Toma este vals con la boca cerrada. Frederico Garcia Lorca: Pequeño vals vienés

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1 Toma este vals con la boca cerrada. Frederico Garcia Lorca: Pequeño vals vienés

2 Toma este vals con la boca cerrada. Ay, Ay, Ay, Ay Take this waltz, take this waltz Take this waltz with the clamp on its jaws Leonard Cohen Frederico Garcia Lorca: Pequeño vals vienés

3 Temporomandibular disorders (and a bit of orofacial pain) Take this waltz with the mouth closed Szilvia Ambrus 14 November 2018 Department of Prosthodontics Director: Prof. Dr. Péter Hermann

4 Anatomy of the masticatory structures (no question mark here) TMJs: mandibular condyle + glenoid fossa of temporal bone articular disc; lubricated by synovial fluid hinging movement (rotation): ginglymoid joint gliding movement (translation): arthrodial joint» ginglymoarthrodial joint «Muscles of mastication elevators: masseter, medial pterygoid, temporal muscles depression: digastric muscles protrusion, laterotrusion: inferior lateral pterygoid muscle stabilization for the condyle and disc: superior lateral pterygoid muscle Associated muscles of head and neck secondary support during mastication functional behaviours: talking, chewing, swallowing parafunctional habits ( bruxism ): grinding, clenching,

5 Temporomandibular disorders? an umbrella term: symptom complex many previous names Costen s syndrome TMJ syndrome Myofacial pain dysfunction Temporomandibular dysfunction Masticatory myalgia Facial arthromyalgia Craniomandibular dysfunction Temporomandibular pain and dysfunction syndrome (IASP) Temporomandibular joint-pain-dysfunction syndrome (ICD) Headache or facial pain attributed to temporomandibular joint disorder (ICHD)

6 Temporomandibular disorders International Classification of Diseases: a type of musculoskeletal disorder A group of musculoskeletal and neuromuscular (and rheumatological) conditions of - TMJs - masticatory muscles - all associated structures Kind: often remitting, self-limiting or fluctuating over time, rarely result in a disabling condition Detrimental to quality of life

7 Temporomandibular disorders Symptoms, signs, diagnosis briefly Major symptoms pain or tenderness (masticatory muscles, preauricular) noises (click or crepitation) of TMJ restricted mandibular movement (limited opening, closed lock, open lock,...) mm overbite incl. Minor symptoms orofacial pain, earache, headache, tinnitus, muscle hypertrophy, attrition change in the occlusion acute / chronic primary (most responsible for chief complaint) / secondary / arthrogenous / myogenous function symptoms adaptation dysfunction

8 The epidemiology of temporomandibular disorders?

9 Epidemiology 3-80% of the population? different data collection different analytic approaches individual factors selected for study a lack of agreement which anomalies to include?»»» RDC/TMD»»» DC/TMD»»»??? (Research) Diagnostic Criteria

10 Epidemiology 3-80% of the population??? 5-12% of the population according to the National Institute of Dental and Craniofacial Research women men 2x young / middle-aged adults children / elderly trauma parafunction physical symptoms (somatisation) comorbidities: headaches, muscle soreness, other body pains, cigarette smoking (also: higher levels of pain, psychosocial distress, sleep disturbances)

11 The etiology of temporomandibular disorders no proven causes multiple factors Initiating factors: causing the onset Predisposing factors: increasing the risk Perpetuating factors: factors that interfere with the healing or enhance the progression onset of TMD???

12 The etiology of temporomandibular disorders Onset of TMD??? Insult or change» adaptive physiologic responses remodelling bone/tmj soft tissue muscle tone regulation Loss of structural integrity (direct extrinsic trauma), or Altered function, or Biomechanical stresses can compromise adaptability, increase the likelihood of dysfunction or pathology Anatomical Systemic Pathophysiologic Psychosocial factors

13 The etiology of temporomandibular disorders 1 Trauma 2 Anatomical factors 3 Pathophysiologic factors 4 Psychosocial factors

14 Trauma The etiology of temporomandibular disorders direct a sudden, isolated blow to the structures, an inpact proximity with signs and symptoms of inflammation fracture, wide/prolonged opening, third molar extraction, intubation TMD symptoms indirect associated with sudden blow, but no direct contact to the affected structures whiplash: limited risk for the development of TMD microtrauma result of prolonged, repeated force over time through postural imbalances or from parafunctional habits forward head position, phone-bracing creating muscle and joint strain, lead to musculoskeletal pain, including headache parafunctional habits indirect measures (self-report, tooth wear)

