Prof .B. Srinivasan. B.SC, MDS
Prof .B. Srinivasan. B.SC, MDS
Prof .B. Srinivasan. B.SC, MDS
Sc , MDS
As Dentist 2
Dental treatments - Aim
3/10/2023
Prompt 2023
ESTHETICS
&
FUNCTION
Prompt 2023
3
3/10/2023
Occlusion
Changes in the oral cavity – effects 4
the Masticatory System !....
3/10/2023
Prompt 2023
Prompt 2023
5
3/10/2023
Loss of Posteriors increase load to anteriors
6
3/10/2023
Prompt 2023
Prompt 2023
7
3/10/2023
Masticatory
System
Changes in Joint effects the Occlusion
8
1. Rheumatoid Arthritis
3/10/2023
Prompt 2023
2. Idiopathic Condylar Hypoplasia
9
3/10/2023
Prompt 2023
TMJ – Unique Joint 10
3/10/2023
Prompt 2023
Functionally the TMJ,
upper part of the
cervical spine and
OCCLUSION are
inter-related.
Any disharmony in one of the regions
can manifest as a disease or
disturbance in the other
Masticatory system – position of the condyle
11
3/10/2023
Prompt 2023
TEMPEROMANDIBULAR DISORDER12
An Assorted Set of Clinical Condition
3/10/2023
Prompt 2023
▶
3/10/2023
Prompt 2023
▶ Intra capsular TMD ( Directly Affects the TMJ )
▶ Derangement of Condyle Disc Complex
▶ Structural incompatibility of articular Surface
▶ Inflammatory Disorder .
3/10/2023
Prompt 2023
Joint and the occlusion .
▶ To know the Silent anatomical features and
function’s of TMJ.
▶ To have an idea of the TMD and its diagnosis and
management .
▶ To discuss various options in prevention and
management of TMD’s in Dental Rehabilitations.
Classification of Joints 16
3/10/2023
Prompt 2023
▶ Class I – Synarthrosis (Immovable union of
connective tissue e.g., Cranial sutures)
Ginglymo-di-arthrodial joint
3/10/2023
Prompt 2023
▶
3/10/2023
Prompt 2023
Mandibular Condyle 19
3/10/2023
Prompt 2023
Mediolaterally –
13 to 25 mm
Anteroposteriorly –
5.5 to 16 mm
3/10/2023
Prompt 2023
Inferior (Concave)
Prompt 2023
3/10/2023
Ligaments 22
3/10/2023
Prompt 2023
Lateral or TM ligament
(check ligament)
prevents anterior jaw
excursion
Accessory ligaments
- Spehonmandibular
- Stylomandibular
Synovial Tissue 23
▶ Connective tissue membrane lining the joint
3/10/2023
Prompt 2023
cavities or spaces
▶ Secretes synovial fluid (ultrafiltrate of blood
plasma and mucin) aiding in lubrication
▶ Viscous (highly polymerized hyaluronic acid)
enabling the joint to withstand shearing forces
▶ Other functions: nutrition, phagocytosis and
immunological response
FDI CDE 2019
Prompt 2023
THE MUSCLES
24
3/10/2023
Joint Movements 25
3/10/2023
Prompt 2023
▶ Depression & Elevation (Opening & closing)
▶ Side to Side/ lateral (grinding) movements
▶ Protraction & Retraction (Protrusion &
Retrusion)
26
Prompt 2023
3/10/2023
OPENING
27
Prompt 2023
3/10/2023
Mouth Opening – I I D 28
( Inter Incisal Distance )
3/10/2023
Prompt 2023
Symptoms of TMD 29
❑ Abnormal joint sounds
3/10/2023
Prompt 2023
(TMJ Clicking & locking )
❑ Change in Occlusion.
( Difficulties in Chewing and Biting )
❑ Altered Range of Motion.
( Difficulty in Mouth Opening )
❑ Pain & Referred Pain
Clinical Examination 30
3/10/2023
Prompt 2023
❑ TMJ (Joint proper )
❑ Muscles (Muscles
of Mastication)
❑ Occlusion
31
Prompt 2023
3/10/2023
On Palpation
Range of Movements 32
3/10/2023
Prompt 2023
Examinations of Muscles
33
3/10/2023
Prompt 2023
Examination under Local Anasthesia 34
3/10/2023
Prompt 2023
Auriculo 35
temporal
3/10/2023
Prompt 2023
nerve
Block
36
Prompt 2023
3/10/2023
Referred Pain
37
Prompt 2023
3/10/2023
Diagnostic Block
Centrally orginated “ P A I N”
38
3/10/2023
Prompt 2023
▶ Localized
treatment
will not
help !....
