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Outline
American Association of Orthodontists
TMD diagnosis
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
Deviation Deflection
Click Crepitus
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X X
Sharp pain, at the left and right
Main complaints X X preauricular regions; during click
sound, during chewing and opening
X movements
Preauricular pain, right and left X
TMJs clicking sounds,
headache, malocclusion, missing Headache
posterior teeth - localization: temporal region, bilaterally
- frequency: often (2-3 times/week)
- intensity: moderate-high (5-7 VAS)
- decreases with rest and increases with jaw
movements
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
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Not necessary
Outline
TMD diagnosis
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7 patients
2 controls
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.
normal joints
normal joints
Left
Wide distribution
Pullinger A, JOR 2013
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CONCLUSION
There is no evidence that asymptomatic TM
joints with posterior positioned condyles are
at risk for disc displacement derangements.
Outline
TMD diagnosis
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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
10 % MVC
No changes in PPT
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Different
adaptation
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
Aim
250 subjects filled the Oral Behaviour Checklist
Oral Behavior Checklist (OBC) Markiewicz et al, 2006
10th 90th
80%
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p<0.01
Conclusion
During AIC occlusal discomfort, headache High trait anxiety Low trait anxiety
and spontaneous pain were higher in individuals individuals
Parafunctional Subjects
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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°
Graded Chronic
Pain Scale
20
10
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° Physiotherapy
2°
Depression
and non
specific
physical ° Prosthetic
3°
symptoms rehabilitation
° Psychiatric
4°
Consultation
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Orthodontic treatment
Main complaint
Bilateral facial pain. Severe pain on both
sides in the masseter and temporal regions.
1) Counseling
Myofascial pain 2) Physiotherapy
3) Drugs
For 3 weeks
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M.S. 25 ys
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
13