TMD and orthodontic by almuzian

UNIVERSITY OF GLASGOW

Orthodontics, TMD & TMJ Ankylosis

Personal notes

Mohammed Almuzian

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Contents

Introduction................................................................................................1

Anatomy of TMJ........................................................................................2

Physiology of the TMJ's.............................................................................4

Disorders of the TMJ's...............................................................................5

Temporomandibular Dysfunction (TMD)..................................................7

Aetiology....................................................................................................7

Incidence of TMD......................................................................................8

Measurement of TMD................................................................................9

Examination of TMD.................................................................................9

Evidences of the Relationship between TMD, Orthodontics, occlusal

interferences & malocclusion...................................................................10

Problems with TMJ research....................................................................13

Orthodontist’s role in the management of TMD......................................13

BOS guidelines for management of TMD...............................................16

What are the main treatments available for TMD?..................................16

Limited mouth opening (Trismus)...........................................................22

Presentation of Ankylosis.........................................................................22

Diagnosis of for ankylosed TMJ..............................................................23

Mohammed Almuzian, University of Glasgow, 2013 1

Treatment Choices....................................................................................23

Surgical Approach and preparation..........................................................25

Complications...........................................................................................25


Orthodontics, TMD & TMJ Ankylosis

Introduction

Interest was aroused in 1987 following litigation in America; the case

was that of Brimm vs. Malloy and is described in more detail, by an

attorney in: Pollack B. Cases of note: Michigan jury awards $850,000 on

orthodontic case: a tempest in a teapot. (Am J Orthod Dentofacial Orthop

1988; 94: 358-60). A patient developed symptoms of a

temporomandibular disorder (TMD) during orthodontic treatment and the

case went against the orthodontist, resulting in almost a million dollars

being paid out.

At the BOS Spring Meeting in 1997, the well-known American academic

Lysle Johnston explained that originally the claim was that the patient

had not received appropriate management when TMD symptoms had first

started in treatment and that there had been inadequate pre-treatment

documentation of the patient's TMD status. Ultimately however, the

orthodontic treatment itself was blamed for causing the patient's TMD.

One of the main reasons for this was the lack of evidence to suggest that

orthodontics had not caused the problem (Giannelly, 1989).

This was confirmed by Reynders (1990) who reviewed relevant studies

spanning the period 1966 - 1988 and found that of 91 relevant papers, 55

were view point articles, 30 were case reports but only 6 were sample

studies. Worse still, half of the case reports were written by one author

and these were published in one journal - of which that author was the

editor.


It is better to start with some introduction before going ahead and

discuss this topic in details.

Anatomy of TMJ

The TMJs are the only freely movable (synovial) articulations in the skull

apart from the joints between the ossicles of the middle ear.

The TMJ consists of:

1. Articular surfaces (of the condyle and the Glenoid fossa):

The TMJ is formed between the articular

surfaces of the squamous part of the temporal

bone and of the condyle of the mandible.

The articular surfaces are covered by

fibrocartilage.

Beneath the articular covering of the condyle is a layer of hyaline

cartilage (sometimes referred to as the condylar cartilage). It is an

important growth site which is more readily apparent in the immature

mandible.

2. Capsule:

A fibrous capsule is attached above to the squamous bone around the

margin of the upper articular surface, and below to the neck of the

mandible.

The capsule is slack between the articular disc and the squamous bone but

much tighter between the disc and the neck of the mandible.


The lateral pterygoid muscle is inserted, in part, into the anterior surface

of the capsule.

3. Articular disc:

It is a plate of fibrocartilage which in the majority of cases completely

divides the joint cavity into upper and lower compartment.

Laterally and medially the disc blends with the capsule of the joint.

In front, it is attached to the capsule and the lateral pterygoid muscle.

Posteriorly the disc is divided into two layers. The upper layer is attached

to the anterior margin of the squamotympanic fissure while the lower

layer is attached to the posterior surface of the neck of the mandible.

The upper surface of the disc is slightly concave anteriorly and markedly

convex posteriorly. The under surface is concave over its whole extent.

The disc is not uniform thickness. The central part is the thinnest and is

relatively avascular

4. Ligaments:

The capsule is strengthened laterally by a thick band of fibrous tissues,

the lateral temporomandibular ligament.

