CRANIOMANDIBULAR DISORDERS

708 CRANIOMANDIBULAR DISORDERS – ANATOMY, PHYSIOLOGY, PATHOLOGY –

TREATMENT MODALITIES – LITERATURE REVIEW

CRANIOMANDIBULAR DISORDERS - ANATOMY, PHYSIOLOGY, PATHOLOGY AND

TREATMENT MODALITIES – LITERATURE REVIEW *

DESORDENS CRÂNIOMANDIBULARES -

ASPECTOS ANATÔMICOS, FISIOLÓGICOS, PATOLÓGICOS E FORMAS DE TRATAMENTO -

REVISTA DA LITERATURA

Gissa Alexandra Nuñez BALDERRAMA ** Gustavo Lopes TOLEDO ***

Clovis MARZOLA **** Daniel Luiz Gaertner ZORZETTO ****

João Lopes TOLEDO-FILHO **** Marcos Maurício CAPELARI ****

Cláudio Maldonado PASTORI **** ____________________________________________________________________ * Based on a monograph submitted to the Posgraduate Program in Oral and Maxillo Facial Surgery

and Traummatolog, São Paulo Association of Dental Surgeons (APCD) - Bauru-São Paulo state, in partial fulfillment of the requirements for a Specialist degree, 2010.

** Specialist in Oral and Maxillo Facial Surgery and TraumMatology. Author of the monograph. *** Professor of the Residency and Specialization in Buco Maxillo Facial Surgery and

Traummatology of the Brazilian Oral and Maxillo Facial Surgery and Traummatology School, Base Hospital of São Paulo, Association of Dental Surgeons (APCD)-Bauru-São Paulo State. Supervisor of the monograph.

****Professors of the Residency and Specialization in Bucco Maxillo Facial Surgery and Traummatology of the Brazilian Oral and Maxillo Facial Surgery and Traummatology School, Base Hospital of São Paulo, Association of Dental Surgeons (APCD)-Bauru-São Paulo State



ABSTRACT There are countless problems related to the temporomandibular joint known as temporomandibular joint disorders (TMD). Successful treatment of patients with TMD depends mainly on a correct diagnosis which will lead us to the best treatment plan among the many options found in the literature as physical therapy, medication, interoclusal devices and arthroscopy, eminectomy and articular devices, divided into conservative and surgical type of treatment, respectively. Thus, this work aims to describe through literature review some aspects involving the temporomandibular joint disorders most commonly diagnosed, the choice of treatment more appropriate to the type of disorder and mainly to create the ability to discern when conservative or surgical treatment are indicated.

RESUMO Inúmeros são os problemas relacionados com a Articulação Temporomandibular, as conhecidas Desordens Craniomandibulares (DCM). O sucesso do tratamento dos pacientes portadores de DCM depende, principalmente, da realização de um correto diagnóstico, que quando bem feito, nos conduz a escolha do melhor plano de tratamento dentre as inúmeras opções encontradas na literatura tais como: fisioterapia, tratamento medicamentoso, dispositivos Interoclusais e Artroscopia, Eminectomia e dispositivos articulares, divididos em conservador e cirúrgico, respectivamente. Sendo assim, este trabalho tem como objetivo uma revista da literatura para o conhecimento da anatomia, fisiologia, patologias, DCM mais comumente diagnosticadas, a escolha do melhor tratamento condizente com o tipo de desordem em particular. Sobretudo, obter a capacidade de discernir quando é necessário um tratamento conservador e um tratamento cirúrgico. Uniterms: Temporomandibular joint; Craniomandibular disorder; Mini-anchors. Unitermos: Articulação temporomandibular; Desordens Craniomandibulares; Mini-

âncora.

INTRODUCTION The temporomandibular joint (TMJ), part of the stomatognathic system, along with maxilla and mandible, nerves and glands, is one of the most important joints in the human body. Given its complexity, is subject to interference and depends on the anatomical and functional stability of the entire stomatognathic system (MACIEL; TURELL, 2003). The TMJ is a bicondyloid synovial joint, formed by the squamous portion of temporal bone and mandibular condyle. These two elements are surrounded by a bony capsule of fibrous tissue brought by a disc consisting of connective tissue. This disc is fixed to the joint capsule and in the condylar process margin. The joint cavity is divided in superior and inferior compartments (HEFFEZ; MAFEE; ROSENBERG, 1995; OKESON, 2000 and MACIEL; TURELL, 2003). Functionally, it allows the mandible to open, close, protrude, retried, and to perform lateral movements as well as the combination of all. To make this



dynamic mechanism, the condylar process performs rotation and translation on its long axis through the action of muscles and ligaments attached to bone and fibrous structures that surround it (NORMAN; BRAMLEY, 1990; SARNAT; LASKIN, 1992 and DAWSON, 1993). Among the structures responsible for movements of TMJ the articular disc is emphasized. The articular disc has a convex shape in its upper portion and concave in its lower portion dividing the joint into two functionally distinct units. The supradiscal compartment performs the movements of translation since it is more mobile and loose allowing sliding movements, on the other hand, the infradiscal performs rotational movement. It joins the head of the condylar process through collateral ligaments, sometimes called discal ligaments. The lateral discal ligament connects the lateral end to the extreme lateral side of the articular disc. The discal medial ligament connects the medial end of the disc to the medial pole of the condylar process (MANNS; DÍAZ, 1983; DAWSON, 1993 and OKESON, 2003). On many occasions the temporomandibular joint harmony is broken creating temporomandibular disorders (TMD) or Craniomandibular Disorders as well (CMD). In this context, the TMD include a number of diseases whose etiology is mostly multifactorial. Furthermore, the complex anatomy and dynamics of TMJ makes the treatment considerably challenging (GRAY, 1973; SPALTEHOLZ, 1988; GRAY, 1995 and MORAIS; OLIVEIRA; OLIVEIRA, 2001). This study was performed using references on the therapy of Craniomandibular Disorders, through a literature review, in this manner this paper aims to discuss the most important points related to TMJ such as anatomy aspects, normal dynamics of ATM and physiological aspects, craniomandibular disorders and the treatment of craniomandibular disorders.

LITERATURE REVIEW

Anatomic Considerations The TMJ, according to the literature, appears as a set of anatomical structures that aided by a group of muscles develops various movements in mastication (GRAY, 1973; SPALTEHOLZ, 1988; FIGÚN; GARINO, 1989; OLIVEIRA, 1994 and GRAY, 1995). It is classified as a complex biaxial synovial articulation, with its anatomical components such as the articular surfaces, the articular disc, the capsules, ligaments, and synovial membranes (OLIVEIRA, 1994). The joint surfaces are formed by a surface of the condyle and an articular surface of the temporal bone (Figure 1) (FIGÚN; GARINO, 1989). The bony parts of the ATM are the condyle, articular eminence and glenoid fosse of the temporal bone. The articular processes can be defined as two oval-shaped protrusions located in the posterior superior angle of the mandibular ramus, whose major axis oriented obliquely dorso-medially, measuring approximately 20 to 22 mm. They are convex on its sagittal and frontal aspects, wide on its lateral aspect, and narrow medially. His side poles are rough and often sharp, joining the ramus by a narrow, slightly bent forward portion of the neck of the mandible, which holds a depression called the pterygoid fovea where the lateral pterygoid muscle is inserted. The TMJ is surrounded by a fibrous capsule rather weak, which allows large movements of the joint. It is attached above the articular portion of the temporal bone and below the mandibular neck. This disc is quite



innervated, sensory, proprioceptive that relates to the auriculotemporal, posterior deep temporal and masseteric nerves (Figures 2 and 3) (SICHER; DU BRUL, 1991). Figure 1 - Skeletal components of the TMJ. (1) Mandibular condyle, (2) Articular Eminence of the

Temporal bone, (3) Articular disc, (4) lateral pterygoid muscle, (5) temporal muscle tendon, (6) Auditory Canal.

Source - Figure taken from site: www.fosjc.unesp.br/anatomia/atm/ATM1-1.jpg&imgrefurl=http://www.fosjc.unesp.br/anatomia/atm/ATM1.htm

Figure 2 – TMJ inervation. Source - Figure taken from the website: www.fosjc.unesp.br/anatomia/quiz-

trigemeo/mandibular01.jpg&imgrefurl



Figure 3 - Articular capsule, temporomandibular ligament, sphenomandibular ligament. Source - Figure taken from the website: http://www.fosjc.unesp.br/anatomia/atm/ATM6.jpg Its blood supply is accomplished through the superficial temporal artery branches and later branches of the maxillary artery posteriorly. Previously, the posterior temporal artery, the masseter and lateral pterygoid, contribute to its irrigation (Figures 4 and 5). Figure 4 – Maxillary artery and its branches: anterior tympanic, deep auricular and middle meningeal

artery. Source - Figure taken from the book: SOBOTTA, J. Atlas de anatomia humana. 18ª ed. Rio de

Janeiro: Ed.Guanabara Koogan, 1990.



