Temporomandibular disorders an evidence based approach to diagnosis and treatment pdf
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Temporomandibular Disorders: An Evidence-Based Approach to Diagnosis and Treatment
Temporomandibular disorder TMD is one of the most common disorders in the maxillofacial region which usually presents with pain, unusual sounds, discomfort in chewing and locking of the jaw.
TMD patients comprise a considerable proportion of patients seeking treatment; early diagnosis is important because it is proven that acute TMD responds well to treatment in contrast to chronic TMD.
True diagnosis and treatment of TMD can be difficult, as these patients often suffer from some other disorder at the same time. In these cases, a successful treatment is due to true diagnosis of all initiating factors, predisposing and perpetuating factors and treatment of other established disorders.
An important point is the close relation of intrajoint disorders to disorders of masticatory muscles. Today, it has been proven that disorder of masticatory muscles can lead to TMD. The opposite of this, is also true. Correct diagnosis is essential. The diagnostic steps and differential diagnosis of TMD and the treatment protocols from supportive treatment, splint therapy and physiotherapy to temporomandibular joint TMJ surgeries are explained herein.
We hope this chapter can help better understand TMJ disorders, diagnosis and recognition of the signs and symptoms of disorders of the temporomandibular and masticatory system. TMD is a general term including clinical problems which affect masticatory muscles, TMJ and adjacent structures. TMD is the most common non-dental pain in the maxillofacial region.
The most common sign of TMD is pain in masticatory muscles, or preauricular region and on the TMJ which becomes severe when chewing or upon other mandibular movements. TMD patients have limitation and asymmetry in mandibular movements. They often have clicking, popping, grating and crepitus. Patients may complain from headache, earache and pain in the mandibulofacial region. Masticatory muscle hypertrophy and an unusual facet of occlusal surfaces of the dentition due to excessive mandibular movements such as bruxism or grinding may be present.
Management of TMJ disorders usually includes finding the cause or etiology. Parafunction and trauma are common causes of TMD. Stress and mental problems are secondary aggravating factors. After initial studies in , Costen proposed that patients suffering from auricular pain, pressure and fullness in the ear and swallowing problems Costen syndrome improve by occlusion correction. In the s, the quality of clinical examinations and scientific studies improved; the importance of occlusion in TMD etiology in was studied.
Methods including tomography, arthrography, computed tomography CT scan and magnetic resonance imaging MRI lead to improvements in examination of intracapsular structures. Today the information in this field show that patients with orofacial pains may suffer from disorders such as systemic, neuromuscular, vascular, and mental or a combination of disorders associated with TMD; some headway in pain mechanism, neurology, physiology and neuoropharmacology have been made.
Different studies demonstrated that TMD treatment has changed based on the diagnosis of the etiology and stage of the disorder. Temporomandibular joint is the junction site of the mandibular condyle to skull base or glenoid fossa of the temporal bone.
A disc separates the two bones. The part of the disc which is in contact with mandibular condyle bone consists of fibrous connective tissue without any nerve or vessel. This joint is a compound one.
The disc is divided into three parts, in sagittal view: anterior, posterior and middle. The middle zone is the thinnest part.
The disc becomes thicker in the anterior and posterior parts. In coronal view, the medial part of the disc is thicker than the lateral part Fig. Disc shape is determined by condyle morphology and mandibular fossa. The disc may become displaced or destroyed via degenerative forces.
In the posterior part, the disc is attached to a loose connective tissue of nerve and vessels named retrodiscal tissue. In the superior posterior part, it is attached to a connective tissue full of elastic bands named superior retrodiscal layer or bilaminary zone. This tissue connects the disc to the tympanic bone posteriorly. Below this, there is the inferior retrodiscal layer which connects the inferior border of the posterior edge of the disc to the posterior part of condyle joint surface.
Inferior disc layer and superior retrodiscal tissue are made of collagen and elastic fibers, respectively. Anteriorly to the disc, superior and inferior adhesions of it connect to the capsular ligament.
Both of these adhesions are made of collagen fibers. Between the capsular ligaments, the disc is adherent to fibers of the superior lateral pterygoid muscle. The disc adheres to the capsular ligament, not only anteroposteriorly, but also mediolaterally. The joint is divided into two separate and distinct spaces.
