20/01/2014

Outline
American Association of Orthodontists
TMD diagnosis

Limiting your risk when Condylar position and TMD risk

treating patients with TMD
Occlusal interference and TMD risk
Ambra Michelotti
michelot@unina.it
Red Flags and TMD risk
University of Naples Federico II

Modified by Diatchenko et al, 2006

Modified by Benoliel et al, 2011
Temporomandibular Disorders
Temporomandibular disorders (TMDs) encompass a group of
musculoskeletal and neuromuscular conditions that involve the Environment
temporomandibular joints (TMJs), the masticatory muscles and all
associated tissues. Occlusion TMD
The signs and symptoms associated with these disorders are diverse, and Orthodontics
may include difficulties with chewing, speaking and other orofacial
functions.

They also are frequently associated with acute or persistent pain, and the
patients often suffer from other painful disorders (comorbidities).

The chronic forms of TMD pain may lead to absence from or impairment
of work or social interactions, resulting in an overall reduction in the GAD65 Cannabinoid Dopamine Serotonin
transporter CACNA1A NET
Na+, K+-
Serotonin receptors receptors ATPase IKK COMT
quality of life. MAO receptor NMDA CREB1
Adrenergic
GR receptors DREAM POMC
Opioid
receptors BDNF NGF Prodynorphin Interleukins

AMERICAN ASSOCIATION FOR DENTAL RESEARCH TMD POLICY STATEMENT REVISION, MARCH 3, 2010
Xp11.23 12q11.2 9q34.3 11q23 5q31-q32 5q31-32 6q24-q25 1p13.1 22q11.21

Fatigue, stiffness or pain of the jaw muscles

TMJ Jaw movements

impairment
Pain Sounds

Deviation Deflection
Click Crepitus

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Main complaints
Preauricular pain, right and left
TMJs clicking sounds,
headache, malocclusion, missing
posterior teeth
X X
Sharp pain, at the left and right
X X preauricular regions; during click
sound, during chewing and opening
X movements
X
Headache
- localization: temporal region, bilaterally
- frequency: often (2-3 times/week)
- intensity: moderate-high (5-7 VAS)
- decreases with rest and increases with jaw
movements

Vertical range of motion Jaw excursions

Unassisted opening Maximum unassisted Maximum assisted Right lateral Protrusion Left lateral
without pain opening opening Excursion 3 mm excursion
41 mm 46 mm 49 mm 5 mm 2 mm

Vertical incisor overlap

3 mm

FAMILIAR PAIN FAMILIAR PAIN

Joint Palpation

FAMILIAR PAIN

FAMILIAR HEADACHE

FAMILIAR PAIN
Joint Sounds
Right joint Left joint

LR LL P C O O C P LL LR

Click X X X X X X X X
Crepitus

Click sound at right and left TMJs during chewing,

opening, closing and lateral movements

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Not necessary

Outline
TMD diagnosis

Condylar position and TMD risk

Occlusal interference and TMD risk

Red Flags and TMD risk

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Reduction of posterior vertical dimension

11 cases in which disturbance of mandibular joint

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

Ronald H. Roth Angle Orthod. 1973

San Mateo, California

7 patients
2 controls

The condyles should be seated superior and anterior in the

fossae against the articular disks and the distal slope of the
articular eminence, and centered transversely.

Mounting dental casts on an articulator helps in measuring the centric relation-centric (Am J Orthod Dentofacial Orthop 2013;144:512-7)
occlusion discrepancy in 3 planes of space. This is important information when the goal is
to treat to a musculoskeletal stable position.
Objective: to evaluate the reliability and validity of 3 bite registrations in relation to
condylar position in the glenoid fossae using magnetic resonance imaging in a
symptom-free population.
Roth Power Centric
Centric Occlusion Centric Relation
Relation

The centricity of the condyles in the glenoid fossa involves a range, and eccentricity does
not necessarily indicate TMD. Therefore, the analysis of articulated casts will not be
diagnostic of TMD per se.

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Interestingly…

OOOO, 2009

• The differences between the 3 bite positions were small and, more
importantly, highly variable.
No association between condylar position
• Variability in the findings between the bite registrations appear to reflect
the lack of accuracy and predictability.
and signs and symptoms of TMD was
found
• Based on the findings that we are not positioning the condyles in specific
positions in the fossae with various bite registrations, the clinical
significance followed by the routine practice of condylar positioning
must be questioned.

Angle Orthod, 2010

normal joints

normal joints

CONCLUSION… Mandibular dysfunction and incisor relationship. A theoretical explanation for

the clicking joint. Berry DC, Waltkinson AC Br Dent J, 1978

Left

Great overlap Deep bite / Class II 2

Wide distribution
Pullinger A, JOR 2013

Condyle position per se is not diagnostic and

would fail any useful prediction values

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The extraction – non extraction dilemma as it relates to TMD

RP McLaughlin, JC Bennett. Angle Orthod, 1995
…however

Excessive anterior interferences resulting in possible posterior

condyle displacement are the result of treatment mechanics

CONCLUSION
There is no evidence that asymptomatic TM
joints with posterior positioned condyles are
at risk for disc displacement derangements.

There is no evidence that centric condylar

position means “healthy” TM joint.

There is no evidence that centric condylar

position limits risk when treating patients with
TMD.

