The need for integrating TMJ therapy with implant prosthodontic cases

In this paper, guidelines for TMJ diagnosis and treatment were reviewed, and a case history was presented demonstrating the need for the integration of TMJ therapy. The case history presented is just one of many cases in the author's practice where the implant candidate also presented with a CM-TMJ disorder. The author emphasizes the incorporation of a CM-TMJ disorder screening exam and history to complement the initial consultation by all practitioners. This should include: 1) check for pops, clicks, in front of ears, (opening, closing, protruding); 2) range of motion (three fingers opening); 3) headaches; 4) grind or brux (night or day); 5) palpate key masticatory muscles of the head and neck; 6) tooth interferences; and 7) bite feels off. The author understands that not all practitioners have access to various diagnostic instrumentation, but emphasizes that this should not prevent the practitioner from diagnosing and treating CM-TMJ disorders or referring for such treatment. The literature has not indicated the overall benefits of implant prosthodontics other than allowing mastication of food and a feeling of self-esteem; but the benefits also allow the treatment and relief of CM-TMJ disorders via a stable occlusion.     

Botulinum Toxin in the Treatment of Muscle Specific Oro-Facial Pain: A Literature Review

Facial pain associated with temporomandibular joint (TMJ) and surrounding structures has been a challenge to clinicians as far as diagnosis and management is concerned. Complexity of anatomical structures within a small area, function of teeth and surrounding periodontal ligament, action of muscles, pathologies, lack of diagnostic investigations, all these complicate specific diagnosis of TMJ disorders. Various classifications have been designed and studied to help diagnose and treat TMJ related disorders, of which the simplest one is pain from TMJ proper and surrounding muscles. Many treatment modalities to treat pain arising from muscles around TMJ like splints, mouth restriction exercises, injection of sclerosing agents etc. have been used with various degrees of success. Botulinum toxin has been shown to be effective in the treatment of oro-facial pain due to muscular disorders and the same is discussed in detail in this review literature.     

Magnetic resonance imaging predictors of temporomandibular joint pain

BACKGROUND: The authors conducted a study to evaluate whether temporomandibular joint, or TMJ, disorder subgroups are related to magnetic resonance imaging, or MRI, diagnoses of TMJ internal derangement, or ID; osteoarthrosis, or OA; effusion; and bone marrow edema. METHODS: The TMJ disorder group was composed of 118 subjects with TMJ pain who were assigned a clinical unilateral single diagnosis of a specific TMJ disorder. The control group consisted of 46 subjects who did not have TMJ pain. Sagittal and coronal magnetic resonance images were obtained to establish the prevalence of ID, OA, effusion and bone marrow edema. The authors used a multiple logistic regression analysis to compute the odds ratios, or OR, for MRI features for control subjects versus four groups of subjects who had TMJ pain: ID type I (n = 35), ID type III (n = 39), capsulitis/synovitis (n = 26) and degenerative joint disease, or DJD, (n = 18). RESULTS: MRI diagnoses that did not contribute to the risk of TMJ pain included disk displacement, or DD, with reduction and effusion. Significant increases in the risk of experiencing TMJ pain occurred selectively with DD without reduction (OR = 10.2:1; P = .007) and bone marrow edema (OR = 15.6:1, P = .003) for the ID type III group and with DD without reduction (OR = 11.7:1, P = .054) for the DJD group. Subjects in the group with ID type I were less likely to be associated with an MRI finding of OA than were control subjects (OR = 1:5.6). CONCLUSIONS: While the contribution of MRI variables to the TMJ pain subgroups was not zero, most of the variation in each TMJ pain population was not explained by MRI parameters. Thus, MRI diagnoses may not be considered the unique or dominant factor in defining TMJ disorder populations. CLINICAL IMPLICATIONS: Therapy for subjects with TMJ based on the evaluation of concomitant morphological abnormalities, whether prophylactically or as treatment for TMJ disorders, may be unwarranted.     

