 Prof.(Dr) Sanath Shetty M.D.S.

, PhD
Head of Dept. of Prosthodontics
Yenepoya Dental College
Yenepoya University
Mangalore, India

PROSTHODONTIC MANAGEMENT OF TMDs

OBJECTIVES

 TO KNOW THE NORMAL ANATOMY OF TMJ

 TO GAIN KNOWLEDGE ABOUT ETIOLOGY, SIGNS & SYMPTOMS

OF TM DISORDERS.

 TO BE WELL VERSED WITH CLASSIFICATIONS OF TM

DISORDERS.

 VARIOUS DIAGNOSTIC APPROACHES AND MANAGEMENT OF

TMDs

INTRODUCTION

- Temporomandibular joint disorders/TMD is major cause of non-dental

chronic pain in orofacial region.

- It is a syndrome/symptom complex.

- The term TMD does not suggest merely problems that are isolated to joints
but includes all disturbances associated with functions of masticatory
system.

- A survey revealed that at least one symptom associated with TMD was seen
in 41%of the subjects, and an average of 56% showed at least one clinical
sign related to TMD.

This embraces broad spectrum of joint & muscle disorders in orofacial area
Characterized by pain, joint sounds & deviatory jaw function.
It impairs the quality of patient’s life, in-fact devastate its victim.
 Epidemiologic studies reveal that most TMD symptoms are reported in
subjects 20 to 40 years of age.

- It is also female dominant. (could be due to hormones, predominantly

estrogen)
- Patients in the older age group when they show signs of TMD, they are more
related to degenerative changes in the joint rather than related to occlusion
or muscles.

TERMINOLOGIES

- Temporo-MandibularDisorder: - Conditions producing abnormal,

incomplete or impaired functions of TMJ and (or) muscles of mastication.
(GPT – 9)

- Disorder: - It is any disturbance in function, structure or both. (GPT – 9)

- AAOP (American Association of Orofacial pain) Definition of TMD :- A

collective term embracing a number of clinical problems that involve the
masticatory musculature or the temporomandibular joint & associated
structures or both.

Evolution of word TMD

• 1934 - Costen Syndrome

• 1956 - TMJ Pain Dysfunction Syndrome
• 1959 - TMJ Dysfunction Syndrome
• 1969 - Myo-facial Pain Dysfunction Syndrome
• 1980 - Craniomandibular Disorders
• 1982 - Temporomandibular Disorders

What causes TMD?

 Many theories regarding the etiology.

 In the past  single etiology  occlusion.

  TMD and Occlusion????

 60% of the studies showed that there is a direct relationship between

occlusal factors and TMD symptoms whereas, the rest didn’t.

 Generally, it is believed that, no simple cause and effect relationship

explains the association between occlusion and TMD.

 Presently

Multifactorial+ Occlusion +Psychological factors [stress].

o Two explanations for the complexity of TMD

1) Either the disorder has multiple causes and that no single

treatment can cure all the causes.

(OR)

2) The disorder is not a single problem but represents an umbrella term

under which multiple disorders are grouped.

The sequence of TMD development can be summed up as:

Normal function>>>>> an event/insult>>>>>physiologic tolerance

>>>>>structural tolerance>>>>>>TMD symptoms

Normal function:

Description of TMJ.
Centric relation and its significance, and how load distribution is best
when condyles are in anterosuperior position. Also why condyle should
articulate with thinnest avascular zone.
Ideal occlusion:
Class 1, jaw relation,
Class 1 occlusion
Proper anterior guidance
Mutually protected occlusion
Canine protected occlusion
No working and non working side interferences in eccentric movements

EVENTS/INSULTS OR FACTORS

Local events( acute and hronic) and systemic events:

 ACUTE LOCAL EVENTS:

- Represents any change in sensory or proprioceptive input,such as the

placement of an improperly occluding crown/FPD, restoration with high
points or any such events which abruptly changes the contact of teeth.

- A local event may also be secondary to trauma involving local tissues. An

example of such trauma is a post injection response after local anesthesia,
cheek biting, ulcers, etc.

