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Ligaments of the TMJ: play key role in protecting the structures, collagenous connective tissues that have
particular lengths and dont stretch. However, with force, suddenly or over a prolonged period of time, the
ligament can be elongated
1. Collateral Discal Ligament: responsible for dividing joint mediolaterally into the superior and
inferior joint cavities,
o true ligaments - collagenous connective tissue fibers so do not stretch.
o Restrict movement of disc away from the condyle allowing disc to move passively with
the condyle as it glides anteriorly and posteriorly.
o responsible for hinging movement of the TMJ, between condyle and articular disc.
2. Capsular Ligament - entire TMJ is surrounded and encompassed by the capsular ligament
o resists medial, lateral, or inferior forces that tend to separate or dislocate the articular
surfaces, retains the synovial fluid.
3. Temperomandibular Ligament- lateral aspect of capsular ligament of strong, tight fibers,
composed of outer oblique portion and inner horizontal portion
o oblique portion - resists excessive dropping of the condyle; limiting mouth opening.
If the jaw is opened wider, distinct change in opening movement will occur,
represents change from rotation to movement forward and down the articular
eminence as TM ligament tightens.
o Inner horizontal portion of ligament limits posterior movement of the condyle and disc
protecting retrodiscal tissues from trauma
4. Sphenomandibular Ligament - accessory ligament, has no significant limiting effects on
mandibular movement.
5. Stylomandibular Ligament - limits excessive protrusive movements of mandible.
Muscles of Mastication: have only one nerve ending near the middle of the fiber, innervates each fiber.
Higher myoglobin = deeper red & slow but sustained contraction (type I muscle fibers), well-developed
aerobic metabolism, thus resistant to fatigue. Lower concentrations of myoglobin are whiter (type II fibers),
fewer mitochondria and rely more on anaerobic activity for function, capable of quick contraction but fatigue
more rapidly.
1. Masseter: elevates mandible and teeth brought into contact.
o Powerful, provides force necessary to chew efficiently, may aid in protruding the
mandible.
2. Temporalis: elevates the mandible and the teeth are brought into contact.
3. Medial Pterygoid: with masseter, forms muscular sling supporting the mandible at mandibular angle.
Elevates mandible and teeth are brought into contact, also active in protruding the mandible.
4. Inferior Lateral Pterygoid: functions with the mandibular depressors to lower mandible and condyles glide
forward and downward on the articular eminences.
5. Superior Lateral Pterygoid: active during power stroke (movements involving closure of mandible) and
when teeth are held together.
6. Digastrics:
right and left digastrics contract to help depress mandible and teeth brought out of contact.
along with suprahyoid and infrahyoid muscles, elevate the hyoid bone, necessary function for
swallowing
Early studies: teeth do not actually contact during mastication. Speculated food between teeth, along with the
acute response of the neuromuscular system, prohibits tooth contacts.
Other studies: have revealed that tooth contacts occur during mastication.
New Food - few contacts initially,
bolus broken down - frequency of tooth contacts increases.
final stages of mastication contacts occur during every stroke.
Two types of contact have been identified:
o gliding contact - cuspal inclines pass by each other
o single contact - occurs in the maximum intercuspal position.
Average contact time during mastication: 194 msec.
contacts influence/dictate initial opening and final grinding phase
chewing strokes of normal vs those with TMJ pain have marked differences.
Normal: chewing strokes well rounded, definite borders, less repeated.
TMJ pain: repeat pattern, short strokes, slower, irregular pathway-all relatable to altered functional
movement of condyle around which pain is centered.
Maximum forces:
Molars 91 to 198 pounds
central incisors 29 to 51 pounds.
Swallowing:
Mandible stabilization important part of swallowing, must be fixed so contraction suprahyoid and infrahyoid
muscles can control movement of hyoid bone.
Somatic swallow - normal adult swallow using teeth for mandibular stability.
o average contact time 683 msec. (3X longer than mastication).
o force applied to teeth during about 66.5 pounds, 7.8 pounds more than during mastication.
Visceral swallow no teeth present (e.g. infant) - mandible must be braced by other means, placing
tongue forward & between dental arches/gum pads, occurs until posterior teeth erupt.
