TMD Final Flashcards
Before permanent therapy is begun, at least 7 general features are common to all appliances. Each possibility must be considered before any permanent occlusal therapy is attempted. What are these 7 features?
- Alteration of occlusal condition
- Alteration of condylar position
- Increase in the vertical dimension
- Cognitive awareness (of functional and parafunctional behavior)
- Placebo effect
- Increased peripheral input to CNS
- Regression to the mean
Initial TMD therapy should be ___ and ___
reversible
non-invasive
What are the most common occlusal appliances?
Stabilization
Anterior positioning (key to success is finding most suitable position for eliminating pt’s symptoms)
According to Solow, what are the purposes for occlusal devices?
- alter the patient’s existing occlusion (control forces during mandibular closure and excursions)
- protect against progressive attrition (bruxism)
- often prescribed for myogenous orofacial pain (muscle hyperactivity)
- preview of occlusal correction before ortho, equilibration, or comprehensive restoration
According Solow, what are the criteria for occlusal devices?
- all teeth contacting evenly on occlusal device in arch of closure when both condyles seated in glenoid fossa
- anterior teeth should not contact more heavily than the posterior teeth
- anterior teeth should smoothly separate the posterior teeth during all excursive movements
What are the four classifications of anterior guidance schemes given by Solow?
class 1 - lateral excursion on canines, protrusive on centrals
class 2 - lateral excursion on canines then centrals, protrusive on centrals or canines then centrals
class 3 - all excursive movements only on canines
class 4 - unacceptable
Describe the study conducted by He and what they found.
evaluated pre-rx ortho pts with signs of TMD and controls with no signs of TMD.
73% of experimental and 11% of control had positive CR-CO discrepancy.
significant correlation between CR-CO discrepancy and signs of TMD
Strong positive correlation with degree of CR-CO discrepancy and severity of signs of TMD
True or false… the Seligman/Pullinger literature review suggests a limited role for intercuspal occlusal factors in the cause of TMD
true
True or false… overwhelming evidence supports the conclusion that ortho treatment performed on children/adolescents is a significant risk factor for development of TMD years later
false
there is a multiplicity of factors that may be responsible for producing/exacerbating a TMD in general
Ortho mechanotherapy produces gradual changes in an environment that is generally quite adaptive
What are five occlusal features that have been associated with specific diagnostic groups of TMD conditions? (McNamara)
- skeletal anterior open bite
- OJ > 6-7mm
- RCP/ICP slides > 4mm
- Unilateral lingual crossbite
- Five or more missing posterior teeth
(first three of these factors are often associated with TMJ arthropthies and may be the result of osseous or ligamentous changes within the themporomandibular articulation)
As pointed out by ___, ortho should identify/document findings related to the TMJ and mandibular function. if painful symptoms arise during ortho, therapy may need to be modified, gross occlusal interferences relieved, forces tending to distalize the mandible eliminated.
Greene
What are the 8 conclusions that can be drawn from the findings of current research (McNamara).
- signs and symptoms of TMD occur in healthy individuals
- signs and symptoms of TMD increase with age, particularly during adolescence. Thus TMD that originates during treatment may not be related to treatment
- Orthodontic treatment performed during adolescence generally does not increase or decrease the odds of developing TMD later in life.
- The extraction of teeth as part of an orthodontic treatment plan does not increase the risk of TMD
- there is no elevated risk for TMD associated with any particular type of orthodontic mechanics
- although a stable occlusion is a reasonable orthodontic treatment goal, not achieving a specific gnathologic ideal occlusion does not result in TMD signs and symptoms
- no method of TD prevention has been demonstrated
- When more severe TMD signs and symptoms are present, simple treatments can alleviate them in most patients
True or false… signs and symptoms of TMD occur only in unhealthy individuals
false
True or false… signs of symptoms of TMD increase with age, particularly during late adulthood.
false. signs and symptoms of TMD increase with age particularly during adolescence.
true or false… orthodontic treatment performed during adolescence is a significant factor in altering the odds of developing TMD later in life
false
true or false.. the extraction of teeth as part of orthodontic treatment plan does not increase the risk of TMD
true
true or false… the type of orthodontic mechanics can be a factor in causing TMD
false
True or false… if the patient is not treated to CR they will eventually develop TMD
false
True or false… when more severe TMD signs and symptoms are present, more extreme treatment modalities must be used to manage it.
false.. simple treatments can alleviate TMD signs/symptoms in most patients
What was the main conclusion from the study conducted by Huang?
this was a summary of 2 systematic reviews.
concluded that occlusal adjustments are NOT beneficial for managing or preventing TMD
According to Rinchuse, experience-based view relies on what four things?
empiricism
rationalism
authority
tenacity
(argument that anecdotal/emperical evidence is equal to/superior to scientific evidence. it is naive and dangerous)
According to Rinchuse, what are some misconceptions GPs may have?