Figure 5 - Venous supply: Pterygoid plexus, superficial temporal and maxillary. Source - Figure taken from the book: SOBOTTA, J. Atlas de anatomia humana. 18ª ed. Rio de

Janeiro: Ed.Guanabara Koogan, 1990. The articular eminence would also be defined as the articular tubercle (GRAY, 1973; SPALTEHOLZ, 1988; FIGÚN; GARINO, 1989 and GRAY, 1995), however some authors are unanimous in considering that the articular tubercle is a protrusion on the external end of the anterior root of the zygomatic process of the temporal bone and therefore not articulated, serving for insertion of the capsular ligaments. The articular eminence of the temporal is the transverse root of the zygomatic arch. Prior to the articular fossa; its anatomic deviation determines the trajectory of condylar movements (GRAY, 1973 SPALTEHOLZ, 1988; SICHER; DU BRUL, 1991; DAWSON, 1993 and GRAY, 1995). The mandibular fosse is situated below and in front of the external acoustic meatus and is limited medially by the squamo tympanic fissure and posteriorly by the temporal bone that forms the posterior border of the glenoid fossa. It is a depression of varying depth, which in ventral-dorsal direction, extends from the articular eminence until the anterior segment of the external acoustic meatus. In the transverse direction, descends from the base of the zygomatic arch to the spine of the sphenoid, but only the anterior portion is articular, while the posterior part forms the anterior wall of external auditory canal. It is noted here that as active elements in the process of the dynamics of the joint, the articular eminence and the mandible are convex in their sagittal and lateral plane. The articular surface of the temporal bone is also covered by fibrous tissue with few cartilage cells, free of vessels and nerves that make it impossible to develop inflammation and scarring. Their nutrition occurs by soaking of synovial fluids, however, dependent on the movement and in cases of restriction there may occur degeneration of this tissue. The coverage of the mandibular fossa, separating it from the middle cranial fossa, is always thin and translucent, allowing concluding that it is not a part of functional pressure, making sure that the functional pressure is between the condyle, the articular disc and



between the disc and articular eminence (GRAY, 1973 SPALTEHOLZ, 1988; FIGÚN; GARINO, 1989 and GRAY, 1995). The articular disc is a small fibrocartilaginous plate with a slightly oval and italic "S" aspect in the sagittal section, it is concave anteriorly, relating to the eminence and convex posteriorly, in contact with the mandibular fossa of the temporal bone, and directed downward and forward. The disc divides the TMJ into two parts, the central portion of the disc is devoid of vessels, and one that supports the higher pressures. The peripheral portion is covered by synovial membrane, richly vascularized (GRAY, 1973; SPALTEHOLZ, 1988; SICHER; DU BRUL, 1991 and GRAY, 1995). The disc is slightly compressible, thick across its border, large in its posterior perimeter and considerably narrower in its central portion. The intermediate or central portion of the disk is thin at around 1 to 2 mm and is located between the articular surfaces that support pressure. This portion of the disc consists of a dense fibrous tissue completely avascular and aneural and, consequently, in any type of lesion shows the character of irreversibility. The articular disc is attached to the joint capsule and to the lateral and medial poles of the condyle by strong fibrous loops. The anterior portion of the disc is connected to the anterior capsule with a projection of the disc itself, which does not happen posteriorly, where there is an extension of soft cushioning with two separate layers of fibers, placing it among the structure of blood vessels and nerves. Its saddle shape in its upper portion is to adjust to the cranial contour and its concavity in the bottom, to accommodate with the articular process of mandible (Figure 6) (OLIVEIRA, 1994). Figure 6 - (1) Articular disc (2) articular eminence, (3) Supradiscal compartment, (4) Condile, (5)

Articular Cartilage, (6) Infradiscal compartment; (7) Articular Capsule; (8) Retrodiscal cushion; (9) External acoustic meatus; (10) lateral pterygoid muscle, (11) temporal muscle tendon.

Source - Figure taken from website: www.fosjc.unsp.br/anatomia/atm/ATM2.htm



In an important study which intended to emphasize the action of the lateral pterygoid muscle during the dynamics of TMJ via 22 human cadavers concluded that: 1. The upper and medial fibers of the superior lateral pterygoid muscle is inserted in the medial portion of the articular disc.

2. Approximately 29.5% of the fibers of the superior portion of the muscle were inserted into the articular disc.

3. The portion of fibers that are inserted in the disc can be interpreted as a tendon insertion in the articular disc and,

4. The proportion of muscle fibers embedded in the articular disc and articular process are not influenced by age (NAIDOO; JUNIPER 1997). Subsequently, the disk interface with the capsule is made by a spongy pad called retrodiscal cushion that curves inferiorly and laterally from the head of the mandible. The two posterior layer bands are called bilaminar zone (GRAY, 1973; SPALTEHOLZ, 1988; SICHER; DU BRUL, 1991 and GRAY, 1995). The superior attaches to the post-glenoid process and is secured by elastic fibers that have a retractable effect to the disc, its medial portion is the true posterior limit of the joint. The bottom blade curves downward to the side of the condyle merging into the capsule at the inferior articular joint space in the mandibular neck. Its function is to supply the anatomical deficiency between the joint surfaces of the condyle and articular eminence of the temporal bone, which are convex, interposing between them as a "cushion" of relative elasticity. Laterally, the disc fuses with the deep fibers of the masseter muscle (GRAY, 1973; SPALTEHOLZ, 1988; FIGÚN; GARINO, 1989 and GRAY, 1995). The articular capsule or ligament is a thin fibrous membrane that surrounds the joint and unites its parts. It consists of connective tissue, rich in collagen fibers which do not stretch. It is represented by two layers, a fibrous loose and tough membrane that is external and a synovial membrane that forms the inner layer of the capsule. The deepest is inserted within the limit of the articular disc, determining the existence of the supra and infradiscal articulations. Their upper limit in the temporal bone are on the anterior portion of the articular tubercle anteriorly, in the squamous tympanic suture posteriorly, laterally in the articular tubercle and zygomatic arch and medially at the base of the spine of the sphenoid. Their lower limits are narrower, being limited to the condyle, standing in the contour of the articular surface except for the posterior part, where the insertion is approximately 5 mm below the fibrocartilage coverage, reaching the neck of the mandible. Thus, the back of the neck is included in the joint (GRAY, 1973; SPALTEHOLZ, 1988; FIGÚN; GARINO, 1989 and GRAY, 1995). Due to the characteristics of the joint capsule, a considerable range of motion and even dislocation of the condyle without its rupture is allowed. The posterior portion of the joint, the retrodiscal, is richly innervated and vascularized, and of undoubted importance in the pathogenesis of craniomandibular disorders (FIGÚN; GARINO, 1989). The lateral ligament can be considered as the one truly functional in the TMJ (GRAY, 1973; SPALTEHOLZ, 1988; SICHER; DU BRUL, 1991; DAWSON, 1993 and GRAY, 1995). This function of limiting movement or medial displacement of the condyle is made by a bony prominence belonging to the temporal bone, in the medial