Studies: swallowing cycle occurs 590 times a day, 146 cycles during eating, 394 cycles between meals while
awake, 50 cycles during sleep. Lower levels of salivary flow during sleep result in less need to swallow.
Speech
Early stages of life taught proper articulation.
Tooth contacts do not occur during speech.
If malpositioned tooth contacts during speech, sensory input relayed information to CNS, which
alters speech pattern to avoid the tooth contact, new pattern may result in a slight lateral deviation of
mandible to produce desired sound without tooth contact.
For many years degree and number of nociceptors stimulated were assumed to be responsible for intensity of
pain perceived by the CNS.
Not found to be true clinically.
In some patients, small injuries create great pain; in others only mild pain is reported with much
greater injury.
As pain has been studied, become increasingly clear that degree of suffering does not relate well to
amount of tissue damage. Instead the degree of suffering relates more closely to the patient's
perceived threat of injury and amount of attention given to injury.
Pain terminology:
Nociception - noxious stimulus originating from sensory receptor, carried into the CNS by the
primary neuron.
Pain is unpleasant sensation perceived in the cortex
Suffering - how human reacts to perception of pain.
Pain behavior - individual's audible and visible actions that communicate suffering to others.
source of pain is where the pain originates.
site of pain is where the patient perceives the pain to be coming from.
The experience of pain (and eventually suffering) may be the most important consideration in caring for
patients.
Types of Pain:
Central pain - When a tumor or other disturbance is present in the CNS, the pain is often felt in
peripheral structures.
Projected pain - neurologic disturbances causing pain sensations down the peripheral distributions of
same nerve root that is involved in disturbance.
3.
Referred pain. sensations are felt in other branches of nerve
Referred pain is not a haphazard occurrence but seems to follow three clinical rules:
o most frequently within a single nerve root, passing from one branch to another (e.g., a
mandibular molar referring pain to a maxillary molar).
o can be felt outside the nerve responsible for it, generally moves cephalad (i.e., upward,
toward the head) and not caudal.
o In trigeminal area, referred pain never crosses midline unless it originates at midline, e.g.
pain in right TMJ will not cross over to left side of face. (not true for cervical region or
below)
Local provocation of pain source increase in symptoms
Local provocation of site of pain generally does not increase symptoms
buccal
in Mx
embrasure
of Mx 1st
posteriors in
overlap
posterior
by
lateral
typical
Mandibular border movements in the frontal plane. 1, Left lateral superior; 2, left
lateral opening - As maximum opening is approached, ligaments tighten and
produce a medially directed movement that causes a shift back in the mandibular midline to
coincide with the midline of the face to end this left opening movement; 3, right lateral superior;
4, right lateral opening (same as left explanation above), ICP, Intercuspal position; PP, postural
position.
By combining mandibular border movements in the three planes (i.e., sagittal, horizontal, frontal), a threedimensional envelope of motion can be produced that represents the maximum range of movement of the
mandible. Although the envelope has this characteristic shape, differences will be found from person to
person. The superior surface of the envelope is determined by tooth contacts, whereas the other borders are
primarily determined by ligaments and joint anatomy that restrict or limit movement
Occurs when elevator muscles are activated with NO occlusal influences musculoskeletally
stable position
There can be some anterior-posterior movement of the position if the joint is not healthy
In a healthy joint, the inner horizontal fibers of the TM ligament do not allow much posterior
movement
Movement is generally < 1mm during intercuspal position
If an unhealthy joint, the inner horizontal fibers of the TML are stretched & DO allow posterior
movement
The posterior movement of the joint during function can cause force to be applied to the
posterior aspect of the disc, inferior retrodiscal lamina, and/or retrodiscal tissues damage to
the retrodiscal tissues can result in PAIN and/or breakdown.
o It can thus be seen that CR and the MS position are the same.
Intercuspal position (ICP) - Muscle stabilized position, NOT musculoskeletal position b/c the inferior
lateral pterygoid prevents the condyles from moving back into the most superoanterior position
Electrical stimulation - Some practitioners have suggested finding CR through use of electrical stimulation
which is supposed to relax muscles until MN goes from ICP to physiologic position
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Increase in horizontal overlap decreased anterior guidance angle, less vertical component to
mandibular movement, and flatter posterior cusps.
Increase in vertical overlap increased anterior guidance angle, more vertical component to
mandibular movement, and steeper posterior cusps.