The sphenomandibular and stylomandibular ligament are described as

accessory ligaments of the TMJ.

5. Synovial membrane:

The internal aspect of the capsule, the non-articular surfaces of the

mandibular neck and to a variable extent, the peripheral areas of the


articular disc is covered with a layer of the synovial membrane which

provide nourishment for the joint structures.

6. Nerve and Blood supply:

The deep temporal and masseteric branches of the maxillary artery and

the branches of the superficial temporal artery, which arise from the

external carotid artery, supply the TMJ.

Venous drainage is via the superficial temporal, maxillary, and pterygoid

plexus of veins.

The capsule of the TMJ is innervated from a large branch of the

auriculotemporal nerve. The anterior region of the joint is innervated

from the masseteric nerve and from the posterior deep temporal nerve.

The articular cartilage and the central part of the disk contain no nerves

Physiology of the TMJ's

There are two basic movements of the TMJ's:

Hinge movement occurs in the first stages of opening. Here the condylar

head remains in the glenoid fossa.

Translation occurs as the condylar head moves down the articular

eminence. It relies on coordinated movement between the condyle and

the disc. In some TMJ conditions the disc and condyle do not move

together for example in anterior disc displacement

Disorders of the TMJ's

The British Association of Oral and Maxillofacial surgeons describe two groups of

patients presenting with TMJ problems:


Condition Example Comments

Those with abnormal anatomy whose function may be

abnormal.

Congenital or

developmental

disorders

Aplasia Very rare - where no condyle

forms at all

Hypoplasia/

Hyperplasia

These can lead to progressive

facial asymmetry

Neoplastic Neoplasia Extremely uncommon

Inflammatory

disorders

Synovitis and

capsulitis

Localised pain associated with

trauma, infection or

immunological conditions

Rheumatoid

arthritis and other

auto immune

diseases

Systemic conditions affecting

the TMJ's

Degenerative or

Age related

problems

Osteoarthritis Degenerative joint disease,

leads to abrasion of the joint

surfaces and remodeling.

Characterised by crepitation.

Traumatic Ankylosis Long term sequela of trauma

Fracture Caused by trauma


TMJ dislocation:

Acute or chronic.

The chronic type is associated

in most of the cases with some

degenerative disorders acute

dislocation occurs when the

patient is hit with the mouth

open

Those with normal anatomy but abnormal function

Dysfunctional Disc displacement

with reduction

Where the disc clicks back

into place part way through

translation

Disc displacement

without reduction

Where the disc remains

permanently displaced

anteriorly

Temporomandibula

r Dysfunction

(TMD).

See below


Temporomandibular Dysfunction (TMD).

It refers to a collection of conditions affecting the temporomandibular

joint (TMJ) and its related structures, including the muscles of

mastication.

The term TMD can describe symptoms such as:-

I. Pain related signs and symptom:

Pain in the face or jaw joint area

Headaches

Earaches

II. Extra oral signs and symptom:

Masticatory muscle hypertrophy

III. Functional signs and symptom:

Clicking or popping sounds from the jaw joint,

Limited opening or closed lock of the TMJ

Reduced lateral mandibular excursions

IV. Intra oral signs and symptom:

Abnormal occlusal wear

Lina alba buccalis


AetiologyA. Old theories regarding the aetiological factors that may cause TMD

independently

1. Factors within the central nervous system: as the emotional stresses.

2. Social conditions: an increased level of anxiety, which may lead to

increased muscle tension.

3. Occlusal interference: such as anterior open bite, crossbites, reverse

overjet, parafunctional activity…etc.

4. Trauma.

5. Internal joint pathology eg disc displacement / destruction. Proffit, 1993

6. Orthodontic treatment: such as changing the condyle position and

changing vertical face height.

7. Orthognathic surgery.

B. New philosophy: Mohlin & Thilander, 1984 described the new opinion

about the aetiology of TMD. It is Multifactorial reason:

1. Psychological

2. Dysfunctional

3. Inflammatory

4. Degenerative

5. Idiopathic

Incidence of TMD

A. Proffit (2002) suggests levels of between 5-30% depending on the

symptoms examined for TMD.(this variation because the studies have no

standardization in their method of assessment)


B. It has also be noted that TMD increases with age, Egermark-Ericson et al

(1983) suggesting an increase in the prevalence of symptoms from 30%

to 60% (two times) between the age of 20 and 45 years.

