20/01/2014

1

Ambra Michelotti

michelot@unina.it

University of Naples Federico II

Limiting your risk when

treating patients with TMD

American Association of OrthodontistsTMD diagnosis

Condylar position and TMD risk

Occlusal interference and TMD risk

Red Flags and TMD risk

Outline

Temporomandibular disorders (TMDs) encompass a group of

musculoskeletal and neuromuscular conditions that involve thetemporomandibular joints (TMJs), the masticatory muscles and all

associated tissues.

The signs and symptoms associated with these disorders are diverse, and

may include difficulties with chewing, speaking and other orofacial

functions.

They also are frequently associated with acute or persistent pain, and the

patients often suffer from other painful disorders (comorbidities).

The chronic forms of TMD pain may lead to absence from or impairment

of work or social interactions, resulting in an overall reduction in thequality of life.

AMERICAN ASSOCIATION FOR DENTAL RESEARCH TMD POLICY STATEMENT REVISION, MARCH 3, 2010

Temporomandibular Disorders

TMD

Modified by Diatchenko et al, 2006

Modified by Benoliel et al, 2011

Environment

Occlusion

Orthodontics

Na+, K+-

ATPase

Serotonin

transporter

BDNF

12q11.2

Cannabinoid

receptorsMAO

11q23

Adrenergic

receptorsNMDA POMC

COMT

Interleukins

5q31-32 22q11.21

Opioid

receptors ProdynorphinDREAM NGF

IKKNET

CREB1

Serotonin

receptor GR

Dopamine

receptors

GAD65 CACNA1A

6q24-q25 1p13.1 5q31-q32 9q34.3 Xp11.23

Fatigue, stiffness or pain of the jaw muscles

Jaw movementsimpairment

TMJ

Pain Sounds

Click Crepitus

Deviation Deflection

20/01/2014

2

Main complaints

Preauricular pain, right and left TMJs clicking sounds,

headache, malocclusion, missing posterior teeth

XX

Sharp pain, at the left and right

preauricular regions; during clicksound, during chewing and opening

movements

Headache

- localization: temporal region, bilaterally

- frequency: often (2-3 times/week)

- intensity: moderate-high (5-7 VAS)

- decreases with rest and increases with jaw

movements

X

X

X

X

Vertical range of motionUnassisted opening

without pain41 mm

Maximum assisted

opening49 mm

Maximum unassisted

opening46 mm

Vertical incisor overlap

3 mm

FAMILIAR PAINFAMILIAR PAIN

Jaw excursionsRight lateral

Excursion5 mm

Left lateral

excursion2 mm

Protrusion

3 mm

FAMILIAR PAINFAMILIAR PAIN

FAMILIAR HEADACHEFAMILIAR HEADACHE

FAMILIAR PAINFAMILIAR PAIN

Joint Palpation

Joint SoundsRight joint Left joint

LR LL P C O O C P LL LR

Click

Crepitus

X X X X X X X X

Click sound at right and left TMJs during chewing,

opening, closing and lateral movements

FAMILIAR PAINFAMILIAR PAIN

20/01/2014

3

Not necessary

TMD diagnosis

Condylar position and TMD risk

Occlusal interference and TMD risk

Red Flags and TMD risk

Outline

20/01/2014

4

11 cases in which disturbance of mandibular joint

function was considered the chief etiologic factor of abnormal ear and head conditions

Left

Reduction of posterior vertical dimension

Ronald H. RothSan Mateo, California

The condyles should be seated superior and anterior in thefossae against the articular disks and the distal slope of thearticular eminence, and centered transversely.

Angle Orthod. 1973

7 patients

2 controls

The centricity of the condyles in the glenoid fossa involves a range, and eccentricity does

not necessarily indicate TMD. Therefore, the analysis of articulated casts will not be

diagnostic of TMD per se.

Mounting dental casts on an articulator helps in measuring the centric relation-centricocclusion discrepancy in 3 planes of space. This is important information when the goal is

to treat to a musculoskeletal stable position.Objective: to evaluate the reliability and validity of 3 bite registrations in relation tocondylar position in the glenoid fossae using magnetic resonance imaging in a

symptom-free population.