Psychometric profiles and facial pain

The myofacial pain-dysfunction syndrome and atypical facial pain are the most prevalent chronic pain disorders of the facial region. Previously, the myofacial pain-dysfunction syndrome included all TMJ/masticatory muscle pain, jaw dysfunction, and joint clicking. We have segregated two major subgroups subsumed within this diagnostic classification and have assigned them to a myogenic facial pain (MFP) group and a TMJ internal derangement (TMJID) group. Significant age and personality differences were uncovered when these subpopulations were compared to subjects with atypical facial pain (AFP). Both MFP and TMJID groups are relatively homologous, involving younger persons than AFP subjects. Alternatively, when MFP, TMJID, and AFP subjects were compared for differences in MMPI psychometric scales, MFP and AFP subjects exhibited significantly higher scores, particularly for hypochondriasis, depression, and hysteria, than did TMJID subjects. It is concluded that subcategorization of myofascial pain-dysfunction patients into a myogenic pain group and a TMJ internal derangement group is justified on the basis of psychometric differences. Furthermore, psychopathologic factors are more significant among MFP and AFP subjects than among TMJID patients.     

Electromyography Before and After Treatment of TMJ Dysfunction

The patient described in this article suffered from pain in the right side of her face for five years before she saw the authors. Earlier treatment with medication and neurosurgery had not been successful. The authors used electromyography to examine the disturbed muscle function and to investigate a possible cause for the pain in the muscles of mastication. The silent periods of the patient's muscles were measured before and after treatment, since it is known from the literature that the EMG silent periods may be elongated in patients with TMJ dysfunction or occlusal irregularities. The coordination of both heads of this patient's lateral pterygoid muscles were bilaterally investigated before and after treatment. Treatment consisted of splint therapy and selective grinding. Oral rehabilitation was also undertaken, beginning three months after the disappearance of the patient's symptoms.     

Alloplastic temporomandibular joint replacement: rationale for the use of custom devices

The essential life functions of mastication, speech, airway support and deglutition are supported by temporomandibular joint (TMJ) function and form. Over a lifetime, this puts the TMJ complex under more cyclical loading and unloading than any other joint. Therefore, to provide long-term effective outcomes, the TMJ total joint replacement (TJR) device selected must be capable of managing the anatomical, functional and aesthetic discrepancies that dictated its use. The primary goal of TMJ TJR is the restoration of mandibular function and form. Outcomes data confirm that any pain relief attained must be considered of only secondary benefit. Despite persistent but reduced chronic pain, increased mandibular function and form improvement have been reported, resulting in quality of life improvement for 85% of custom TMJ TJR patients studied long-term. Based on the literature and the accepted orthopaedic criteria for the development and utilisation of successful TJR devices, this paper presents a rationale for the use of custom TMJ TJR devices as a 'fitting' management option for end-stage TMJ disorders.     

偏侧咀嚼对大鼠颞下颌关节及咀嚼肌影响的研究

目的　研究偏侧咀嚼对大鼠颞下颌关节及咀嚼肌的影响。方法　 80只大白鼠随机分为 4组 ,实验组拔除右上颌磨牙 ,对照组未做处理 ,饲养条件相同。实验 1组拔牙后 4周末、实验 2组拔牙后 8周末处死动物 ,取其双侧颞肌、咀嚼肌及颞下颌关节进行病理切片检查 ,结果与对照组对照。结果　实验 1、2组双侧颞下颌关节、颞肌及咀嚼肌均出现受损的病理变化。髁状突及关节盘均有破坏 ,咀嚼肌有炎性变化。结论　偏侧咀嚼是颞下颌关节紊乱病的病因之一。     

Neuroendocrine, immune, and local responses related to temporomandibular disorders

Orofacial pain frequently originates from pathologic conditions in the masticatory muscles or temporomandibular joints (TMJs). The mediators and mechanisms that monitor pain and inflammation, centrally or peripherally, are of great interest in the search for new treatment modalities. The neuropeptides substance P (SP), calcitonin gene-related peptide (CGRP), and neuropeptide Y (NPY) have all been found at high levels in the synovial fluid of arthritic TMJs in association with spontaneous pain, while serotonin (5-HT) has been found in association with hyperalgesia/allodynia of the TMJ. Interleukin-1 beta (IL-1 beta) and tumor necrosis factor alpha (TNF alpha) have been found in arthritic TMJs, but not in healthy TMJs, in association with hyperalgesia/allodynia of the TMJ as well as spontaneous pain. Anterior open bite, which may be a clinical sign of TMJ destruction, has been found in association with high levels of CGRP, NPY, and IL-1 beta in the synovial fluid of the TMJ. Interleukin-1 beta has also been related to radiographic signs of joint destruction. Prostaglandin E2 (PGE2) and leukotriene B4 (LTB4) are both present in the arthritic TMJ, and PGE2 has been shown to be associated with hyperalgesia/allodynia of the TMJ. Very little is known about pain and inflammatory mediators in muscles. However, we know that 5-HT and PGE2 are involved in the development of pain and hyperalgesia/allodynia of the masseter muscle in patients with fibromyalgia, whereas local myalgia (myofascial pain) seems to be modulated by other, as yet unknown mediators. Interaction between the peripheral nervous system (sensory and sympathetic nerves), the immune system, and local cells is probably of great importance for the modulation of pain and inflammation in the TMJ and orofacial musculature.     