- Occlusion has a secondary role in the multifactorial nature of TMD, not primary
- Experience-based practitioners might believe their methods are effective, but for TMD pts it could be placebo effect or due to the cyclic nature of TMD
What are the indications for an Aqualizer splint?
release of a closed lock (muscle relaxing appliance)
can help you find CR
Why is the Aqualizer theoretically a perfect splint?
stabilizes immediately
self-balancing
If a patient didn’t have TMD before but developed TMD symptoms during orthodontic treatment, you should….
stop class 2 elastics
What are the four most important things for occlusal appliance therapy success?
selection
fabrication
adjustment
patient cooperation
How does okeson recommend finding CR?
Bilateral manipulation
a stop is located in anterior region of appliance and CR is located using the pts muscles
If CR is difficult to find, what 2 things should be done first?
ask patient to close their back teeth
recline them so gravity helps
have pt place tongue on posterior of soft palate
What are 8 things that need to be done before final delivery of a stabilizing splint?
stable and retentive
all mandibular cusps and incisal edges must contact
during protrusive movement, mandibular canines must contact appliance with even force
in any lateral movement, the mandibular canine should exhibit laterotrusive contact on appliance
mandibular posterior teeth must contact slightly more heavily than the anterior teeth during closure
in the alert feeding position the posterior teeth must contact the appliance more prominently than anterior teeth
occlusal surface of appliance should be as flat as possible with no imprints for mandibular cusps
occlusal appliance is poised so it won’t irritate adjacent soft tissue
The anterior repositioning splint is not meant to permanently alter the mandible’s position, but temporary increase adaptation of ____
retrodiscal tissues
What is the main purpose of the anterior bite plane?
muscle disorders related to orthopedic instability or an acute change in occlusal condition
What are the five criteria before delivering an anterior positioning appliance?
- accurately fit the maxillary teeth with total stability and retention
- in the established forward position, all the mandibular teeth should contact it with even force
- the forward position should eliminate the joint symptoms during opening and closing to and from that position
- the lingual recursive guidance ramp should contact and on closure direct the mandible into the therapeutic forward position
- the appliance should be smoothly polished and compatible with adjacent soft tissue structures
What is the pivoting appliance and what is it an indication for?
provides single poster contact at furthest point around which mandible pivots
indication = disc displacement/dislocaiton
What are the two accessory ligaments of the TMJ?
stylomandibular and sphenomandibular
The two types of movement the TMJ allows for are…
hinging
sliding
From the anterior view, the articular disc is thicker…
medially
The articular surfaces of the condyle and mandibular fossa are lined with…
dense fibrous connective tissue
A goal of orthodontics should be ___ during mandibular movements
stability and functional balance
The uniqueness of Roth’s treatment goals was the inclusion of ___
gnathology
What are the 8 conclusions that Rinchuse drew from 8 systematic reviews?
- traditional ortho does not increase TMD prevalence
- joint hyper-mobility does not have a clear relationship with TMD
- CT scans are not recommended for diagnosis of disc displacement
- EMG biofeedback is effective for TMD
- Occlusal splints might be beneficial in treatment of TMD
- Occlusal adjustments are not recommended for treatment/prevention of TMD
- Insufficient evidence to support HA injections
- Few associations established between occlusion and signs/symtpms of TMD
TMD is a ____ disorder of the masticatory structures
repetitive motion
What are the minimum acceptable ranges of motion? (Wright)
40mm opening
7mm lateral
6mm protrusive
When should you refer for physical therapy to manage TMD? (Wright)
cervical: neck pain or cervicogenic headaches
postural: forward head posture, abnormal posture increases pain, desire to change poor sleep posture
Outcome-oriented: initial therapy not adequate, needs TMJ surgery (only 2.5% of TMD patients)
If a patient has had a click for many years that suddenly disappears, then locking occurs. what happened?
turned into disc displacement without reduction
Crepitus is an indication of ___
degenerative joint disease (arthritis)
True or false.. if the disc becomes displaced (for whatever reason) the occlusion will change. (gray)
true
What are the acute symptoms of whiplash?