wall of the articular cavity of the temporal glenoid fossa. Although it is believed that this ligament limits the retrusive movements of the mandible, protecting the tissues of the posterior region of the ATM (DAWSON, 1993). The medial ligament is described as small in volume and of dubious or questionable function, lifting off the base of the spine of the sphenoid bone and descending obliquely backward and outward, inserting in the posterior medial part of the neck of the mandible, 10 to 15 mm below the articular line (GRAY, 1973; SPALTEHOLZ, 1988; FIGÚN; GARINO, 1989 and GRAY, 1995). The combination of ligaments works as a valuable protection considering that the effects of trauma which should be directed to the articular structure against the tympanic plate or on the roof of the middle cranial fossa reaches initially the anterior portion of the mandible producing fractures in the symphysis and / or in the mandibular angle (DAWSON, 1993). The posterior ligament is represented by elastic fibers that connect the squamous tympanic fissure to the neck of the condyle and the posterior edge of the disc. It is responsible for limiting the excursion of the mandibular condyle and disc in the protrusion of the mandible (GRAY, 1973; SPALTEHOLZ, 1988; FIGÚN; GARINO, 1989 and GRAY, 1995). In addition to the described ligaments there are accessory ligaments (DAWSON, 1993). Described as a group of fibrous elements in an apparent anatomical and functional relation to the structures of the TMJ (GRAY, 1973; SPALTEHOLZ, 1988; FIGÚN; GARINO, 1989 and GRAY, 1995). These ligaments would be the sphenomandibular the estilomandibular and the pterigomandibular. The temporomandibular ligament has its fibers oriented in such a way that during movements of the articulation these fibers are not distended or relaxed indicating that the TMJ ligaments do not restrict the funcitonal movement of the jaw and are not necessary for the functioning of the joint. Although it is believed that this ligament limits the retrusive movements of the mandible, protecting the tissues of the posterior region of the TMJ (SICHER; DU BRUL, 1991 and DAWSON, 1993). Sphenomandibular ligament is a remnant of Meckel's cartilage. Rises from the angular spine of the sphenoid bone and petrotympanic fissure and then run backwards and externally to insert in the mandibular lingula. This ligament is passive during jaw movement, keeping on the same stress intensity during the opening and closing of the mouth (GRAY, 1973; SPALTEHOLZ, 1988; SICHER; DU BRUL, 1991; DAWSON, 1993 and GRAY, 1995). The stylomandibular ligament is a dense concentration located in the cervical fascia, extending from the styloid process to the mandibular angle, covering the outer surface of the styloid process, inserting to the bone connecting in the posterior surface of the mandibular angle, spreading anteriorly as a broad fascial layer covering the inner surface of the medial pterygoid muscle (SICHER; DU BRUL, 1991 and DAWSON, 1993). The stylomandibular ligament is loose when the jaws are closed or when the mandible is at rest and relax remarkably when the mouth is open, because the angle of the mandible swings up and back, while the condyle slides down and forward (Figure 7) (SICHER; DU BRUL, 1991 and DAWSON, 1993).



Figure 7 - (1) Esfenomandibular ligament (2) Temporomandibular ligament; (3) Articular capsule; (4)

Styloid apophysis (5) Estilomandibular ligament. Source: Figure taken from website www.auladeanatomia.com/artrologia/atm.htm The synovial membranes create internally the articular supradiscal and infradiscal spaces. The supradiscal is a cylinder limited superiorly by the insertion of the articular capsule in the temporal bone and inferiorly implants into the upper surface of the articular disc. The infradiscal extends from the edge of the articular disc to the mandibular neck. In case of perforation of the articular disc, there is a communication between these two cavities. It is abundant in the vascularized and innervated portions of the upper and lower surfaces of the retrodiscal area. The supradiscal space is bulkier than the infradiscal, both joint compartments are irrigated by the synovial fluid, which is responsible for alleviating the friction of joint surfaces (GRAY, 1973; FIGÚN; GARINO, 1989 and GRAY, 1995). The TMJ receives vascularization from the posterior temporal and masseteric deep arteries. The middle and posterior surfaces of TMJ are irrigated by branches of the maxillary artery, anterior tympanic artery, and middle meningeal. The posterior and lateral sides of the joint are irrigated by branches of the superficial temporal artery. The veins that drain the joint arising into the pterygoid plexus, superficial temporal and maxillary arteries correspond to the arteries that irrigate it (GRAY, 1973; SPALTEHOLZ, 1988; FIGÚN; GARINO, 1989 and GRAY, 1995). Regarding the innervation was observed that the anterior portion of the TMJ is innervated by the anterior branch of the mandibular nerve (branch of the trigeminal nerve) and branches of the masseteric nerve. The posterior portion of the TMJ is innervated by branches of the auriculotemporal nerve from the posterior division of the mandibular branch of trigeminal nerve (GRAY, 1973; SPALTEHOLZ, 1988; FIGÚN; GARINO, 1989 and GRAY, 1995).

TMJ DYNAMICS Functionally, the TMJ allows the mandible to be able to make opening and closing movements including protrusion, retrusion and lateral movements as well



as the combination of all. To make this dynamic, the condylar process performs rotation and translation due to the presence of muscle, bone and fibrous structures. The major muscles involved in this condition are the temporal muscles, which guide the condyles superiorly in the fossa, the masseter and medial pterygoid, the lateral inferior pterygoid muscles in an anterior and superior position guiding the condiles horizontally on the posterior wall of articular eminence (SARNAT; LASKIN, 1992 and MACIEL, 1996). It is known that the mandible is the only mobile bone of the face being attached to the skull base through a double joint bilaterally. The TMJ appears as the most complex articulation of the body capable of performing sophisticated movements. The articulation assist in several vital processes such as chewing, swallowing, speech and posture and it is protected by the articular disc and ligaments formed from collagen fibers (CABEZAS, 1997). According to the literature the presence of ligaments causes restriction of certain functional movements as rotation and translation, within acceptable limits for proper function and integrity of the joint capsule, ligaments and muscles (MOLINA, 1995). Some pathological changes observed in the TMJ result from functional overload to the ligaments since they do not have great capacity for dimensional changes. The inferior joint is composed of condyle and articular disc inserted by ligaments that form the disc-condyle complex where the rotation occurs. The upper joint is formed by the disc-condyle complex that articulates with the mandibular fossa, where the translation occurs (OKESON 1991). Temporal, masseter, medial pterygoid and lateral mandibular muscles are essencial in mandibular masticatory movement as others, as mentioned (Figure 8) (DOUGLAS 1988). Figure 8 – Muscles responsible for movement of the joint. Source - Figure extracted from website: http://www.miologia.hpg.com.br/atm2.jpg The temporal muscle is well known to elevate the jaw when its anterior fibers contract in maximum aperture and subsequent retraction of the mandible by the posterior fibers and acts in the contralateral displacement and elevation of the mandible. Its dorsal fibers contract at translation with occlusion and



the ventral fibers contract at rotation with occlusion. This muscle is crucial in determining muscle tone in the postural position of mandible. The masseter muscle helps not only in the mandibular anterior projection but also in lateral movements bilaterally. The medial pterygoid muscle, as well as masseter muscle lifts the jaw acting in protrusion and lateral movements (SARNAT; LASKIN, 1992). Another important group is that of the depressor muscles which have the basic function of opening the mouth and also execute other secondary functions. This group is divided into lateral pterygoid and digastrics muscles, and also the mylohyoid and geniohyoid muscles. The lateral pterygoid muscle is responsible for the opening of the mouth, anterior projection and movements of laterality, with unilateral contraction and contralateral loosening. The digastric muscle, a suprahyoid muscle, is primarily a depressor, like all the suprahyoid muscles. It is important to emphasize that mouth opening starts with the lateral pterygoid and followed by the digastrics muscle. The other muscles responsible for mouth opening are the following. The geniohyoid muscle which is also suprahyoid and mandible depressor. When the mouth is closed it pulls the hyoid upward, lowering the floor of the mouth and making swallowing easier. It is also responsible for retruding the mandible as the digastrics (Figure 9) (SICHER; DU BRUL, 1991; SARNAT; LASKIN, 1992 and MACIEL, 1996). Figure 9 – Digastric Muscle. Source - Figure extracted from website: www.fotosearch.com More than a suprahyoid muscle, the mylohyoid depresses the jaw when hyoid bone is fixed, otherwise it helps swallowing pulling the hyoid bone up, as does the geniohyoid (Figure 10) (SICHER; DU BRUL, 1991; SARNAT; LASKIN, 1992 and MACIEL, 1996). According to this becomes clear the action of the mandibular elevator muscles which assisted by ligaments induce the mandibular condyle to articulate with the glenoid fosse and maintain its movement. Despite the pressure between the condyle, disc and glenoid fosse comply with the activity of the elevator muscles some pressure is always maintained to prevent separation of joint surfaces. If the contact between them is lost, displacement may occur.



