Conservative management of tempromandibular disorders



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CONSERVATIVE MANAGEMENT OF

TEMPROMANDIBULAR DISORDERS:
Interrelationship of various TMD:


  • Accurately diagnosing and treating TM disorders can be a difficult and confusing task primarily because patients’ symptoms do not always fit into one classification

  • In many patients one disorders contributes to another:

Acute muscle disorders  disc interference disorders

Trauma  myositis

Disc interference disorders  acute muscle disorders

 inflammatory disorders


  • When disc interference progress, the bony articular surface of the joint is likely to undergo changes.

  • pressure in joint leads to remodeling in bone and cartilage

disc interference  acute muscle disorders



Trauma


Inflammatory disorders mandibular hypo-mobility disorders

General types of treatment of TM Disorders:


  • All the treatment methods being used can be categorized generally into:

1. Definitive treatment: refers to those methods directed towards controlling or eliminating the etiologic factors.

2. Supportive therapy: refers to treatment methods that are directed toward altering patient symptoms without treating the cause




  • Definitive treatment

  • Parafunctional activity results from 2 etiologic factors:

1. Malocclusion (high cusp, high filling, etc)

2. Emotional stress (continous input on the muscles by nervous system)

Definitive treatment is directed towards altering or changing one or both those factors

Meaning we've to correct the malocclusion or treat the stress

Occlusal examination may identify obvious dental interferences but it is difficult to determine whether those are the only conditions responsible for the disorder or they are within physiologic tolerance of the patient.

i.e: patient has interferences yet he shows no signs of a parafunctional activity such as clenching or bruxism and malocclusion are only found as incidental findings

Others may have small slight malooclusion problems yet suffers from severe parafunctional activities. Both cases depends on the body's ability to tolerate the malooclusion
Questioning the patient for high level of emotional stress is equally difficult

Some patients deny it, others don't realize they have it (subconscious)

All initial treatment should be conservative, reversible and non invasive
Occlusal therapy:


  • It is considered to be the treatment that is directed towards changing the mandibular position and/or occlusal contact pattern of teeth.

We need to change mandibular position if maximum intercuspation is not coincidental with the ideal position of condylar head with disc and fossa


  • It can be either:

1. Reversible: which changes the patient’s occlusion temporarily and is best made by occlusal splint which is an acrylic appliance worn over the teeth in one arch (usually on maxillary arch as it's easier to adjust the contacts when used on maxilla) and has an opposing surface which changes the mandibular position (optimum disc fossa relationship) and occlusal contact pattern of the teeth
2. Irreversible: like selected grinding of the teeth, restorative procedures, orthodontic treatment, and surgical procedures which are aimed at changing occlusion and/or mandibular position.

Splints that are designed to change growth or permanently reposition the mandible are also considered irreversible occlusal therapy.




  • If the centric relation splint (which is used as a diagnostic procedure to reach definitive diagnosis) fails to relief symptoms of the patient this suggests that the major etiologic factor is not related to occlusion or mandibular position and it is assumed that emotional stress is the major factor and treatment to change this factor should be pursued


Emotional stress therapy:

  • Review of the personal traits and emotional states:

enormous variation exists in this patient population and this prevents the common traits from being helpful in identifying the etiologic factors of TM disorders. (it's difficult to categorize these patients as they can fit into more than one group)

  • Common emotional states: levels of anxiety can be significant, apprehension, frustration, anger, anxiety…

Types of emotional stress therapy



    • Patient awareness (inform patient of having the problem)

    • Voluntary avoidance

    • Relaxation therapy 

1. Substitutive relaxation therapy: ask the patient to perform any activity that he enjoys and removes him from a stressful situation.

2. Active relaxation therapy: therapy that directly reduces muscle activity such as self hypnosis, meditation, biofeedback, negative feedback


Other considerations in treating parafunctional activity

Parafunctional activities can be classified into two types:



  • Diurnal (during the day) which may result from an occlusal interference and can be managed by either behavioral modification or when occlusal interferences are present by reversible occlusal therapy.

Behavioral modification is possible as patient is aware

  • Nocturnal (during the night) where the use of occlusal splint therapy can reduce nocturnal bruxism.



