this presentation addresses the TM Joint disorders focusing on the conservative and no-surgical methods of treatment , with special emphasis on the effective role of occlusal splints .

1. ‫‪Conservative Management of‬‬
‫‪TemporoMandibular Disorders‬‬
‫التدابير المحافظة لالضطرابات الوظيفية‬
‫الفكية الصدغية‬
‫‪Dr . Marwan Mouakeh , Consultant Orthodontist‬‬
‫د. مروان موقع – استشاري تقويم األسنان‬
‫المستشار العممي لمجمع عيادات أكاديمية الحقيل‬

2.  Temporomandibular Disorders ( TMDs )
 A Collective term embracing a broad spectrum of
clinical Joint & Muscle Problems in the Orofacial Area .
 These Disorders are characterized primarily by:
- Pain,
- Joint Sounds , and
- Irregular Limited Jaw Function .
 TMDs represent a major cause of nondental pain in
the orofacial region .

3.  Temporomandibular Disorders ( TMDs )
•Because various components of
the masicatory system are
affected , it is appropriate that
dentists take responsibility for
diagnosing and treating TMDs .

4. Classification of TMDs
The American Academy of Orofacial Pain ( AAOP)
I- TMJ Disorders
II- Masticatory Muscle Disorders
III- Congenital & Developmental
Disorders

5.  Classification of TMDs
the American Academy of Orofacial Pain ( AAOP)
I- TMJ Disorders
1- Deviation in form
2- Disc Displacements
3- Displacement of the Disc-Condyle Complex
- Hypermobility
- Dislocation
4- Inflammatory Disorders
- Capsulitis & Synovitis
- Retrodiscitis
5 – Degenerative Diseases
6 – Ankylosis
- Fibrous
- Bony

6.  Classification of TMDs
the American Academy of Orofacial Pain ( AAOP)
II- Masticatory Muscle Disorders
- Acute
1- Myositis
2- Reflex Muscle Splinting
3- Muscle Spasm
- Chronic
1- Myofascial Pain
2 – Muscle Contracture
3 – Hypertrophy
4- Myalgia Secondary to Systemic Disease

7. Reported TMD Symptoms in 18 Epidemiologic Studies
“ Carlsson 1984”
Symptoms
Mean Value
%
TMJ Sounds
19
Tiredness,Stiffness of jaw
11
Pain on Mandibular function
6
Limitation of Mandibular
movement
8
Locking
4
Frequent Headache
17

8. Age distribution of 5 samples of patients
with TMDS
•A Common Peak in the
age distribution of the
patients , specifically
during the period between
20 and 40 years .
• A higher prevalence of
TMDs signs & symptoms
in women than in men .

9. Physiologic & Functional Considerations

10. TMJs
• From a functional and pathologic point of view , the
most important elements are the Articular Disc & the
Lateral Pterygoid Muscle .

11. Posterior Band
Sup. Attachment
Intermediate Zone
Elastic
Anterior Band
Bilaminar
Zone
Inf. Attachment
Non-Elastic
Parts of the Articular Disc - Sagittal view

12. The Articular Disc
Frontal View
Medial
Lateral
Collateral Discal Ligaments
‫األربطة الجانبية للقرص المفصلي‬

13. Physiologic Position of the Articular Disc
‫خالية من األوعية‬
‫الدموية واألعصاب‬
1
12o’clock position
2
3
 The Absence of Blood Vessels & Nerves in the Intermediate Zone
of the Disc Enables this part of the disc to act as a Pressure-Bearing
Area .

14. Healthy Joint
Elastic
Collagenous
 Tight discal ligaments and self-seating wedges provided by
thick posterior and anterior borders of the disc maintain the disc
in proper relationship .