Outline
TMD diagnosis

Condylar position and TMD risk

Occlusal interference and TMD risk

Red Flags and TMD risk

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However…
In animal models, artificial occlusal alterations can result in disorders
or damage of TMJs, masticatory muscles, and the nervous system.
Results from animal studies cannot be
directly extrapolated to humans
Long term mechanistic
nociception is related not only

Xie et al, JOR 2013

Xie et al, JOR 2013

to peripheral sensitization of
nociceptive neurons but also
to central sensitization

10 % MVC

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

Decrease in number of Decrease of contraction …however sometimes

activity periods intensity

None of the subjects developed signs

and symptoms of TMD

No changes in PPT

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

Michelotti et al., in preparation

Different
adaptation

Artificial interferences seem to play a different role in

responses in subjects with an earlier TMD history
compared to those without

No differences in number of activity 5

periods during active interference 4

TMD subjects showed
Dur (s)

3
CTR
TMD
higher number of
2
events with higher
1
intensity compared to
0
IFCbefore DIC
Session
AIC IFCafter
healthy subjects
25
90

80
20
70
* *
A mean (%MVC)

60
15
50

N/hr
CTR
40 CTR
10 TMD
TMD
30

5 20

10

Different adaptation to occlusal changes 0

IFCbefore DIC AIC IFCafter
0
IFCbefore DIC AIC IFCafter
Session Session

Aim
250 subjects filled the Oral Behaviour Checklist
Oral Behavior Checklist (OBC) Markiewicz et al, 2006

10th 90th

80%

Hans Christian Andersen 10 without 10 with

The Princess and the Avignon Palais de Popes parafunctions (nPAR) parafunctions (PAR)
Pea
(9 f,1 m; mean age ± Exclusion criteria
(6 f,4 m; mean age ± SD Dental prostheses
22.3±1.8) SD 20.4±1.17) Orthodontic treatment
One or more missing teeth with the exception of third molars
Neurological disorders
Michelotti et al. JOP 2012 Assumptions of drugs affecting the Central Nervous System.

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p<0.01

State Anxiety Trait Anxiety

Visual Analogue Scale Higher values of trait anxiety in

(VAS)
- occlusal discomfort Parafunctional subjects
- spontaneous pain
- headache
☺ 

Conclusion

Perceived the occlusal Perceived the occlusal

interference as cause interference as cause
of high discomfort of discomfort

They reported pain or They did not report pain

signs of dysfunctions or signs of dysfunctions

During AIC occlusal discomfort, headache High trait anxiety Low trait anxiety
and spontaneous pain were higher in individuals individuals
Parafunctional Subjects

Take Home Message

Outline
NORMAL Decreased
parafunctional
FUNCTION activities
Occlusal
hypovigilance
TMD diagnosis
Occlus Physiologic
Adaptabilit
al y
al
tolerance Occlusal Condylar position and TMD risk
change hypervigilanc
e

Physiological Somatosensory Occlusal interference and TMD risk

tolerance exceeded amplification

Red Flags and TMD risk

Increased
TMD SYMPTOMS parafunctiona
l activities
Michelotti and Iodice, JOR 2010

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P. A. 45 ys P. A. 45 ys

Main complaints
• Facial pain
• Limited jaw movement
• Headache

Axis I
° Myofacial Pain with referrals
1°

FAMILIAR PAIN

• Facial Pain from 1 years (24h/24h; 7days/7days). The tongue is ° Headache attributed to TMD
2°
affected too. Started after the prosthodontic rehabilitation. She changed
many prosthetic manufactory but the pain is always present.
FAMILIAR HEADACHE
• Headache (bilateral)
• Cervical and back pain
° Cervical Pain
3°

RDC/TMD Psychological Evaluation Axis II

Graded Chronic
Pain Scale

20

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Psychological Evaluation Axis II Treatment protocol

° Counseling
1°

° Physiotherapy
2°

Depression
and non
specific
physical ° Prosthetic
3°
symptoms rehabilitation

° Psychiatric
4°
Consultation

Flag areas that might be associated

with history taking
• Chronicity
• Functional limitation
• Discrepancy in findings
• Overuse of medication
• Inappropriate behaviour
• Inappropriate expectations
• Inappropriate responsiveness to prior treatment
• Identify red-flags from self-report screener
Recommendations on rehabilitation of TMDs
Cairns B, List T, Michelotti A, Ohrbach R, Svensson P

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Orthodontic treatment

Range of motion WNL

Surgery Two months later… M.S. 25 ys

Main complaint
Bilateral facial pain. Severe pain on both
sides in the masseter and temporal regions.

Pain increases during mandibular

movements, chewing and yawning, so that
he could eat only soft meals
Headache, bilateral, localized at temples.
Present everyday, worse in the evening.
Stress increases headache.

1) Counseling
Myofascial pain 2) Physiotherapy
3) Drugs

Headache attributed to TMD

For 3 weeks

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M.S. 25 ys

During class II elastics • Suspend class II elastics

• Preauricular pain on right
• Limited jaw movement
• Pain during jaw movement
• Distraction of the right TMJ
• Coordination exercise of the jaw opening
• Home regimen physiotherapy

Symptom free Take Home Message Conservativ

No pain
e treatment

Myofascial
Patient pain
information
and counseling
Patient Continue the
develops TMD Differential orthodontic

+
signs and
symptoms diagnosis treatment
during
orthodontic
treatment Suspend TMJ
temporarily active
orthodontic
disease
treatment
Revaluate the
Conservativ orthodontic
e treatment treatment plan

Michelotti and Iodice, JOR 2010 No pain

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