C. Females have higher prevalence due to (Warren and Fried, 2001):

Physiological differences

Anatomical differences

Behavioural differences

Genetic differences.

Measurement of TMD

Studies investigating TMD have used indices:

1. Helkimo Clinical Dysfunction Index. (HCDI) The following are

scored:

TMJ sounds,

Symptoms of reduced movement capacity

Locking or luxation of the mandible,

Deviation on opening,

Pain on movement,

Muscle and TMJ tenderness.

Each symptom is judged according to a three grade scale. Problems with

the use of this index are described (Van der Weele and Dibbets 1987)

including insufficient evidence to support or to document the validity of

this index. This index contains useful elements and should be adapted

rather than replaced to improve its' validity


2. Craniomandibular index CMI (Fricton and Schiffman, 1987)

Index has had little use in the orthodontic literature but it addresses the

problems of validity and reproducibility associated with Helkimo Index.

Examination of TMD

History:

Before any clinical examination, the patient should be asked about

symptoms such as pain, clicking, crepitus or locking of the jaw.

Ask the patient about any previous treatment that he/she had for the

TMJ such as medications, splints, occlusal adjustments, physical therapy

or surgery.

Clinical Examination:

The joint should be palpated simultaneously by placing the middle finger

over the condylar head whilst the patient is instructed to open and close

and to move laterally. Any clicks, crepitus, and locking should be

recorded. It is probably prudent to record any negative findings as well.

The muscles of mastication should also be examined for areas of

tenderness.

Special Tests:

1. Mounted study models

2. Radiographs

3. If problems persist MRI and arthrogram may be considered


Note: Subjects with removable dental prostheses will be examined with the

prostheses in their mouth Bite plates and other appliances that do not replace teeth are to be removed for

the examination. Vertical incisal overlap, and midline deviation, is included so corrections to

measurements of mandibular range of motion can be done to determine actual values of openings and excursions. Therefore, to determine the actual amount of opening, the amount of vertical incisor overlap should be added to the recorded opening measurements. If midline deviation is greater than 0, this measurement should be added to one side of the lateral excursion and subtracted from the other side (For example: If a subject has a 2 mm deviation to the right, then subtract 2 mm from the value given to the right lateral excursion

and add 2 mm to the value given to the left lateral excursion).

Evidences of the Relationship between TMD, Orthodontics, occlusal

interferences & malocclusion

With Against

A. Correlation between occlusal interference, malocclusion and TMD

There are weak evidences by

(Thilander et al., 2002) regarding

the association between TMD and

the following malocclusion traits:

AOB

Deep OB

Excess OJ (either CI II or III)

Posterior crossbite,

Proffit (2002) only 5-30% of

individuals have TMD yet 50-75% has

at least a moderate malocclusion.

Luther (1998) Notes there may be a

weak association between TMD, AOB,

Class III malocclusion, crossbite and

nonworking-side contacts.

Occlusal interferences and TMD,

Magnusson & Enbom, 1984 signs

Sadowsky & BeGole, 1980 non-

working side contacts are common and


and symptoms of TMD are two

times more in a group of subjects

with artificially induced non-

working side interferences

compared with controls

not relate to the development of TMD.

B. Orthodontics as a curative methods for TMD

Proffit (1999) believes that

orthodontic treatment causes the

periodontal ligament to become

temporarily painful which reduces

any bruxing habits and therefore

rests the TMJs, in turn this reduces

the TMD symptoms.

TMD reduced in patients having

fixed appliances (Sadowsky and

BeGole, 1980). This reduction was

not statistically significant.

Egermark et al., 2003, 2005, 20 yr

follow-up: orthodontic treatment in

childhood does not reduce the risk of

developing TMD.

C. Orthodontics as a causative factor for TMD

Roth, 1973 thought that condylar

position can be altered with the aid

of some mechanics:

Elastics

Retraction of the ULS

HG to the maxilla

HG to the mandible

Johnston & Luecke, 1992 orthodontic

treatment does not force the condyle

distally, in fact it moves temporarily

forwards 0.7mm (in 70%), movement

due to loss of anchorage in buccal

segments.