15. Healthy Joint
1
2
3
•Synovial Fluid :
‫السائل الزليلي‬
•Nutrition
• Lubrication
• Heat absorption

16. Lateral Pterygoid Muscle
Sup. Belly : Elevator
Inf. Belly : Depressor

17.  Functional role of the upper & lower lateral pterygoids
Sup. Belly : Elevator
Inf. Belly : Depressor
Opening
Closure

18. Masticatory Pains
Arthrogenous
(TMJs )
‫منشأ مفصلي‬
Myogenous
(Masticatory Muscles )
‫منشأ عضلي‬
Combination of Both Types

19. • Myalgia
Masticatory Muscles Pain
 Dull , Deep , and Diffuse pain
 Felt in the morning when
related to Nocturnal Bruxism .
 Influenced by functional
demands ( chewing…)
 Depressing

20.  Myofascial Pain
 A very common TM disorder
, involves discomfort or pain in
the muscles that control Jaw
function .
 Characterized by Referred pain from Trigger Points
within the myofascial structures.
Pain referral pattern from the masseter muscle

21.  Myofascial Pain
•Trigger points (TrP) are tight,
highly irritable spots in a taut
band of muscle that can cause
referred pain, or pain located
away from the trigger point
itself.

22. Masticatory Muscles Palpation

23. Lateral Pterygoid Palpation

24. Restricted Mouth Opening : Less than 30 -35 mm

25.  Arthralgia = Pain originating from the joint
 Localized in the TMJ Region
 Increased with mandibular
movement.

26. Arthralgia (Articular Pain)
 TMJ Pain-sensitive structures :
- Collateral discal ligaments
- Posterior attachment
- Articular capsule .

27.  Disc Displacement
 Commonly referred to as Internal Derangement
• A Disorders characterized
by abnormal relationship
between the articular disc,
mandibular condyle, and
articular eminence.

28.  Disc Displacement
• Patho-physiology
 Muscle ( lat.ptery ) incoordination
 Deformation or thinning of the of
the posterior band
 Elongation of discal attachments .
Disc Displacement

29.  Disc Displacement
• Patho-physiology
 In this position , excessive
pressure on the TMJ can cause
thinning of the posterior border
of the disc.
 These changes lead to loss of
disc’s self-seating capacity .

30. Anatomic Classification
 Anterior Disc Displacements

31. Anatomic Classification
 Sideways (Rotational ) Displacements
Medial

32. Anatomic Classification
 Sideways (Rotational ) Displacements
Lateral

33. Antero-medial Disc Displacement
the most common clinical condition …
The medial component occurs
because of a compromised lateral
discal ligament & the pull of the
superior laterl pterygoid .

34. Anatomic Classification
 Posterior Disc Displacements
• Very Rare
 Known as “ Open Lock “

35. Anterior Disc Displacement
 Functional Classification
‫االنزياح األمامي الردود‬
A.D.D With Reduction
‫االنزياح األمامي غير الردود‬
A.D.D Without Reduction

36. ‫االنزياح األمامي الردود‬
A.D.D With Reduction
The Displaced Disc recaptures its normal relationship
with the condyle on opening .

37. • Disc Displacement With Reduction
Closed
Partially Open
Fully Open

38. • Disc Displacement With Reduction
‫الطقة المفصلية المتبادلة‬
Opening
Major Symptom
Closing
Reciprocal Click

39. • Disc Displacement With Reduction
• Mandibular midline Deviation ( ipsilateral )

40. • Disc Displacement With Reduction

41. ‫االنزياح األمامي غير الردود‬
A.D.D Without Reduction
The Displaced Disc can’t recapture its normal
relationship with the condyle on opening .

42. • Disc Displacement Without Reduction
•Acute Phase
 Closed Lock : Severely restricted
opening ( < 25-30 mm ) in the
Acute phase .

43. • Disc Displacement Without Reduction
•Acute Phase
Closed
Major Symptom
Open
Closed Lock

44. • Disc Displacement Without Reduction
1
2
3

45. D.D Without Reduction
Chronic Phase
• Progressive increase in
mouth opening .
• Mild pain , if any …

46.  Disc Perforations
 Disc displacements have a high correlation with
TMJ osteoarthrosis, which is characterized by
degenerative changes in the articular surfaces.
 Crepitation ….