(Am J Orthod Dentofacial Orthop 2013;144:512-7)

Centric Occlusion Centric RelationRoth Power Centric

Relation

20/01/2014

5

• The differences between the 3 bite positions were small and, more

importantly, highly variable.

• Variability in the findings between the bite registrations appear to reflect

the lack of accuracy and predictability.

• Based on the findings that we are not positioning the condyles in specific

positions in the fossae with various bite registrations, the clinicalsignificance followed by the routine practice of condylar positioning

must be questioned.

No association between condylar position

and signs and symptoms of TMD was found

OOOO, 2009

Interestingly…

normal joints

normal joints

Angle Orthod, 2010

Pu

llin

ge

rA

, JO

R 2

01

3

Great overlap

Wide distribution

Condyle position per se is not diagnostic and

would fail any useful prediction values

CONCLUSION…

Left

Deep bite / Class II 2

Mandibular dysfunction and incisor relationship. A theoretical explanation for the clicking joint. Berry DC, Waltkinson AC Br Dent J, 1978

20/01/2014

6

The extraction – non extraction dilemma as it relates to TMDRP McLaughlin, JC Bennett. Angle Orthod, 1995

Excessive anterior interferences resulting in possible posterior

condyle displacement are the result of treatment mechanics

…however

There is no evidence that asymptomatic TM

joints with posterior positioned condyles are

at risk for disc displacement derangements.

CONCLUSION

There is no evidence that centric condylar

position means “healthy” TM joint.

There is no evidence that centric condylar

position limits risk when treating patients with

TMD.

TMD diagnosis

Condylar position and TMD risk

Occlusal interference and TMD risk

Red Flags and TMD risk

Outline

20/01/2014

7

Long term mechanisticnociception is related not onlyto peripheral sensitization ofnociceptive neurons but alsoto central sensitization

Xie

et a

l, J

OR

20

13

In animal models, artificial occlusal alterations can result in disorders

or damage of TMJs, masticatory muscles, and the nervous system.

However…

Results from animal studies cannot be

directly extrapolated to humans

Xie

et a

l, J

OR

20

13

10 % MVC

Gallo LM, Palla S. J Oral Rehabil 1995; 22: 455-462

Decrease of contractionintensity

Decrease in number of activity periods

No changes in PPT

None of the subjects developed signs

and symptoms of TMD

…however sometimes

20/01/2014

8

Artificial interferences seem to play a different role in responses in subjects with an earlier TMD history

compared to those without

Differentadaptation

…why? Effects of occlusal interference in patients with muscle pain

Michelotti et al., in preparation

No differences in number of activityperiods during active interference

Different adaptation to occlusal changes 0

10

20

30

40

50

60

70

80

90

IFCbefore DIC AIC IFCafter

N/h

r

Session

CTR

TMD

0

1

2

3

4

5

6

IFCbefore DIC AIC IFCafter

Du

r (s

)

Session

CTR

TMD

0

5

10

15

20

25

IFCbefore DIC AIC IFCafter

A m

ean

(%

MV

C)

Session

CTR

TMD

**

TMD subjects showed

higher number of events with higher

intensity compared to

healthy subjects

Avignon Palais de PopesHans Christian Andersen

The Princess and the

Pea

250 subjects filled the

Oral Behavior Checklist (OBC)

10 without

parafunctions (nPAR)

10 with

parafunctions (PAR)

80%

10th 90th

(6 f,4 m; mean age ± SD

22.3±1.8)

(9 f,1 m; mean age ±SD 20.4±1.17)

Oral Behaviour Checklist

Dental prostheses

Orthodontic treatment

One or more missing teeth with the exception of third molars

Neurological disorders

Assumptions of drugs affecting the Central Nervous System.