Chin cap

Other believed that the TMJ disc

position can be altered by

orthodontic treatments leading to

TMD.

Kircos et al., (1987) there appears to

be no evidence that the TMJ disc

position can be altered by

orthodontics. Even if it does but there

is no strong correlation between disc

position, clicking and TMD.

Extraction force the condyle distally

and trap the disc anteriorly Witz and

Yertz, 1985.

The frequency of TMD symptoms is

the same in groups of extraction and

non-extraction cases (Paquette et al.,

1992; Luppanapornlarp and Johnson,

1993).

Orthognathic treatment can cause

change of the condyle position

leading to TMD.

Orthognathic surgery does not

necessarily increase or decrease the

signs/symptoms of TMD, Egermark et

al., 2000

Cochrane review by Luther 2010: There are insufficient research data on

which to base our clinical practice on the relationship of active orthodontic

intervention and TMD. There is an urgent need for high quality randomised

controlled trials in this area of orthodontic practice.

Problems with TMJ research

Reynders, 1990

Many viewpoint publications and case reports but relatively few

sample studies.Mohammed Almuzian, University of Glasgow, 2013 15

Biased case sampling

Inappropriate or non-existent control groups

Inadequate design ie not matched for ethnic background, socio-

economic status, sex, inter observer variability, types of appliances, age

etc

Incomplete or inaccurate data collection

Unjustified assumptions

Faulty interpretation

Orthodontist’s role in the management of TMD

Also the evidence seems to suggest that orthodontics has no effect on

TMJ, but TMD could be present or appear during treatment, therefore

certain protocols should be followed.

Pre-treatment. 1. Full history.

2. Any signs or symptoms of TMD should be noted

3. If the patient already has a TMD, then the patient

informed that orthodontic treatment has no

influences according to the evidence based

literatures.

4. If the condition is sever and acute it is better not

to commence orthodontic treatment until the


condition is stabilized by a specialist.

During

treatment

If TMD manifest’s during treatment, a number of

steps can be taken.

1. Initially reassure the patient that TMD is not

necessarily a progressive problem and for many,

symptoms spontaneously improve over time.

2. An explanation of the relationship with stress (e.g.

can get worse around exam time) is also useful.

3. Modify the treatment .

Reduce forces on headgear,

Remove or lighten elastics.

Eliminate occlusal interferences by using a bite

plane.

4. Advice on some practical measures can include:

Resting the joint - e.g. avoiding over opening during

wide yawning etc.

Soft diet - some patients find certain foods will

trigger symptoms.

Analgesics - e.g. non-steroidal anti-inflammatory

drugs (if not otherwise contraindicated).

Application of heat - e.g. a heat pack can be used to

relax muscles.


5. Suspend treatment

If symptoms continue treatment such be suspended

4. Referral.

If following cessation of treatment and conservative

measures, the patient may need referral to a

specialist in TMD.

Then the TMD might managed by the specialist

with conservative measures, soft diet, muscle

relaxants, analgesics, occlusal splint or surgery.

Post treatment The patient should be monitored through out

retention for the signs and symptoms of TMD.


BOS guidelines for management of TMD

What are the main treatments available for TMD?


1. Patient education and

self-care

2. Home physiotherapy

programme

Massage

Exercise

Short Wave Diathermy

Ultrasound

Laser

3. Behavioural

intervention

Stress management

Counselling

Cognitive Behavioural intervention

Hypnosis

4. PharmacologyNSAID's

Corticosteroids

Hypnotics/Anxiolytics/Tricyclic

antidepressants

5. Splint TherapySoft splints

Localised occlusal interference splint

Anterior bite plane

Anterior repositioning splint

Stabilisation splint


6. Occlusal

equilibration

7. TMJ surgeryArthocentesis

Arthroscopy

Arthrotomy

In details…………………..

A. Patient education and self-care

Self-care = resting the masticatory system (habit awareness and

modification).

