TEMPOROMANDIBULAR DISORDERS: AN OVERVIEW AND ITS ASSOCIATION WITH PARAFUNCTIONAL ACTIVITY

Naveen Mohan Mentors: Dr. Grace and Dr. Greenspan

MR. M

INITIAL APPOINTMENT

Patient presented to PCC SOTD (8/2010)

CC: Sensitivity of UL quadrant. Pain and clicking in UR quadrant

Pain had been occurring for 3 months History of seeking urgent care only Several failed appointments

Patient of record since 2007

Right masseter/temporalis muscles tender to palpation Multiple caries present Temporary crown #14 missing Heavy occlusal wear Prescribed 10mg Flexeril no more than TID Instructed patient to seek comprehensive care

MEDICAL HISTORY
Type II Diabetes Hypertension Coronary Artery Disease LAD stent (11/2008)

MEDICAL HISTORY (CONTD)

Medications:
Crestor

5mg Plavix 75mg ASA 325mg Ramipril 5mg Glipizide 5mg / BID Metformin 500mg / BID

DENTAL HISTORY
Several amalgam restorations One composite restoration 3 PFM crowns #14 prepared for crown,

CLINICAL EXAMINATION
Heavy cuspal wear in posterior region Generalized gingivitis Missing #1, #31 Defective O amalgam restorations on #2, #15, #16, #17, #29 #30 occlusal table worn away Generalized spacing

ANTERIOR VIEW

RIGHT QUADRANTS

LEFT QUADRANTS

MAXILLARY ARCH

MANDIBULAR ARCH

TREATMENT PLAN
Extraction: #2, #16, #17, #32 Prophy Core build-up: #15 and #29 All metal crown: #14, #15, #29, #30 Occlusal guard Consultation with Dr. Grace

MEDICAL CONSULT

Medical Consult
Indicated

to ensure stable cardiovascular state Indicated to ensure diabetes well controlled

Medical Consult returned

Patient

cleared for dental treatment Stable HbA1c (actual level not indicated on consult) Hypertension stable

TMD CONSULTATION
Examination performed by Dr. Grace Used stethoscope on TM joint to examine clicking

Noise

heard upon opening

Palpated masticatory muscles

Knot

detected along right lateral pterygoid muscle Patient felt discomfort upon palpation of this area

Inquired about parafunctional habits

Patient

reported bruxing/clenching habit

TMD CONSULTATION

Recommendations
3rd molars in order to eliminate occlusal interferences and stabilize occlusion Restore dentition to stabilize occlusion Massage right lateral pterygoid daily intraorally Fabrication of occlusal guard
Extract

THE TEMPOROMANDIBULAR JOINT

ANATOMY

Temporomandibular joint is the articulation of mandibular condyle with the squamous portion of the temporal bone

From Okeson, Jeffrey P. Management of Temporomandibular Disorders and Occlusion, 6th ed. St. Louis: Mosby, Inc., 2008.

ANATOMY - BONES

Temporal bone
Articular

eminence

From Okeson, Jeffrey P. Management of Temporomandibular Disorders and Occlusion, 6th ed. St. Louis: Mosby, Inc., 2008.

ANATOMY - BONES

Temporal Bone
Mandibular

Fossa

From Okeson, Jeffrey P. Management of Temporomandibular Disorders and Occlusion, 6th ed. St. Louis: Mosby, Inc., 2008.

ANATOMY - BONES

Mandible
Condyle

From Okeson, Jeffrey P. Management of Temporomandibular Disorders and Occlusion, 6th ed. St. Louis: Mosby, Inc., 2008.

ANATOMY - LIGAMENTS

Capsular Ligament
Encases

entire TMJ Attachments Temporal bone and condylar neck Lined with specialized endothelial cells which produce synovia
Acts

as lubricant Medium for transportation of nutrients to articular disc due to lack of vascularization

ANATOMY - LIGAMENTS

Capsular Ligament

From Okeson, Jeffrey P. Management of Temporomandibular Disorders and Occlusion, 6th ed. St. Louis: Mosby, Inc., 2008.

ANATOMY - LIGAMENTS

Lateral Ligament aka Temporomandibular ligament

Runs along lateral aspect of the TMJ Attachments: temporal and zygomatic bone (superiorly), condylar neck Prevents excessive mouth opening and posterior movement of condyle Essential for translation of the mandible.