▶ Should
treat
centrally
MUSCLE VS JOINT PAIN (Intra Capsular)
39
3/10/2023
Prompt 2023
Capsular ligament and Condylar movement
40
3/10/2023
Prompt 2023
DISC - MOUTH OPENING
41
Prompt 2023
3/10/2023
CLOSED LOCK
CLICK
EXAMINATION OF OCCLUSION 42
3/10/2023
Prompt 2023
❑ Centric
❑ Anterior Guidance
❑ Canine Guidance
❑ Group Function
Alterations in hard and soft tissues
43
of the TMJ
3/10/2023
Prompt 2023
Radiological Investigations 44
3/10/2023
Prompt 2023
Conventional
Vs
Advanced
TRANSPHARYNGEAL VIEW 45
3/10/2023
Prompt 2023
OSTEOARTHRITIS
SHOWING A SEPARATED OSTEOPHYTE IN JOINT SPACE
46
3/10/2023
Prompt 2023
47
Prompt 2023
3/10/2023
TRANSORBITAL VIEW
PANORAMIC RADIOGRAPHY 48
3/10/2023
Prompt 2023
Advanced Radiographs & CT 49
3/10/2023
Prompt 2023
MAGNETIC RESONANCE IMAGING
50
3/10/2023
Prompt 2023
OPEN MOUTH
CLOSED MOUTH
ARTHROSCOPIC – DIAGNOSIS 51
3/10/2023
Prompt 2023
52
Prompt 2023
3/10/2023
CLASSIFICATION OF TMJ DISORDERS
53
▶ Developmental
Aplasia, Hypoplasia, Hyperplasia
3/10/2023
Prompt 2023
▶ Inflammatory
Rheumatoid arthritis, Osteoarthritis, Still’s disease etc…
▶ Trauma
Condylar fractures
▶ Tumor
Osteoma ,Chondroma, Osteosarcoma, Chondrosarcoma
▶ Miscellaneous
MPDS
Internal Derangement
INTERNAL DERANGMENT 55
3/10/2023
Prompt 2023
▶ Localized disturbance & uncoordinated
movement between the disc and the
head of the condyle
ETIOLOGY 56
3/10/2023
Prompt 2023
▶ Functional Overloading
▶ Joint Laxity
▶ Masticatory Muscle Spasm
▶ Degenerative Joint Disease
▶ Increased Friction
CLASSIFICATION 57
Deviation in form
3/10/2023
Prompt 2023
▶
▶ Disc Displacement
▶ Partial anteromedial disc displacement
▶ Anteromedial disc displacement with reduction
▶ Anteromedial disc displacement with intermittent locking
▶ Anteromedial disc displacement without reduction
▶ ADD with perforation of retrodiscal tissue
58
3/10/2023
Prompt 2023
▶
3/10/2023
Prompt 2023
Pain ( on mandibular movements )
3/10/2023
Prompt 2023
Clinical features
1. No collapse of joint space (there
is no or minimum interference of
joint function)
2. No clicking
,
3. Slight early deviation
4. Discomfort in the joint area after
prolonged clenching
ADD with Reduction 61
3/10/2023
Prompt 2023
1, Hinge opening
2, Lock - Pain
3, Deviation away from the
painful side and returns to the mid line
4. Clicking ( Open Click)
5. Full translatory mouth opening
6. Clicking (Reciprocal)
7. Translatory mouth closure
A. Resting, 62
closed joint position
3/10/2023
Prompt 2023
B. Early stage of
translation
3/10/2023
Prompt 2023
of elasticity
•----Loss of spontaneous reduction
ADD without Reduction
64
Hinge opening
3/10/2023
Prompt 2023
▶
▶ Pain
▶ Deflection towards painful side
▶ Pain (Painful side remains
locked)
▶ Translatory opening of the
opposite side
65
Resting,
3/10/2023
Prompt 2023
closed joint position
3/10/2023
Prompt 2023
▶
Displaced meniscus
3/10/2023
Prompt 2023
Restricted forward
translation
Prompt 2023
3/10/2023
ADD with perforation 69
3/10/2023
Prompt 2023
▶ Chronic condition
▶ Pain
▶ Referred pain
▶ Tinnitus, headache
▶ Crepitus
▶ Diffuse muscle tenderness
Adhesive Disc Hypomobility 70
3/10/2023
Prompt 2023
Microtrauma
Damage to the disc
Bleeding
Repair
Fibrous tissue
Adhesion
Restricted movement
A. Closed B. Open: A n adhesion occurring between the disc and the fossa
preventing normal translatory movement creating a closed lock with a vertical
opening of 25 to 30 mm . No collapse of the joint space and no displacement of the
disc
Displacement of the Disc-Condyle Complex
71
3/10/2023
Prompt 2023
SUBLUXATION
WILKIES STAGING OF INTERNAL DERANGEMENTS
72
STAGE CHARACTERISTICS IMAGING
1. Early Slight forward disc. Normal
3/10/2023
Prompt 2023
Painless clicking. No restricted
motion osseous contours
2. Early Intermediate Occasional painful clicking. Slightly forward disc Early disc
Intermittent locking Headaches deformation Normal osseous
contours
Prompt 2023
3/10/2023
74
Prompt 2023
3/10/2023
75
Prompt 2023
3/10/2023
Management of I D of TMJ as per the Staging
STAGE CHARACTERISTICS IMAGING
76
1. Early Painless clicking. No restricted Slight forward disc. Normal
3/10/2023
Prompt 2023
motion osseous contours
(Medical and physical)
2. Early Intermediate Occasional painful clicking. Slightly forward disc Early disc
Intermittent locking Headaches deformation Normal osseous
(Medical and physical) contours
3/10/2023
Prompt 2023
▶ Physical therapy.