Figure 10 – Suprahyoid muscles. Source - Figure extracted from the website of Anatomy:

www.transtornostemporomandibulares.blogspost.com/20.htm During mouth opening, the articular disc spins posteriorly near the mandibular condyle, while the disc-condyle complex moves forward and down, close to the articular eminence. The posterior ligament tension during half opening of the mouth helps to bring back the disc rotating around the condyle (SOLBERG 1989). Anteriorly to disc-condyle complex is the lateral pterygoid muscle with its upper and lower fibers. It is believed that the lower portion of the pterygoid is activated along with the depressor muscles of the mandible during mouth opening (CABEZAS 1997). During the full mouth opening, slide of the disk is nullified by the stretching limit of the muscle, by resistance of the capsule and the lack of articular surface available. The exaggerated movement of mandible opening beyond this point causes subluxation, as the irregular, spasmodic movement of the disc-condyle complex on the non articular surfaces. When the mouth is opened completely, the soft tissue is sucked into the posterior lateral sides of the joint (BARROS; RODE 1995). Mouth opening or mandibular depression is performed by bilateral contraction of both lateral pterygoid muscles, with the assistance of the digastric anterior and milohyoid. At the same time, in each TMJ, the disc-condyle complex is moved down the articular eminence, leading to a stretch of the superior retrodiscal compartment, resulting in posterior movement of the articular disc in the mandibular head or condyle (GRAY, 1973; SPALTEHOLZ, 1988; SICHER; DU BRUL, 1991; SARNAT; LASKIN, 1992; GRAY, 1995 and MACIEL, 1996). In the first phase of opening there is a small movement of the condyle, which rotating around its axis determines the rotational movement. In the opening sequence, the entire disc-condyle structure slides along the posterior wall of articular eminence, characterizing the movement of translation. It is reported that during closure of the mouth, the basic contraction function of the superior lateral pterygoid muscle appears to be to coordinate the return of the articular disc smoothly to its resting position (MACIEL 1996).



During closure the joint receives the maximum tension. At this point, sudden disruptive forces are created on the condyle, by the resistance of the bolus. The activity in the upper fibers of the lateral pterygoid muscle along with the mandible elevator muscles produces an anterior component of strain on the disc and causes it to move forward. The author claims that during closing, the disc acts as a wedge in motion to ensure full contact between the components of articulation for maximum function (SOLBERG 1989). During the opening and closing of the mandible, disc and condyle move together which is not determined by insertion of the ligaments, but for two main reasons: morphology of the disc and intra-articular pressure. The protrusion is achieved by simultaneous contraction of the bilateral inferior branches of the lateral pterygoid muscle. The retrusion of the mandible is accomplished by the middle portion of the middle temporal muscle and suprahyoid, perhaps with some assistance from the deep portion of the masseter and posterior branch of the temporal muscle (SICHER; DU BRUL, 1991). The movement of the mandible to the left or right side involves the contraction of the lower lateral pterygoid muscle on the opposite side, aided by the posterior and middle fibers of the temporalis muscle on the same side. For example, the movement of the jaw to the left involves the contraction of the right inferior lateral pterygoid muscle, assisted by the middle and posterior fibers of the temporalis muscle on the left. As this movement is accomplished, the disc-condyle complex is rotated on the left and relocated on the right side of the TMJ. Usually, the lateral excursion is formed in combination with protrusive excursion, producing a anterolateral dislocation of the mandible (SICHER; DU BRUL, 1991; SARNAT; LASKIN, 1992 and MACIEL, 1996). The morphology of the disc and intra-articular pressure always present ensure maintenance of the condyle in the intermediate thinner disc zone. If there is any change in morphology of the disc or a change in intra-articular pressure, the dynamic condyle-disc can be changed and, indeed, is the beginning of disc disorder interference (CABEZAS 1997). To understand the biomechanics of the joint, rotational movement between the disc and head of the mandible or condyle and translation between the upper surface of the disc and articular eminence should be carefully studied, especially its relation to dental occlusion. Because the mandible is unable to achieve full opening through only a hinge-like movement, a combination of both, rotation and sliding motion, come to characterize most of the mandibular movements (DOUGLAS, 1988; OKESON, 1991). During movement, the stability of the TMJ is provided by anterior and posterior rotation of the disc which keeps its intermediate zone between the articular process of the mandible and the temporal articular eminence. The superior retrodiscal zone rotates the disc posteriorly and the superior lateral pterygoid muscle moves the disc in an anterior direction (DOUGLAS, 1988). The translation cycle starts from the rest position, consisting of an earlier stage, in which the disc-condyle complex moves down and forward along the eminence and a return phase in which it moves up and returns to its resting position. In this position, the thin intermediate zone of the disc is maintained between the articular process of the mandible and the temporal articular eminence. The upper retrodiscal structure is relaxed at rest position, but as the disc-condyle complex



moves forward towards the articular eminence, it becomes active, then retracting the disc posteriorly to the head or condyle. This action prevents the disc from being displaced anteriorly during the full opening of the mouth. During the previous phase, the superior lateral pterygoid muscle is inactive. In the return phase, the upper retrodiscal blade becomes inactive and the superior lateral pterygoid muscle contracts to spin the disc above the condyle. With their integration into the neck of the articular process of the mandible, the superior lateral pterygoid muscle also exerts some control over the movement of the disc-condyle complex at the return stage (GRAY, 1973; SPALTEHOLZ, 1988; OKESON, 1991 and GRAY, 1995). The articular surfaces of the synovial joint require continuous contact at all times to maintain stability. Since the TMJ articular surfaces are not directly connected, this contact is achieved by muscular action. In the rest position, joint stability is achieved by the muscle tone in the elevator muscles. During translation, interposed between the posterior temporal and inferior portion of the lateral pterygoid the disc-condyle complex and the temporal articular eminence remain in firm contact. Occlusion of the teeth provides the necessary stability in maximum intercuspal position. The temporomandibular ligament does not contribute actively to stabilize the joint, serving rather passively to limit the posterior and inferior condylar displacement (GRAY, 1973; SPALTEHOLZ, 1988; OKESON, 1991 and GRAY, 1995). Perhaps the most important element in maintaining stability of the joint is the position of the articular disc in relation to the articular process of the mandible. This position depends in the contour of the central zone of the disc, as well as in the antero-posterior motion of the disc. Another important factor is the intra-articular pressure between the condyle and eminence. When teeth are occluded, this pressure is increased, the disk space is reduced and the lower portion of the disc thickness twists between the condyle and eminence. At rest, the opposite occurs; intra-articular pressure is insignificant, the disk space is wide and the slightly thicker portion of the disc spins to occupy or fill the space between the condyle and eminence. The intra-articular pressure can be divided into two types, active and passive. The passive intra-articular pressure is the result of contraction of skeletal muscles during function and is due to muscle tone that can be modified by gravity, is also influenced by emotional stress, fatigue, illness and age (OKESON, 1991). No discussion involving the biomechanics of the TMJ could be complete without addressing the role of occlusion. Since most of the mandibular movement does not involve dental contact, occlusion does not appear to directly influence the function of the joint. The closure also does not play an important role when the jaw is at rest because the teeth are not in touch, heads or condyles are stabilized by muscle tone. Only when the teeth are tightly occluded, the relationship between the teeth of the maxilla and mandible in fact occurs. The optimal stable musculoskeletal joint position can be defined as "one in which the head or condyles are in their most superior and anterior position in the glenoid fossa, lying along the slope or posterior inclination of articular eminence, with the articular disc properly superposed". This is the best alignment to prevent injury to the articular structures, when forces of great intensity are applied, this position is similar to the currently most accepted definitions for centric relation (OKESON, 1998).