- Trauma can also arise from opening the mouth too widely (strain) or some
movement of the mandible the patient is not accustomed to.

 CHRONIC LOCAL EVENTS:

- Orthodontic treatment.

- Loss of a tooth leading to drifting

- Absence of bilateral posterior stop

- Unreplaced missing posterior teeth.

- Untreated painful tooth.

- Parafunctional habits
 SYSTEMIC EVENTS:

- The whole body, and the central nervous system is affected due to
psychological problems mostly related to stress.

- The influence of emotional stress in TMD is now considered a major and a

very important precipitating factor.

- In such cases dental therapies are likely to be ineffective and could frustrate
us.

These events can also be classified as:

 Predisposing factor – Factors that increase the risk of TMD or orofacial pain
developing. Eg.Systemic factors,Psychologic factors,Structural
factors,Genetic factors.

 Initiating factors – Factors that cause the onset of disorder.

Eg.Trauma,Parafunctional habits.

 Perpetuating factors – Factors that interfere with healing and complicate

management. Eg.Mechanical and Muscular stress, Metabolic problems.

Physiologic tolerance

- All individualsdo not respond in the same manner to the same event.

- It is related to the physiologic tolerance of an individual.

- When the condyle is in a musculoskelitally stable position [orthopedic

stability]

- An even contact of all posterior teeth occurs, directing the forces through the
long axes of these teeth

- Show mutual protection & canine protection

 The system can tolerate worst of the insults.

When these conditions don’t exist….

 Compounded by psychological and genetic factors
 Compounded by Physically being weak
Relatively insignificant events can often disrupt the function of the
system

Structural Tolerance

- When functional change exceeds a critical level, alteration of the tissue

begins. This level is known as the structural tolerance.

- Each component of the masticatory system has a specific structural

tolerance.

- If structural tolerance of any component is exceeded, breakdown will occur.

- The initial breakdown is seen in the structure with the lowest structural
tolerance.

Therefore, the breakdown site varies from individual to individual.

Potential sites of breakdown:

Muscles
TMJ
Supportive structures of teeth
Teeth

 THIS BREAK DOWN EVENTUALLY LEADS TO A COMBINATION

OF SIGNS AND SYMPTOMS TERMED AS TMD.

 With a broad concept of normal structure and function, symptoms form the
foundation for diagnosis and treatment of TM disorders, for it is by
symptoms we recognize what is wrong with the masticatory system.
 Symptoms of TMD

Those affecting the dentition:

- Tooth wear
- Tooth pain
- Tooth mobility

Those affecting the masticatory muscles:

Masseter
Temporalis
Medial Pterygoid
Lateral Pterygoid

Those affecting theTMJ:

- Limited mouth opening

- Jaw getting stuck

- Clicking, popping, grating sounds

 Other symptoms like Ear pain and Headache

Signs of TMD:

Examination of teeth

 Pain

 Mobility

 Fractured restoration

 Wear facets

 Overjet and overbite

 Occlusal examination
  Occlusal examination

- The occlusal contact pattern of teeth is examined in all possible positions

and movement of mandible:

1. CR=MI
2. Inter-cuspal position
3. Mutual protection
4. Canine protection or group function

o Determining Centric Relation

- Until the positions of TMJ’s are precisely determined, an accurate maxillo-

mandibular relationship cannot be verified and correct occlusal analysis is
not possible.

- Bilateral relaxation of external pterygoid muscle is essential to obtain true

centric.
1. Chin point guidance - Guichet (1970): Thumb and forefinger—positions
the condyle in RUM position.

2. Bimanual method - Peter Dawson (1974): Guides the mandible in most

superoanterior position.

o Anterior Deprogramming Devices

- It provides anterior stop to eliminate posterior tooth contacts during closure

of jaws, thereby eliminating proprioceptive influence from the teeth.

