Name : Dr.

Shenavi – Keluskar

Designation : Prof & Head of the Department KIDS, Belgaum.

Qualification : B.D.S. Kud Dharwad May 1989
M.D.S.Kud Dharwad Feb -1994

Email :

Title : New Concepts and Treatment modalities in Temperomandibular joint

dysfunction

ABSTRACT

“Healer” or “Precipitator”
of TMD

TMD is an “IN” complaint of the developed world. With development

instead of humans lilfe becoming more relaxing it has become more
competitive and stressful, this has lead to various parafunctional habits like
bruxisim or night grinding, nail biting, hyperactivity of muscles and
abnormal posturing and all these have deleterious habits lead to TMD.

The interest of Orthodontic community in TMD was chaperoned by the

famous MICHIGAN TMD LAWSUITE in which the Orthodontist was
accused of causing TMD was penalized by a very high amount .After this
incidence numerous studies were conducted all over the world to find if
orthodontic treatment can actually lead to TMD.

The term TMD was coined by Dr. Laszla Shwartz in 1955, since then the
term has been changed by various researchers all over the world from being
called as COSTEN SYNDROME, to craniofacial disorder, TMJ dysfunction
syndrome, etc, but the term TMD gained wide acceptance.
Temperomandibular disorder, in the board sense are to be considered a
cluster of joint and muscle disorders in the orofacial area, characterized
primarily by pain , joint sounds and irregular or deviating jaw function.
According to “American Academy of Orofacial Pain” – Temperomandibular
disorder is a collective term embracing a number of clinic all problems that
involve the Masticatory musculature, Temperomandibular joint and
associated structures or both. Before I go into the intricacies of this
problems lets revive some basic aspect of the same. TMJ also known as
ginglymoarthroidal joint for the reason both gliding and hinging action are
seen, it is as synovial joint, and is one of the most complex joint in the entire
human body. The fact that two TMJ are joined to the same bone makes it a
further complex of a joint. Each joint involves the temporal Articulare
tubercle and anterior part of the mandibular fosse above and mandibular
condyle below. An billaminar concavo-convex Articulare disc divides the
joint, usually completely, into upper and lower parts . The joint is composed
of three major ligaments which are the capsular ligament, the collateral
ligament and the tm ligament, apart from these two minor ligaments
namely sphenomandibular and stylomandibular ligaments are also there.
Apart from these there is a retrodiscal pad just posterior to the joint which
provides the nutrition and nervous innervations to the joint.

Prodigiuous number of factors are implicated in the etiology of TMD DE

BOEVEN and CALRSON IN 1994 grouped these factors into.

PREDISPOSING FACTORS
Systematic factors – medical conditions such as rheumatic infections,
nutritional and metabolic disorders can influence masticatory system to an
extent that TMD may emerge.
Psychologic factors – Personality, behavior can affect masticatory system.
Structural factors – All types of occlusal discrepancies, improper dental
treatment, postural abnormalities, skeletal deformation, past injuries etc.
Genetic factors.

Initiating factors:

Trauma – Microtrauma or Macrotrauma

Overloading of joint structures
Parafunctional habits etc.
Perpetuating factors:
Mechanical and Muscular stress.
Metabolic problems.

For diagnosing any illness we should know the sings and symptoms elicited
by that illness.

Pain is one of the chief complaint that the patient may come to us with. The
pain is a muscle pain and may vary from slight tenderness to server
discomfort. Joint may elicit either clicking or crepitus. The muscle may
undergo fatigue and spasm so that any stretching or contraction can lead to
an increase in pain. The condyles may get dislocated as generally seen in
case of arthritis. The close proximity of the ear to the TMJ as well as there
common trigeminal nerve innervation may lead to frequent condition of
referral pain. Recurrent headaches.

Before starting any case its proper diagnosis is a must. IN order to be on the
safe side orthodontist are always advised to go through the complete and
detailed procedure of diagnosis and have all the needed records for future
referral.