CRANIOMANDIBULAR DISORDERS The temporomandibular joint (TMJ), ranked as the most complex of the human body can be affected by the same diseases and disorders that affect other joints of the musculoskeletal system, such as disc displacement, degenerative joint disease (osteoarthritis), inflammatory arthritis and synovitis (WOLFE; SMYTHE; YUNUS et al., 1990; MACIEL; WESTESSON; TURELL et al., 2003 e LASKIN; GREENE; HYLANDER, 2006). For the appropriate function of the temporomandibular joint, the very temporomandibular joint, dental occlusion and neuromuscular balance must relate harmoniously, but it does not always happen. During life, the individual can not always maintain its stable stomatognathic system, being often submitted to dental treatments, deficient anatomical restorations, unsatisfactory prosthetic devices, untimely dental extractions, among others, causing occlusal maladjustments, producing, consequently, damage to the entire masticatory apparatus (JUNQUEIRA, 1990). The etiology of TMD is multifactorial, has no single cause, where various aspects such as: changes in occlusion (tooth loss, tooth wear, loose or ill-fitting dentures, caries, inappropriate restorations among others); traumatic or degenerative alterations of the TMJ; skeletal problems ; psychological factors (cause tension and increase muscle activity, generate spasm and fatigue) and deleterious habits (nail biting, hand in support of mandible, inadequate posture of mandible, smoking, biting objects, thumb sucking or pacifier, bruxism and others ) can be harmful and lead to imbalance and disharmony of the TMJ and the entire stomatognathic system. The temporomandibular disorders (TMD) was suggested (BELL, 1982) and gained wide acceptance and popularity. The term includes not only problems related to the temporomandibular joint (TMJ), but also includes the functional disturbances of the masticatory system (OKESON, 1997). Since the symptoms are not always restricted to the temporomandibular joint, some authors believe that a more collective term should be used, then going to the term Craniomandibular Disorders (PAIVA; VIEIRA; COSTA et al., 1993). Population studies have reported that about 70% of the population has one or more symptoms of temporomandibular and muscular disorders. Although most patients are women (5:1) when compared to men, the rate of symptoms in both is only slightly different. Most patients seeking treatment are women between 20 and 40 years old (ASH; RAMFJOR; SCHMIDSEDER 1998). Similarly to terminology and etiology, classification of temporomandibular disorders has also been very diverse. Based on the literature, the classification that seems to be most accepted is that proposed (BELL, 1990 e LASKIN; GREENE; HYLANDER, 2006), which divides temporomandibular disorders in: A - Acute muscle disorders (muscle spasm, myositis). B – Disc-condyle complex disorders. C - Inflammatory disorders of TMJ. D - Changes in mandibular mobility. E - Changes in growth and development. The main signs and / or symptoms of TMD are pain in the masticatory muscles or temporomandibular joint or in surrounding areas. The pain is spontaneous or during chewing. There are also noises, limitation of opening,



uncoordinated movements, marked mandibular dental abrasions or frequent fractures of teeth and / or restorations (TAKAHASHI; ARAÚJO 1995). Other authors argue that the main symptoms are pain in the preauricular area, temporal, pterygoid and masseter muscles sensitivity, popping in the temporomandibular joint, eccentric movement limitations of mandible, sensitivity to all cervical muscles and stomatognathic system (RHODEN; NICOLINI; SORDI et al., 1992). The most common initial symptom is localized pain in the masticatory muscles or TMJ region, often exacerbated during chewing or during mandible movements (SOVIEIRO; ABREU; CASTRO et al., 1997). Other symptoms include earaches, headaches and pain in the face as well as difficulty in swallowing, deviation of the mandible during opening, modification in dental occlusion, small cracks to open and close the mouth, sensation of locking of the jaw, pain in joint, face , shoulders and neck, asymmetry of the mandible, facial asymmetry, micrognathia and macrognathia. Noises in the joint and limitations in mandibular movements represent the clinical signs most frequently observed. Other signs include tightness of the masticatory muscles and jaw locking or dislocation (AGUIAR, 1988).

EVALUATION OF CLINICAL SYMPTOMS

There are several diseases which can settle in the TMJ, although not presenting defined etiology, it is believed that functional, structural and psychological factors aspects are combined, featuring the multifactorial origin of this dysfunction (SOVIEIRO; ABREU; CASTRO et al., 1997). The authors classified it as (VALMASEDA; ESCOBA 2002): 1. Masticatory muscle disorders: The disorders related to masticatory muscles are most often found on temporomandibular disorders, some related to noxious stimuli that when disappear, cease the related painful symptoms, although there are others who tend to follow a chronic course for which treatment can be very complex (STEGENGA, SCHOUTEN, 2007). 2. Protective muscle contraction: In some situations, the muscle tone increases in response to central nervous system in defense of certain sensory stimuli such as bruxism, constant emotional tension, intubation, and others (OKESON, 1999). The stimulus may be temporary or may cease with time simply displaying the etiologic agent and limiting jaw movements (VALMASEDA; GAY ESCODA, 2002). 3. Muscle spasm: It is a tonic prolonged contraction induced by central nervous system. Does not fit as an inflammatory disorder caused by prolonged muscle contraction or myofascial pain, as a central excitatory effect produced by a painful stimulus, or an extrapyramidal effect originated from the use of phenothiazine. The contraction may cause a malocclusion and limitation of mandible movement. The restriction is extracapsular, there is a spasm of the elevator muscles although the lateral movements may be perfectly normal, data of extreme importance in the final diagnosis of a craniomandibular disorder (RAMFJORD, 1984).



4. Myofascial pain: It is a prolonged painful disorder, characterized by areas of hypersensitivity presenting muscular trigger points on which increased pain appears when stimulation occurs. Some people associate it with the emotional stress, systemic changes and deleterious postural habits. There is a slight deficit of mandibular movements as well as in their velocity. This condition is defined by the American College of Rheumatology as a muscular-skeletal disorder in which there is widespread pain in more than 3 months at many points (18 or more) in 3 or 4 body quadrants being one of the muscle-related disorders most commonly found in the TMJ. Diagnosis is difficult since it must first rule out all possible organic causes. Transcranial, transpharingeal or panoramic radiographs, computed tomography and magnetic resonance imaging to determine the position of the intra-articular disc can help in diagnosis (WOLFE; SMYTHE; YUNUS et al., 1990; DAWSON, 1993 e BROWNE; EDMONDSON; ROUT, 1995). Laboratory tests may also be useful to exclude systemic diseases such as, for example, rheumatoid arthritis. 5. Myositis: It is a muscle inflammation due to local injury either by trauma, infection or excessive physical activity. It is characterized by signs of inflammation with pain at rest that increases as there is movement. It usually affects the elevator muscles of the mandible producing limited mouth opening with lateral and protrusion movement preserved (WOLFE; SMYTHE; YUNUS et al., 1990 and OKESON, 1992). 6. Disorders caused by interference of the articular disc: Due to an overload in TMJ there is a decrease in joint space leading to a collapse of the disc in relation to the articular space. The causes of adhesions are dental clenching, bruxism, chewing hard foods. This fact is common in people with a habit of nocturnal bruxism which is likely to be observed as a clear limitation of the mouth opening resulting in a click sound in the joint when trying to open the mouth. Disc displacements are caused by ligamentous disruption between the intra-articular disc and condyle with consequent displacement of the lateral pterygoid muscle with reduction in which the disc is moved anteriorly and medially or laterally from its position, with reduction in total openness, often resulting in a noise and without reduction and with limited opening, in which the disc is displaced from its normal position to a position anterior and medial or lateral, with limited mandibular opening (OKESON, 1997 and GARCIA; MADEIRA; PAIVA et al., 2008).

DEVELOPMENTAL, TRAUMATIC AND CONGENITAL ANOMALIES

Condylar agenesis

In condylar agenesis concomitant problems may be present in other parts of the mandible, middle and inner ear, temporal bone, parotid gland, masticatory muscles and facial nerve. One way to diagnose this condition is by means of a radiographic examination of the mandible (condyles projection) and TMJ showing the level of involvement of associated bones. Treatment is often early surgical / orthodontic settling the normal height of the mandible and restoration of growth alteration (CABEZAS, 1997).



Condylar hypoplasia The condylar hypoplasia may be in the majority of cases of infectious origin or also congenital, or caused by trauma or irradiation during growth. One consequence of this anomaly is the facial deformity as a result of the reduction of the mandibular body deviating towards the affected side and enlargement of the contralateral side. The diagnosis is made by anamnesis, physical and radiographic evaluation. The surgical treatment is based on lengthening of the hypoplastic portion or shortening of the normal side in the adult, followed by orthodontic treatment, to establish a normal occlusion (CABEZAS, 1997).

Traumatic injuries The articular fosse is rarely affected by condylar trauma due to the absortion of the impact by the articular disc, the condylar head is angled forward over the neck of the mandibular ramus, the neck of the condyle, being much thinner than the ramus or the condyle tends to fracture first, thus protecting the thin roof and the middle cranial fosse. The most common signs and symptoms observed are pre-auricular pain, trismus, deviation of the mandible on the affected side, and usually anterior open bite. The diagnosis is based on physical and radiological findings. The treatment consisted of maxillomandibular fixation and sometimes open reduction (BARROS; RODE 1995 and CABEZAS, 1997).

Luxation Obvious feature here is the inability to close the mouth. Three forms can be defined: 1. Simple acute episode. 2. Chronic recurrent dislocation. 3. Permanent chronic dislocation. The first requires manual reduction under local anesthesia and sedation or general anesthesia. Chronic recurrent dislocation and chronic permanent dislocation require surgical treatment (BARROS; RODE 1995 and CABEZAS, 1997).

