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TEMPOROMANDIBULAR DISORDERS, OCCLUSION, SPLINT THERAPY TMDI (TEMPOROMANDIBULAR DISORDER INDEX)
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TEMPOROMANDIBULAR DISORDERS, OCCLUSION, SPLINT …€¦ · clinician who never looks at occlusion.” Okeson. FACTORS CONTRIBUTING TO TEMPOROMANDIBULAR DISORDERS 1.TRAUMA 2.PARAFUNCTIONAL

Aug 22, 2020

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Page 1: TEMPOROMANDIBULAR DISORDERS, OCCLUSION, SPLINT …€¦ · clinician who never looks at occlusion.” Okeson. FACTORS CONTRIBUTING TO TEMPOROMANDIBULAR DISORDERS 1.TRAUMA 2.PARAFUNCTIONAL

TEMPOROMANDIBULAR DISORDERS, OCCLUSION, SPLINT THERAPY

TMDI(TEMPOROMANDIBULAR DISORDER INDEX)

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WHERE ARE WE NOW?

u We have not succeeded in answering all of our problems; indeed, we often feel we have not answered any of them! The answers we have found only serve to raise a whole new set of questions. In some ways, we feel we are as confused as ever; but we believe we are confused on a much higher level and about more important things.

u Linus to Charlie Brown

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Cause and Effect Relationship?

uThe confusion and controversy concerning the relationship between occlusion and TMD continues. The general message is that there is no simple cause-and-effect relationship explaining the association between occlusion and TMD.

u (Okeson 105)

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Occlusal Signs and Symptoms

u Most clinicians would also agree that … occlusal conditions …. do not always lead to TMD symptoms. In fact, these findings are commonly seen in symptom-free populations. To appreciate the role of occlusion in TMD, one must better understand the many factors that can influence function of this extremely complex system.

u (Okeson 107)

u

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Occlusion/TMD/Masticatory system

” The clinician who only looks at occlusion is missing as much as the clinician who never looks at occlusion.”

Okeson

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FACTORS CONTRIBUTING TO TEMPOROMANDIBULAR DISORDERS

1.TRAUMA2.PARAFUNCTIONAL HABITS3.EMOTIONAL STRESS4.OCCLUSAL IMBALANCE5.SYSTEMIC DISEASE6.SLEEP DISORDERS

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Bilateral Subcondylar Fracture from Blunt Trauma to Symphysis.

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Occlusal Contacts and Muscles

uThe occlusal contact patterns of the teeth will influence the precise functional activity of the masticatory muscles. However, does this mean that occlusal contacts are related to masticatory muscle pain?

u (Okeson 120)

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Occlusion and TMD

u If occlusion does play a significant role in the etiology of TMD, the dentist can and should play an important role in the management of these disorders. No other health care providers can provide this treatment.

u (Okeson 103)u Okeson, Jeffrey P. Management of

Temporomandibular Disorders and Occlusion, 7th Edition. Mosby, 052012. VitalBook file.

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Occlusion and TMD

u If occlusion plays no role in TMD, any attempt by the dentist to alter the occlusal condition is misdirected and should be avoided.

u (Okeson 103)u Okeson, Jeffrey P. Management of

Temporomandibular Disorders and Occlusion, 7th Edition. Mosby, 052012. VitalBook file.

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Musculoskeletally Stable Position

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Occlusion and Muscle Hyperactivity

u On reviewing the literature, it becomes obvious that the precise effect of the occlusal condition on muscle hyperactivity has not been clearly established. It appears to be related to some types of muscle hyperactivity and not to others. Yet this confusing issue is the essence of how dental therapy either fits or does not fit into the management of masticatory pain disorders.

u (Okeson 120)

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Muscle Hyperactivity

umuscle hyperactivity is an inclusive term referring to any increased level of muscle activity that is NOT associated with a functional activity. This includes not only bruxism and clenching but also any increase in muscle tonicity related to habits, posture, or increased emotional stress.

u (Okeson 120)

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Terminology

uOrthopedic Stability

uBiologic Burden

uBilateral, Simultaneous, and Stable

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Terminology• Condylar/Mandibular position

• Orthopedic stability

• Harmonious tooth contacts

• Disharmonious tooth contacts

• Biologic Burden

• Parafunctional Habits

• Bilateral, Simultaneous, Stable (BSS)

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Etiologic Factors

uOcclusal imbalance/disharmonyuTrauma- (intracapsular disorders vs.

muscular disorders)uMacrotrauma-uMicrotrauma-

uEmotional Stress—“The nonspecific response of the body to any demand made upon it.” Hans Selye

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Masticatory System Overload—Structural Breakdown

u Tooth wearu Pulpitisu Tooth mobilityu Muscle painu TMJ painu Ear painu Headache pain

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Tooth Loss, Splaying of Anterior Teeth and Supra-eruption

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Parafunction

uDiurnal Activityu Lip and cheek bitingu Nail bitingu Chewing gumu Clenching

uNocturnal Activityu Bruxing

uClenching

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Contributing Factors

uPredisposing factors- Factors that increase the risk of TMD (Okeson 108)

u Initiating factors- Factors that cause the onset of TMD(Okeson 108)

uPerpetuating factors- factors that interfere with healing or enhance the progression of TMD(Okeson 108)

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CURRENT DEFINITION OF CENTRIC RELATION

u CENTRIC RELATIONu A condylar position that is in the most anterior

and superior position within the glenoid fossa and with the articular disc properly interposed against the articular eminence.

u There is no tooth contact in the centric relation position.

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Design and function of Splintsu Stable and Passive: Orthopedically stable and Occlusally

stableu Minimally invasive u Incorporate functionally ideal occlusal principles

u Bilateral, simultaneous, stable CO tooth contacts at CR hinge axis. (BSS)

u Canine guidance and incisal guidanceuNo interfering tooth contacts in eccentric jaw positions

u Maintain symptom improvement over timeu 3 months of update visits every two weeksu Symptom improvement levels over 50% since initiation of

splint therapy

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When pain is present, healing is compromised.

NSAIDS and OTCsMUSCLE RELAXANTS

ANTIANXIETY AGENTSOPIOIDS

With all medication use, mindful counseling is required!!

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Occlusion/TMD/Masticatory system

” The clinician who only looks at occlusion is missing as much as the clinician who never looks at occlusion.”

Okeson

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Sleep

uIt is very important that the clinician treating TMDs have an appreciation of the relationship between sleep and muscle pain.

u (Okeson 111)

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Sleep stages and Bruxing eventsuStudies have indicated that bruxing may be closely

associated with the arousal phases of sleep.uFrequency and duration of bruxing events

uWide variation between individualsuStudies show average of 5 to 6 seconds per event.uVoluntary clenching of 20-60 seconds elicits pain in jaw

muscles.uIntensity of bruxing events

uNocturnal bruxing can reach 60% of a voluntary maximum clench

uOne factor that seems to influence bruxing activity is emotional stress.

u (Okeson 113)

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SNORING AND SLEEP APNEA

ROOM AIR (06:53:00)

TAP III (07:01:00) CPAP @ 10cm (06:12:36)

HIGHEST SPO2 97% 98% 98%

LOWEST SPO2 72% 77% 88%

MEAN SPO2 89.4% 90.6% 93.1%

DESATURATION EVENTS<3min

104 51 13

DESATURATION EVENTS>3MIN

16 11 7

TIME SPO2 <90 3:01:24 0:58:16 0:01:24

TIME SPO2 <88 1:01:36 0:23:48 0:00:00

DESATURATION EVENT INDEX

15.1 events/hr 7.3 events/hr 2.1 events/hr

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