The superior space is located between the glenoid fossa and superior part of the disc; the inferior disc space lies between the disc and condyle. Internal surfaces of superior and inferior spaces are lined with special endothelial cells which secrete synovial fluid. This fluid has two functions: 1-Molecular transport and metabolism and 2-Lubrication of joint surfaces; the fluid is secreted on the joint surfaces under pressure and results in friction reduction.
During function, forces entering to the joint surfaces lead to movement of this fluid into intrajoint tissues. In coronal view, the condyle has a medial and lateral pole; the medial pole is thicker than the lateral one. The TMJ is supported by three major and two minor ligaments. TMD is considered as a multifactorial disorder and there is no special or individual cause for it. There are factors which can damage the balance in TMJ and the masticatory system.
Bone deformations, soft tissue metaplasia of TMJ and muscle activity reduction are often adaptive responses to changes. Hyperactivity of masticatory muscles resulting from parafunctional habits can lead to adaptive responses in dynamic balance because of hyperactivity and high load in the long term. Excessive changes in any of the above functions can lead to disability to adapt leading to TMJ disorders.
For example, external trauma to any part results in injuries and disorders in normal joint function. Moreover, anatomic, systemic, pathophysiological and emotional causes can make the disorder more severe. Nowadays, trauma is believed to be the initial cause of TMD. In fact, excessive trauma because of parafunctional forces can damage the masticatory system.
These damages may result in joint injuries and pain in eating, smiling, yawing or excessive opening of the mouth. External trauma such as a punch, sport activities and injuries because of dental practice can lead to TMD. An important type of trauma is parafunctional trauma. Postural habits such as head forwarding or holding the phone handset place pressure on joints and muscles which result in musculoskeletal pains such as headaches in TMD patients.
Additional habits and movements such as clenching, bruxism, attrition, lip biting and abnormal posture of the jaws common in society may lead to TMD. Although in some patients, it is known as an initial factor, parafunctional habits can be aggravated by stress, anxiety, sleeping and eating disorder.
Anatomical factors affecting the TMJ can be hereditary, developmental or acquired. Some skeletal disorders such as small mandibular arch, class II occlusion etc.
However, millimetric changes in face vertical dimension, overbite, over jet or cross bite alone, are not the only cause of TMD. Today it is believed that dental occlusion disorders are second in importance.
These include: degenerative disorders, endocrine disorders, infections and blood disorders. It is revealed that viscosity of synovial liquid and its lack of lubricant property may be the initial cause of internal derangement and clicking. Stress and mental stresses, can result in excessive load on masticatory system and parafunctional habits.
Mental and emotional disorders can be predisposing TMD causes. So, it is highly important to consider the socio-mental factors upon examination of patients with TMD. Classifying TMDs, makes diagnosis easier.
As there are numerous similar disorders and pains in the head and neck region, differential diagnosis is paramount Table 1. In differential diagnosis of TMJ disorders and pains, problems such as neoplasms, migraine, neuralgia and mental disorders should be considered. Moreover, it is noticeable that, growth-developmental disorders include aplasia, hypoplasia, hyperplasia and dysplasia can lead to TMJ problems.
Aplasia is defective growth of skull or mandible bones. These belong to one group of mandibular anomalies named hemifacial microsomia or first and second brachial arch syndrome. These are the most common developmental defects which have no articular fossa or eminence and the patient suffers from hearing problems.
Hypoplasia is low or incomplete growth of bones which is congenital or acquired. This is milder than aplasia. Many craniofacial anomalies include incomplete growth of cranial and mandibular bones, for example Treacher-Collins syndrome. Hyperplasia is extensive growth of bones in congenital or acquired form which is unilateral in mandibular body, coronoid or condyle and leads to asymmetry. Dysplasia or fibrosis dysplasia is a benign disorder with defective mandible or maxilla growth which demonstrates itself as fibrotic connective growth.
On radiography, it varies from lucent to ground glass. Neoplasia may be benign or malignant. From the benign ones, osteoma, chondroma, osteoblastoma, chondroblastoma, ameloblastoma and synovial chondromatosis which is common in TMJ can be named.