B. Home physiotherapy programme

Massage: Increases blood flow, relaxes muscles

Exercise: Mobilisation can be used when there is decreased range of

motion due to muscle contracture, disc displacement without reduction or

fibrous adhesions in the joint

Short Wave Diathermy: Thermal stimuli increased blood flow to

increase oxygenation and metabolite removal.

Ultrasound: The sound waves produce pressure waves in the tissue

resulting in micro massage


Laser: Laser treatment does not increase the tissue temperature but is

thought to increase capillary permeability and stimulate fibroblast

production

C. Cognitive Behavioural intervention

Stress management

Counselling

Hypnosis

D. Pharmacology

Analgesics like (NSAID's)

Corticosteroids, these are not usually prescribed for systemic use in TMD

treatment because of their side effects. The exception is for acute

generalised muscle and joint inflammation associated with

polkyarthrides. Intracapsular steroid injections have been recommended

on a limited basis in cases of severe joint pain where conservative

treatment has been unsuccessful.

Hypnotics/Anxiolytics/Tricyclic antidepressants have been shown to be

effective for short-term management (1-2 weeks) especially for bruxism.

E. Splint Therapy

Splints are the widely used as a treatment in the UK.

Types of splints:

Soft splints

Localised occlusal interference splint


Anterior bite plane

Anterior repositioning splint

Stabilisation splint

In details …..

1. Soft splints - these are usually made of a vacuum formed polyvinyl

material. They can be thought of as a simple emergency treatment for

patients with symptoms of TMD e.g. the student with an acute pain

around exam time. Their mode of action is unclear - they may simply be a

habit breaker but there is a risk that it can induce more parafunctional

activity.

2. Localised occlusal interference splint - this is an acrylic splint with

ball clasps that deliberately places the entire occlusal load on 4 teeth so as

to overload the proprioceptive fibres and break clenching or grinding

habits. It is meant to be worn by grinders at night or at other times when

they may parafunction e.g. whilst driving.

3. Anterior bite plane (Lucia jig). This is a deprogramming splint,

made at the chairside for emergency (short-term) treatment of patients

with acute muscle spasm and pain. The aim is to provide ideal anterior

guidance and to dis-occlude the posterior teeth.

4. Anterior repositioning splint - a hard acrylic splint fitted on the

lower teeth used to treat anterior displacement with reduction. The

mandible is postured forwards (a little like a functional appliance) which

keeps the disc in the correct position on the condylar head in order to

achieve 'click free' opening and closing. Short term these can work well

in reducing symptoms, but one questions how they can work long-term?


5. Stabilisation splint (Tanner appliance, Fox appliance, Michigan

Splint, Centric Relation Appliance) - a hard acrylic splint constructed on

a semi adjustable articulator and ground in in the mouth. This splint is

intended to provide a temporary ideal functional occlusion. It is likely

that like all other splints it is a habit breaker. Some clinicians consider the

success of a stabilisation splint to be an indication that orthodontic

treatment or occlusal equilibration may be successful.

Cochrane review by Al Ani 2009 found no evidence regarding the

advantage of splint in treatment of TMD

F. Occlusal equilibration

It has long been recommended for the treatment of TMD

This is the is the removal of non-working side contacts by selective

grinding

Cochrane review by Koh 2009 Occlusal adjustment cannot be

recommended for the management or prevention of TMD

G. TMJ surgery

Non-invasive measures are preferred to surgery for the treatment of

TMD.

Surgery may be considered if conservative measures fail or if pathology

e.g. neoplasia is suspected.

The surgeries include: Arthocentesis, Arthroscopy and Arthrotomy

Type of

Surgery

What does it

involve?

When is it used? Is it Successful?


Arthocentesi

s

Intra-articular

irrigation with or

without steroids.

Often used with

joint mobilisation

For intra-articular

joint restrictions

Thought to be

equally as

effective as

arthroscopy in

anterior disc

displacement

without reduction

Arthroscopy Insertion of a

camera into the

joint (usually upper

joint space). Allows

direct observation

and can then also

irrigate, debride,

incise minor

adhesions and take

biopsies.

As above Further research

needed but no

better than physio

in improving

range of

movement or

decreasing pain.