47.  Disc Perforations
 it is too late for conservative treatment.

48. What causes TMJ disorders?
The Exact Causes Are Not Clear Yet …

49.  Contributing Factors
 Predisposing Factors : increase the risk of TMDs.
( systemic conditions- skeletal deformities-postural imbalances …)
 Initiating Factors : cause the onset of the disorders.
( Acute or Chronic Trauma )
 Perpetuating Factors : interfere with healing and
complicate treatment .
( emotional stress - anxiety- sleep disorders )

50.  Initiating or Precipitating Factors
 Macrotrauma : as a result of a single event
- Extrinsic ( blow , sport accidents … )
- Intrinsic ( hard foods, prolonged mouth opening… )
Whiplash

51.  Initiating or Precipitating Factors
 Microtrauma : repetitive adverse loading of the
masticatory system
- Parafunctional activities ( Bruxism & Clenching )

52.  Bruxism
• Clenching or grinding the teeth during nonfunctional
movements of the mandible.
- Nocturnal Bruxism , related to sleep disorders and may
be influenced by stress .
- Diurnal Bruxism , a learned behavior .

53. What causes TMJ disorders?
Stress: Emotional & Physical
 Stress frequently leads to unreleased nervous energy. It is
very common for people under stress to release this nervous
energy by grinding and clenching their teeth.

54. What causes TMJ disorders ?
•Specific Forms of Malocclusion
Anterior open bite
Forced bite
Class II-2
Anterior crossbite

55. Evolution
How joint and muscles disorders progress is not clear .
Symptoms worsen and ease over time, but what causes
these changes is not known.
‫تكيف‬
‫وظيفة طبيعية‬
‫فرط وظيفة‬
‫خلل وظيفي‬

56. Conservative Management
of TMDs

57.  The
Management Goals
 Reduction of Pain and Anxiety .
 Reduction of Functional or Parafunctional
Activities Leading to Adverse Loading .
 Restoration of Acceptable Function .
 Resumption of Normal Daily Activities .

58. Conservative Treatment of TMDs
• Reversible
•Not just a “Symptomatic “ treatment

59. The Management Program
1
Emergency Therapy
2
3
Initial Therapy
Long-Term Management

60. • Conservative Treatment of TMDs
 Emergency Therapy
• Patient Education & Reassurance .
• Medication to relieve pain (Analgesics – Anti - inflammatory)
• Injecting active trigger points with local anesthetic
agents .
• Short – term of soft vinyl splint to relieve pressure on
joint structures .

61. • Conservative Treatment of TMDs
 Emergency Therapy
• Analgesics
 NSAIDs
 Muscle Relaxants

62.  Emergency Therapy
Articular & Masticatory
Muscle Injections
- only in severe pain cases …

63.  Emergency Therapy
• Soft Resilient Splint
for 2-3 days at maximum …..

64. • Conservative Treatment of TMDs
• after the Emergency Treatment
 Initial Therapy : Should Be
• Reversible
• Palliative
• A Mean to Promote Healing

65. Initial Therapy
• Patient Education
• Home - care Instructions
• Intra - oral Appliance Therapy (occlusal splints)
• Physiotherapy
• Pharmacotherapy
• Behavioral therapy

66. Initial Therapy
- Patient Education
Understanding the :
• Nature of the Problem
• Role of Contributing Factors ( Bruxism )
• Possible Side Effects and Prognosis

67. Initial Therapy
• Home - Care Instructions
Aids the healing process and prevents further injury.
> Soft diet
> Local ice packs / Moist heat
> Rest (avoiding extreme jaw movements)
> Relaxation and Stress – Reducing
Techniques.
> Stretching & Relaxing Exercises.

68. Initial Therapy
•Home - Care Instructions
 Ice massage (acute pain).
 Moist heat (chronic pain).
Cara Heating Pad with Select
Heat, Moist/Dry

69. Initial Therapy
• Pharmacotherapy
 Effective control of Pain and Inflammation .
 Most effective when used as an adjunct to
other treatment modalities .

70. Initial Therapy
• Pharmacotherapy
Drugs frequently used:
 Analgesics
 NSAIDS
 Corticosteroids
 Muscle relaxants
 Antianxiety agents

71. • Pharmacotherapy
 Skeletal Muscle Relaxants
• Centrally or Peripherally acting agents .
• Relieve acute musculoskeletal pain by
reducing muscle spasm.
 Valium : An Antianxiety drug , but very
effective in reducing muscle spasm and
pain .
Diazepam

72.  Physiotherapy
• Objectives :
- To relieve pain of musculoskeletal origin .
- To improve or restore normal masticatory
function .
• Adjunctive role

73.  Physiotherapy
•Jaw muscle exercises

74.  Physiotherapy
Home jaw opening stretching:
Best after application of moist heat packs to face/jaws/neck

75.  Physiotherapy
 Clicking avoidance
opening from a protrusive jaw position to stay on the
displaced disc , jaw opening muscle exercises from
a protrusive or incisal edge to edge position to
avoid the clicking displacement while opening to
stretch out the splinting jaw muscles .