Malignant tumors such as osteosarcoma, Ewing sarcoma, chondrosarcoma, fibrosarcoma and adenocarcinoma are usually rare. Fractures can result in displacement, damage of joint surfaces, ligaments and disc in combination with bleeding, then adhesion, or joint derangement can be expected.
Joint deformation is a mechanical painless disorder or deviation in the form of internal hard and soft tissues which may be developmental or acquired. Deviation in form is due to destructive forces resulting in physiologic deformation. Any growth or acquired remodeling and anatomic deformation that destroy joint surfaces results in mechanical interference that clinically results in joint noises or clicking during opening and closing.
One of the most important signs of this disorder is deviation of the jaw on mouth opening and closing. Radiographic findings may demonstrate bony changes or deviation in joint form i. Disc displacement: Disc displacement is the most common TMD in which the disc is displaced anteriorly. It may be with or without reduction.
Patient information : See related handout on temporomandibular disorders , written by the authors of this article. Temporomandibular disorders TMD are a heterogeneous group of musculoskeletal and neuromuscular conditions involving the temporomandibular joint complex, and surrounding musculature and osseous components. TMD is classified as intra-articular or extra-articular. Common symptoms include jaw pain or dysfunction, earache, headache, and facial pain. The etiology of TMD is multifactorial and includes biologic, environmental, social, emotional, and cognitive triggers. Diagnosis is most often based on history and physical examination.
This book continues the tradition established by 4 editions of the classic monograph, The Temporomandibular Joint: A Biological Basis for Clinical Practice , which was coedited by Daniel Laskin, the senior editor of this book. Temporomandibular Disorders is written primarily for oral and maxillofacial surgeons and other clinicians and researchers interested in the etiology, pathogenesis, and treatment of temporomandibular joint TMJ disorders. It integrates the contributions of basic scientists and clinicians in an evidence-based approach to temporomandibular disorders TMDs. The book consists of 36 well-referenced chapters grouped in 2 parts. The latter section includes chapters on chronic orofacial pain, TMJ articular disk derangements, molecular events involved in the pathogenesis of osteoarthritis in the TMJ, and less common systemic disorders that may affect the TMJ eg, connective tissue diseases. These sections include chapters that briefly review the diagnostic criteria and important features of various arthritic diseases, evaluate the effectiveness of physical treatment modalities in patients with TMDs, and describe a self-administered exercise program for patients. For instance, the section on diagnosis includes a chapter reviewing the diagnostic criteria and important features of various arthritic diseases eg, rheumatoid arthritis, gout.
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Patients with temporomandibular disorders TMD can become very complex. This article aims to highlight the importance of the multimodal and multidisciplinary approach in this type of patients to improve clinical outcomes. At present we have innumerable techniques and tools to approach this type of patients from a biopsychosocial model where active and adaptive type treatments are fundamental. There are various health professions that have competence in the treatment of TMD, however, although in the most complex cases should be treated simultaneously, still too many patients receive unique treatments and only from one point of view. This review exposes the treatments available from a clinical-scientific perspective and also emphasizes the importance of working in specialized units with those professionals who have competencies on the different conditions that may occur.
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Okeson, DMD Perhaps the preeminent text book currently available for the serious student of masticatory function and disorders, Dr. Okeson brings to this field a unique balance of clinical and academic erudition. Wright, DDS This manual is very much focused on the clinical practice of temporomandibular disorders and can provide a quite clear, yet academically rigorous, guide to the clinical dentist. The bibliographies with each chapter provide current citations to the related literature, including to several adjunctive disciplines that the dentist might not otherwise encounter.
This article traces the history of the development of the current diagnostic and therapeutic approaches to the management of temporomandibular disorders, with emphasis on the mistakes or misconceptions that occurred during their development and the lessons that can be learned from these errors. It also makes recommendations for future areas of investigation, and methods for facilitating such studies, in order to improve the future treatment of these patients. This is a preview of subscription content, access via your institution. Rent this article via DeepDyve. T Annandale ArticleTitle Displacement of the interarticular cartilage of the lower jaw and its treatment by operation Lancet 8 —2 Occurrence Handle Google Scholar.