15 The etiology of temporomandibular disorders Parafunctional habits teeth clenching, teeth grinding lip biting abnormal posturing of the mandible Exacerbated by stress, anxiety, sleep disorders, neuroleptics, alcohol COMMON, usually don t result in TMD But initiating/perpetuating factors for a certain group of TMD patients Exact role of this habits is unclear? Signs, as? attrition severity, secondary to bruxism can not distinguish TMD patients from asymptomatic subjects muscle hyperactivity not associated with arthrogenous TMJ disorders clenching doesn t cause neuromuscular fatigue (neurophysiology of muscles)

16 The etiology of temporomandibular disorders Parafunctional habits Exacerbated by stress, anxiety, sleep disorders, neuroleptics, alcohol patients with neurologic disorders (epilepsy) Masticatory muscle hyperactivity associated with emotional behaviour

17 Anatomical factors The etiology of temporomandibular disorders skeletal factors genetic / developmental / iatrogenic skeletal malformations past injuries to the teeth this role is less strong than previously believed steep articular eminence: proposed as an etiologic factor in internal derangement of the TMJ asymptomatic patients: steeper eminence associated with increased posterior rotation of the disc potential anatomic risk factor but: less steep eminence was found in several TMDs (joint sounds, ) occlusal relationships dentists but: loss of posterior support, unilateral crossbite; little evidence

18 The etiology of temporomandibular disorders Pathophysiologic factors systemic factors degenerative, endocrine, infectious, metabolic, neoplastic, neurologic, rheumatologic, vascular disorders they can act at central and/or local level generalized joint laxity (hypermobility) internal derangements local (peripheral) factors masticatory efficiency (nr. of occlusal units, nr. of posterior teeth) muscle tenderness (prolonged central hyperexcitability) disc displacement, morphologic changes??? mechanical stress (accumulation of free radicals) genetic factors» pain sensitivity

19 Psychosocial factors The etiology of temporomandibular disorders individual, interpersonal, situational factors» patient s capacity to function adaptively GENERAL DISTRESS + personality characteristics, enduring stressors, physical response to stress, limited coping skills some TMD patients: more anxiety than control group some TMD/orofacial pain symptoms: a somatic manifestation of emotional distress some muscle pain: caused by excessive sympathetic nervous system activity (overresponse to life stressors) DEPRESSION and ANXIETY (life events)» perception, tolerance of physical symptoms» seeking care lower back pain, headache: similar psychosocial and behavioural characteristics

20 The comorbidities of temporomandibular disorders? other pain syndromes headache disorders, chronic low back pain/neck pain, irritable bowel syndrome, rheumatoid arthritis, systemic joint laxity,...

21 The prevention of temporomandibular disorders Primer prevention eliminating initiating and predisposing contributing factors parafunctional habits Secondary prevention early diagnosis and treatment? chronic pain Terciary prevention pain management, restrain progression

22 The diagnosis of temporomandibular disorders PAIN in the masticatory muscles and/or in the preauricular area Chewing usually aggravates the pain LIMITED RANGE of mandibular movement TMJ SOUNDS described as clicking, popping, grating, crepitus Jaw ache, earache, headache, facial pain Nonpainful masticatory muscle hypertrophy is associates with oral parafunction (jaw clenching, tooth grinding) TMDs often coexist with other craniofacial and orofacial pain disorders

23 The diagnosis of temporomandibular disorders Clinical examination extraoral intraoral Medical imaging X-ray? CT, CBCT MR?

terms are extraoral not used properly: dislocation of the joint DDwR/DDwoR intraoral vs.

24 Internal The joint diagnosis derangements of temporomandibular disorders Disc displacement with reduction (DDwR, ADD+R) Disc displacement Clinical examination without reduction (DDwoR, closed lock, ADD-R)! terms are extraoral not used properly: dislocation of the joint DDwR/DDwoR intraoral vs. subluxation of the condyl (open lock) Medical imaging X-ray? CT, CBCT MR? closed: Disc Displacement open: DDwoR

Deviation, deflection Deviation: - a C- or S-pattern movement during the opening - the midline returns to the start point at the end of the opening - this may be a disc displacement with reduction

25 Deviation, deflection Deviation: - a C- or S-pattern movement during the opening - the midline returns to the start point at the end of the opening - this may be a disc displacement with reduction Deflexion: DDwoR of the right TMJ - continuous displacement of the midline, no return to the center - the cause may be - disc displacement without reduction (DDwoR) - myogen spasm The term deviation is also used for deflexion in the international litterature.