Non-surgical treatment of sports-related temporomandibular joint disorders in basketball players

Abstract –  In this study, 18 basketball players (11 female, seven male; age range 14–32 years) with temporomandibular joint (TMJ) problems who had a history of sport injuries related to head or jaw region were evaluated and the results of the treatment were presented. A standardized functional examination of the masticatory system was performed including measurement of maximal jaw movements, recording of joint sounds, pain on movement of the jaw as well as tenderness to palpation of the both TMJ or masticatory muscles. Patients were also evaluated periodontally. Diagnosis was made according the criteria, described by Okeson, and appropriate treatment was applied using different kind of splints. At the end of treatment only one patient continued with right TMJ reduction with slight pain. Except for that patient, none of the patients had pain after treatment. The maximum opening of the jaws and the maximal jaw movements were statistically increased after treatment. Patients with TMJ problems also showed periodontal problems, most likely due to inadequate oral hygiene because of the limited jaw movements and pain. Periodontal parameters including probing depth (PD), Plaque index (PI), and Sulcus Bleeding Index (SBI) improved after treatment. Sports-related TMJ injuries may result in complex problems such as pain, TMJ sounds, limitation in maximal jaw movements and maximum opening of the mouth, difficulty in chewing. With the appropriate diagnosis this could be treated non-surgically in 6–8 months. This study also showed that the TMJ disorders may cause periodontal problems, which may affect all teeth and also the general health of the athlete.     

Rheumatoid Arthritis and Its Implications in Temporomandibular Disorders

Rheumatoid arthritis is known to afflict the temporomandibular joint (TMJ) with common symptoms including pain during function, tenderness on palpation, stiffness, and crepitus. New evidence suggests that metalloproteinases may be responsible for tissue changes that occur in rheumatoid arthritis. These enzymes are collagenase, gelatinase, and proteoglycanase. Anti-inflammatory drugs are the first line of management for pain and inflammation in rheumatoid arthritis. This paper, however, suggests that because increased joint load is believed to cause a greater expression of destructive metalloproteinase, it is appropriate to assess even the asymptomatic temporomandibular joint and the muscles of mastication for early objective signs of dysfunction or discomfort. Interceptive management, by the use of load-reducing appliance therapy, may enable reduction of the expression of destructive metalloproteinase within the joint, thereby reducing joint destruction.     

Condylar resorption during active orthodontic treatment and subsequent therapy: report of a special case dealing with iatrogenic TMD possibly related to orthodontic treatment

A 28-year-old female underwent orthodontic treatment for approximately 22 months. During the later stages of this treatment, the patient reported right shoulder and neck-muscle pain. In addition, temporomandibular joint disorder (TMD) with a 'clicking' sound during mastication commenced 5 months prior to treatment completion. Specific medication to deal with these symptoms was suggested by medical specialists, as were some stress-relief methods, although the pain still progressed, and subsequent clinical and radiographical examinations were undertaken by another orthodontist. Right mandibular condylar resorption was observed from both the panorex and temporomandibular joint (TMJ) radiographs. No clinical signs of rheumatic disease were observed, although bruxism was noted. Following the termination of the orthodontic treatment by the second practitioner, the patient was treated with splint therapy 1 month subsequent to which, the previous symptoms of pain in the shoulder and neck, and the clicking sound during mastication had subsided. During the 14-month period of splint therapy and follow-up, new bone growth in the right condyle was observed from radiographs.     

Is the incidence of temporomandibular disorder increased in polycystic ovary syndrome?

