temporomandibular joint & orthodontics-seminar
TRANSCRIPT
8/4/2019 Temporomandibular Joint & Orthodontics-Seminar
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& Orthodontics
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Take Home Message
• s gns an symp oms appear n ea y n v ua s.•The signs and symptoms usually increase with age.
related to treatment.•Orthodontic Tx does not increase / decrease odds of TMD.• o spec c r s s assoc ate w t any part cu ar ort o ont c
mechanics.
result in TMD.•No method of TMD prevention has been demonstrated.
• MD signs and symptoms usually are alleviated by simple Txin most cases.
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Questions to be answered
• What impact does occlusion have on TMJ disorders ?
• Does orthodontic treatment cause TMD ?•
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Gross Anatomy
•TMJ
– r cu a on e ween
the mandibular condyleand the mandibularfossa of the temporal
bone
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• An articular disc
joint space into upper
–Posterior attachment of
disc to condyle andtemporal bone
–Loose fibrous connective
– Vascular and innervated
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Muscle Insertion
•Primary insertion is
muscle to the anterior
and a few muscle
fibers inserting intothe anterior band of the disc
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Innervation
Mandibular division of the trigeminal nervew ith some primary
auricuotemporalnerve and the
r rv
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Blood Supply
•Blood supply is fromt e maxi ary an
superficial temporal
external carotid artery
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TMJ – A Synovial Joint
• Load bearing surfaces which are
avascu ar an no nnerva e• Lubrication by synovial fluid
– Less than 1 cc of synovial fluid per
compartment• Fibrous capsule contains synovial fluid
and maintains relationship between
joint components during function
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• Difference between TMJ and other
synov a o n sStructure: The TMJ has an articular disc whichcomp ete y v es t e o nt space nto
separate upper and lower joint. .
Function : the TMJ is a Hinge-sliding joint
– sliding action (translation – upper)
Complex structure & complex function
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Biomechanics
Hinge / sliding joint
between the condyleand the inferior surfaceof the disc during early
opening• rans a on s ngbetween the disc-cond le com lex andthe temporalcomponent during
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Biomechanics
•During opening the
on the condyle
between the condyle
and the temporalcomponent
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Histological Features
• The osseous tissues of the condyle and
articular “soft tissue” which as the
– Articular zone of fibrous connective tissue -
Functional – Proliferation zone of undifferentiated
mesenchymal cells – Progenitor cells of the
car age ayer – Cartilage zone – Hyaline cartilage which is
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TUBERCLE COVERING
OSSIFICATION
CALCIFICATION
PROLIFERATIVE II}
(FIBROUS) I
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MATURE CONDYLAR LAYERS
ARTICULAR I
PROLIFERATIVE II
FIBROCARTILAGE III
OSSIFICATION
new bone on calcifiedcartilageSUBCHONDRAL
BONE TRABECULAE
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ARTICULAR
TUBERCLE/u er s novial cavit
TMJ
GLENOID FOSSA PROTUBERANCE/ EMINENCE
lower synovial cavitylower synovial cavity
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• The articular surfaces of the TMJ arecovered w ith fibrous connective tissue
not hyaline cartilage, as in most others novial oints
MANDIBULAR CONDYLE
Condylar cartilage(not all cartilage)
Spongy bone
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• The posterior attachment is composed of oose rous ssue w vascu ar y aninnervation
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Adaptive variations
– Articular surface irregularities (deviation in
• orp o og ca c anges may a er o n
biomechanics and/ or produce jointsoun s suc as c c ng or crep a on
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Adaptive variations
• The apparent potent ial of the TMJ for
rationale for conservative treatment
and disability rather than correcting
altered mor holo
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Embryology
• TMJ develops between 8 – 14 weekscompare o - wee s or o ersynovial joints
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Embryology – TMJ
• 10 – 11 weeksOssification of the temporal components begins
• 12 w k – the condylar cartilage is present at the most
superior aspect of the ramus. – e em ryon c connec ve ssue mesenc ymebetween the grow ing condyle and temporal bonecondenses to form the articular disc
• 13 weeks –
then the upper compartment
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• 14 weeks
– Joint development completed
• Persistence of the condylar cartilage as
the cartilage zone of the articular softtissue is presumed to contribute to theadaptation capacity of the adult condyle
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Pathologic symptoms and signs-TMD
• Definition:
– Collection of medical and dental conditionsaffecting the temporomandibular joint
r u , was contiguous tissue components.