Ankylosis The most common etiologic factor in TMJ ankylosis is possibly trauma and / or rheumatoid arthritis, possibly congenital abnormalities, infections and cancers, and the two most frequent types of joint involvement found are the involvement of the joint alone or involving extra-articular structures. An important factor in diagnosis is the condylar deformity, followed by narrowing and irregularity of the intra-articular space or obliteration of the normal morphology of the bone. Surgical treatment is mandatory (BARROS; RODE 1995 and CABEZAS, 1997).

Arthritis Among the malignancies most commonly found in association with TMJ arthritis is largely found due to some major origins such as: 1. Traumatic: causes increase in intra-articular space or bleeding. In the case of children, parents should be counseled about the possible delay of mandibular growth. Treatment is



symptomatic with restricted mobility of TMJ. 2. Infections: these are rare in the TMJ. May be associated with systemic infections such as syphilis, gonorrhea or tuberculosis, derived from local infection or through hematogenic route. It is characterized by signs of inflammation and trismus. Treatment is with antibiotics and anti-inflammatories, surgical drainage may eventually be required. 3. Rheumatoid arthritis: it might not always be the first symptom. Clinically is represented by bilateral pain, stiffness and joint swelling and limitation of movement. Treatment is with NSAIDs, corticosteroids and eventually hydroxychloroquine and penicilamide. Surgery may be necessary in the presence of ankylosis (RINTALA; METSARANTA; SAAMANEN, 1997 and WOLFORD; PITTA; MEHRA, 2001).

Neoplasias Chondromas, osteomas and osteochondromas are quite unusual but might be found. The rarest benign tumors are: myxoma, fibrous dysplasia, giant cell granuloma, sinovialoma, chondroblastoma, osteoblastoma and synovial hemangioma. Malignant tumors are even more unusual fibrosarcoma, chondrosarcoma and multiple myeloma. There may be invasion of TMJ by the cheek or parotid tumors. Signs and symptoms are pain, limited movement of the mandible and difficulty of dental occlusion. The x-ray shows bone destruction with images of apposition and resorption. Surgical treatment is indicated (CZLUSNIAK; FERES, 1993).

TREATMENT OF CRANIOMANDIBULAR DISORDERS

The treatment of TMD requires a thorough knowledge of the etiology of the problem. Structural, functional and psychological aspects seem to be related, determining a multifactorial origin. In order to promote a correct treatment plan a proper diagnosis is required. It is vital to understand that patients respond differently to different therapies, and the practitioner must adequate the treatment to the patient, to obtain the best possible results. There are actually several types of treatment for TMD, as they have a variety of symptoms and have a multifactorial etiology. The treatment modalities include: patient education and self-care, behavior modification (including relaxation techniques), medications, physical therapy, occlusal stabilizing plates, occlusal therapy (orthodontics, oral rehabilitation) and surgery (FAVERO, 1999; STECHMAN NETO et al. 2001 e LASKIN; GREENE; HYLANDER, 2006). 1. Occlusal splints: The occlusal splints have gained noticeable importance in the treatment of TMD explained by the low-cost treatment and the achievement of a high success rate. The occlusal splint stabilizer also called conventional occlusal splint or Michigan is the most widely used because it causes less risk of irreversible occlusal changes: as anterior open-bite, pathologic extrusions and tooth migration (PORTERO; KERN; KUSMA et al., 2009). The use of occlusal splints is an effective therapy for various types of structural disturbances of the masticatory system (RAMJORD; ASH 1984). The splints are made of rigid or resilient



materials, the resilient splints can reduce the symptoms of TMD, but the hard acrylic reduce symptoms more quickly and better, so the resilient splints are mainly indicated for protection against injuries to the teeth (OKESON 2000). It is important to observe that occlusal splints or so-called miorrelaxant splints have an important role in the treatment of TMD, but they are not the only treatment option and should never be considered that way, but as part of or even as an adjunct to other therapies as medication or physical therapy and it is necessary that the etiology of the disorder be well established. 2. Physical therapy: The main goal here is to guide the patient, eliminate pain and inflammation, restore muscle tone, relax muscles in hyperactivity and working those into disuse, cryotherapy, electrotherapy, exercise and postural reeducation. Each one provides physiological effects that will assist in reducing pain, muscle strengthening, and postural reeducation (FÁVERO, 1999). The TMJ disorders are basically composed of musculoskeletal, orthopedic and neurological nature (KURODA; TANIMOTO; IZAWA et al., 2009). Injection of local anesthetic in trigger points and physiotherapy treatment modalities are used recently, in these types of disorders. This is because these approaches have a long history of success in treating problems similar to those of TMJ, in different parts of the body (FARELLA; MICHELOTTI; GARGANO et al., 2000 and MURAYAMA; STUGINSKI-BARBOSA; MORAES, 2009). A variety of techniques is responsible for the physical treatment among these are thermotherapy and the use of ultrasound. Thermotherapy the heat causes an impaired vasodilatation in tissues and leads to reduction of symptoms. The cooling therapy promotes relaxation of the contracted muscle and so relieving the associated pain (OKESON, 2000). The ultrasound produces a temperature increase in the tissue interface and affects the tissue more deeply than hot surfaces, increases blood flow in deep tissues and improves flexibility and extensibility of connective tissues. Between the physiological and therapeutic effects: increased metabolism, increased blood supply, effects on muscle tissue, effects on inflammatory process, and decrease pain (BASSANTA, 1997). The use of laser as a physical therapy resource in the treatment of TMJ dysfunction is being increasingly used, due to several advantages, as well as acting as a healing factor and supporting tissue reorganization, it is a resource that produces rapid response to treatment, being easy to handle, and can be used both in acute and chronic pain, even in the absence of medication, it also promotes analgesy (LASKIN, 2007). The cold laser speeds up the synthesis of collagen, increases vascular tissue, decreases the number of microorganisms and decreases pain (OKESON, 2000). The therapeutic effects are: analgesic, anti-inflammatory, anti-edematous effect and healing effect, the first step of treatment is to relieve pain, the effect being sought by the therapist (FAVERO, 1999). After a literature review, authors have concluded that the recommended treatments for craniomandibular disorders are the use of drugs, physical therapy procedures, muscle relaxation, in addition to the correction of dental occlusion, using or not splints.



As medication NSAIDs can be prescrit and is generally the most suitable for the treatment of TMJ internal derangement and myofascial pain, and sometimes administered with benzodiazepine (DONALDSON; KROENING, 1979; FAVERO, 1999 e PORTERO; KERN; KUSMA et al., 2009). 3. Speech therapy: After physical therapy it is important to adequate the muscle tone and mobility in order to relieve muscle pain, especially during inactivity, and also during function (FÁVERO, 1999 e SZUMINSKI, 1999). Speech therapy consists in advising the patient on what he can or can not do in certain phases of the proposed therapy, thermotherapy to enable changes in oxygenation and muscle relaxation, massage therapy and functional myotherapy. This therapy is assisted by heat especially in chronic cases where there is increased muscle tension. Its effect is relaxing and analgesic however to the same authors, the application of heat is contraindicated in acute cases, the occurrence of inflammatory processes, as well as in cases of neurological alterations, and cryotherapy is indicated in cases of joint limitations, spasms relaxation and acute pain processes. Exercises are essential to the maintenance of muscle function without pain and producing muscle relief, with the principle of breath and is directly related to the proprioceptive activity. The ultimate goal of the myofunctional therapy is the adequacy of the stomatognathic function and relieve pain by better blood supply afforded by the workouts (ANELLI; QUINTO; SANTOS, 1997; BIANCHINI, 1998 e SZUMINSKI, 1999). 4. Pharmacological therapy: The primary goal of pharmacological therapy is to control pain but without eliminating it. Among the palliative drugs used to control pain and anxiety caused by it are the anxiolytics that produce an calming and mild muscle relaxation effect. For the TMD, the drugs should be prescribed at regular intervals for a specific period, and at the end of this time, it is expected that the definitive treatment improves the symptoms and is not necessary to extend the use of medication (FAVERO, 1999). As described the indicated pharmacological treatment for TMD is: analgesics, corticosteroids, and anxiolytics, to treat acute pain, NSAIDs, muscle relaxants, local anesthetics for acute and chronic condition, and tricyclic antidepressants for chronic pain (OKESON 2000). 5. Medication dynamics: - Analgesics are indicated when the profound pain leads to the disorder. NSAIDs are indicated to relieve moderate inflammatory conditions and acute postoperative pain, especially musculoskeletal pain, promote symptomatic relief and does not stop the progression of pathological tissue injury (ibuprofen). It is indicated as a short term therapy, when anxiety and muscle spasms are prominent, but the patient must be warned that prolonged use can cause side effects (FAVERO, 1999).

