patient only transitions

Trigem

inal Neu

ralgia

A Den

tal Per

spec

tive

A Multidisciplinary

Approach

Differential Diagnosis

The Stomatognathic TriadThe Stomatognathic Triad

• Articulation Of The Teeth – Dominant

• Joints – Accommodate

• Muscles – Accommodate

• Articulation Of The Teeth – Dominant

• Joints – Accommodate

• Muscles – Accommodate

Articulatio

n of

the teet

h (Bite

)

Bite

TMJ PainTMJ NoiseHeadaches

Cervical PainEar CongestionLimited Opening

Postural ProblemsParathesia of Finger Tips

TMJ PainTMJ NoiseHeadaches

Cervical PainEar CongestionLimited Opening

Postural ProblemsParathesia of Finger Tips

Dizziness -VertigoRinging in ears - Tinnitis

Swallowing difficulty - DysphagiaBell’s Palsy

Trigeminal NeuralgiaNervousness/ InsomniaNon-Specific Facial Pain

Dizziness -VertigoRinging in ears - Tinnitis

Swallowing difficulty - DysphagiaBell’s Palsy

Trigeminal NeuralgiaNervousness/ InsomniaNon-Specific Facial Pain

Video Tmj # 9

•Video TMJ # 9

•Next

No Matter How MalpositionedThe Occlusion

No Matter How MalpositionedThe Occlusion

Muscles Will Struggleto Create a Centric Occlusion (C.O.)

They Accommodate

Muscles Will Struggleto Create a Centric Occlusion (C.O.)

They Accommodate

The Temporomandibular Joints Accommodate

The Temporomandibular Joints Accommodate

Disc and Condyle Rotation Then Translation

Disc and Condyle Rotation Then Translation

• Should move synchronously

• Maintain spatial relationship

• Adequate disc space• Synchronous non-

hypertonic musculature

• Should move synchronously

• Maintain spatial relationship

• Adequate disc space• Synchronous non-

hypertonic musculature

Asynergy of Disc and CondyleRotation And Translation

Asynergy of Disc and CondyleRotation And Translation

• Can be the result of mechanical impingements

• Or muscle spasms that result in uncoordinated disc movement

• Can be the result of mechanical impingements

• Or muscle spasms that result in uncoordinated disc movement

Clinical Range Of MotionClinical Range Of Motion

•40 mm or Around Three Fingers

•Lateral About ¼ Of Max Opening

•Symmetrical – No Deviations

•Asymmetrical – Deviates To The Side Of The Dysfunction

•Clicking Joint

•Non Reducing Disk

Smooth MovementSmooth Movement

1. Centric (Habitual) Occlusion with posterior teeth in maximum cuspation.

2. Normal opening free of clicks and dyskinesia.3. Normal Closing.4. Maximum speed of opening.5. Maximum speed of closing.6. Speed of mandible at moment of tooth contact.7. Note: Lack of lateral deviation during opening and closing

movements.

Uncoordinated functionUncoordinated function

• Slowing mandibular movement

• Characteristic of reciprocal click

• Slower closing

• Slowing mandibular movement

• Characteristic of reciprocal click

• Slower closing

A. Clicks will be more reproducible during “normal” opening. Patient overrides clicks during “fast” opening.

B. Click in velocity trace is usually accompanied by a lateral shift in the jar movement in the frontal plane.

C. Lateral deviation may be anatomic (condyle/disk) or unilateral muscle spasm.

Sonography - Normal discSonography - Normal disc

• Low frequency sounds• Amplitude is a factor• Intact discs can have a

click or pop

• Low frequency sounds• Amplitude is a factor• Intact discs can have a

click or pop

Sonography - Chronic impingement with crepitis

Sonography - Chronic impingement with crepitis

Severe degeneration Severe degeneration

The Stomatognathic TriadThe Stomatognathic Triad

• Teeth – Dominant

• Joints – Accommodate

• Muscles – Accommodate

• Teeth – Dominant

• Joints – Accommodate

• Muscles – Accommodate

Normal

Posterior Displaced Condyle

The Stomatognathic TriadThe Stomatognathic Triad

• Teeth – Dominant

• Joints – Accommodate

• Muscles – Accommodate

• Teeth – Dominant

• Joints – Accommodate

• Muscles – Accommodate

MusclesMuscles•Function is to Contract

•With the ability to vary speed, power and extent of that contraction

•This is how they act as Mandibular Accommodators

The structural units are Actin And Myosin With ATP Being The Energy Source

•The Muscle Motor Unit consists of the nerve cell body, a single axon of the motor nerve, its terminal branches and the muscle fibers supplied by these branches

•It’s the occlusion that determines the amount of joint compression however this will not occur until muscle motor units are called upon to move the mandible under function or Parafunction

Pain/Spasm Cycle

•Is almost universal in TMD

•As muscles are called upon to continually accommodate an occlusion they become contracted and function at a decreased working length

•This results in lymphatic and vascular impingement, inhibits metabolism with the resultant build up of spasmogenic metabolites

HypertonicityHypertonicity

•A condition of excessive tone of the skeletal muscles

•Characterized by increased muscle motor unit firing to maintain posture at rest

•A condition of excessive tone of the skeletal muscles

•Characterized by increased muscle motor unit firing to maintain posture at rest Video

Neuromuscular Dentistry #5

• Neuromuscular

Dentistry #5• Next

• Neuromuscular Dentistry #5

• Next

A.High postural EMG activity is common in patients with TMD.

B.The anterior temporalis is usually elevated more than the masseter since it is a posturing muscle. The masseter is a force muscle.

C.High posterior temporalis activity is common in patients with cervical myofacial dysfunction.