  • Supportive therapy

1. Pharmacologic therapy

2. Physical therapy


Pharmacologic therapy

  • Patients should be aware that medication does not always offer a solution to their problem.

  • Medication in conjunction with appropriate physical therapy and definitive treatment does offer the most complete approach to many problems.

  • It is recommended that when drugs are indicated they should be described at regular intervals for a specific period e.g. 3tid for two weeks

Types of medications given:

1. Analgesics like aspirin and substitutes

2. Tranquilizing agents: usually helpful when high levels of emotional stress is usually suspected, the change the patients’ reaction to stress, the most common medication used is valium which should not be used more than 10 days, this medication is helpful to relax the muscles and decrease nocturnal parafunctional activity. Antidepressants may also be prescribedfor chronic pain therapy; these drugs are best left for professionals.

3. Local anesthetics (lidocaine or carbocaine without epinephrine):

Important for the treatment of myofacial trigger areas, injecting into the painful muscle may be both diagnostic and therapeutic. Used in acute states or in severe pain

4. Anti-inflamatory agents useful for inflammatory joint disorders and myositis should be taken for a min of 2 weeks in low doses

5. Injected agents e.g. hydrocortisone

6. Muscle relaxant: found to be not very effective. placebo effect
Physical therapy


  • Thermotherapy: heat increases circulation and causes vasodialation leading to reducing the symptoms. Ultrasound and diathermy are also types of thermotherapy but affect deeper in the tissues

  • Coolant therapy: cold encourages relaxation of the muscles, applied directly to the affected area but should not exceed 5 min to prevent ischemia (chloride spray)

  • Massage therapy: stimulates sensory nerves causing inhibitory influence on pain

  • Electrical stimulation therapy

  • Relaxation therapy

Supportive therapy for dysfunction:




  • Restrictive use: avoid painful movement

  • Exercise:

    • Active: usually required after orthognathic surgery, limited mouth opening, when muscles had contracture or fibrosis, to exercise tissues

    • Passive

Active: assissted stretching

resistant exercise

clenching exercise (biting on tongue depressor)




TREATMENT OF ACUTE MUSCLE DISORDERS
Muscle splinting
Patient reports pain with no restriction of movement.

Due to new restoration, denture digging into sulcus, anaesthesia



  • Definitive treatment: treat the cause

Splint therapy is indicated to relax muscles and disengage the teeth, which is worn during the times when parafunctional activity is suspected especially at night.

  • Supportive therapy: restrict movement

soft diet

short term pain medication

simple muscle relaxation therapy
Myospasm


  • Etiology: when muscle splinting is not controlled (pain persists more than 3 days without treatment). Any of the etiologic factors that cause muscle splinting can lead to myositis.

Most common causative factor is parafunctional activity. Or constant deep pain input of various unrelated origins: dental, neurologic, vascular.

    • Definitive treatment: treat the cause.

Whether it is parafunctional, psycological or referred.

    • Supportive therapy:

control pain

restrict movement

soft diet

pain medication

coolant therapy

thermotherapy

gentle massage

electric muscle stimulation

diazepam

muscle exercise



Myositis

  • Etiologic factors: if pain continues more than 10-14 days without resolving the problem of myospasm then myositis is likely to be present.

Most common cause is protracted parafunctional activity.

    • Definitive treatment:

-antibiotic therapy (in some cases)

-occlusal splint therapy and emotional stress therapy

- progressive relaxation therapy and bio-feed back

-nonsteroidal anti-inflammatory (there is an inflammatory factor)



    • Supportive therapy:

restricted use

ultrasound

passive exercise

TREATMENT OF DISC INTERFERENCE DISORDERS


  • Dysfunction of the condyle disc complex against the mandibular fossa

  • many are reported as chronic and asymptomatic

  • Pain may or may not accompany the disorders and if present it should be thoroughly evaluated since it can originate from intracapsular structures or be associated with muscle splinting or muscle spasms

Pain is present when we've pain or destruction
Class I interference


  • Definitive treatment: the major cause is disharmony between CO and the musculoskeletal stable position of the condyles in the closed position

Correction is made first by reversible centric relation splint
Class II interference

  • Etiologic considerations: occurs in maximum intercuspation and at the beginning of translation.