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Prevalence of TMD
• 32% of population report at least one
– Difficulty opening
–
– Pain on movement
–
– Muscle fatigue
–
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Historical Perspective
• Thompson was the first to note patients w ith
to TMD – Advocated the elimination of all interferences in
“freeway space” envelope of movement
• T. Graber w as the first to note the,
only one factor – Cited stress and nocturnal parafunctional habits as
contributors – Advocated psychological counseling as part of
thera
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Questions to be clarified
emporo
Disturbances Mandibular
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emporo
Treatment
Mandibular
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Prevalence
,
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In primary dentitions,
I d lt ti t ?
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Schmit ter et al., J Oral Rehab il. 2005 Jul;32(7):467-73
In adult patients?
Fifty-eight geriatric patients VS. 44 young subjects
•Geriatric subjects more often exhibited objective
opening), but rarely suffered from pain (pain at rest: 0%,
joint pain: 0%, muscle pain: 12%).
•In contrast, young subjects rarely exhibited objective
symp oms o n soun s: , u su ere morefrequently from pain (facial: 7%, joint pain: 16%,.
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Q 1: Is there prevalence data which shows that one typeQ 1: Is there prevalence data which shows that one typeof malocclusion is more likely to be associated w ith a TMD?of malocclusion is more likely to be associated w ith a TMD?
• There is no association between overbite or overjet
John et al., J Dent Res. 2002 Mar;81(3):164-9.
and self-reported TMD. N= 3033
• 82 asymptomatic volunteers vs. 263 symptomatic
MD atientsLiterature does not suggest that replacement of missing posterior teeth prevents the development of
MDs. However, missing man i u ar posterior teetmay accelerate the development of degenerative
.
Talents et al., J P rosthet Dent. 2002 Jan;87(1):45-50.
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• Few malocclusions except socioeconomic parameters
were assoc a e w s gns, an ese assoc a onswere mostly weak.
clinically relevant and was associated with TMD signsodds ratio OR = 4.0 . This malocclusion however
was of rare occurrence, with a prevalence of 0.3% (n =
9).Sample size of 4310 men and women aged 20 to 81 years(response 68.8%) was investigated for TMD signs, malocclusions,
using multiple logistic regression analysis
Gesch et al., Angle Orthod. 2004 Aug;74(4):512-20
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emporo
Disturbances Mandibular
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Q2: Is there any prevalence data which shows that onetype of occlusion (for instance, canine guidance) is
more likely associated w ith TMD?
u r
Looked at predictive values of occlusal variables in TMD
normals.
he predictive power of the occlusal values was low(odds ratio of 2:1)Patients with disc displacement were characterized by
n atera cross te an ong - s es.Patients with osteoarthritis were related with very long
No variable was associated w ith canine guidance
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Q 2-1 Are canine guidance (CG) and joint clicking related?
., -
In non-patients (n=46) and patients (n=46,with clicking)
In non-Pts, 70% without CG and 30% with CG, .
In both Pts and non-Pts61% with non-CG and 38% with CG.
No-evidence that both distal (retrusive) and mesial(protrusive) CG was associated with ipsilateral
.
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Q3, Is there a relationship between disc derangement
Kahn et al., J Prosthetic Dent 1999, 82: 410-5
.
Q 4: How often do post orthodontic cases show
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Q. 4: How often do post-orthodontic cases showbalancing interferences?
Non-working side contacts occurred in 30% of subjects.n pos er or con ac s on pro rus on n .
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orthodontic treatment
and increased likelihood of getting a
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Questions
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Questions
addressed by the NIH technology assessment
conference, 1996
as TMD and w hat occurs if these areuntreated?
2. What signs and symptoms provide a
basis for init iat in intervention?3. What are effective initial therapies?
persistent TMD?