Arthrotomy Open surgical

intervention

E.g.: discoplasty,

discal repositioning,

discectomy (with or

without

replacement),

arthroplasty

(recontouring of the

Bony or fibrous

ankylosis,

neoplasia, severe

chronic

dislocations,

persistent painful

disc derangement,

severe

osteoarthritis, Less

commonly -

Variable success.

Alloplastic disc

replacements are

now

contraindicated

and it has actually

been

recommended that

all Proplast

implants are


articular surfaces

with or without

removal of the

disc), high

condylectomy

displaced condylar

fractures

actually removed

Limited mouth opening (Trismus)

There are many causes of limited mouth opening which may be classified

as follows.

1. Intra-articular (intracapsular)

Functional: Anterior displacement of the meniscus without reduction.

Trauma: Osseous or fibro-osseous ankylosis, secondary to trauma

Inflammatory: Ankylosing spondylitis, juvenile rheumatoid arthritis.

Infection in the joint.

Tumour of the joint structures.

2. Extra-articular (extracapsular)

Muscle trismus.

Disuse muscle atrophy, contractures secondary to intra-articular

ankylosis or psychogenic trismus.

Post-radiotherapy and thermal scarring.

Post-traumatic scarring.


Oral submucous fibrosis.

Infection or inflammation of the masticatory muscle

Anatomical like Eagle syndrome.

Presentation of Ankylosis

If developed at early age:

Ankylosis in children produces impaired mandibular growth with

bilateral deformity in all dimensions.

This deformity is asymmetrical in unilateral cases with a straight small

hemi-mandible on the ankylosed side, and a marked contralateral bowing

deformity.

Retrognathia and retrogenia become more apparent with age.

This produces an occlusal cant down to the normal side.

In rare bilateral cases the mandible is short but symmetrical.

In all cases the inter-incisal opening can be up to 10 mm even with total

bony fusion reflecting the bone elasticity within the masticatory system.

Diagnosis of for ankylosed TMJ

History and clinical examination

Imaging techniques including:

1. OPG.

2. True lateral skull.

3. PA


4. CT scan with 3D reconstruction.

5. Standard orthognathic photographic series.

Treatment Choices

Resection of the ankylosis should be carried out as early as possible to

enable normal growth and avoid secondary deformity.

There are many treatment strategies depending on the age of the patient

the duration of the deformity and degree of secondary deformity.

A. Ankylosis presenting in childhood or Ankylosis presenting during or post

adolescence

1. Excision of the condyle

2. Insertion of an interpositional temporalis myofascial peninsular flap

3. Bilateral coronoidectomies (coronoidotomies) to free temporalis

contractures

4. Costochondral growth centre to restore function and ramus growth with

or without Distraction osteogenesis.

NB: The anteroposterior deficiency and asymmetry in childhood is

usually self-corrected with catch-up growth.

B. Ankylosis presenting after the completion of facial growth.

1. Excision of the condyle

2. Insertion of an interpositional temporalis myofascial peninsular flap

3. Bilateral coronoidectomies (coronoidotomies) to free temporalis

contractures


4. Reconstruction of the condyle with or without distraction osteogenesis.

5. In addition to one of these:

Genioplasty

BSS or inverted L osteotomy.

The maxillary procedure can be done to correct secondary problems

C. Very late ankylosis in adults with no interference with facial growth.

Exactly as B but in addition to 7-day pre- and 2-month postoperative

course of bisphosphonate, which is currently alendronic acid 10 mg a day

in the morning to avoid the localised fibrodysplasia ossificans .

Surgical Approach and preparation

The preoperative preparation differs from the standard orthognathic

workup in several respects.

1. The anaesthetist must be skilled in fibre optic intubation and

tracheostomy or submental approach.

2. The temporal area must be shaved and cleaned before the patient is

taken into theatre.

Complications

1. Scar

2. Damage to the orbital and frontal branches of the facial nerve.

3. Frey’s syndrome

4. Damage to parotid salivary gland


5. Limited opening due to

Inadequate bone removal

Failure to do a bilateral coronoidectomies.

Postoperative fibrodysplasia ossificans

Fusion of the graft with re-ankylosis

6. Failure of the costochondral graft to grow.

7. Excess growth of the graft

8. Pneumothorax.


TMD and orthodontic by almuzian

Health & Medicine