- This allows the patient’s neuro-musculature to seat the condyles in its centric
position within the glenoid fossae without the influence of periodontal
proprioception or engram

 Lucia Jig
 Leaf guage
 Tongue blade
 HEAD AND NECK EXAMINATION

- Examination of other head and neck Muscles

- Examination of Eye

- Examination of ENT

- Sinus evaluation

Examination of Muscles:

PHYSICAL PALPATION: of all the muscles of mastication

FUNCTIONAL MANIPULATION

 Check for tenderness on Functional manipulation:

- Superior lateral pterygoid

- Inferior lateral pterygoid
- Medial pterygoid

o EXAMINATION OF TMJ

- Palpation

- Auscultation

- Mouth opening

- Mandibular movements
  TMJ PALPATION

- Pt relaxed  medial force applied

- Pt open and closes mandible

- Pt opens maximally, and fingers rotated slightly posteriorly to apply force to

posterior aspect of the condyle

 AUSCULTATION

- Click
Opening click
Reciprocal click

- Thud

- Crepitation-Crepitus can indicate degenerative problems such as disc

damage (e.g. perforations), osteoarthritis, and in some cases end stage “bone
on bone” grinding.

 MOUTH OPENING: maximum comfortable opening and maximum opening

- END FEEL

Hard Soft

 MANDIBULAR MOVEMENTS: slowly open, close(40-50mm), retract(1-

3mm), protrude(6-12mm) and laterally deviate (laterotrusion-8-12mm)

Deviation: Movement away from midline followed by a return to center and

is often described as either a “C” or “S” pattern. Mostly deviation without
click is muscular.
Deflection :Movement away from the midline during opening without return
to center during the movement. It occurs due to restricted movement in one
joint.
 ADDITIONAL DIAGNOSTIC AIDS

- Imaging- x ray, Tomogram.

- MRI- gold standard, helps evaluate soft tissues.
- Arthroscopy.
- Sonography.
- Diagnostic nerve blocking.

CLASSIFICATION OF TMD

 Diagnostic Classification of TMDs (McNeill et al.)

 Congenital or developmental disorders
 Aplasia
 Hypoplasia
 Hyperplasia
 Neoplasia

 Disk derangement disorders

 Disk displacement with reduction
 Disk displacement without reduction
 Joint dislocation

 Inflammatory conditions
 Capsulitis/synovitis
 Polyarthritides

 Noninflammatory (Osteoarthrosis)
 Osteoarthritis: primary
 Osteoarthritis: secondary

 Ankylosis
 Fibrous
 Bony

 Fracture (Condylar process)

  According to Peter Dawson

 Masticatory muscle disorders

 Structural intracapsular disorders
 Conditions that mimic TMD.

Okeson Modification of Bells Classification

How to distinguish where the problem lies?...

- For the purpose of diagnosis, TMD can be broadly grouped into:

Extracapsulardisorders (myogenous) Intracapsulardisorders(arthrogenous)

• Protective muscle splinting a) Disk derangement
• Muscle hyperactivity or i) Anterior disk displacement with
spasm reduction (clicking)
• Myositis ( muscle ii) Anterior disk displacement
inflammation) without reduction (closed lock)
b) Subluxation
c) Spontaneous Dislocation (open lock)
d) Osteoarthritis
e) Synovitis, Retrodiscitis, Capsulitis
 EXTRACAPSULAR DISORDERS
- Exist outside of the joint itself.

- Patients often have little or no mechanical problems within the TMJ but
suffer the effects of the structures outside of the joint.

- Myofascial pain dysfunction- This is the most common TMJ dysfunction

and usually involves muscle imbalance with muscle spasm and pain. This
has a multitude of causes such as stress, grinding of teeth, instability of the
bite and others.

- Diseases and pathology of the surrounding area-This can include tumors

of the jaw, salivary glands and associated structures, neurologic disorders,
systemic disorders effecting the head and neck, and referred pain from the
neck, back, and associated structures.

 INTRACAPSULAR DISORDERS
- Damage or disease to the joint itself such as the disc, condyle, articular
eminence, ligaments.

