Dr Zaheed Patel

 Temporomandibular disorders-conditions
producing abnormal, incomplete, or impaired
function of the temporomandibular joint(s)
JPD 2005
 Pain dysfunction syndrome (PDS) is the most
common temporomandibular disorder (TMD)
 Fascial arthromyalgia, TMJ dysfunction
syndrome, myofacial dysfunction syndrome,
craniomandibular dysfunction and
myofascial pain dysfunction syndrome (Gray,
Davies & AA, 1994).
 Masticatory muscle disorders

 TMJ articular disorders

 Masticatory muscle disorders
 Myofacial pain
 Myositis
 Muscle spasm
 Muscle contracture
 TMJ articular disorders
 Disk Derangement Disorders
 Osteoarthritis (Non-inflammatory disorders)
 Inflammatory Disorders
 Hypermobility disorders
 Hypomobility( Ankylosis)
 Traumatic Injuries
 Congenital or Developmental Disorders
 Neoplasia
 Myofacial pain
 Myositis
 Muscle spasm
 Muscle contracture
• It can be acute or chronic and includes trigger
points that manifests as taut skeletal
muscles, tendons or ligaments.
• The pain that arises can occur most of the
time at the trigger point but can also be
referred to another area.
• An important diagnostic criterion is
reproducible duplication of the pain with
specific palpation (Fricton, 2007)
• Muscle spasm is an acute disorder.
• There is involuntary contraction of the muscle.
• It results from over stretching of a previously
weakened muscle, protective splinting of an
injury, it is centrally mediated.
• A muscle in spasm is acutely shortened, painful
with a limited range of movement.
• If the lateral pterygoid muscle is in spasm, then
there can be a shift of the occlusion to one side
(Fricton, 2007).
• Muscle contracture is a chronic condition.
• It is characterised by gross shortening of the
muscle with a significant limited range of
movement.
• Trauma, infection or hypermobility can induce
this condition.
• Muscular fibrosis and contracture can develop if
the muscle remains in its shortened state.
• There is little to no pain unless the muscle is
forced to lengthen (Fricton, 2007).
 Myositis is an acute condition.
 It manifests as localised or generalised
inflammation of the muscle and connective
tissue.
 There is an associated pain and inflammation
resulting in tenderness of the muscle.
 Pain is common during motion.
 The inflammation is due to local causes, such
as overuse, excessive stretch, drug use, local
infection (pericoronitis), trauma or cellulitis
 Pain
 Muscle Tenderness
 Limited range of motion
 The common sites for pain include jaw pain,
facial pain, temple, frontal, or occipital
headaches, preauricular pain, earache and
neck pain.
 Pain varies from hours to days.
• In myofacial pain the trigger points are deep,
localised and about 2-5mm in diameter.
• It is located in a taut band of skeletal muscle and
is associated with consistent patterns of pain
referral, but in myositis and muscle spasm the
pain can be generalised over the whole muscle.
• Myofacial trigger points are common and are
either active or latent.
• Active trigger points are hypersensitive and have
continuous pain whereas as latent trigger points
do not have pain but are hypersensitive.
• In myofascial pain, limitation in the range of
motion may be slight (10-20%) whereas in
muscle spasm, myositis, and contracture it
may be gross (≥50%).
• Myofacial pain patients demonstrated a
slightly diminished range of 35mm to 45mm.
• This is considerably less than was found in
joint locking that is due to TMJ internal
derangement (Fricton, 2007
• Okeson describes the ideal TM position in this as the
“optimum functional relationship”.
• Okeson defines CR and its clinical importance, as:
“The occlusal examination begins with an observation
of the occlusal contacts when the condyles are in their
optimum functional relationship. This is when they are
in the CR position, located most superoanteriorly in
the mandibular fossae and braced against the
posterior slopes of the articular eminences with the
discs properly interposed (musculoskeletally stable).”
•
• ideal TM position is and be able to use the
technique required to find this position.
• The proper or ideal TM position has been a
source of intense debate.
• Dental students were taught to retrude the
mandible to its most superior location to find a
reproducible position for restoration.
