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Trigem
inal Neu
ralgia
A Den
tal Per
spec
tive
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A Multidisciplinary
Approach
Differential Diagnosis
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The Stomatognathic TriadThe Stomatognathic Triad
• Articulation Of The Teeth – Dominant
• Joints – Accommodate
• Muscles – Accommodate
• Articulation Of The Teeth – Dominant
• Joints – Accommodate
• Muscles – Accommodate
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Articulatio
n of
the teet
h (Bite
)
Bite
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TMJ PainTMJ NoiseHeadaches
Cervical PainEar CongestionLimited Opening
Postural ProblemsParathesia of Finger Tips
TMJ PainTMJ NoiseHeadaches
Cervical PainEar CongestionLimited Opening
Postural ProblemsParathesia of Finger Tips
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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
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Video Tmj # 9
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•Video TMJ # 9
•Next
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No Matter How MalpositionedThe Occlusion
No Matter How MalpositionedThe Occlusion
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Muscles Will Struggleto Create a Centric Occlusion (C.O.)
They Accommodate
Muscles Will Struggleto Create a Centric Occlusion (C.O.)
They Accommodate
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The Temporomandibular Joints Accommodate
The Temporomandibular Joints Accommodate
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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
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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
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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
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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.
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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.
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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
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Sonography - Chronic impingement with crepitis
Sonography - Chronic impingement with crepitis
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Severe degeneration Severe degeneration
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The Stomatognathic TriadThe Stomatognathic Triad
• Teeth – Dominant
• Joints – Accommodate
• Muscles – Accommodate
• Teeth – Dominant
• Joints – Accommodate
• Muscles – Accommodate
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Normal
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Posterior Displaced Condyle
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The Stomatognathic TriadThe Stomatognathic Triad
• Teeth – Dominant
• Joints – Accommodate
• Muscles – Accommodate
• Teeth – Dominant
• Joints – Accommodate
• Muscles – Accommodate
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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
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The structural units are Actin And Myosin With ATP Being The Energy Source
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•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
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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
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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
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• Neuromuscular
Dentistry #5• Next
• Neuromuscular Dentistry #5
• Next
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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.
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A.Lowering rest EMG activity after therapy is the desired therapeutic objective.
B.Lowered postural EMG activity indicates improved physiologic status.
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Posterior Cervical Muscles
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“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:
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“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:
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T.E.N.S.T.E.N.S.NEURAL STIMULATIONNEURAL STIMULATION
TRANSCUTANEOUS ELECTRICAL
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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
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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
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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
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A Normal Bite ??????
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Do you have a malpositioned
occlusion?
?????????????????
Do you have a malpositioned
occlusion?
?????????????????
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LOOKSARE
DECEIVING!!
LOOKSARE
DECEIVING!!
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Class II Div II
Posterior Displaced Mandible And
Condyle
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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.
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ComputerizedJaw TrackingComputerizedJaw Tracking
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Video Diagnosing Problems #7
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• Diagnosing Problems #7
• Next
• Diagnosing Problems #7
• Next
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• •
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EMGElectromyography
EMGElectromyography
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Hyper Active
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• •
Relaxed After Tens
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CentralNervous System
CentralNervous System
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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.
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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.
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Myofascial Triggers And
Referred Pain
Myofascial Triggers And
Referred Pain
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Trape
zius
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Sternocleidomastoid
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Medial Pterygoid
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Masseter
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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
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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
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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.
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NTI Appliance And MigrainesNTI Appliance And Migraines
Video A Dental Perspective #1
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• Next #1• NTI and Migraines
• Next #1• NTI and Migraines
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