Effects of the plane of occlusion on cusp height:
As horizontal overlap increases, anterior guidance angle decreases.
As vertical overlap increases, anterior guidance angle increases.
Flat plane of occlusion greater angle mandibular posterior teeth move away from maxillary
posterior teeth taller cusp.
Acute plane of occlusion smaller angle of mandibular posterior tooth movement flatter teeth
can be.
Effects of lateral translation movement on cups height:
When distance exists between medial wall and medial pole of orbiting condyle and the
temporomandibular (TM) ligament allows some movement of the rotating condyle, lateral translation
movement can occur. More medial wall from condyle = greater lateral translation movement.
Looser TMJ ligament = greater amount of mandibular translation movement = posterior cusps
shorter to permit lateral translation without creating contact.
The greater the lateral translation movement, the shorter is the posterior cusp.
VERTICAL DETERMINANTS OF OCCLUSAL MORPHOLOGY (CUSP HEIGHT AND FOSSA DEPTH)
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change), trigger points often refer pain to other areas of the head
E.g. a TP in neck causes pain in templeso treat TP!
TP may be active or latent (not sensitive to palpation at that time)look for them when
symptoms present
TP DO NOT resolve w/o treatment
Myospasm a CNS induced tonic muscle contraction
Jaw positional changes can occur due to muscles in spasm
Firm mucles upon palpation indicate spasm
As muscle pain progresses from acute to chronic, effectiveness of local treatment diminishescatch it early
How pain gets chronic
Protracted cause fail to eliminate cause
Recurrent cause recurrent episodes ( bruxism, trauma)
Theraputic mismanagement misdiagnosis incorrect treatment
Patients with fibromyalgia, systemic muscle pain, often misdiagnosed & treated for TMD.
Emotional stress most common systemic factor which can interrupt normal muscle function.
Protective co-contraction is a CNS response to injury or threat of injury. This response has also been called
protective muscle splinting
Essentially this means that your TMJ automatically braces itself using antagonistic muscle
groups which are normally not active during their opposers function.
o Co-contraction immediately follows an eventtake a good history
CNS makes pain worse when one of three things happens
Ongoing deep pain input
Increased emotional stress
Changes in inhibitory system to
counteract afferent input
Discal and capsular ligaments and retrodiscal
tissues have pain receptors normal articular
surfaces do not click (short), pop (louder than
click), crepitation (multiple rough gravel like
sounds)
When the mandible is protruded the major
directional pull of the muscle is medial, not
anterior
Functional displacement of the disc
condyle on posterior border, disck displaced
anterior
Click is felt as condyle moves over the posterior border into the intermediate zone of the
diskupon opening
Reciprocal click (not always there) heard as condyle moves from intermediate zone onto the posterior
border of the diskupon closing
Functionally disocated disk joint space has narrowed and disk is trapped completely anteriorly to condyle
The dislocation without reduction has also been termed a closed lock (without reduction person
is unable to return disk to normal positionmouth opening is lessened)
Dislocation with reduction disk can still slide over the condyle allowing more normal opening
and excursive movements
Macrotrauma to the joint can cause structural alterations, primarily through elongation of the discal ligaments
Direct trauma blow to the chin
Indirect trauma whiplash in car wreck, VERY LITTLE evidence that indirect affects TMJ
Microtrauma basically bruxing with Jaw in an unstable orthopedic position. MUST have both bruxer and
orthopedically unstable jaw
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o
o
Dental examination
Mobility from bone loss or heavy occlusal forces
o Movement >0.5mm is recorded
Widening of PDL space
o Osteosclerosis, Hypercementosis, Pupitis
Tooth wear: most common sign of breakdown in the dentition
o Functional or parafunctional?
Abfractions
o Abfractions are noncarious cervical lesions or wedge-shaped defects in a tooth
Occlusal exam
o Occlusal contact pattern is examined in CR, ICP, protrusive, left and right laterotrusive
movements
CR Contacts: when condyles in optimum functional relationship,
o Musculoskeletally stable, most superioranterior in the mandibular fossae and braced
against post slopes of articular eminences, discs interposed.