▶ Occlusal Deprograming ( SPLINT )
( Functional correction of the Occlusion )
▶ Prolotherapy
▶ Artherocentesis & Lavage
( Release of the adhesion )
▶ Arthroscopic Surgery
▶ Open Joint Surgery ( Discectomy , Meniscoplasty)
MEDICAL THERAPY
78
Tricyclic antidepressants-
3/10/2023
Prompt 2023
▶
Dothiepin 75mg
Amitryptilline
Fluoxetine 20mg
3/10/2023
Prompt 2023
Derangement
Z U M J – Sept 2013
Prompt 2023
3/10/2023
PHYSICAL THERAPY 81
3/10/2023
Prompt 2023
▶ EXERCISE THERAPY
▶ ELECTROTHERAPY
INDICATIONS:
INFLAMMATION
HYPERMOBILITY
HYPOMOBILITY
82
Prompt 2023
3/10/2023
Exercise
83
LASER
3/10/2023
Prompt 2023
SOFT LASERS ( L I L T )
INDICATIONS
TISSUE HEALING
SPLINT THERAPY 84
Diagnostic & Therapeutic
3/10/2023
Prompt 2023
Alter the Occlusal plane
Prevent attrition
Treat Myalgia
Decrease Para function
Alter the structural relation of the TMJ*
THEORIES OF SPLINT (CLARKES,1984) 85
3/10/2023
Prompt 2023
1. Occlusal disengagement theory
(restore neuromuscular balance)
2. Maxillomandibular realignment theory
(restore neuromuscular balance)
3. Restored vertical dimension theory
4. TMJ repositioning theory
5. Cognitive awareness theory (placebo effect)
MUSCULAR DEPROGRAMING 86
3/10/2023
Prompt 2023
TYPES OF SPLINTS: 87
3/10/2023
Prompt 2023
A soft splint made of polyvinyl of uniform thickness)
Arch - maxillary or mandibular
Records - none
Contacts - not needed
Usage - at night / 6 weeks to 3
months
Indication 1. Absorb Occlusal forces
2. Habit breaker
88
Prompt 2023
3/10/2023
SOFT BITE GUARD
D. ANTERIOR REPOSITIONING 89
APPLIANCE ARPS)
3/10/2023
Prompt 2023
It is a splint which repositions the mandible in a
protrusive position where there is no click when the
patient opens and closes.
Arch - Maxillary
Records - Protrusive record
Contacts - All occlusal surfaces in anterior
position of mandible
90
Duration - 24 hours a day (even while
eating) 6-12 weeks
3/10/2023
Prompt 2023
Indication
1. Internal derangement of the TMJ
with a displaced disc which
reduces on opening.
2. Intermittent or chronic locking
3. Inflammatory disorders like Retro
discitis.
ANTERIOR REPOSITIONING APPLIANCE
91
(ARPS)
3/10/2023
Prompt 2023
ANTERIOR REPOSITIONING APPLIANCE
92
(ARPS)
3/10/2023
Prompt 2023
Reversible Occlusal Therapy 93
3/10/2023
Prompt 2023
OCCLUSAL THERAPY 94
(IRREVERSIBLE)
3/10/2023
Prompt 2023
When it has been proved beyond
reasonable doubt that the existing
occlusal condition is responsible for the
TMD.