A single or reciprocal joint sound may be present with or without pain.

    • Definitive treatment :

directed towards achieving a more normal condyle- disc relation.

Usually done by placing a separator between the posterior teeth which repositions the mandible downward and forward placing the condyle on the intermediate zone which eliminates the sounds



  • Anterior repositioning splint is made in the earliest forward position that will eliminate the sound. It is worn for 2-4 months giving time for the tissues to repair. If symptoms do not subside then total repair was not achieved. If 6-9 months of wearing the splint haven’t removed symptoms then permanent occlusal adjustment should be carried out.

  • Emotional stress therapy is also initiated trying to reduce parafunctional activity.

    • Supportive treatment: when pain is present it needs to be controlled as it leads to cyclic myospasms which continues parafunctional activity.

One to two weeks of pain medication is prescribed.

Some exercises can help in the treatment of class II interferences.


Class III interferences

  • Commonly referred to as internal derangements

  • Can result from:

1. Excessive passive interarticular pressure

2. Structural incompatibility of the sliding surfaces

3. Impaired function of the condyle disc complex

1. Excessive passive inter-articular pressure


  • Definitive treatment:

Since the etiology is parafunctinal activity definitive treatment is directed towards controlling this activity.

Occlusal splint therapy and emotional stress therapy.

Relaxation therapy is highly indicated.


  • Supportive therapy

Controlling pain, instruct the patient to restrict movement within painless limits, soft diet, and small dose of diazepam before sleep.
2. Structural incompatibility of the sliding surfaces:



  • Definitive treatment:

Surgical intervention to change the surfaces that have created the incompatibility to improve normal function, this should be only considered after supportive therapy has failed and the patient finds the symptoms intolerable


  • Supportive therapy

Develop a pattern of movement that avoids pain and minimizes dysfunction.
3. Impaired function of the condyle disc complex


  • Functional displacement of the disc:

Similar to that of class II.

Permanent occlusal consideration is more likely to be needed.

Pain should be appropriately managed.

Thermotherapy, ultrasound and relaxation techniques are also needed.




  • Functional dislocation

    • Posterior dislocation: self reducing and never permanent. The patient is instructed to bite on a hard object on the affected side on posterior teeth that will activate the lateral pterygoid on that side and reduce the disc.

    • Anterior dislocation: more common than posterior dislocation. The disc can be reduced by a manipulative procedure (support mandible from below, thumps on posterior teeth then move mandible downward and push the chin upward and backward. Requires strength to perform). Anterior repositioning splint is introduced as clinching on posterior teeth tends to re-dislocate the disc. If trying to reposition the disc fails, then permanent damage to the retro-discal lamina has occurred and the only way to reduce the disc is surgery.

Pain that persists after 6-8 weeks of splint therapy suggests that this treatment is not successful. Radiographic evidence of degenerative changes of the joint both suggests the need for surgery.

Supportive therapy includes educating the patient about the movement that might cause disc dislocation
Class IV interference (subluxation)


  • Partial dislocation of the disc or joint hypermobility.

  • Clinically presents as a momentary pause upon wide opening and then a jump forward.

  • Steep inclination of the articular eminence may be a contributing factor



  • Definitive treatment

The only definitive treatment is surgical alteration of the morphology of the joint itself by reducing the steepness of the articular eminence.

More effort should be directed towards supportive therapy to reduce the symptoms to a tolerable level




  • Supportive therapy

Educate the patient about the cause and which movement can create it, the patient must restrict the mouth opening.

When the patient is uncooperative intraoral devices to restrict movement are employed



Spontaneous anterior dislocation of the disc


  • Definitive treatment

Directed towards increasing the disc space which allows the superior discal lamina to retract the disc.

Role of elevator muscles:

Elevator muscles: lateral pterygoid: superior head attached to condylar disc relaxes during mouth opening. Inferior head attached to condylar head contacts to pull mandible downward and forward on articular eminence. Opposite occure upon mouth closing

When reducing the patient must try to open wide activating the depressor muscles and inhibiting the elevator muscles at this time slight posterior pressure is applied to the chin and this will help reducing the dislocation.