The prevalence of temporomandibular disorders is higher among women than men (ratio 3:1 -9:1). Polycystic ovary syndrome(PCOS) is the most common endocrine disorder in women, which is characterised by chronic low-grade inflammation and excess of androgenic hormones that lead to metabolic aberrations and ovarian dysfunction. Increased activities of various matrix metalloproteinases (particularly MMP-2 and 9) in the serum of these patients has been reported, and it has been hypothesised that high activities of MMP may contribute to loss of matrix and chronic inflammation of the fibrocartilage in temporomandibular disorders. Our aim was to evaluate the incidence of temopormandibular dysfunction in women with PCOS compared with an age-matched, disease-free, control group. We studied 50 patients with previously diagnosed PCOS and 50 volunteers who had normal menstrual cycles. We made a comprehensive clinical examination of the temporomandibular joint (TMJ) and muscles of mastication in both groups and recorded the Visual Analogue Scores (VAS) for pain. There were significant differences (p < 0.001) in the incidence of temporomandibular disorders (n = 43 (86%) in the PCOS group compared with n = 12 24% in the control group), muscle tenderness(n = 32 (64%) in the PCOS group compared with n = 14 (28%) in the control group) and pain in the TMJ (mean (SD) VAS 2.9 (2.61) compared with 0.3 (1.56). We confirm the higher incidence and severity of disorders of the TMJ in patients with PCOS and suspect that chronic low-grade inflammation may play a part in the aetiology of the disease.     

Cryoanalgesia in the management of intractable pain in the temporomandibular joint: a five-year retrospective review

Cryoanalgesia is a controversial adjunct to the management of chronic pain, but we know of no studies that have investigated its effect in the management of temporomandibular joint (TMJ) pain. In this five-year retrospective study we treated 17 patients who had severe pain that had failed to respond to all forms of conventional conservative treatment and were not appropriate for simple open operation. None had a clear indication for open operation on the joint or had too severe disease to warrant a simple procedure. Preliminary diagnostic injections of bupivacaine to the TMJ relieved the pain. We applied the cryoprobe in the region of the auriculotemporal nerve and TMJ capsule. There was a small but insignificant improvement in mean mouth opening together with a significant (p = 0.000) improvement in visual analogue pain scores (VAS) from 6.8 (range 4–10) to 2.0 (range 0–7). Two patients had no change in their pain scores, and 2 had complete resolution of their pain. The mean number of pain-free months after treatment was 7 (IQR 3–15). Three patients had long-term pain relief, and 12 temporary relief; 6 of these subsequently had successful relief after total replacement of the TMJ. One patient had further cryoanalgesia, one was referred for specialist pain management, and one controlled the pain with nortriptyline. Of the 17 cases studied, 2 had temporary complications after cryoanalgesia. Cryoanalgesia is a useful adjunct to the management of intractable pain in the TMJ. Short-term pain relief can be achieved, and long-term relief is possible in some, deferring more complex and costly treatments.     

Temporomandibular disorder or Eagle's syndrome? A clinical report

This clinical report describes the diagnosis and treatment of a patient under emotional stress with orofacial pain, headaches, and the feeling of a foreign body in the throat. An elongated styloid process at the beginning of the oral pharynx was diagnosed. Although these symptoms could be aspects of Eagle's syndrome, deflective occlusal interferences, tender muscles of mastication, and a clicking temporomandibular joint led to an evaluation for temporomandibular disorder related to malocclusion. An occlusal splint was used to confirm the diagnosis and to alleviate symptoms. Occlusal adjustments were subsequently performed. In a 10-year follow-up, the patient had no complaints.     

Soft versus hard occlusal splint therapy in the management of temporomandibular disorders (TMDs)

Aim

To compare between soft and hard occlusal splint therapy for the management of myofacial pain dysfunction (MPD) or internal derangement (ID) of the temporomandibular joint (TMJ) with reciprocal clicking.

Patients and methods

This study included 50 patients (age range: 24–47 years) who had been diagnosed with MPD or ID of the TMJ in the form of reciprocal clicking. Patients were divided into two groups. They were treated for 4 months with either a vacuum-formed soft occlusal splint constructed from 2-mm-thick elastic rubber sheets (soft splint group) or a hard flat occlusal splint fabricated from transparent acrylic resin (hard splint group). Monthly follow-up visits were performed during the treatment period. Before treatment and 1, 2, 3 and 4 months after treatment, the dentist measured all parameters of TMJ function (pain visual analog scores, tenderness of masticatory muscles, clicking and tenderness of the TMJ, and range of mouth opening).