76. Behavioral therapy
• Management of noxious habits accompanying the
musculoskeletal disorder:
 Hypnosis , Acupuncture
 Biofeedback
 Relaxation exercises

77. Interocclusal Appliances
or
Occlusal Splint Therapy
‫المعالجة بالجبيرة اإلطباقية‬
• Joint-stabilization S.
• Anterior Repositioning S.
• Anterior Bite Plates
• Posterior Bite Plates
• Soft ( Resilient ) S.

78. Occlusal Splint Therapy
A Non – invasive and Reversible Biomechanical
Method of Managing Pain and Dysfunction of the
TMJ and its Associated Musculatures .

79. Purpose of Occlusal Splint Therapy
 Stabilize or improve the function of the TMJs .
 Improve the function of the Masticatory Muscles
& Reduce abnormal muscle activity.
 Protect Teeth from attrition and adverse
traumatic loading .

80. Occlusal Splints
2 Main Types
Stabilization splint
Permissive
‫مثبتة للمفصل ومرخية للعضالت‬
Anterior Repositioning splint
Directive
‫معدلة لوضعية الفك السفلي‬

81. Types of Occlusal Splints
Anterior Bite Plane
Posterior Bite Plane
Full-Coverage” Maxillary”
Full-Coverage” Mandibular”

82. The Joint- Stabilization Splint
- Synonyms :
- Muscle Relaxation S.
- Centric Relation S.
-Michigan S.
- Bruxism Appliance
 The most commonly used appliance , which is a hard
acrylic splint that provides a temporary & ideal
occlusion .

83. The joint - stabilization splint
• Main purposes :
 To stabilize the TMJs by decreasing pressure on joint
structures and reducing parafunctional activity such as
bruxism .

84. The Stabilization Splint
- Covers the entire dental arch
- Occludes with all opposing teeth
- The Occlusal surface is flat , with slight indentations for
opposing cusp tips

85.  Placement in the Maxilla or Mandible ?
- Most often in the Maxilla for reasons of comfort .
- Mandibular placement is recommended for
esthetic reasons and in patients with Angle’s Class III
malocclusion .

86.  Joint-Stabilization splints
Area to Cover ?
- All the teeth as well as areas without teeth if these
areas are opposed by teeth in the opposite arch , to
achieve optimum stability.

87. • Stabilization Splint
 Retention ?
- By having the acrylic pass the prominence line of
the teeth by about 1 mm.
- In most cases retention by clasps is unnecessary .

88. The Stabilization Splint
Thickness ?
- The bite rise in the frontal
region should be 3 – 4 mm in
most cases , but in patients with
severe bruxism it can be made
another 1 to 2 mm thicker .

89. The Stabilization Splint
 Occlusal Relationships ?
- The teeth in the opposite
arch should have point contact
against the appliance, and its
occlusal surface should be as
flat as possible .

90. Adjustments

91.  the Stabilization Splint
 Occlusal Adjustments ?
- It is Very Important to recheck the occlusion at
follow-ups since the occlusal relationships may change
as a consequence of jaw-muscle relaxation , forcing the
mandible in a more backward position .

92. The Joint- Stabilization Splint
 Possible Effects
• Decrease loading on the TM joints
• Reduce muscle hyperactivity
• Distribute the forces created during bruxism
• Reposition mandibular condyles

93. Use of the Stabilization Splint
 Primarily at night
- Static Pain ( Muscular involvement) : Nocturnal use
only .
- Dynamic Pain ( Joint involvement) : Full-time use .
 Acute Cases : Full-time use initially ,then decreased
gradually.
 Nocturnal Bruxism : Continued Night-time use

94. Anterior Repositioning Splint

95. 
Anterior Repositioning Splint
•The appliance has a well-defined fossae on the occlusal
surface to actively guide the mandible into a more
protrusive position to improve the disc-condyle
relationship.