A.Lowering rest EMG activity after therapy is the desired therapeutic objective.

B.Lowered postural EMG activity indicates improved physiologic status.

Posterior Cervical Muscles

“Authors who have reviewed the TMJ literature generally agreethat muscle hyperfunction is the principle cause of myogenous TMJ disorders.”JADA, 12:283-290, 1990

“Authors who have reviewed the TMJ literature generally agreethat muscle hyperfunction is the principle cause of myogenous TMJ disorders.”JADA, 12:283-290, 1990

Hypertonicity:

“There is a general agreement among both clinicians and investigators that masticatory muscle activity is greater in symptomatic patients as compared to normal subjects.”McCall, W.D., A Textbook of Occlusion, Quintessence, 1988

“There is a general agreement among both clinicians and investigators that masticatory muscle activity is greater in symptomatic patients as compared to normal subjects.”McCall, W.D., A Textbook of Occlusion, Quintessence, 1988

Hypertonicity:

T.E.N.S.T.E.N.S.NEURAL STIMULATIONNEURAL STIMULATION

TRANSCUTANEOUS ELECTRICAL

Group ActionGroup ActionFacial Nerve Mandibular Nerve

Muscle of Nose Masseter

Buccinator Temporalis

Risorius Medial Pterygoid

Orbicularis Oris Lateral Pterygoid

Muscles of Lower Lip Tensor Palati

Platysma Mylohyoid

Stylohyoid Ant Belly Digastric

Post Belly Digastric

Low Frequency TENSLow Frequency TENS

1. Pumps waste metabolites and lactic acid from hypertonic muscles

2. Increases vascular flow, oxygen, ATP, Glucose, and Calcium

1. Pumps waste metabolites and lactic acid from hypertonic muscles

2. Increases vascular flow, oxygen, ATP, Glucose, and Calcium

3. Changes muscle metabolism from anaerobic (lactic acid) to aerobic

4. Endorphin effect

3. Changes muscle metabolism from anaerobic (lactic acid) to aerobic

4. Endorphin effect

Low Frequency TENSLow Frequency TENS

A Normal Bite ??????

Do you have a malpositioned

occlusion?

?????????????????

Do you have a malpositioned

occlusion?

?????????????????

LOOKSARE

DECEIVING!!

LOOKSARE

DECEIVING!!

Class II Div II

Posterior Displaced Mandible And

Condyle

If it has been measured, it is a FACT.

If it has not been measured,it is an OPINION.

If it has been measured, it is a FACT.

If it has not been measured,it is an OPINION.

ComputerizedJaw TrackingComputerizedJaw Tracking

Video Diagnosing Problems #7

• Diagnosing Problems #7

• Next

• Diagnosing Problems #7

• Next

• •

EMGElectromyography

EMGElectromyography

Hyper Active

• •

Relaxed After Tens

CentralNervous System

CentralNervous System

The Trigeminal Nerve comprises 60% of all neural tissue of the 12 cranial nerves and is associated with the reticular activating (awakening) center. Sensory information from the occlusion is carried along the 5th cranial nerve to the awakening center.

The Trigeminal Nerve comprises 60% of all neural tissue of the 12 cranial nerves and is associated with the reticular activating (awakening) center. Sensory information from the occlusion is carried along the 5th cranial nerve to the awakening center.

As a noxious stimuli such as from a bite prematurity travels to the reticular activating center the message is instantly processed and the mandible is pulled away from the prematurity. Significant accommodation is often required. This OCCLUSAL PROPREOCEPTION often becomes a common cause of muscle hypertonicty.

As a noxious stimuli such as from a bite prematurity travels to the reticular activating center the message is instantly processed and the mandible is pulled away from the prematurity. Significant accommodation is often required. This OCCLUSAL PROPREOCEPTION often becomes a common cause of muscle hypertonicty.

Myofascial Triggers And

Referred Pain

Myofascial Triggers And

Referred Pain

Trape

zius

Sternocleidomastoid

Medial Pterygoid

Masseter

Therapeutic ObjectivesTherapeutic Objectives

• Restore Normal Blood Flow (aerobic metabolism)

• Eliminate Sources Of Nerve And Vascular Entrapments

• Eliminate Neuromuscular Trigger Points• Restore Postural Integrity At Rest With

Minimal Muscle Activity• Elimination Of Neuromuscular And

Temporomandibular Joint Compression

• Restore Normal Blood Flow (aerobic metabolism)

• Eliminate Sources Of Nerve And Vascular Entrapments

• Eliminate Neuromuscular Trigger Points• Restore Postural Integrity At Rest With

Minimal Muscle Activity• Elimination Of Neuromuscular And

Temporomandibular Joint Compression

Neuromuscular Occlusal Objectives

Neuromuscular Occlusal Objectives

• Provide An Occlusal Relationship Of The Mandible To The Maxilla That Minimizes The Need For Muscle Accommodation

• Provide An Occlusal Relationship That Allows Normal Decompression Of Neural And Vascular Intracapsular Tissue And Associated Connective Tissue

• Provide An Occlusal Relationship Of The Mandible To The Maxilla That Minimizes The Need For Muscle Accommodation

• Provide An Occlusal Relationship That Allows Normal Decompression Of Neural And Vascular Intracapsular Tissue And Associated Connective Tissue

The individual will experience

pain and pathology when

the stress exceeds their

ability to adapt.

The individual will experience

pain and pathology when

the stress exceeds their

ability to adapt.

NTI Appliance And MigrainesNTI Appliance And Migraines

Video A Dental Perspective #1

• Next #1• NTI and Migraines

• Next #1• NTI and Migraines