Irreversible Occlusal Therapy 95
3/10/2023
Prompt 2023
Occlusal 96
Adjustments
3/10/2023
Prompt 2023
MINIMAL INVASIVE TECHNIQUE
98
Prompt 2023
3/10/2023
ARTHEROCENTESIS
99
Prompt 2023
3/10/2023
Arthrocentesis in TMJ – evaluation 100
3/10/2023
Prompt 2023
JOMS 59:874-877: 2001
▶ Severe Pre Operative pain
▶ Relapse in amount of mouth opening
▶ Boney changes of the condyle
3/10/2023
Prompt 2023
Andrew L. Young
Jr of In Prostho Society | Jan-Mar 2015 | Vol 15 | Issue 1
3/10/2023
Prompt 2023
Plast Aesthet Res / Vol 1 / Issue 1/ Jun 2014
Pain - Vasoconstriction and Release of nitric oxide,
reactive oxygen species (ROS), and Thiobarbituric acid.
Elevated ROS levels in synovial fluid may result from
mechanical stress and high pressures directed to the upper
compartment during clenching and jaw movement
Lavage and decreases intra-articular pressure. Furthermore,
the elimination of nitric oxide and ROS relieves the pain.
103
Prompt 2023
3/10/2023
Arthroscopy
104
Prompt 2023
3/10/2023
105
Prompt 2023
3/10/2023
Arthroscopy Lysis and lavage in 106
ID of TMJ
3/10/2023
Prompt 2023
458 patients (611 joints ) Wilkies 2-5
ID of TMJ
3/10/2023
Prompt 2023
458 patients (611 joints ) Wilkies 2-5
3/10/2023
Prompt 2023
derrangement
Prompt 2023
3/10/2023
MENISECTOMY
110
Prompt 2023
3/10/2023
Discectomy
111
Prompt 2023
3/10/2023
CONDYLECTOMY
Sub Sigmoid Osteotomy 112
3/10/2023
Prompt 2023
113
Prompt 2023
3/10/2023
Surgery for TMJ internal derangement 114
(Evaluation of treatment outcome and criteria for
success)
3/10/2023
Prompt 2023
Combine modalities are often more
effective than single approach .
(Medical, Physical ,and Surgical)
3/10/2023
Prompt 2023
In cases with no improvement after
non surgical treatment – this
procedure shows good results in pain
control following adaptive changes .
3/10/2023
Prompt 2023
The Literature is unequivocal in support for surgery in
management of certain disorder of TMJ ( Internal
Derangement )
3/10/2023
Prompt 2023
Dent Clin N Am 51 (2007) 195–208
3/10/2023
Prompt 2023
Effective surgical treatment in Disc
Displacement in TMJ internal
Derrangement .
JOMS ; 68:239-242:2010
Quality of the life – In Discectomy 119
Pre & Post
3/10/2023
Prompt 2023
Discectomy with Dermis fat grating –
Positive quality of life , Reducing Pain
and increase in ROM in Stage 4 ID
JOMS 68:101-106:2010
TMJ interposition with Dermis Graft in
120
Internal Derangement – a critical
review ( G. Dimitroulis)
3/10/2023
Prompt 2023
No Ideal Interposition material that Satisfies all
Criteria for replacement of articular disc
following TMJ Discectomy
3/10/2023
Prompt 2023
Stomatological Dis Sci 2019;3:5
Based on the present review, the studies with highest evidence
conclude that:
(1) High-degree evidence is insufficient in relation to the effect of surgery
(2) Surgery is useful in patients refractory to conservative treatment;
(3) There are not differences among surgical techniques
(4) Arthroscopy and Arthrocentesis are effective in the treatment of chronic
closed lock.
(5 ). Arthroscopy is preferred as the first option due to its
Minimal invasive nature
Total joint replacement 122
3/10/2023
Prompt 2023
123
Prompt 2023
3/10/2023
Conclusion
▶ Alterations in the occlusion can Damage the TMJ
124
▶ Pathologies in the TMJ can alter the occlusion .
3/10/2023
Prompt 2023
▶ In any Dental Rehablitaion , Masticatory system should be taken care and
should be examined completely before treatment .
▶ Dental Rehablitation is not complete with out considering the Muscle of
head & Neck & Tempromandibular Joint
▶ Muscle Deprograming should be considered before definitive therapy
▶ Managing Pain and Dysfunction in the TMJ is mandatory before Dental
Rehabilitation
▶ Irreversible alteration in the Teeth, Muscle and TMJ should be reserved as
the last option
▶ Assessments & Diagnosis is Very Important
▶ Non Invasive , Minimal Invasive , and Invasive Management
TMJ Association
126
3/10/2023
Prompt 2023
▶ Good Patient Feed Back
3/10/2023
Prompt 2023
To Know More !.....
128
3/10/2023
Prompt 2023
Thank you all
Have a Nice day