1. What is the diagnose?

Missing posterior teeth and TMD:

The factors supporting the hypothesis of an association between posterior teeth and
functioning of TMJ, to name a few are
1. The absence of posterior support results in overloading of the temporomandibular joint
(TMJ) structures.
2. It has been assumed and experimentally proved that the absence of posterior teeth
would result in mandibular overclosure and as a consequence, the condyles would deviate
from their normal centric position in the TMJ,
causing dislocation in the joint. [15, 16]
3. Joint pain has also been reported more frequently on the side with most missing teeth
and increased risk of joint disorders were found in subjects without any molar support.
4. Correlation between absence of posterior support and osteoarthritis of TMJ was
reported in several studies.[18] However, this has been controversial as few other studies
have concluded that risk of osteoarthritis of the temporomandibular joint in people
without posterior teeth was not different from those with complete dental arches.
Furthermore no correlation could be found between the number of remaining teeth and
severity of symptoms of temporomandibular disorders.[19,20]
5. Missing posterior teeth has been associated with the TMJ sound like clicking. Previous
studies have also observed that TMJ sounds may originate from changes in articular
surfaces, deviations in the form of articularcomponents [21,22]and lack of muscle
coordination.[23] In another study, it was observed that loss of molar support was
involved in the initiation of lesions on the load bearing articular surfaces of the condyle
and articular eminence of younger individuals.[24] A recent study examined the
relationship between missing mandibular molars and TMJ dysfunction. It was concluded
from the study that clicking joint sound and condylar flattening of the TMJ was more
significant in unilateral loss of molars as compares to bilateral loss. [25]
Source: http://www.iosrjournals.org/iosr-jdms/papers/Vol13-issue12/Version-4/N0131246063.pdf
2. Why the doctor suggested the patient to use bite plane anterior (find the picture)?

An anterior biteplate is an appliance that would fit snuggly to the palate of the patient (roof of
the mouth) and disarticulates the front teeth (stops the upper and lower front teeth from
touching each other). The appliance is retained in the mouth with the help of the clasps found
in the appliance. Adams clasps around the molars and ball clasps in the space between teeth
are most commonly used for this purpose of retention.
Components:

1. Palatal acrylic coverage and anterior baseplate

2. Adams clasps for retention
3. Hawley type labial bow for anterior stabilization (optional)
Note: a C-clasp may be used instead of an Adams clasp if the Adams clasp is found to
interfere with the occlusion.
Indications:

An anterior biteplate is most commonly used to correct a deep bite (when the upper front
teeth greatly overlap the lower front teeth). Such cases render orthodontic treatment harder to
deliver: deep bite combined with low overjet (upper front teeth sliding too close against the
lower front teeth) leads to shearing off of lower brackets. Deep overbite also hinders the
anterior-posterior movement of teeth (teeth moving forward and backward), leading to delays
in response to orthodontic dental treatment.

Its main function is to disocclude posterior teeth with relative intrusion of anterior teeth to
allow for:

1. Correction of deep bite by extrusion of posterior teeth and relative intrusion of anterior
teeth
2. Correction of posterior crossbite of dental origin
3. Eliminate adverse forces of occlusion
4. Eliminate occlusal interference to facilitate tooth movement
5. Correction of some temporal mandibular disease when use in combination with fixed
appliance
6. Correction of a Class II div. I. Used as a functional appliance, it causes the disarticulation
of the posterior teeth and forces the mandible to bite in a more forward position.
The disarticulation of the front teeth by the biteplate opens a space in the back of the mouth
between the posterior teeth as shown in the picture (Fig3) The space now existing between
the upper and lower teeth (the posterior ones) encourages them to erupt further. This is due to
the fact that teeth keep growing until they come against resistance. The eruption of the
posterior teeth will decrease the overbite (amount of lower front teeth covered/overlapped by
upper front teeth when biting).
Contraindications:

- Incompliant patient
- High caries risk
- Poor oral hygiene
- Patient with long lower face height

3. What are the appliances that can be used to treat TMD? (find the picture)

4. Congenital, pathologic, and traumatic dislocation

Congenital dislocation of the hip dislocations in the hip joint), the most
frequent. Predominantly occur in girls. Connected with the underdevelopment
of the hip joints (both one or more often).
Traumatic dislocations occur from excessive (beyond normal movement)
movement in the joint - violent or produced victims (for example, the
dislocation of the lower jaw when yawning, shoulder while waving his hand).
Less dislocation occurs from a punch in the joint area. As a rule, dislocations
are accompanied by a rupture of the articular capsule. The exception is the
dislocation of the lower jaw.
Pathological fractures occur in diseases of the joints, accompanied by the
destruction of the articular ends of bones. Most frequent pathological fractures
of the hip joint (tuberculosis, infectious inflammation, with some organic
diseases of the nervous system).

5. Types of surgery: (open and close method)

Arthrocentesis:
This is performed under general anesthesia or IV sedation. In this procedure, the
surgeon injects local anesthesia and fluids inside the joint to flush out inflamed
fluids. It is indicated in cases where the articular disc has adhered to temporal
fossa. This procedure requires approximately 15 minutes.
Arthroplasty:
This procedure refers to open surgery of TMJ. It includes Disc repositioning,
Discectomy and joint replacement
o Disc Repositioning:
This is done in conditions of disc displacement which creates a popping
noise inside the joint. It is done with the patient under general anesthesia.

The surgeon makes an incision over the joint area. The disc is then moved
back to its original position and sutured.
o Discectomy:
This is done when the disc is damaged. Under general anesthesia, the
surgeon makes an incision and the disc is removed.
o Articular Eminence Recontouring:
This is indicated when the articular eminence is too deep due to excess
force exerted on the condyle. In this procedure, the surgeon shortens and
smoothes the articular eminence.
TMJ replacement:
This is indicated in cases of badly damaged joints from severe degenerative
disease, advanced rheumatoid arthritis and congenital deformity of TMJ.
There are two types of TMJ replacement surgery:
o Partial Joint replacement: In this surgery only one of the components (disc,
ball or socket) is replaced. If the temporal bone surface is not smooth, a
metal liner (fossa replacement) is placed to restore motion. When the ends
of the jawbone are damaged (condylar injury), they can also be replaced.
o Total joint replacement: The ball and joint both are replaced with metal
components. Once placed the two metal components glide smoothly across
each other.
6. Open joint surgery
There are many types of open joint surgeries. In all of them, the surgeon operates on
the TMJ without the use of special equipment like video monitors. Instead, an incision
is made just in front of the ear and the joint is operated on under direct vision. Your
oral surgeon may suggest this type of surgery if:

Your problem cannot be corrected with arthroscopy

Your TMJ is degenerating

You have tumors in or around your TMJ

It takes longer to heal from this type of surgery than it does from arthroscopy. Although there
is a chance of scarring, the incision usually heals very well and is difficult to notice. Your
surgeon will discuss other risks of surgery.
Open-joint arthroplasty is surgery to repair, reposition, replace, or remove parts in a joint.
When used to treat temporomandibular disorder (TMD), this usually involves the articular
disc that cushions the jaw joint.