Results

All parameters of TMJ function showed significant improvement in both groups during the follow-up period, with a statistically significant difference between the two groups at the 4-month follow-up visit.

Conclusions

Both forms of occlusal splints (soft and hard) improved TMJ symptoms in patients with MPD or ID of the TMJ. However, the soft occlusal splints exhibited superior results after 4 months of use.     

Treatment prostheses in TMJ dysfunction-pain syndrome

Various types of acrylic resin therapeutic prostheses commonly used in the treatment of TMJ dysfunction-pain syndrome were described. Each design was related to recent data concerning optimum condylar positions in the fossae, the physiologic condylar suspension system, and individual treatment objectives for repositioning the mandibular condyles. For example, alteration of the vertical dimension of occlusion is a popular treatment procedure that is empirical in nature and is usually used without TMJ radiographs or a differential diagnosis. It can violate the physiologic requirements of the interocclusal distance or the speaking space and does not necessarily move the condyles forward as has been commonly thought. The dangers of empirical treatment procedures for a multicausal dysfunction syndrome have been pointed out. An example was cited where the mandible was moved forward for a long period of time with a repositioning prosthesis; this produced pathologic TMJ remodeling and continued pain. It was recommended that specific mandibular repositioning be based on the type of condylar displacement observed on the radiographs. Sometimes the condyles should be retruded, and other times they should be repositioned anteriorly or occasionally inferiorly on one side. Long-standing use of any acrylic resin repositioning prosthesis is contraindicated, particularly without close supervision. Acrylic resin anterior bite plates (with a minimum opening of 1 mm) were recommended for the relief of acute trismus or intractable pain. Usually the prosthesis is used in conjunction with heat and drug therapy. This type of prothesis can also be utilized to deprogram the muscles when a strong habit of eccentric occlusion develops as a result of missing teeth. (This should be confirmed by TMJ radiographs.) Occasionally atypical pain is present and a differential diagnosis can be established between TMJ dysfunction or neurologic etiology by the physiologic response to bite plate therapy. When it is necessary to reposition the mandibular condyles anteriorly the occlusion is adjusted to provide the planned anterior movement without increasing the vertical dimension of occlusion. A temporary acrylic resin prosthesis is used to retrain the muscle programming to the anterior therapeutic mandibular position. When the symptoms are relieved and the corrective condylar position is confirmed with TMJ radiographs, a more permanent repositioning prosthesis is made. The treatment of TMJ dysfunction-pain syndrome should be based on documented data including the pain history, TMJ radiographs, condylar position in the fossae, electromyographic evidence, and occlusal analysis. This information will help determine if the patient's centric relation is functional or dysfunctional and will indicate the recommended treatment procedures.     

Determining predictor variables for treatment outcomes of arthrocentesis and hydraulic distention of the temporomandibular joint.

PURPOSE: Arthrocentesis and hydraulic distention of the temporomandibular joint (TMJ) has been described as an effective modality in the treatment of patients demonstrating clinical findings consistent with the diagnosis of disc displacement without reduction. The purpose of this study was to investigate whether the clinical variable of TMJ pain chronicity and the magnetic resonance (MR) imaging variable of osteoarthrosis (OA) may predict treatment outcomes of arthrocentesis and hydraulic distention of the TMJ. PATIENTS AND METHODS: The study consisted of 29 TMJ pain patients, who were assigned a unilateral clinical temporomandibular disorder (TMD) of "TMJ pain associated with an internal derangement (ID) type III (disc displacement without reduction)," and a TMJ pain side-related MR imaging diagnosis of disc displacement without reduction. Bilateral sagittal and coronal MR images were obtained immediately preoperatively to establish the presence or absence of ID and OA. TMJ pain level of function and mandibular range of motion were assessed preoperatively and compared with the respective 2-month follow-up findings. Outcome criteria of success were 1). an absence of signs and symptoms characteristic of a diagnosis of ID type III and/or 2). a reduction in pain level of 85% or greater. A multiple logistic regression analysis was used to compute the odds ratio for TMJ pain chronicity (duration >6 months and <2 years) and OA for successful outcomes versus nonsuccessful outcomes. RESULTS: The pretreatment data revealed no significant relationship between the clinical disorder "TMJ pain associated with ID type III" and the MR imaging finding of OA (P =.103). At 2-month follow-up, clinical evaluation showed a significant reduction in TMJ pain during function (P =.000), a significant reduction in clinical diagnoses of TMDs (P =.000), and a significant increase in mandibular range of motion (P =.000). Significant increase in risk of a nonsuccessful outcome (pain reduction <85%) occurred with TMJ pain chronicity (odds ratio of 41.0) (P =.018). Significant increase in benefit of a successful outcome (absence of ID type III) occurred with TMJ OA (odds ratio 1:16.7, P =.06) (P =.044). CONCLUSIONS: Arthrocentesis in chronic TMJ pain patients was less successful than in nonchronic patients with regard to treatment outcome of pain reduction. Arthrocentesis in patients with TMJ OA was more beneficial with regard to the disappearance of ID type III than in non-OA patients. Predictive modeling may provide clinicians with the opportunity to identify "at-benefit" patients early and initiate specific treatments.     