inability to open mouth comfortably
inability to chew
forced soft food diet
pain from masticatory muscles or joints themselves
How do you treat whiplash patients?
as you would with any other similar TMD
True or false… the TMD symptoms associated with whiplash are commonly caused by stretched and/or torn posterior attachment tissue and polar distal attachments. also crushed poster attachment tissue
true
According to Bollen, there is a correlation between the presence of malocclusion and ___
periodontal disease
greater malocclusion have more severe perio, but also dependent on oral health status
True or false.. according to Bollen, ortho treatment has a significant impact on improving periodontal health
false… there is an absence of reliable evidence on the effects of ortho treatment and periodontal health. There is a small detrimental effect on periodontal.
both systematic reviews conclude that ortho treatment is not warranted to prevent future perio problems except for specific malocclusions
Discuss clicking in regard to diagnosis of TMD problems
engagement and disengagement of the disc with the condyle (initial click on opening when the disc engaged between the condyle and the articular eminence and a second click (sometimes inaudible) when the disc comes off the condyle (usually anteriorly)
Discuss closed lock in regard to diagnosis of TMD problems
The disc has anteriorly slipped in front of the condyle and the patient is unable to open. as the condyle begins to translate it runs into the disc and the disc can proceed no further. the treatment for this is a splint if necessary to unload the joint in the hopes of the retrodiscal fibers retracting the disc, or surgery to pin the disc onto the condyle in severe cases.
Discuss open lock in regard to diagnosis of TMD problems
when the whole condyle has dislocated anterior to the eminence. the patient is unable to close. the oral surgeon is usually able to reduce without surgery or muscle relaxants. in severe cases, surgery may be warranted to flatten the eminence. sometimes a patient will have to be sedated and given paralytic in the OR in order for the surgeon to reduce.
Discuss pain of the muscles of mastication in regard to diagnosis of TMD problems
extracapsular sign of TMd; tenderness or pain may indicate muscular compensations for a deranged stomatognathic system. if patients are unable to open due to the pain there is a ‘soft end feel’ whereby the patient is unable to open fully. usually unable to translate but may be manipulated to open further by the practitioner
Discuss pain of the TMJ in regard to diagnosis of TMD problems
an intracapsular sign of TMD. may be associated with capsulitis, synovitis, or retrodiscal inflammation. if patients are unable to open due to TMJ pain there usually is a “hard end feel” whereby the patient is unable to open further even with chair side manipulations by the practitioner.
Discuss crepitus in regard to diagnosis of TMD problems
“crackling” sounds associated with early degenerative changes to the TMJ; signifies early damage to the disc, condyle, or eminence
Describe the stabilizing appliance and the indication for its use.
Full coverage maxillary splint with bilateral and even contacts in CR with incisal and cuspid guidance. in fabricating, the patient must be in CR, the ramps should not lock in the anterior teeth, and the areas lateral to the posterior occlusal table should be beveled for comfort.
indication: alleviate muscular pain associated with TMD and bruxism
Describe the anterior repositioning appliance and the indication for its use.
Can be either maxillary or mandibular. the maxillary one is used more commonly because it does not allows the mandible to retrude during sleep. the splint is fabricated with the patient in a protrusive position which relieves the patient’s TMD pain. after the protrusive stop is made, the posterior part of the appliance is filled in with acrylic. even and bilateral posterior contacts should be present. the anterior ramp should be hollowed in the lingual part, the sides of the splint beveled, and the splint polished.
indications: disc derangement, can recapture an anteriorly displaced disc
Describe the anterior bite plane and the indications for its use.
an anterior stop is added to a maxillary splint in either CR or protrusive. no posterior contacts are present and only the central incisors contact at the stop which is flat and level.
Indication: nocturnal grinding. deprogram the joint
disadvantages: posterior eruption and anterior intrusion
Describe the posterior bite plane and the indications for its use.
flat mandibular plane splint which covers only the posterior teeth. posterior, even and bilateral contact in CR. the acrylic is reduced to the level of the cusp tips to create a flat plane. no guidance is build into this appliance.