ICP, MIP stability vs. joint stability , arch integraty, VDO, Eccentric Occlusal contacts
(protrusive, laterotrusive, mediotrusive)
Imaging of TMJ
o 4 useful radiographs
panoramic, transpharyngeal, transcranial, anteroposterior (AP) or transmaxillary
Tomography
o uses controlled movement of the head of the radiograph tube and the film to obtain a
radiograph of the desired structures that deliberately blurs out other structures
Arthrography: Contrast medium is injected into the joint spaces to outline important soft tissue
structures because routine radiographic techniques only show bony structure (not soft tissue).
MRI and Bone scanning
Mounted Casts
Remodeling of the condyle or fossa can occur from mild forces applied over a long period of
time
o destructive changes associated with osteoarthritis can occur if forces become too great
Electromyography, Songraphy, Vibration Analysis, Thermography
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IV.
If patients problem does not fall into one of these categories, more extensive exam procedures required.
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Most NSAIDs reduce inflammation but diminish gastric secretions that protect stomach
wall pain reduction with stomach irritation & ulcers
Anti-inflammatory agents: Helpful with inflammatory joint disorders and chronic centrally
mediated myalgia, need 3 weeks to achieve proper levels in blood
o Corticosteroids: potent anti-inflammatories but undesirable side effects.
o Oral corticosteroids: significant dose early in treatment and gradual reduction in dosing
until medication is stopped
o Can inject hydrocortisone into joint for pain relief and restricted movements
Antidepressants: Effect related to ability to increase availability of the amines, serotonin, and
norepinephrine in CNS
o Effect related to ability to increase availability of the amines, serotonin, and
norepinephrine in CNS
o Tricyclic antidepressants good with doses as low as 10mg in treating muscle contraction
headaches and musculoskeletal pain
Local Anesthetics: can differentiate true source of pain from a site of pain
o When source of pain is present in muscle or joint, injection of LA into source will
eliminate pain, which confirms the diagnosis
o Most common is 2% lidocaine and 3% mepivacaine
2. Physical therapy: Used with definitive treatment
Physical therapy modalities:
Thermotherapy: use of heat to increase circulation to area
o Creates vasodilation in compromised tissues to reduce symptoms
Coolant therapy: use of cold
o It relaxes muscles that are in spasm
o Ice to affected area and moved in circular motion without pressure to tissues
o When numbness starts, remove ice-not be left on tissues for longer than 5-7 mins
Ultrasound therapy: Increase in temperature at interface of tissues to affect deeper tissues
o increases blood flow in deep tissues and separates collagen fibers to improve flexibility
of connective tissues
Phonophoresis: Administering drugs through skin via ultrasound
Iontophoresis: Meds introduced into tissues w/o affecting any other organs, meds in a pad, pad
put on desired tissue area, drives med into tissue
Electrogalvanic stimulation therapy: Use of electrical stimulation of muscle to cause contraction,
Rhythmic electrical impuse to muscle creates involuntary contractions and relaxations
Transcutaneous electrical nerve stimulation: Continuous stimulation of cutaneous nerve fibers at
a subpainful level
Acupuncture: Uses bodys own anti-nociceptive system to reduce levels pf pain
Cold laser: accelerates collagen synthesis, increases vascularity of healing tissues, decrease
number of microorganisms, and decrease pain
Manual techniques:
Soft tissue mobilization: Useful for muscle pain by superficial and deep massage
o Gentle message of tissues overlying painful area can reduce pain perception
o Deep massage better than gentle for reestablishing normal muscle function
Joint mobilization: decreases inter-articular pressure and increases range of joint movement
Muscle conditioning: Pts with TMD usually decrease use of jaw b/c of pain, if prolonged, can
cause muscles to shorten and atrophy
Passive muscle stretching: counteracts shortened muscle length that contributes to decreased
blood flow
o Patient should open mouth slowly and until pain is felt
Assisted muscle stretching: After muscle has been stretched, warmed with hand and procedure
repeated 2-3 times
Resistance exercises: Use concept of reflex relaxation to give increase in mandibular opening.
o
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4. Myospasm - involuntary CNS-induced tonic muscle contraction, associated with local metabolic
conditions within the muscle tissues.
continued deep pain input or local metabolic factors associated with fatigue or overuse.
patient reports a sudden onset of restricted jaw movement w/ muscle rigidity & acute malocclusion
common.
pain at rest & pain is increased with function.