26 The differential diagnosis of temporomandibular disorders!!! Dentogenic disease - dental cavity, dental abscess, Gum disease - tooth root sensitivity, - cracked tooth syndrome Tooth root sensitivity Cervicogenic headache Sinusitis Neoplasm Masticatory muscle disorders...

27 The management of temporomandibular disorders Is there a treatment need?? Conservative (reversible)» 50-90% of TMD patients with few or no symptoms Goals: - decreased pain - decreased adverse loading - restoration of function - resumption of normal daily activities Patient education and self-management instructions (relaxation, heat, massage) Behavioural modification (visual reminders, stress management, biofeedback?) Physical therapy (posture training, excercises,...) Medications (analgesics, NSAIDs, muscle relaxants) Acupuncture, Ultrasound, LLL??? STOP! information reassurance Trigger point injections (...) Medications (corticosteroides, benzodiazepines, low-dose antidepressants) Orthopedic appliances (splints)... Occlusal therapy... (irreversible!) Surgical treatment (invasive) Arthrocentesis/..., Arthroscopy, Arthrotomy natural course? of TMDs

28 The management of temporomandibular disorders Orthopedic appliances (interocclusal splints, bite guards, bite planes, nightguards,...) removable acrylic resin appliances that cover the teeth to alter occlusal relationships redistributing occlusal forces? prevent wear and mobility of the teeth reduce bruxism and parafunction to treat masticatory muscle pain and dysfunction to treat painful TMJs to alter structural relationships in the TMJ mechanism? occlusal design? efficacy? - stabilization appliances (flat plane / gnathologic / muscle-relaxation appl.) Michigan-splint - partial-coverage appliances (NTI-TSS,...)» malocclusion/internal TMJ changes? - anterior (re)positioning appliances guiding the mandible in protrusive position

appliances (flat plane or gnathologic or

..) guiding the mandible muscle-relaxation

29 The management of temporomandibular disorders Types of interocclusal splints? stabilization partial-coverage anterior (re)positioning appliances appliances appliances (flat plane or gnathologic or (NTI-TSS,...) guiding the mandible muscle-relaxation appl.) causes malocclusion or in protrusive position Michigan-splint internal TMJ changes?

30 The management of temporomandibular disorders Occlusal therapy - occlusal adjustment - restorative therapy - orthodontic-orthognathic therapy role of occlusion? dental treatment not necessarily for the purpose of treating TMDs? 1980s two-phase treatment I. Anterior positioning appliance II. Rearticulation (newly acquired jaw position) occlusal adjustment, restaurative/prosthodontic treatment, orthodontic/orthognathic treatment definitive occlusal therapy is not required for the effective treatment of most TMDs! treating chronic malocclusions to treat TMDs is unsupported!

31 Occlusal adjustment Irreversible! - premature contact of a tooth? - positive percussion test, but vital pulp - tooth mobility - X-ray: widened periodontal space/bone loss - adjust fillings, crowns, when placed/controlled Limited indication, stay conservative...

32 Sure about the right diagnosis?! ( Really? ) DOs and DON Ts Tooth pain caused by TMD TMD symptoms caused by cracked tooth-syndr. etc. Any other possible cause of pain??? History of malignity? Sudden changes? Trauma? Neurogenic origin? Stay conservative As long as possible no irreversible treatment (including prosthetic works) learn to say NO Be curious, but critical regarding (new)? treatment methods

34 Take this waltz

35 TMD pain is characterized by

36 The more important factor in the development of TMD s is

: ADDwR: the disc is anterior displaced in closed situation and springs back to the

37 In an anterior disc displacement without reduction (DDwoR) a clicking sound can be heard while opening the mouth N.B.: ADDwR: the disc is anterior displaced in closed situation and springs back to the right (superior) place when opening ADDwoR: the disc remains displaced also in open position, the translation of the condyle is disturbed

38 Thank you! I think I have TMD.

39 Temporomandibular disorders (and a bit of orofacial pain) Thank you for your attention!

Up Date on TMD WHAT IS TMD? Temporomandibular Disorders (TMD)*: Donald Nixdorf DDS, MS

Up Date on TMD WHAT IS TMD? Temporomandibular Disorders (TMD)*: Donald Nixdorf DDS, MS Up Date on TMD Donald Nixdorf DDS, MS Associate Professor Division of TMD and Orofacial Pain WHAT IS TMD? Temporomandibular Disorders (TMD)*: MUSCLE and JOINT DISORDERS * Temporomandibular Muscle and Joint