• However, few patients — approximately 15
percent — can tolerate this position, known as
centric relation (CR). (Olmos, 2008)
 An occlusal appliance (splint) is a removable
device, usually made of hard acrylic, which
fits over the occlusal and incisal surfaces of
the teeth in one arch, creating precise
occlusal contact with the teeth of the
opposite arch.
 It is commonly referred to as a bite guard,
night guard, interocclusal appliance or even
an orthopaedic device (Okeson, 2002).
 Reversible Occlusal Therapy
 Irreversible Occlusal Therapy
 There are various types of occlusal splints
(bite plates or intra-oral appliances of
variable designs used in the management of
TMD) described in the literature and they
have different indications and functions.
 The stabilisation splint (SS) is one such type of
occlusal splint and is also known as the Tanner
appliance, the Fox appliance, the Michigan
splint or the centric relation appliance.
 The stabilisation splint is a hard acrylic splint
that provides a temporary and removable ideal
occlusion (Gray,1995).
 Providing an ideal occlusion by the use of splint
therapy reduces abnormal muscle activity and
produces’ neuromuscular balance’ (Al-Ani etal,
2004).
 All splints are classified as either permissive
or nonpermissive (directive)
 A permissive splint allows the teeth to move
on the splint unimpeded, which in turn allows
the condylar head and disk to function
anatomically.
 Examples of permissive splints include bite
planes (anterior jigs, Lucia jig, anterior
deprogrammer) and stabilization splints (flat
plane, Tanner, superior repositioning, and
centric relation.
 . A nonpermissive splint has a ramp or
“indentations” that position the mandible
inferiorly and anteriorly and secure it there
 An example of a nonpermissive splint is a
repositioning splint (anterior repositioning
appliance). S
 To relax the muscles,
 To allow the condyle to seat in CR,
 To provide diagnostic information,
 To protect teeth and associated structures
from bruxism,
 To mitigate periodontal ligament
proprioception, and
 To reduce cellular hypoxia levels (Dylina,
2001
 It has been well documented that tooth
interferences to the CR arc of closure
hyperactivate the lateral pterygoid muscle
(Ramford and Ash, 1983); posterior tooth
interferences during excursive mandibular
movements cause hyperactivity of the closing
muscles (Manns etal, 1993); and the elimination
of posterior excursive contacts by anterior
guidance significantly reduces elevator muscle
hyperactivity (Williamson 1983).
 stability;
 balance in CR;
 equal intensity stops on all teeth;
 immediate posterior disclusion;
 a “skating rink” surface;
 smooth transitions in lateral, protrusive,
and extended lateral excursions (crossover);
 comfort during wear; and
 reasonable esthetics.
 This splint is generally used to treat muscle
hyperactivity
 wearing it can decrease the parafunctional
activity that often accompanies periods of
stress
 This appliance encourages the mandible to
assume a position more anterior than the
intercuspal position
 Its goal is to provide a better condyle disc
relationship in the fossae
 The goal of treatment is not to alter the
mandibular position permanently but only to
change the position temporarily so as to
enhance adaptation of the retrodiscal
tissues
 This appliance is used primarily to treat disc
derangement disorders
 Patients with joint sounds can sometimes be
helped with it.
 Intermittent or chronic locking of the joint
can also be treated with it.
 Some inflammatory disorders are managed
with this appliance, especially when a slight
anterior positioning of the condyles is more
comfortable for the patient.
 The NTI-tss (Nociceptive Trigeminal Inhibition-
tension suppression system) device is a small
pre-fabricated anterior bite stop which covers –
in its most widely used form – the two maxillary
(or mandibular) central incisors
 The fit along the teeth is accomplished at the
chair side by filling either an autopolymerising
acrylate or a thermoplastic material into the
base of the device, which is subsequently
adapted along the central incisors, thereby
increasing the vertical dimension between the
upper and lower jaw.
 prophylactic treatment of medically
diagnosed migraine pain
 the prevention of bruxism and TMJ syndrome
through reduction of trigeminally innervated
muscular activity.
 Studies by Hansen etal 2007 revealed that a
strong and lasting inhibition of EMG activity
in masseter muscles during sleep was caused
by wearing the NTI splint compared to the
SS.A study cited by Hansen 2007 also
indicated that patients who were on long
term treatment with the NTI had harmful
occlusal changes.