Once

ligament becomes taut, translation initiated and rotation inhibited Fun fact: This function of the TM ligament is uniquely human

ANATOMY - LIGAMENTS

Lateral Ligament
Outer

oblique Inner horizontal

From Okeson, Jeffrey P. Management of Temporomandibular Disorders and Occlusion, 6th ed. St. Louis: Mosby, Inc., 2008.

ANATOMY - LIGAMENTS

Accessory ligaments
Sphenomandibur
No

ligament

significant effect on TMJ

Stylomandibular
Limits

ligament

excessive protrusion of mandible

ANATOMY - MUSCLES
Part of the masticatory system and TMJ Muscles of Mastication Suprahyoid muscles

Posterior

and anterior digastric muscle

Infrahyoid muscles

ANATOMY ARTICULAR DISC

Composed of dense fibrous connective tissue Not vascularized (synovia delivers nutrients) Slightly innervated Attaches to retrodiscal tissue posteriorly

Highly

vascularized and innervated

Attaches to capsular ligament via discal ligaments

Separates

joint into superior and inferior cavity

ANATOMY ARTICULAR DISC

Regions

From Okeson, Jeffrey P. Management of Temporomandibular Disorders and Occlusion, 6th ed. St. Louis: Mosby, Inc., 2008.

ANATOMY

Innervation
Auriculotemporal

nerve (branch of CN V3)

Vascularization
Superficial

temporal artery Middle meningeal artery Internal maxillary artery

BIOMECHANICS

TMJ is a ginglymoarthroidial joint

Ginglymo
Takes

hinging or rotation movement

place in the inferior joint space Condyle and inferior border of articular disc
Arthroidial
Takes

gliding or translation movement

place in superior joint space Articular disc and articular eminence

BIOMECHANICS

In healthy state, articular disc always situated between condyle and eminence

From Okeson, Jeffrey P. Management of Temporomandibular Disorders and Occlusion, 6th ed. St. Louis: Mosby, Inc., 2008.

TEMPOROMANDIBULAR DISORDER

THE MASTICATORY SYSTEM

OUR SYSTEM 3 Major functions

Mastication Speech Swallowing

TMJ is an integral part of the system

DEFINITION

According to the textbook, Management of Temporomandibular Disorders and Occlusion, TMD is defined as any functional disturbance of the masticatory system

DEVELOPMENT OF TMD
If an event causes a part of the system to exceed its physiologic tolerance, then the system responds Normal function + Event > Physiologic tolerance TMD symptoms

DEVELOPMENT OF TMD
Normal function + Event < Physiologic tolerance TMD symptoms Each component of the masticatory system has some degree of physiologic tolerance to events. Once the threshold is exceeded, symptoms will arise.

DEVELOPMENT OF TMD

Normal function + Event < Physiologic tolerance TMD symptoms The threshold for each component varies from person to person

E.g. Neurons, muscles, teeth, bones, disc, ligaments, etc

The weakest link in the chain will break first

The component with the lowest threshold will be the first to cause disfunction
From Okeson, Jeffrey P. Management of Temporomandibular Disorders and Occlusion, 6th ed. St. Louis: Mosby, Inc., 2008.

DIAGNOSIS OF TMD

TMDs can be classified into four broad categories

1.

Masticatory Muscle Disorders 2. Temporomandibular Joint Disorders 3. Chronic Mandibular Hypomobility 4. Growth Disorders

DIAGNOSIS OF TMD

From Okeson, Jeffrey P. Management of Temporomandibular Disorders and Occlusion, 6th ed. St. Louis: Mosby, Inc., 2008.