 Classification
• Disk displacement with reduction:
- The disk is displaced from its position between the condyle and the
eminence to an anterior and medial or lateral position, but reduces on full
opening, usually resulting in a noise(click).

Etiology:
It results from elongation of the capsular and discal ligaments
coupled with thinning of the articular disc which commonly results from
macro/microtrauma. The other causes are orthopedic instability plus joint
loading.
Clinical characteristics:
Clinical examination reveals a relatively normal, range of movement
with restriction only associated with the pain. Discal movement can be felt
by palpation of the joints during opening and closing. Deviations in the
opening pathway are common.
 • Disk displacement without reduction: (Closed lock)
- A condition in which the disk is displaced from normal position
between the condyle and the fossa to an anterior and medial or lateral
position, associated with limited mandibular opening.

- Etiology:
Macro-trauma and micro-trauma are the most common cause.

- Clinical characteristics:
Examination reveals limited mandibular opening (25-30mm) with normal
eccentric movement to the ipsilateral side and restricted eccentric movement to the
contralateral side.

 SUBLUXATION

- During final stage of maximal mouth opening condyle is seen to suddenly

jump forward with a thud sensation.
- Condyle is placed anterior to articular eminence.
- Difficult to close the jaw.
- Cause: seen due to problem in anatomy of articular eminence
 SPONTANEOUS DISLOCATION
(OPEN LOCK)

Clinically:
- Patient with open mouth
- Pain secondary to patient`s attempts to close mouth.

 Inflammatory & Non-Inflammatory disorders:

They are generally characterized by continuous joint area pain, often

accentuated by function.

The four categories are:

• Synovitis.
• Capsulitis.
• Retro discitis.
• Arthritis and Arthrosis.
 HOW TO DISTINGUISH IF IT IS EXTRA-CAPSULAR or INTRA-
CAPSULAR PROBLEM ???

- Method for distinguishing Anterior bite plane.

 Aids in diagnosis in two ways

 By eliminating occlusal contacts, it eliminates the need for lateral pterygoid

bracing and allows condyles free access to CR, by breaking the muscle
engram.

 By taking away all posterior contacts of teeth, it effectively tests the joint for
response to pressure.

Anterior bite plane>>>>problem is not relieved or it worsens>>>>intra

capsular problem.
Anterior bite plane>>>>>patient becomes comfortable>>>>problem
related to occlusion/muscle.

Treatments

- Just as the cause may not be single, there is no definitive single line of
treatment.

- Effectiveness of the treatment also varies from patient to patient.

- Line of treatment should be such that it is reversible.

- Treatments range from simple self-care practices and conservative,

reversible, non-intrusive & non-surgical treatments to occlusal rehabilitation,
injections and surgeries.

- Treatment should always begin with conservative, reversible, nonsurgical

therapies first, with occlusal rehabilitation and surgery left as the last resort.

 BASIC TREATMENT

- Resting the jaw

- Soft food
- Avoid extreme jaw movements
- Good posture
- Apply moist heat or cold packs.
- Advice practicing relaxation techniques to combat stress.
 PHARMACOTHERAPY

- NSAIDs- To relieve muscle pain and swelling.

- Muscle relaxants (especially for people who grind or clench their teeth)
- Anti-anxiety medications can help relieve stress that is sometimes thought to
aggravate TMD.
- Antidepressants, when used in low doses, can also help reduce or control pain.
-
 OCCLUSAL APPLIANCE THERAPY

- Splint therapy is the art and science of establishing neuromuscular harmony

in the masticatory system and creating a mechanical disadvantage for
parafunctional forces with removable appliances.

 According to Glossary of Prosthodontic Terms- 9, occlusal splint is:

“Any removable artificial occlusal surface for diagnosis or therapy
affecting the relationship of the mandible and maxillae. It may be used
for occlusal stabilization, for treatment of temporomandibular
disorders, or to prevent wear of dentition”

 According to Okeson:
“An occlusal appliance (splint) is a removable device usually made of hard
acrylic that fits over the occlusal and incisal surfaces of the teeth in one arch,
creating precise occlusal contact with the teeth of the opposing arch.”