Temporomandibular Joint Surgery: What Does it Mean to India in the 21st Century?

While India boasts the largest collective experience in the surgical management of TMJ ankylosis, times are changing and Indian Surgeons will need to begin thinking about other TMJ disorders that have previously gone under the radar. A growing Indian middle class with greater access to health facilities will demand treatment for TMJ disorders like myofacial pain and dysfunction, internal derangement and osteoarthrosis which Oral & Maxillofacial Surgeons must be prepared to manage. The aim of this paper is to review the role of TMJ surgery and its place in the treatment armamentarium of temporomandibular disorders. Indications, rationale for surgery, risks vs benefits are discussed and complemented with examples of clinical cases treated by the author. As India moves up the economic ladder of success, TMJ disorders that have largely been confined to Western nations will begin to appear in the rising middle classes of India. Indian Oral & Maxillofacial Surgeons must be prepared to recognize and manage disorders which present with more complex symptomatology where the role of TMJ surgery is less clear cut.     

Anterior repositioning appliance therapy for TMJ disorders: specific symptoms relieved and relationship to disk status on MRI

Forty-eight (48) consecutive patients seeking treatment in a referral based practice for complex chronic painful temporomandibular joint (TMJ) disease were enrolled in a prospective study to assess specific symptom relief from anterior repositioning appliance (ARA) therapy and the relationship between specific symptom relief and the status of the TMJ disk. Each patient was assessed on 86 symptoms based upon whether each symptom was present before treatment and absent, better, unchanged or worse after Maximum Medical Improvement (MMI). The most common symptom was occipital cephalalgia (94%). The least common symptom was pain and burning of tongue (8%). A profile of a temporomandibular disorder (TMD) patient was developed. The typical TMD patient has cephalalgia, mainly in the occipital, temporal and frontal region, pain upon chewing food, pain upon opening and closing the mouth, TMJ pain, pain in the back of the neck and difficulty chewing food. Before treatment, patients with bilateral displaced disks had more symptoms than those with unilateral displaced disks and the opposite side normal. After MMI, the maximum benefit (percent of pretreatment symptoms relieved) was found in patients with normal or recaptured disks. The minimum occurred in patients whose disks did not recapture with therapy. ARA therapy improved or eliminated symptoms in all patients in the study.     

The concurrency of temporal tendinitis with TMD

Temporomandibular disorder (TMD) is a type of orofacial pain that can originate from a number of craniofacial mandibular structures. These include the TM joints, the muscles of mastication, related nerves, tendons, ligaments, bones and teeth. Symptoms include impaired jaw function, TM joint noises and pain, limited opening, often with jaw deviations or deflections to the affected side. Temporal tendinitis is a disorder of the fibrous insertion of the temporalis muscle tendons on the coronoid process of the mandible that is characterized by both inflammation and degeneration. Sometimes, temporal tendinitis can be the primary disease entity, but the authors found that it frequently coexists with TMD. This retrospective study was undertaken to determine the prevalence of temporal tendinitis with TMD. The charts of 449 patients diagnosed with TMD were reviewed to determine the incidences of temporal tendinitis. The referred pain sites and their incidences were also determined.