If not successful:

Surgery when chronic or recurrent




  • Supportive therapy

Teach the patient the reduction technique
TREATMENT OF INFLAMATORY DISORDERS OF THE TEMPROMANDIBULAR JOINT
Capsulitis and synovitis
1. Traumatic capsulitis and synovitis :


  • Definitive treatment

Not indicated since the etiology is self limiting


  • Supportive therapy

Instruct the patient to limit mandibular movements.

Patients complaining from pain should be prescribed analgesics

Heat therapy and ultrasound might be helpful
2. Secondary inflammatory capsulitis or synovitis:

Caused by extension of inflammation from adjacent structures




  • Definitive tratment

Appropriate antibiotic therapy and medical care are provided.

When the cause is arthritis, it should be treated.

When it is caused by disc interference disorders, disc interference should be treated


  • Supportive therapy

The same as traumatic capsulitis


Retrodiscitis:
1. Retrodiscitis from extrinsic trauma


  • Supportive therapy

If there is no evidence of acute malocclusion analgesics are given and the patient is asked to restrict movement to within painless levels and begin a soft diet.

Ultrasound and thermotherapy are often helpful.

A single intracapsular injection of corticosteroids may be used in isolated cases of trauma.

As symptoms are resolved reestablishment of mandibular movement is encouraged.

When acute malocclusion is present intermaxillary fixation is needed but should be released twice daily for 10 min to avoid ankylosis.
2. Retrodiscitis from intrinsic trauma

Intrinsic trauma occurs when disc is dislocated anteriorly so when joint returns to its postion and disc doesn't retrodiscal tissues will be traumatized form joint movement




  • Definitive treatment

Directed towards eliminating the traumatic condition.

Anterior repositioning splint is needed to reestablish a proper condyle disc relationship. This often relieves the pain. The splint is gradually removed to restore the normal condylar position.

If splint therapy fails, surgery may be needed


  • Supportive therapy

Restriction of mandibular movement to painless levels

Analgesics

Thermotherapy and ultrasound

Intraarticular injection is not indicated


Inflamatory arthritis:
Infectious arthritis, hyperurecemia, rheumatoid arthritis



  • Definitive treatment

A centric relation occlusal splint should be fabricated to decrease the load on the joint.

Any oral habits the cause pain should be discontinued.

A common finding in rheumatoid arthritis is heavy posterior occlusal contact with anterior open bite


  • Supportive therapy

Arthritis is caused by changes in the joint surface due to bone remodeling that leads to changes in occlusion when affecting the condylar head

There are several arthritic conditions whose cause is unknown like degenerative joint disease.

Supportive therapy begins by an explanation of the general course of the disease.

The disease runs a course of degenration and then repair.

The syptoms usually run a bell curve.

Fabrication of a splint, antibiotics, analgesics, restriction of mandibular movement, soft diet, thermotherapy, and passive muscle exercise is encouraged to reduce myostatic or myofibrotic contracture and maintain joint function.

If the symptoms are severe and do not resolve within 2 months a single injection of intracapsular corticosteroids is indicated.

If unsuccessful, surgery is indicated.

When the symptoms resolve the sequelea (occlusion) need to be treated.

CHRONIC MANDIBULAR HYPOMOBILITY AND GROWTH DISORDERS
Chronic mandibular hypomobility


  • Most of these cases are generally asymptomatic so supportive therapy is not required


1. Myostatic contracture

Treated by passive stretching or resistant opening exercise.


2. Myofibrotic contracture

It is permanent, the muscle can relax but its length can not increase.

Surgical detachment and re-attachment of the muscle is done.
3. Capsular fibrosis

Treatment is not indicated since this is not a major functional problem to the patient.


4. Ankylosis

Surgery is the only definitive treatment if the movement is impaired.



Treatment of growth disorders

  • Hyperplasia, hypoplasia, neoplasia

  • Treatment must be tailored to the patient’s condition.

  • Treatment is needed to restore function and minimize trauma to the associated structures



Note: Sheet contains both the slides and the extra notes said during the lecture

Done By: Haneen N. El-Dali






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