 It is a hard acrylic appliance worn over the
maxillary teeth, providing contact with only the
mandibular anterior teeth in all movements.
 It is primarily intended to disengage the
posterior teeth and thus eliminate their
influence on the function of the masticatory
system. It must extend far enough labially so
that the patient cannot protrude past the edge
of the appliance or retrude far enough to lock
behind it.
 It is indicated for the treatment of muscle
disorders related to orthopaedic instability
or an acute change in the occlusal condition.
 Parafunctional activity may also be treated
with it but only for short periods.
 The posterior bite plane is usually fabricated
for mandibular teeth and consists of areas of
hard acrylic located over the posterior teeth
and connected by a cast metal bar.
 The treatment goals of this bite plane are to
achieve major alterations in vertical
dimension and mandibular positioning
 Posterior bite planes have been advocated in
cases of severe loss of vertical dimension or
where there is a need to make changes in
anterior positioning of the mandible.
 The use of this device may be indicated for
certain disc derangement disorders. The concern
is that this appliance can allow supraeruption of
unopposed teeth or intrusion of the occluded
teeth.
 It should not be used constantly and for long
term use
 The pivoting appliance is a hard acrylic device
that covers one arch and provides a single
posterior contact in each quadrant.
 This contact is far back as possible. When an
upward force is applied to the chin, the
anterior teeth move closer together and pivot
the condyles downward around the posterior
pivoting point
 This appliance was developed with the idea
that it would lessen interarticular pressure
and thus unload the articular surfaces of the
joint. This was thought to be possible when
the anterior teeth moved closer together,
creating a fulcrum around the second molar
and pivoting the condyle downwards away
from the fossa.
 However this is only possible if the forces that
close the mandible are located anterior to the
pivot. Unfortunately, the forces of the
elevator muscles are located posterior to the
pivot and hence do not allow a posterior
pivoting action. The anterior positioning
device is more suitable for treating joint
sounds, since it provides better control of the
positional changes
 It is usually fabricated of resilient material
that is usually adapted to the maxillary teeth.
 Treatment goals are to achieve even and
simultaneous contact with the opposing
teeth.
 likely to receive trauma to their dental arches.
Protective athletic splints decrease the
likelihood of damage to the oral structures when
trauma is received.
 Soft appliances have also been recommended
for patients who exhibit high levels of clenching
and bruxism. It seems reasonable that soft
appliances should help dissipate some of the
heavy loading forces encountered during
parafunctional activity.
 However, soft appliances have not been
shown to decrease bruxing activity. A study
by Okeson in 1987 demonstrated that
nocturnal masseter EMG activity was
increased in 5 of 10 patients with a soft
appliance. The opposite occurred when a
hard stabilization appliance was used, 8 of
the 10 patients had significant reduction of
nocturnal EMG activity.
 The Bite Soft splint is a removable mouth
piece that is worn over the teeth during sleep
and is a very effective solution for Bruxism.
Many scientific studies demonstrate that
splints are extremely effective in preventing
or reducing headaches and jaw pain (Loke
etal 2005, Becker etal 1999, Dahlstroom etal
1989).
 comfortable to wear
 smaller than a full arch splint
 offers the same protection from Bruxism as a
full arch splint
 reduces clenching and associated head and
jaw pain (unlike full arch splints)
 The answer is communication.
 demonstrate an experience that conveys to
the patient this concept of force and the need
for control.
 Worn crayons are the last physical prop that
can be used to demonstrate the mechanics of
tooth wear.
 How do we know if patients wear their splint?
 small articulator mark
 to credit them
 A review of the literature has led me to
conclude that careful patient selection for
TMD treatment using oral appliances is
mandatory
 There are various types of oral appliances
that function as orthotics, move the mandible
forward, and prevent grinding and clenching
 The chosen appliance must maximize
treatment outcomes and minimize undesired
side effects.
 Some oral appliances have been found to be
highly effective in the management of TMDs.
 The successful treatment of TMDs is a team
effort, and splint therapy is only one aspect.