96.  Anterior Repositioning Splint
•The Goal is to advance the mandible forward into a
“ therapeutic position” to maintain the disc in proper
alignment and thus eliminate pain and joint noise.

97. The Anterior Repositioning Splint
The Therapeutic Position
•The Therapeutic Position of the mandible : 2-3 mm forward of
the IC Position.
• Represents the smallest anterior change from the patient’s
habitual IC position that will maintain the disc between the
condyle and eminence .

98. The Anterior Repositioning Splint
Indication :
• Anterior Disc Displacement With Reduction
when the disc displacement is thought to be the
source of pain.
- the disc can be reduced by moving the
mandible only 2-3 mm forward of the IC position
- the use of stabilization splint has not
reduced pain symptoms .
 For patients with Retrodiscitis .

99. Anterior Repositioning Splint
Drawbacks :
•Creation of a posterior
or lateral open bite .

100. Anterior Bite Plates
 A hard acrylic – resin appliance placed in the
maxillary arch and has a bite platform that provides
contact only with the mandibular anterior teeth .

101. Anterior Bite Plates
• Aim :
- To disengage the posterior teeth in order to
eliminate their role in masticatory function .
• To alleviate Masticatory Muscle Pain .

102. Posterior Bite Plates
• Used to decompress the TM joint and reduce
overloading .

103. •Posterior Bite Plates
- Decompression splint
• Indicated in cases of Articular pain & symptoms
related to an inflammation localized in the TMJ area.
• Very effective in Acute ADD Without Reduction .

104. •Posterior Bite Plates
•Drawbacks
• Long-term use of this partial coverage splints may
encourage the development of posterior open bite .

105. • Soft Resilient Splints
• For temporary relief for patients in acute distress due
to injury or severe muscle spasm .
• To protect dental and TMJ structures against traumatic
injury during contact sports .
Aqua Splint

106. •Soft Resilient Splints
- Disadvantages
• Difficulty in adjusting and
polishing the appliance .
• Can be easily perforated .
• Ineffective in treating
bruxism because the
resiliency of the material
stimulated the patient to
clench on the appliance.
Aqua Splint

107. The Weaning Process
- When Symptoms Have Been Significantly Reduced
- Patient is Asymptomatic for a Minimum of 3 Months .
- Discontinue the splint use in a GRADUAL Manner :
 Stop Daytime Use , Then
 Stop Nighttime Use .

108.  TM Disorders
 Long - term Management
 Reevaluation of patients responding well to
conservative measures at the conclusion of initial
therapy .

109.  TM Disorders
 Long - term Management
• A trial period of weaning the patient from an occlusal
appliance is often employed with periodic monitoring .
• Determining whether a change in the present occlusal
scheme is necessary .
• Evaluating the role of Perpetuating Factors .

110. Conclusions

111. Conclusions
 Current research has reinforced the view that
patients with TMD suffer from a musculoskeletal
condition and that their problems are
heterogeneous in nature & multifactorial in
etiology.

112. Conclusions
 Signs & Symptoms of TMDs often fluctuate , may be
transient and self-limiting , and can be resolved without
serious long-term effects.
 Therefore , it is recommended that irreversible
treatments be avoided in the early phase of TMD
management , such treatment is rarely necessary in TMD
patients .

113. Conclusions
 Interocclusal appliance therapy is the most commonly
used treatment modality for managing symptoms of TMD.
 Many different interocclusal appliances , each with its
own unique indications , have been used clinically .
Because of its broad range of indication , the most
common is the stabilization splint .
 Its effectiveness in reducing symptoms of TMD has been
estimated at between 70% & 90% when used in
conjunction with other conservative treatment methods .

114. Conclusions
 The majority of patients suffering from TMDs
respond well to conservative therapy that is based on
simple principles.
 Numerous follow-up studies of TMD patients
covering periods of 6 months to 7 years have shown
that between 60% & 90% of the patients have either
no symptoms or greatly diminished symptoms
following simple treatment .
G.E .Carlsson & T. Magnusson

115. Thank you
…
Dr.Marwan Mouakeh
Aleppo – Public Park