- Anti-inflammatory drugs suppress the body's overall response to the irritation. Corticosteroids are not prescribed by their side effects.

- Anxiolytics are indicated for supportive therapy (diazepam). - Muscle relaxants are given to prevent the increase in muscle activity associated with TMD (mephesin, flexeril).



- Tricyclic Antidepressants require increased dosage therapy. It is indicated as a short term therapy, when anxiety and muscle spasms are prominent, but the patient must be warned that prolonged use can cause side effects. Local anesthetics are used for localized pain in muscle, myofascial trigger point (lidocaine, mepivacaine) (OKESON, 2000). 6. Surgical therapy: In some situations, as previously mentioned, drug treatment can not by itself be responsible for remission of symptoms and not fully deal with the problem of the patient. So if conservative treatment for TMD is not effective, an option to consider is TMJ surgery. Regarding the surgical treatment of TMD, some conditions are imposed with respect to the modality in the surgical management: a joint surgery should be performed only when conservative treatment was not effective; forms of pre-surgical treatment should follow rational and appropriate criteria, and various types of therapy should have been used before referring for surgery, patients who have persistent chronic or acute signs and symptoms, in which pain is the main component and the signs and symptoms are resistant to conventional therapy. The TMJ surgery can be open or closed (MOLINA 1995; FAVERO 1999 and CABEZAS 2006). For some authors in closed TMJ surgery (arthroscopy or arthrocentesis), a cannula is introduced with a video lens in the superior articular joint space. A lateral incision can be made to allow introduction of instruments for biopsy, remodeling of articular disc and lysis of adhesions. Among the indications is failure of conservative treatment, uncertain diagnosis; disc displacement without reduction, adhesions of the disc, and arthralgia. For these authors, open surgery of the TMJ is the last treatment option to be considered. Arthrotomy can be performed, discoplasty, discectomy. TMJ open surgery shall be performed only in much selected cases. The decision to surgically treat a patient depends on the degree of pathology he shows (Figure 11) (FAVERO, 1999; CARDOSO; BELMIRO; VASCONCELOS et al., 2005 e CABEZAS, 2006). Figure 11 - Articular eminence osteoplasty. Source: Figure extracted from the article: CARDOSO, A. B.; BELMIRO, C. E.; VASCONCELOS et

al., Estudo comparativo da eminectomia e do uso de miniplaca na eminência articular para tratamento da luxação recidivante da articulação temporomandibular. Rev. bras. Otorrinolaringol., v.71, n.1, p.32-7, jan.,/fev., 2005.



The articular disc covers the head or condyle until the adhesion points, medially and laterally, and its posterior margin is relatively thick. As much more inclinated the eminence is, the thicker the distal edge of the disc becomes. The functional position of the articular disc is a key factor in mandibular movements, many disorders may result from its lack of coordination. Chronic dislocations of the articular disc that could be treated invasively are currently treated with devices used to stabilize it in the posterior aspect of the condyle. It is known as "Minianchor" used years ago as: (1) articulate endosseous stabilizer, (2) restoration of the articular disc, (3) condylar restoration, (4) restoration of the articular fosse and (5) total joint prostheses. Some of these devices have been used in the treatment of TMJ disorders although in some situations they lead to functional impairment to patients. Other factors should also be considered in choosing a articular device: (1) Autoimmune disorders, (2) endocrine dysfunction, (3) biomechanical problems, (4) nutritional deficiencies, and (5) genetic predispositions that lead to joint disturbs. Considering this, it becomes relevant to highlight the actions of the devices used in TMJ, knowing the dynamics of them and how they are responsible for functional improvement of patient’s quality of life.

ENDOSSEOUS IMPLANTS Endosseous implants can be used fixed in the condyle to assist in the positioning of joint structures. Several approaches can be used to expose the posterior condylar head to place a device known as minianchor (Mitek Mini Anchor, Mitek, Inc., Norwood, Mass.) stabilizing the position of the articular disc. This mininchor is composed of titanium with 5 mm in length and 1.8 mm wide. Two titanium "wings" provide lateral intraosseous locking making suture viable in the region and the formation of artificial ligaments (VAN LOON; DE BONT; STEGENGA et al., 2002). In a study conducted in 63 patients (59 women and 4 men), designated group 1, with a mean follow up of 12.2 months (range 8 to 16 months), with 12 bilateral and 51 unilateral cases, a total of 114 joints. Group 2 consisted of 32 patients (30 women and 2 men) followed for a median of 25.5 months (range 18 to 36 months), 7 cases with unilateral and 25 bilateral, a total of 57 joints (WOLFORD; PITTA; MEHRA et al., 2001). In group 1, 57 of 63 patients (90%) had successful results with an incisal opening of 35 mm or more, jaw and occlusal stability, and a significant reduction in pain, with an average of 4.1 points in a -10 0-visual analog scale. In group 2, 29 of 32 patients (91%) had successful results with the same criteria, with an average decrease in pain of 4.0 points on a 0-to-10 visual analog scale. It was demonstrated osseointegration in two condyles of the anchors in about 3 months after implantation. Absence of inflammation or bone resorption was observed around these devices (FIELDS; FRANCO; WOLFORD, 1997). A cephalometric study was conducted to evaluate changes in long-term positioning of the anchor in the condyle and the effects of the process on the morphology of the condyle. The sample consisted of 29 patients (n = 54 joints) with a mean age of 31.3 years (ranging from 15 to 52 years) and a mean follow up of 16.8 months (between 12 and 29 months). Positional changes were minimal for the horizontal and vertical movement, with an average change of 0.01 mm (range, -1.5 to



1.5 mm). Condylar and ramus average height changes were -0.02 mm (range -1 to 1 mm). These studies support the use of Mitek mini anchors for the stabilization of the articular disc of TMJ (CARDENAS; WOLFORD; GONCALVES et al., 1997).

USE OF MINI-ANCHORS FOR ARTICULAR DISC, FOSSA, CONDYLE, AND COMPLETE ARTICULAR REPOSITIONING

Numerous materials are used for either partial or total reconstruction of the TMJ. Materials such as polimethyl methacrylate, polyethylene of high molecular weight, and a series of metals (Figures 12 and 13) (MEHRA; WOLFORD, 2001). Figure 12- Mini-anchor body. Source - Figure extracted from: MEHRA, P.; WOLFORD, L. M. The Mitek mini anchor for TMJ disc

repositioning: surgical technique and results. J. oral Maxillofac. Surg., v. 30, p. 497–503, 2001.

Figure 13A – Cross-sectional image of condyle showing fixed mini-anchor. Fig. 13B – Coronal section of condyle showing fixed mini-anchor. Source - Figure extracted form: WOLFORD, L. M.; DALLAS, A. T. Temporomandibular joint

devices: Treatment factors and Outcomes. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod., v. 83, p. 143-9, 1997.