Anamnesis comes from Greek word means recollection that is patient

recollection of previous signs and symptoms. Palpation of lateral portion of
the joint both directly over the joint and then palpating the posterior aspect
of the condyle by placing the little fingers in the external acoustic meatus.
Also we need to Palpate the muscle of mastication, the cervical musculature.
Also while palpation presence of any click can be detected Sometime to
hear the clicking a stethoscope aid may be needed.In case of milk click the
patient should be kept under observation and checked for the same
regularly. Crepitus may be heard that is the sound of bone rubbing with
bone. This is usually sign of perforation of the disc.

Movements of the mandible in this the maximum opening and the lateral
excursive movements are seen. Also any deviation while opening or closing
the mandible is seen. In case of TMD the opening of the mouth is generally
decreased due to the muscular splinting. Also in case of muscular splinting
on one side, or due to any Occlusal interferences the mandible might
deviate.
Joint imaging has helped us to peek through the blanket of the dark, helping
us to see the joint and its structures.
It started by conventional radiographs
Transcranial, --
Transpharyngeal –
Transorbital --

Arthrougraphy still one of the best methods to visualize the TMJ involves a
contrasting media is inserted into the jont area before taking the radiograph.
With the advent of computers in the field of imaging. Temography was the
next level. It is the radiographic equivalent of taking a slice of a given depth
of the target area. The pinnacle has been reached with the advent of MRI
technique in which both the hard and soft tissues are visualized.

In order to find whether the role of a orthodontist is that of a healer or a

precipitator of TMD, I went through various articles. The articles were
selected from the MEDLINE facility on following criteria’s.
Orthodontic treatment was completed in each patient.
Clinical TMD evaluation was performed in each patient.
Case reports and opinion papers were excluded.
Articles were written in English.
1. It has been reported anecdotally that orthodontic treatment can
produce TMD, particularly an internal derangement that is often
characterized by joint sounds.
2. This proposition was refuted after the assessment of these twenty two
articles in which the treatment ranged from that for class I to those in
which extraction therapy, or functional therapy was used.
3. Most of the studies showed that orthodontic treatment has no
influence on the TMJ.
4. Four studies show that in fact the treatment improves the TMJ
condition.
5. While three studies showed increase chances of TMD after an
orthodontic treatment.
6. Ricketts stated that clinical symptoms of joint derangement have been
noted as occlusions were changed, and he suggested that the various
orthodontic forces provided during therapy may predispose patients
to temporo mandibular joint problems.
7. witzig and Spahl wee critical of premolar extraction, stating that this
method of treatment “was a technique that was never designed with
 the face, the stability of the occlusion, nor the health of the TMJ in
mind, merely the decrowding of arches”.
8. Even though it is widely stated that extraction causes decrerase in the
vertical dimension, there are no controlled published studies to
support this hypothesis.
9. On the other hand studies have shown that, Orthodontic treatment
produced a net increase in vertical dimension with no significant
difference between extraction and non-extraction group.

Also there is no evidence ini the literature indicating that premolar

extraction treatment causes distal mandibular displacement and subsequent
posterior condylar displacement. Instead, the literature supports the view
that condyles are in a more concentric position at the end of orthodontic
treatment.

1. Also research has shown that position of the condyles is variable in

both symptomatic and asymptomatic population and does not
accurately predict articular disc position pulling the articular disc
anteriorly along with it and thus, interfering with the physiologic
function of the stomatognathic system.
2. The debate about Orthodontic treatment as a risk factor for
Temporomandibular Disorders (TMD) led to this paper.
3. Although the concern about Orthodontics as a possible etiological
factor for TMD is lessening, there is still a debate.
4. The debate is driven by a continuing lack of sufficient information of
the kind most readily obtained from systematic, propective,
longitudinal studies.
5. The overwhelming evidence in my study, supports that the
orthodontic treatment is generally not a risk factor for the
development of TMD in later years.
6. This may be attributed to the reasons that
a) TMD is caused by multiple factors and not occlusion along.
b) Also as by a Orthodontic treatment, gradual changes are
produced in the TMJ environment ; which itself is quite
adaptive.

Few cases will be shown here.