Indications: acute TMD pain associated with unstable occlusion and for disocclusion of teeth in conjunction with orthodontic treatment; increases VDO
disadvantages: anterior eruption, posterior intrusion
Describe the pivoting appliance and the indications for its use.
bilateral and unilateral types of appliances. it is a maxillary splint in which the only contacts occur on the most posterior teeth, either bilaterally or unilaterally. the bilateral form is rarely used because unloading of the joint could often not be accomplished. the unilateral appliance is still useful if disc derangement exist unilaterally. the posterior contact is created on the side of occlusion contralateral to the joint that needs to be unloaded in the case of unilateral splint and it is quite effective.
indication: disc derangement
Describe the soft splint and the indications for its use.
thick soft splint which can be placed in the maxilla or mandible. bilateral posterior contact are achieved with adjustment and the appliance is thinned and beveled at the borders for comfort. without adjustments, this appliance is basically just mouth guard.
indication: relief of muscular TMD symptom
disadvantages: can make symptom worse (chew toy phenomenon)
What are 4 common “experience-based” theories? (will be test question)
- extractions cause dished in appearance and large buccal corridors
- functional appliances alter mandibular growth
- occlusion is the primary cause of TMD
- orthodontics causes TMD
What was the conclusion from the Sadowsky study?
“overwhelming evidence supports the conclusion that orthodontic treatment performed on children and adolescents is generally not a risk for the development of TMD years later”
conclusion is not surprising for 2 reasons:
- the multiplicity of factors that may be responsible for producing or exacerbating TMD.
- Orthodontic mechanics produces gradual changes in an environment that is quite adaptive
What are the three goals of orthotic appliance therapy?
- provide the best condyle-fossa relationship possible at the time of treatment
- decompress the capsular inflammation
- restore proper muscle length bilaterally
According to Rinchuse which is better for diagnosing disc position, MRI or CT?
MRI
What are the 9 conclusions from the Rinchuse + McMinn “Summary of evidence-based systematic reviews of TMDs”?
- Occlusion plays a secondary role at best in the etiology and treatment of TMD
- Traditional orthodontic treatment does not increase the prevalence of TMD.
- Joint hyper mobility does not have a clear relationship with TMD
- CT scans for TMJ are not recommended for the diagnosis of disc displacement
- EMG biofeedback treatments are effective for TMD
- The use of occlusal splints might be beneficial in the treatment of TMD
- Occlusal adjustments are not recommended for the treatment or prevention of TMD
- There is insufficient evidence to support or refute use of HA injections in the TMJ for TMD treatment
- Few associations have been established between malocclusion or functional occlusion and the signs and symptoms of TMD
True or false… occlusion is a primary cause of TMD
false. it plays a secondary role at best
true or false…. traditional orthodontic treatment does not increase the prevalence of TMD
true
True or false… joint hyper mobility does not have a clear relationship with TMD
true
True or false… CT scans are superior to MRI scans for imaging the TMJ
false. MRI is better
true or false… EMG biofeedback treatments are effective for TMD
true
true or false… the use of occlusal splints might be beneficial in the treatment of TMD
true
True or false… occlusion adjustments are the best way to prevent TMD
false
true or false… HA injections have been shown to be effective in the treatment and prevention of TMD
false
true or false… few associations have been established between malocclusion or functional occlusion and the signs and symptoms of TMD
true
According to Wright and North “Management and treatment of TMDs: a clinical perspective” TMD affects up to ___% of individuals within their lifetime. It is a ___ disorder of the masticatory structures and may be more effectively cared for when ___ are involved in the treatment process.
33%.
repetitive motion
physical therapists
According to Wright and North, what are the minimum acceptable range of motion values for the mandible?
40mm opening
7mm excursive
6mm protrusive
tooth pain is the source of about ___% of TMD referrals to the dentist
3%
Which article stressed the importance of performing a thorough TMJ exam in 2-3 minutes at every visit and to keep precise records?
Gray - Risk management in clinical practice
What 6 things should be evaluated in a TMJ exam?
- Range of motion
- Joint tenderness
- Joint sounds
- Muscle tenderness
- Signs of bruxism
- Occlusion
True or false… loss of occlusal vertical dimension leads to TMD
false
According to Gray, what are the signs of occlusal instability?
tooth hyper mobility tooth wear abreaction periodontal breakdown stress fractures exostosis muscle enlargement loss of posterior occlusion
What is a pano useful in evaluating the TMJ?
gross abnormalities (osteophyte formation, sclerosis)
What is a CT useful in evaluating the TMJ?
signs of degenerative joint disease (erosion w/>60% demineralization, loss of cortical outline of condylar head or fossa
What is a MRI useful in evaluating the TMJ?
degree of disc displacement and disc perforation