Treatment - massage, vapocoolant spray, ice or LA injection into muscle, rest.
Nocturnal Bruxism - muscle hyperactivity that is difficult to control.
Occlusion has no influence, stress influenced.
Occlusal appliances decrease via noxious peripheral stimulus-excites negative feedback mechanism
and shuts down heavy muscle activity.
No known treatment eliminates bruxism-always treat conservatively at first with reversible therapy.
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o intrinsic intrinsic trauma often remains, treatment aims to remove source of trauma
Arthritides inflammation of articular surfaces of joint caused by joint overloading
o Osteoarthritis one of most common affecting TMJ, treatment aims to decrease loading,
when muscle hyperactivity suspected make appliance to reduce loading force
o Osteoarthrosis when bony changes are actively occurring, adaptive process so treatment
needed
o Polyarthritides a group of arthritic conditions, rarely occurs in TMJ
Traumatic arthritis trauma can lead to loss of subarticular bone and change in occlusal function,
with gross trauma no definitive treatment indicated
Infectious arthritis bacteria into TMJ, usually from trauma (puncture wound), appropriate antibiotic therapy
Rheumatoid arthritis chronic, systemic disorder of unknown origin producing persistent
inflammation and destruction of articular surfaces, no treatment since cause is unknown
Hyperuricemia gout increase in urate leading to urate crystals in joints, usually distal extremities,
treatment is to lower serum uric acid levels (modify diet)
Psoriatic arthritis inflammation with psoriasis, no treatment because cause unknown
Ankylosing spondylitis chronic inflammatory disease, mainly of spinal column, can affect TMJ
occasionally, unknown cause so no definitive treatment.
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Alteration of the condylar position: to either a more structurally compatible and functional
position effect on joint stability can decrease in symptoms
Increase in the vertical dimension: this effect is universal, regardless of treatment goals. Increase
in vertical dimension can temporarily decrease muscle activity and symptoms
Cognitive awareness: As cognitive awareness is increased, factors that contribute to the disorder
are decreased decrease in the symptoms
Placebo effect: Approximately 40% of the patients suffering from certain TMDs respond
favorably to such treatment. May be from the competent and reassuring manner or favorable
doctor-patient relationship
Increased peripheral input to the central nervous system: Noctural muscles hyperactivity appears
to have its source in the CNS. An occlusal appliance is placed between the teeth provides a
change in peripheral input and thus decrease CNS-induced bruxism bruxism return if use of
device is stopped.
Regression to the mean: the common fluctuation of symptoms associated with chronic pain
condition. The intensity of the pain often varies on a daily basis. Patient most commonly report
when the pain intensity is great. When therapy is provided and the symptoms return to average
level, the clinician mist question if the reduction was a result of therapeutic effect or simply a
natural regression of the patients symptoms to the mean.
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opposing central fossae, only slight alterations in the occlusal condition will be needed to
achieve the treatment goals. The greater the distance that the centric cusps are positioned from
the opposing fossae, the more extensive will be the treatment needed to achieve the treatment
goals.
Each inner incline of the posterior centric cusps is divided into three equal parts. If (when the
mandibular condyles are in their desired position) the centric cusp tip of one arch contacts the
opposing centric cusp inner incline in the third closest to the central fossa, selective grinding can
usually be performed without damage to the teeth
If the opposing centric cusp tip makes contact in the middle third of the opposing inner incline,
crown and fixed prosthodontic procedures will usually be most appropriate for achieving the
treatment goals. In these cases selective grinding is likely to perforate the enamel, creating the
need for a restorative procedure.
If the cusp tip contacts the opposing inner incline on the third closest to the cusp tip or even on
the cusp tip, the appropriate treatment is orthodontic procedures. Crown and fixed prosthodontics
in these instances will often create restorations that cannot adequately direct occlusal forces
through the long axes of the roots, thus producing a potentially unstable occlusal relationship.
It is equally important to visualize the buccolingual relationship of the entire arch in determining
appropriate treatment. On occasion the tooth contact will not be typical of the entire arch and
therefore not be the best determinant of treatment.
Five factors can influence the selection of treatment: (1) symptoms, (2) condition of the
dentition, (3) systemic health, (4) aesthetics, and (5) finances.
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