 FUNCTIONS OF SPLINTS

- Properly fabricated splints have at least 5 functions, includes the following:

- 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

Occlusal Appliances (splints) Materials:

Commonly there are two different materials, based upon consistency, which
are used in the fabrication of occlusal appliances.

 Hard acrylic resin Occlusal appliances that are either self-cured (by
chemical reaction) or heat cured, resulting in hard and rigid tooth-borne and
occlusal surface.
 There are soft or resilient occlusal appliances, which are somewhat flexible
and pliable tooth-borne and occlusal surface.
 Dual laminated, as its occlusal surface consists of hard acrylic resin and the
tooth-borne surface consist of a soft material. This produces an occlusal
appliances with advantages of a soft material (fitting well and providing
comfort for the supporting teeth), and an adjustable occlusal surface of the
hard acrylic resin.(Hybrid night guard) (Two distinct layers of ethylene-vinyl
acetate)

 TYPES OF SPLINTS:

- All splints are classified as either permissive or nonpermissive.

1. A permissive splintallows 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).

2. Nonpermissive splint/ directive splint/ stabilization 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 (ARA).

 MUSCLE RELAXATION (MR) APPLIANCE

 Gnathologic splint, Michigan splint.

What does it do….

 PROVIDE JOINT STABILIZATION,
 PROTECT THE TEETH,
 REDISTRIBUTE THE OCCLUSAL FORCES,
 RELAX THE ELEVATOR MUSCLES,
 DECREASE BRUXISM.

 Description:

• The MR appliance is generally fabricated for the maxillary arch and provides an
occlusal relationship considered optimal for the patient.

• When it is in place, the condyles are in their most musculo-skeletally stable

position at the time that the teeth are contacting evenly and simultaneously.

• Canine disocclusion of the posterior teeth during eccentric movement can also be
provided.

• The treatment goal with the MR appliances is to eliminate the malocclusion that
contributed to the patient’s TM disorder.

WHICH TYPE OF SPLINT SHOULD BE USED AND WHEN???

BRUXISM AND HEADACHES BUT NO TMD:

 The use at night, of a full-coverage splint, in which acrylic covers an entire

arch of teeth, is often adequate to protect the teeth.
 Muscle relaxation is an added benefit that often relieves or eliminates
tension headaches.
 Studies suggest that a minimum of a 4-mm increase in vertical dimension is
necessary to protect bruxing patients.
 If the patient is wearing a splint 4 mm in thickness and still experiences
muscular soreness, headache, and/or facial muscle tightness immediately
after waking, splint thickness should be increased incrementally until
symptoms disappear.

BRUXUSM, HEAD ACHE, MUSCLE DISORDERS AND NO TMD:

 Bite planes are indicated as they separate the teeth, as they are initiated by
hyperocclusion; allowing the muscles to relax.
 These appliances should not be worn for longer than 24 to 48 hours
continually, as they cover the maxillary anterior teeth, and intrusion/supra-
eruption of posterior teeth could occur from lack of contact.
 Full-coverage stabilization splints, which are flat plane splints covering the
entire dental arch, are also acceptable, and may be the treatment of choice
for unreliable patients.
 Muscle disorders are effectively treated with appropriate splint therapy (bite
planes and stabilization appliances).

HEAD ACHE, MUSCLE DISORDERS AND TMD SIGNS:

 Identified by joints that click, pop or grate.

 These disorders tend to be more chronic in nature (unless there has been an
acute exacerbation), and are associated with more damage.
 Stabilization splints are the treatment of choice, as they provide long-term
wear that is usually needed.
 They also cover the entire dental arch, ensuring that the covered teeth do not
move.
 They must be worn continually for 24 hours (except when eating) for as long
as required to eliminate muscle, disc, ligament, and tooth symptoms.
 3 to 6 months of wear is often required. These disorders may be reversible if
detected relatively early and treated appropriately.