MASTICATORY MUSCLE DISORDERS MYOGENOUS TMDS

Muscle pain is the most common cause for persistant pain in the head and neck region
50%

of chronic head and neck pain are myogenous

Category has 5 TMD diagnoses

MYOGENOUS TMDS

Protective Co-contraction
Increased activity of antagonist muscles during agonist function. E.g. increased lateral pterygoid action during occlusion of mouth Normal process (protective), however, can be pathologic Potential Causes

Altered

sensory/proprioceptive input

E.g. placing a high crown

Constant

deep pain input

emotional stress

E.g. pulpitis

Increased

MYOGENOUS TMDS

Local Muscle Soreness

Local

changes to muscle tissue causing pain or discomfort Aka non-inflammatory myalgia Potential causes:
Protective

co-contraction Trauma (including excessive function) Emotional stress Idiopathic myogenous pain

MYOGENOUS TMDS

The rest:
Myofascial pain, myospasm, centrally mediated myalgia Unlike first two, these conditions have heavy CNS influence CNS can be the origin, e.g. upregulation of ANS or hypersensitization of peripheral neurons Local factors (such as soreness or protective cocontraction) can cause and increase CNS influence locally Although not specifically a TMD, the systemic condition of fibromyalgia can also be considered part of this category

DIAGNOSIS OF TMD

From Okeson, Jeffrey P. Management of Temporomandibular Disorders and Occlusion, 6th ed. St. Louis: Mosby, Inc., 2008.

TMJ DISORDERS
Disorders of the temporomandibular joint 3 categories within TMJ disorders

Derangements

of the Condyle-Disc Complex Structural incompatabilities Inflammatory disorders of the joint

DERANGEMENTS OF THE CONDYLE-DISC COMPLEX

Most common etiologic factor associated with these types of injuries is trauma
Includes

macrotrauma and microtrauma

Can occur due to elongation of discal ligaments (attach disc to capsular ligament) Can occur when posterior zone of disc becomes thinner 3 Diagnoses under this category

DERANGEMENTS OF THE CONDYLE-DISC COMPLEX

Disc Displacement
Usually

an anterior displacement May or may not be painful Often associated with a single or double click during opening/closing Disc articulates with condyle at rest

DERANGEMENTS OF THE CONDYLE-DISC COMPLEX

Disc Dislocation with Reduction

Disc and condyle no longer articulate at rest dislocation Reduction disc relocated during function into physiologic position Associated with a history of clicking sounds with recent catching sensation

From Okeson, Jeffrey P. Management of Temporomandibular Disorders and Occlusion, 6th ed. St. Louis: Mosby, Inc., 2008.

DERANGEMENTS OF THE CONDYLE-DISC COMPLEX

Disc Dislocation without Reduction

Disc prevents condyle from translating Very limited mouth opening hard end feeling at maximum opening Usually present with history of disc dislocation with reduction

From Okeson, Jeffrey P. Management of Temporomandibular Disorders and Occlusion, 6th ed. St. Louis: Mosby, Inc., 2008.

TMJ DISORDERS
Disorders of the temporomandibular joint 3 categories within TMJ disorders

Derangements

of the Condyle-Disc Complex Structural incompatabilities Inflammatory disorders of the joint

STRUCTURAL INCOMPATIBILITIES
Incompatibility of the articular surfaces Can result from a variety of reasons:

Anatomic

defects Adherence or adhesion of the articular disc Subluxation of the TMJ Spontaneous dislocation (aka open lock)

TMJ DISORDERS
Disorders of the temporomandibular joint 3 categories within TMJ disorders

Derangements

of the Condyle-Disc Complex Structural incompatabilities Inflammatory disorders of the joint

INFLAMMATORY DISORDERS OF THE JOINT

Patient is usually in deep, constant pain Includes inflammation of muscles, ligaments or any component of masticatory system Can be caused by other TMDs Can also be caused by osteoarthritis or rheumatoid arthritis

TMD

arising from RA is almost always bilateral

ETIOLOGY OF TMD

ETIOLOGY
Complex and multifactorial Predisposing factors

Increase

the risk of TMD development

Initiating factors
Cause

onset of TMD symptoms

Perpetuating factors
Interfere

with healing or enhance progression of

TMD

ETIOLOGY

5 major factors are associated with TMDs

Occlusal
Trauma Emotional

condition

Stress Deep pain input Parafunctional activity

PARAFUNCTIONAL ACTIVITY
Any activity of the masticatory system aside from mastication, speech, and swallowing Examples: clenching, bruxing, nail-biting

LITERATURE REVIEW

Glaros, A, et al. Prospective Assessment of Parafunctional Activity in Temporomandibular Disorder Patients. Journal of Dental Research 81 (2002): A-458. 45 participants diagnosed with myosfacial pain, disc displacement, arthralgia, or no TMD participated All subjects given pagers. Every two hours during nonsleep time, they were signaled to take a questionnaire concerning the amount of tooth contact time. Limitations: small sample size, self-reporting study, data is not very objective Conclusions: Higher levels of parafunctional activity were associated with a greater likelihood of receiving a diagnosis of TMD.