1 What clinical conditions are classified as TMD and what
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1. What clinical conditions are classified as TMD and what
occurs if these are untreated ?
• Specific etiology of TMD lack ing; therefore, diagnosisepen s on s gns an symptoms
• Conditions affecting muscles of mastication: – Pol m ositis – Dermatomyositis
• Conditions affecting the TMJ:
– – Ankylosis – Growth disorders
– ecurren s oca on – Neoplasias – Cond lar fracture – Systemic il lness
What are classified as TMD and what occurs if these
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What are classified as TMD and what occurs if these
• TMD can be either muscle or joint pain or a
• Peak prevalence in young adults (20-40)
• ome s u es s ow equa gen er pre ec on,but others show higher number of females
• -
• Few data to assess long term course in
2 What signs and symptoms provide a basis for
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2. What signs and symptoms provide a basis for
• Physical examination: – a n
– Limited range of motion –
– Muscle tenderness
–
• Conservative non-invasive treatment –
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3 What are effective initial therapies?
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3. What are effective initial therapies?
•Physical therapy
–Stabilization splints•
–Controversial
–Irreversible –Not demonstrated in randomized clinical trials tobe superior to reversible therapies
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4. What are effective therapies for persistentTMD?
• Pharmacologic therapies
–
– Opiates• Ma or concerns include:
– Addiction potential
– Analgesic tolerance
– Uncontrolled side effects i tch in const i at ion nausea
– Anx iolytic/ Hypnotic drugs (benzodiazepines)• Pain disorders can result in sleep disorders
•
Pharmacologic management of TMD
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Pharmacologic management of TMD
• NSAIDS
– Effective in relieving acute inflammatory
pain
– When prescribed for weeks or months,how ever, increased risk for GI ulcerations,
COX-2 Inhibitors
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COX 2 Inhibitors
• Selectively inhibit COX-2 enzymes,
prostanoids
• Rofecoxib (Vioxx)
• n a y popu ar or e managemen oosteoarthritis and rheumatoid arthritis
• ow popu ar or c ron c oro ac a pa n
Side Effects
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Side Effects
• Drug interactions
– May decrease the effectiveness of ACE-
inhibitors used to treat hypertension
• May alter k idney function
• Not safe for use durin re nanc• Drug allergies to NSAIDS or ASA
Occlusal stabilization splints
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Occlusal stabilization splints
•Used often in clinical practice
•Monoplane, acrylic appliance•Either maxi llar or mandibular
• Adjust until point contacts
•Relaxes muscles of mastication
•Constructed to place patient
•Eliminates tooth guidedcondylar position
What does the literature say?
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What does the literature say?
• Article published in JADA, 2001
• groups
• Weaknesses in design: – ac s u y umpe pa en s a oge er, regar ess o
symptoms
– Need to evaluate effectiveness of splint therapy for each
, , ,
• Overall, concluded that splints work as behavioralinterventions to produce changes in the
position of the mandible
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TMD can be treated or caused by Orthodontic
Treatment ?
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– Signs and symptoms may occur inhealthy persons
– Signs and symptoms increase w itha e often start in adolescence
•Orthodontic treatment and TMD
if a true relationship
– adolescence does not increase or
as an adult
• Extraction during treatment does not
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• Extraction during treatment does not
ncrease r s o – Certain types of orthodontic mechanics does
– Little evidence orthodontic treatment preventsTMD
• The role of unilateral posterior crossbitecorrection in the prevention of TMD needs further
investi ation• Pullinger noted that patients w ith unilateral
posterior crossbite in childhood had an odds
• Hypothesized that, in a small percentage of patients,
a mandibular shift places increased loading on
one TMJ, leading to internal derangement and TMD asan adult
Conclusions
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• TMD is multifactorial in nature
– Warrants a multi-faceted approach
• Self-limiting in nature
• Conservat ive, non-invasive, reversible
initial treatment• Pharmacologic therapy for persistent
– COX-2 inhibitors important in
Litigations
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Litigations
• Common
• Can occur spontaneously
• Record record record
• Be conservative!