HEAD ACHE, MUSCLE DISORDERS AND ADVANCED TMD

SIGNS:

 Identified in patients who experience jaw locking and/or noises, painful

joints, and sometimes increasing pain with splint wear.
 Patients with acute trauma may require an anterior repositioning appliance
for 7 to 10 days to keep the condyle away from the retrodiscal tissues, so
that inflammation can subside.
 These patients often have a long history of joint pain, locking, and
instability.
 Stabilization splints are the treatment of choice, and must be balanced to
accommodate the specific needs of the patient.
 Splints may need to be worn for 6 months to 2 years depending on the
patient.
  These disorders are usually not reversible, but with treatment patients can
experience passivation of symptoms.

When these basic treatments prove unsuccessful

1. Transcutaneous electrical nerve stimulation (TENS). This therapy uses

low-level electrical currents to provide pain relief by relaxing the jaw joint
and facial muscles. This treatment can be done at the dentist's office or at
home.

2. Ultrasound. Ultrasound treatment is deep heat that is applied to the TMJ to

relieve soreness or improve mobility.

3. Trigger-point injections. Pain medication or anesthesia is injected into

tender facial muscles called "trigger points"" to relieve pain.

4. Radio wave therapy. Radio waves create a low-level electrical stimulation

to the joint, which increases blood flow. The patient experiences relief of
pain in the joint.

o When all these simple and reversible treatment modalities fail……

- It shifts to irreversible and aggressive procedures, after a thorough
assessment of the underlying problem…

IRREVERSIBLE TREATMENTS- last option!!

- Eliminating all occlusal interferences by Enameloplasty.

- Orthodontics to change the position of the teeth to restore occlusal stability.
- Correcting occlusal plan, and prosthodontic rehabilitation of missing teeth.
- Correcting any faulty restoration.
- Crowns for badly malposed teeth
- Full mouth occlusal rehabilitation in case of severely worn-down dentition

 SURGERY
- Surgery should only be considered after all other treatment options have
been tried and patient is still experiencing severe, persistent pain.
- There are three types of surgery for TMD:
- arthrocentesis,
- arthroscopy
- open-joint surgery.
  The type of surgery needed depends on the TMD problem.

To conclude:
Temporomandibular dysfunction, is a complex pool of disorders, which
needs to be treated with lot of caution and a thorough knowledge of the
systems involved is needed to diagnose the problems after complete
assessment of the signs and symptoms. As stress and psychological issues
compound on the existing issues, careful management of the patients with
conservative treatments is the need of the hour rather than aggressive
occlusal adjustments.

 References
- OKESON J. Management of temporomandibular disorders and occlusion. 7th
ed. china: MOSBY; 2013.
- ROBERT L. GAUER, MD, and MICHAEL J. SEMIDEY, DMD, Diagnosis
and Treatment of Temporomandibular Disorders; American Academy of Family
Physicians. 2015;91(6):378-386.
- HarsimranKaur ; Kusum Datta Prosthodontic Management of
Temporomandibular Disorders J Indian Prosthodont Soc (Oct-Dec 2013)
13(4):400–405
- Dworkin SF, LeResche L, DeRouen T, Von Korff M (1990) Assessing clinical
signs of temporomandibular disorders: reliability of clinical examiners. J
Prosthet Dent 63:574–579
- Prosthodontic Considerations of Temporomandibular Joint Disorders Surekha
Godbole, Aniket Gupta Jaypee publishers Pg No : 141-163
- Okeson JP: Orofacial Pain: Guidelines for Assessment, Diagnosis, and,
Management, 3rd ed. Chicago: Quintessence;1996:45-52.
- McNeill C, Mohl N, Rugh J, Tanaka T (1990) Temporomandibular disorders:
diagnosis management, education, and research. J Am Dent Assoc 120:254
- Malik P, Rathee M, Sehrawat R. Temporomandibular Disorders and their
Management. American Journal of Health Research. Special Issue: Rethinking
Temporomandibular Joint in Health and Disease: At Diagnosis and
Interventional Level. Vol. 3, No. 3-2, 2015, pp. 1-5.