surg. J. 201–8.. Miniplate eminoplasty: a new surgical treatment for TMJ dislocation. 1997. Oral. OKESON... SOVIEIRO. 449p. v. RAMJORD. n.. 65-72. A. 1984. LASKIN. n. São Paulo: Ed. n. et al. – Current Diagnostic Classification Schema and Assessment of Patients with Temporomandibular Disorders. F. Disfunção muscular da articulação temporo . C. Rev. et al. J. Z. Oral. brasil. Med. P. n. Placas oclusais no tratamento da disfunção temporomandibular (DTM). 2007. The temporomandibular joint: A biological basis for clinical pratice. VIEIRA.. Tratamiento de la oclusión y las afecciones temporomandibulares. 5ª Ed. et al. p. 1. J. 3. M.. RHODEN. B.. P. E. M. Oral Surg. 45. NICOLINI. n. Tratamiento de Oclusión y Afecciones Temporomandibulares. 1988. B. Ortop. J. 4ª ed. São Paulo: Quintessence. P. STECHMAN NETO. C. Dores bucofaciais de Bell. Rio de Janeiro: Ed. Philadelphia: Ed.34. Mandibular pain and movement disorders. 61-4. R. ASH. I. 4th ed.. C.. SIMON. WALDHART.. Livraria Roca. Anatomia oral. DU BRUL. 1993. Oral. v. 21. 1997. Abnormal craniofacial growth and early mandibular osteoarthritis in mice harbouring a mutant type II collagen transgene.. P. Pat.. p. 113–24. p. 1991. 1963. M. D. PORTERO. Artes Médicas.. 1. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW OKESON. Maxi.. PUELACHER. 41-6... H. SAAMANEN. p. W. et al. São Paulo: Ed. v.24.1. J. Atlas de anatomia humana. RINTALA. v. . p. 1992. M. SORDI. 1997. Atlas de anatomia humana. H. OKESON. C.
Baylor Univ. B. PATHOLOGY – TREATMENT MODALITIES – LITERATURE REVIEW SZUMINSKI. v. C.. p.. Luxação da articulação temporomandibular – Revisão da literatura. p... feb. Maxillofac. M. Cirurg. M.. 33. VASCONCELOS. S. A. 13. São Paulo. v. F.143-9. VALMASEDA. 1997. C. WOLFE. SMYTHE. v. 2008. 3.. M. 2001. Oral Med. I.. S. Development and first clinical application. v. L. 98.740 CRANIOMANDIBULAR DISORDERS – ANATOMY.930–947. 92.8. E. Educ. et al. MEHRA. p. C. n.Cent. M. Mitek anchors for treatment of chronic mandibular dislocation.. 2004... oral Maxillofac. T. ORL-DIPS. p. Surg. Med. n. TMJ Disorders: Future Innovations in Diagnostics and Therapeutics. J. OLIVEIRA. n. F.CEFAC: Centro de Especialização em Fonoaudiologia Clínica Motricidade Oral. n.. 25. M. 1994. M. M. Diagnóstico y tratamiento de la patología de la articulación temporomandibular. VAN LOON. n. v. v. out. n. GAY ESCODA. L. STEHGENGA. E.Distúrbios funcionais da oclusão e sua correlação com radiografias transcranianas da articulação temporomandibular em pacientes portadores de fissuras labiopalatais. WEINBERG. 135–8. Oral pathol.. ARAÚJO. 44-52. v. p. H. 1. J. S. Oral Pathol. Cranio. L. S. KARRAS.. et al. R. L. 137-51. KAPILA. Simultaneous TMJ and orthognathic surgery. n.. P. Eminectomy and meniscorhaphy for internal derangements of the temporomandibular joint. 273-82. Custom-made total joint prosthesis for temporomandibular joint reconstruction. oct.. YUNUS. BMF. 29. Oral Med. et al. WADHWA. p. 495–8.. Endod. Int. Rev. p. v. p... p. TAKAHASHI. 52.. Temporomandibular joint devices: Treatment factors and Outcomes. DE BONT. Oral Radiol. B. L.. UNESP. dent. Arthritis Rheum./dez. DALLAS. A. The American College of Rheumatology 1990 criteria of the classification of fibromyalgia. p. 24.. 1-8. p. 4. WOLFORD. D. 1984. oral Surg. . 1999.. WOLFORD.72. S.. v. 2. MEHRA. Rev. 2000. Oral Radiol.. M. n. Groningen temporomandibular joint prosthesis. 2002. M. 160-72. 218-22. Odontol. B. Traumat. 2007. J. Surg. L. p.. C. o0o . J. 55-70. C.. v. Proc. Oral. CAMPELLO. 4. 241-9.83. P. WOLFORD. WOLFORD. 1995. WOLFORD. 57. Endod. Clinical indications for simultaneous TMJ and orthognathic surgery. Dissertação (Mestrado) . Oral Surg. E... M. PHYSIOLOGY. J. Oral Surg. 1. v. PITTA. 2002. 1990. 31. 4. A. P. M. A Fonoaudióloga e as Disfunções da Articulação temporomandibular. G. v.
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