Exclusion criteria

Markiewicz et al, 2006

Aim

Michelotti et al. JOP 2012

20/01/2014

9

- occlusal discomfort- spontaneous pain

- headache

Visual Analogue Scale (VAS)

☺ �

p<0.01

State Anxiety Trait Anxiety

Higher values of trait anxiety in Parafunctional subjects

During AIC occlusal discomfort, headacheand spontaneous pain were higher in

Parafunctional Subjects

Perceived the occlusal

interference as cause of discomfort

They did not report pain

or signs of dysfunctions

Perceived the occlusal

interference as cause of high discomfort

High trait anxiety

individualsLow trait anxiety

individuals

They reported pain or

signs of dysfunctions

Conclusion

Michelotti and Iodice, JOR 2010

Take Home Message

Occlus

alchange

yAdaptabilit

ytolerance

Physiological

tolerance

Occlusalhypovigilance

Occlusalhypervigilanc

e

Occlusalhypervigilanc

e

Somatosensoryamplification

Somatosensoryamplification

Increased parafunctiona

l activities

Increased parafunctiona

l activities

Physiological tolerance exceeded

Physiological tolerance exceeded

TMD SYMPTOMSTMD SYMPTOMS

Decreased parafunctional

activities

NORMAL

FUNCTION

NORMAL

FUNCTIONTMD diagnosis

Condylar position and TMD risk

Occlusal interference and TMD risk

Red Flags and TMD risk

Outline

20/01/2014

10

P. A. 45 ys

Main complaints

• Facial pain

• Limited jaw movement

• Headache

P. A. 45 ys

• Facial Pain from 1 years (24h/24h; 7days/7days). The tongue is

affected too. Started after the prosthodontic rehabilitation. She changed many prosthetic manufactory but the pain is always present.

• Headache (bilateral)

• Cervical and back pain

Axis I

1°°°° Myofacial Pain with referrals

2°°°° Headache attributed to TMD

3°°°° Cervical Pain

FAMILIAR PAINFAMILIAR PAIN

FAMILIAR HEADACHEFAMILIAR HEADACHE

RDC/TMD Psychological Evaluation Axis II

Graded Chronic

Pain Scale

20

20/01/2014

11

Psychological Evaluation Axis II

Depressionand non specificphysical

symptoms

Treatment protocol

1°°°° Counseling

3°°°° Prosthetic

rehabilitation

2°°°° Physiotherapy

4°°°° Psychiatric

Consultation

• Chronicity

• Functional limitation

• Discrepancy in findings

• Overuse of medication

• Inappropriate behaviour

• Inappropriate expectations

• Inappropriate responsiveness to prior treatment

• Identify red-flags from self-report screener

Flag areas that might be associated

with history taking

Recommendations on rehabilitation of TMDs

Cairns B, List T, Michelotti A, Ohrbach R, Svensson P

20/01/2014

12

Orthodontic treatment

Range of motion WNL

Surgery

Bilateral facial pain. Severe pain on both

sides in the masseter and temporal regions.

Pain increases during mandibular

movements, chewing and yawning, so that

he could eat only soft meals

Headache, bilateral, localized at temples.

Present everyday, worse in the evening.

Stress increases headache.

M.S. 25 ysTwo months later…

Main complaint

Myofascial pain

Headache attributed to TMD

1) Counseling

2) Physiotherapy3) Drugs

For 3 weeks

20/01/2014

13

M.S. 25 ys

• Preauricular pain on right

• Limited jaw movement

• Pain during jaw movement

During class II elastics • Suspend class II elastics• Distraction of the right TMJ

• Coordination exercise of the jaw opening• Home regimen physiotherapy

Symptom free Take Home Message

Michelotti and Iodice, JOR 2010

Differential

diagnosis

Patient information

and counseling

+Suspend

temporarily active orthodontic

treatment

orthodontic treatment

Patient develops TMD

signs and symptoms

during

orthodontic treatment TMJ

disease

Conservativ

e treatment

Myofascial

pain

Conservativ

e treatment

No pain

Revaluate the orthodontic

treatment plan

No pain

Continue the

orthodontic treatment