This procedure is widely used in the constant displacement of articular disc that leads to inability to perform normal mandible movements, leading to a better condylar position preventing dislocations, producing a slight lock, limiting non physiological movement (MEHRA; WOLFORD, 2001). Numerous metals have been used for that purpose. The basis of chromium and cobalt are used for reconstruction of the condylar head and high molecular weight polyethylene to the surface of the glenoid fosse. TMJ models are initially produced on a computer in three - dimensions, of course adapted to the structure to be reproduced, and copied according to the peculiar anatomy of each patient in addition to the essential use of CT scans for the same purpose (VAN LOON; DE BONT; STEGENGA et al., 2002). The replacement of the articular disc for alloplastic materials was popular technique in the 1970s and 1980s. Two materials were shown to be the first choice as joint implants interpositional discs that were Proplast Teflon (Vitek, Inc., Houston, Tex.), And Silastic (Dow-Corning, Midland, Mo.). Later it was observed that the formation of microscopic particles of these materials in the human body was unable to degrade and can cause severe foreign body reactions, and lesions of giant-cell, particle migration, pain, lymphadenopathy, severe osteoarthritis, bone resorption, perforation of the fosse, and immune dysfunction (WOLFORD; MEHRA, 2000 and DATAMORE; ATHANASIOU, 2003). One hundred and seven patients were evaluated with the use of these types of materials when failed in the use of Teflon was observed. The reconstruction was performed using autogenous bone grafts, including temporal fascia and muscle grafts, and also cartilage, dermis, costochondral and sternoclavicular grafts, with a follow-up of 4 years a success rate around 8% to 31% was observed. The failures were noticed, especially by the presence of giant cell lesions, pain, foreign body reaction and ankylosis. Patients who had previous implants were treated with Teflon denture materials for orthopedic, improved function and occlusal stability with a significant decrease in pain in 84% of cases (HENRY; WOLFORD, 1993). Such articular devices have being used successfully for some years. There are reports of success around 86% with a clinical follow up 16 to 46 months. In this study the mini-anchors replaced successfully Teflon widely used for several decades, in 49% of cases. In 14 patients had had one or no symptoms of pain, instability and occlusal function and 19% had up to two such nuisance. A clinical study was published in which the use of mini-anchors as a treatment for TMD was considered as a well established treatment because it leads to a success rate of about 91% of a total of 43 patients and 78 treated TMJ with clinical follow-up time of over 2 years (COTTRELL; WOLFORD, 1993). Sixty-six mini-anchors and their action on changes in vertical and horizontal cephalometric tracings were studied and it was observed that this device leads to an excellent joint stability in condylar replacement (CARDENAS; WOLFORD; GONÇALVES, 1997).

MATERIAL AND METHOD This study was performed using references on the therapy of Craniomandibular Disorders, through a Literature Review so this paper aims at discuss the very important points regarding the Temporomandibular Joint concerning



- anatomy - normal dynamics of TMJ; physiological aspects - craniomandibular disorders - treatment of craniomandibular disorders.

DISCUSSION Through the literature a large number of Craniomandibular Disorders are verified. According to a study of 12% to 87% of the population carries some form of disorder, with symptoms ranging from joint pain, headaches, myofascial pain, decreased ability to jaw movements by vertigo (KIEHN; DESPREZ, 1962; SILVER; SIMON, 1963; FLYNN; BROWN; LAPP et al., 1990 and LASKIN, 2007). Treating cases of TMD requires a thorough knowledge of the etiology of the problem. The multifactorial origin of TMD is characterized as structural, functional and psychological problems that appear to be fulfilled. Thus it is evident that the correct diagnosis is the key to successful treatment. It is vital to understand that patients respond differently to different therapies, and the practitioner must tailor the treatment to the patient, to obtain the best possible results. Thus it is evident that the correct diagnosis is the key to successful treatment. It is vital to understand that patients respond differently to different therapies, and the practitioner must adapt the treatment to the patient, to obtain the best possible results (FAVERO, 1999 and STECHMAN NETO, 2001). Other predisposing factors are cited in literature such as trauma, TMJ deleterious habits, malocclusion, viral or bacterial infections and systemic or local diseases. For both the range of treatment options is also large and the main indications for treatment of recurrent chronic TMD are pain and dysfunction (MONGINI, 1998 and MEHRA; WOLFORD, 2001). Therefore, for any treatment to be successful it is imperative to know the particulars of each treatment, either surgical or nonsurgical (LASKIN; GREENE; HYLANDER, 2006 and LASKIN, 2007). There is a consensus in the literature regarding the need for multidisciplinary treatment (FAVERO, 1999 and OKESON, 2000), being the non-surgical treatment based in medication, psychological management, intermaxillary fixation, physical therapy and the application of sclerosing agents in the articular capsule, ligaments and bilaminar tissue. In the surgical treatment there are procedures performed in soft tissue, removal of the structure that is causing some kind of interference, creating an obstruction to certain translation movements and mandibular osteotomy (WEINBERG, 1984; ALMEIDA; RODRIGUES; TOLEDO-FILHO et al., 1991 and VASCONCELOS; CAMPELLO; OLIVEIRA et al., 2004). Regarding surgical treatment, several methods have been described as eminectomy (MYRHAUG, 1951; IRBY, 1957 and HALE, 1972), scarification of the tendon of the temporalis muscle by intraoral approach, intending thereby to limit mandible movements (VASCONCELOS; CAMPELLO OLIVEIRA et al., 2004), scarification of the articular capsule (VASCONCELOS; CAMPELLO OLIVEIRA et al., 2004), the oblique osteotomy of the root of the zygomatic bone or Dautrey procedure (VASCONCELOS; CAMPELLO OLIVEIRA et al., 2004). One can cite the myotomy of the lateral pterygoid muscle via intraoral (VASCONCELOS; CAMPELLO OLIVEIRA et al., 2004), the use of miniplates in the articular eminence (BUCKLEY, TERRY, 1988 and PUELACHER; WALDHART, 1993),



the articular eminence augmentation by the use of alloplastic graft and the employment of the use of mini-anchors "Mitek" in the condyle and the posterior root of zygomatic arch (VASCONCELOS; CAMPELLO OLIVEIRA et al., 2004). Specifically regarding the use of mini-anchors the nickel-titanium is used mainly for the purpose of repositioning the disc, which is relevant to note is that according to the literature this method overlaps in terms of advantages over other mechanisms with the purposes (WOLFORD; COTTRELL; KARRAS, 1994; WOLFORD, 1997 and MEHRA; WOLFORD, 2001). The use of mini-anchors for disc repositioning was reported in more than 400 TMJ with successful results (WOLFORD, 2007). A favorable result was also obtained when a minimal change in the position of mini-anchors in human condyles in long postoperative follow-up was noted (CARDENAS; WOLFORD; GONÇALVES, 1997). An interesting feature of the use of mini-anchors was demonstrated (FIELDS; FRANCO; WOLFORD, 1997): osseointegration. This fact is a unique aspect, provides a stable anchor position. Also showed that osseointegration occurs in 3 months despite the application of forces in this period. The same authors also mention, mini-anchors used in 5 patients with control of 4 years in which there were no failures demonstrating excellent clinical results. This technique shows how you can realize the following advantages: 1. Translational control of mandibular movements. 2. Effectively prevents the displacement of the condyle without altering the anatomy of the joint (WOLFORD; DALLAS, 1997 and FIELDS; FRANCO; WOLFORD, 2001). Just as it has been for osseointegration in dental implants, surgery here in joints, the force that will be exercised on the TMJ should be minimal. Excessive force may lead to peri-implantitis and mobility, with the formation of fibrous tissue at the interface of the implant and bone tissue (ISIDOR, 1996). Low mobility is perceived when the placement of mini-anchors, however, there is no consensus about the strength and the vector that can focus on the relationship notwithstanding, more studies should be made to that effect. Some items should be considered before placing mini-anchors for the treatment of TMD (MEHRA; WOLFORD, 2001): 1. The implanted devices must be safe, do no injury any joint structure and not change the anatomical site unless necessary. 2. Access to the temporomandibular joint should be as small as possible in order to preserve a greater amount of soft tissue. 3. The positioning of the articular disc should be passive in relation to the condyle. 4. During surgery the periosteum should be preserved and the bone should be carefully worked and plenty irrigated. 5. Keep at least 2 mm in the bilaminar tissue in the distal portion of the posterior band of articular disc to be sutured to the mini-anchor. 6. The occlusion should always be checked if necessary an orthodontic treatment followed by orthognathic surgery can be performed. As reported one of the great advantages of using this device, is the predictability of a good positioning in the joint structure, not changing the three dimensional conformation of the mandibular condyle (WOLFORD; DALLAS, 1997). Based on this it is clear that the use of mini-anchors for treatment of Craniomandibular Disorders is a reality, especially in treatment of recurrent



dislocations of the articular disc in which there is no control in eccentric mandible movements. It is imperative for this procedure that the surgeon be aware not only of the surgical technique, but also the complex anatomy of the Temporomandibular Joint, one of the most complex and elaborate structures of the human body. Interventions without an adequate preparation would not be prudent. What would be made of the numerous articles published in the literature if not to help to increase satisfactory surgical results. The study of techniques and new materials should be done constantly.

CONCLUSIONS Based on literature review, we conclude that: 1. A correct diagnosis is the key to successful treatment for this, anatomical knowledge of the temporomandibular joint is of paramount importance. 2. The use of mini-anchors as a treatment of TMD was highly effective and, therefore, is a technique of choice when properly indicated. 3. One of the most important aspects of the use of mini-anchors is the possibility of osseointegration when used in condyles. Existing mini-anchors which have this advantage makes the results more predictable and positive

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