LITERATURE REVIEW

Glaros, A, et al. The Role of Parafunctions, Emotions and Stress in Predicting Facial Pain. Journal of the American Dental Association 136 (2005): 451-458. Same design study and limitations Pool is now 96 subjects Expanded questionnaire: now included questions regarding current facial pain, muscle tension, mood, and stress levels Conclusions: Parafunctional behaviors, especially those that increase muscle tension, and emotional states are good predictors of jaw pain levels in patients with TMD and healthy control subjects.

LITERATURE REVIEW

Carlsson, GE, et al. Possible Predictors of Temporomandibular Disorders: What are the possible Predictors of Signs and Symptoms of TMD in the LongTerm? Evidence-Based Dentistry 4 (2003): 55. 20 year cohort study with 402 randomly selected subjects in groups aged 7, 11, and 15 at initiation After 20 years, 320 subjects responded to questionnaire 100 of the subjects from the 15 year old group were examined clinically after 20 years Limitations: Majority of data based on self-reported data Conclusion: Presence of bruxism, oral parafunctions, TMJ clicking and deep bite at baseline were found to be significant predictors of TMD

LITERATURE REVIEW

Manfredini, D., et al. Relationship between Bruxism and Temporomandibular Disorders: A Systematic Review of Literature from 1998-2008. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 109 (2010): e26-50. Systematic literature review Using the PubMed database, 46 articles met the selection criteria, 21 of which were studies with questionnaires Conclusion: Positive association between bruxism and TMD pain. However, as studies became more quantitative and specific regarding the diagnosis of bruxism, the association grew weaker

ASSOCIATIONS BETWEEN NOCTURNAL ACTIVITY AND EMOTIONAL STRESS

From Okeson, Jeffrey P. Management of Temporomandibular Disorders and Occlusion, 6th ed. St. Louis: Mosby, Inc., 2008.

MASTICATORY FUNCTION

From Okeson, Jeffrey P. Management of Temporomandibular Disorders and Occlusion, 6th ed. St. Louis: Mosby, Inc., 2008.

CONCLUSIONS
One or many components of the masticatory system can be affected resulting in TMD Actual causes of TMD are still being researched No clear cause and effect relationship has been found between parafunctional activity and TMD

REFERENCES

Okeson, Jeffrey P. Management of Temporomandibular Disorders and Occlusion, 6th ed. St. Louis: Mosby, Inc., 2008. Glaros, A, et al. Prospective Assessment of Parafunctional Activity in Temporomandibular Disorder Patients. Journal of Dental Research 81 (2002): A-458. Glaros, A, et al. The Role of Parafunctions, Emotions and Stress in Predicting Facial Pain. Journal of the American Dental Association 136 (2005): 451-458. Carlsson, GE, et al. Possible Predictors of Temporomandibular Disorders: What are the possible Predictors of Signs and Symptoms of TMD in the Long-Term? Evidence-Based Dentistry 4 (2003): 55. Manfredini, D., et al. Relationship between Bruxism and Temporomandibular Disorders: A Systematic Review of Literature from 1998-2008. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 109 (2010): e26-50.

QUESTIONS?

QUIZ
1. Which structure seperates the TMJ capsule into a superior and inferior cavity? A: The Lateral Pterygoid muscle B: The capsular ligament C: The Articular disc D: The Retrodiscal tissue

2. Which one of the following is not considered one of the five major factors associated with TMD? A: Emotional Stress B: Sleep Apnea C: Trauma D: Occlusion

3. With disc dislocation without reduction, the patient ability to open maximally is not really affected. TRUE/FALSE

4. Which TMD is almost always affects the TMJ bilaterally A: Disc Dislocation with Reduction B: Osteoarthritis C: Retrodiscitis D: Rheumatoid arthritis

5. Studies are conclusive that bruxism is a causative factor in the development of TMD. TRUE/FALSE