TMJ OSTEOARTHRITIS

Prepared by Lubna M. Qanber; Under the supervision of: The oral med. Specialist Dr. Muhassad Hameed
Dentistry college, University of Kufa

INTRODUCTION:
TMJ disorders are traditionally divided into three
generalized categories:
Group I (myofacial pain)
Group II (disc displacement)
Group III (inflammatory/ degenerative disorders)
with the last, which includes TMJ OA,
(Tempromandibular joint osteoarthritis).
Osteoarthritis (OA) is a joint degenerative disease
affecting the synovial joints and, according to
Waldron (2008), osteoarthritis is the most commonly
observed disease in skeletal remains.
OA results from a breakdown of the articular
cartilage --> which eventually alters the morphology
of the underlying bony structure.
Occasionally OA leads to immobility of the affected
joint (where the proliferation of marginal osteophytes
prevents the joint from moving normally, effectively
locking it in place), although this is rarely observed
in the TMJ.
OA

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2
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PROGRESSES IN THREE STAGES:

- Enzymatic breakdown

joint surface, 'pitting on the joint surface' or

porosity (sometimes linked to subchondral
cysts), alteration to joint contour (such as
flattening and widening), and eburnation, an
area of polished bone, caused by bone-on-bone
contact.
Clinically, OA can be diagnosed either by
symptoms observed during a physical
examination or through radiography, although
radiography is generally considered to be the
more accurate method of diagnosis. The
diagnosis of (TMJ) OA is primarily a
radiographic diagnosis.
1- The clinical signs of OA are crepitus
(grinding in the joint) associated with
movement, restriction of jaw movements, and
pain within
the joint cavity, which tends to be intermittent.
2- The radiographic signs of TMJ OA are as
follows: subchondral bone sclerosis, erosion,
flattening/irregularities or deformation of the
surface of the mandibular condyle, osteophytes,
and reduction of joint space.

- Cartilagenous breakdown
- Inflammation/bony response.

In an attempt to repair the damage caused by the

breakdown of cartilage and inflammation, the bony
tissue responds by producing extra bone to try and
stabilize joint integrity --> creating the distinctive
morphologic features of OA visible in skeletal
remains, including:
- New bone around the joint margins, new bone on

Oral appliances in the management of TMD

Oral appliances are described as
deprogrammers or jaw repositioners that can:
- Establish ideal craniomandibular relationships
- Relieving pain
- Restoring function
The changes in our understanding of the
pathophysiology of TMDs require that
traditional ideas about using OAs also must be
reconsidered.

TMJ osteoarthritis 1

Oral appliance designs

1- Flat plane stabilization appliance:
(Also known as the Michigan splint, muscle
relaxation appliance, or gnathologic splint) is
generally fabricated for the maxillary arch.
Alternatively, some clinicians have argued
that for reasons of enhanced esthetics and less
effect on speech, this type of appliance
should be fabricated for the mandibular arch.
The appliance is fabricated so that the
opposing dentition occludes uniformly,
evenly, and simultaneously with the
occluding surface of the appliance.

There are basically 2 different materials, based

upon consistency, which are used in the
fabrication of OAs.
First, there are hard acrylic resin OAs that are either
chemically cured or heat/pressure processed,
resulting in hard and rigid tooth-borne and occlusal
surfaces. Alternatively, there are soft or resilient
OAs manufactured from plastics or polymers,
producing an appliance which has a somewhat
flexible and pliable tooth-borne and occlusal
surface. There exists a third variation of material
known as dual laminated, because it consists of hard
acrylic resin on the occlusal surface and a soft
material on the inner aspect (tooth-borne surface).
It might seem from these studies that differences
between the use of soft and hard OAs in the
management of TMDs are not significant. However,
the majority of scientific evidence has shown more
consistent support for the use of hard acrylic resin
OAs rather than soft ones for the reduction of TMD
symptoms. Additionally, owing to the material and
adjustability advantages discussed earlier, it seems
reasonable to recommend the use of a hard acrylic
resin OA over a soft version for most patients with
appropriate TMD signs and symptoms. However,
soft OAs may be useful as a short-term treatment
measure in certain acute-onset TMD patients, as
well as for those patients where cost is a concern.
Because the most common and well validated
indication for appliances made with soft materials is
as athletic mouthguards to protect against and
diminish injury to the oral structures.

The intent of this appliance as outlined by the

American Academy of Orofacial Pain
guidelines is to:
- provide joint stabilization
- protect the teeth
- redistribute the [occlusal] forces
- relax the elevator muscles
- decrease bruxism
- increases the patients awareness of jaw
habits and helps alter the rest position of
the mandible to a more relaxed, open
position

.
Figure 1: Michigan OA
2- Traditional anterior bite plane:
In general, they are designed as a palatalcoverage horseshoe shape with an
occlusal platform covering 6 or 8
maxillary anterior teeth. They prevent
clenching, because posterior teeth are not
engaged in closing or in parafunctional
activities.

TMJ osteoarthritis 2

However, some critics have argued that these

appliances can lead to overeruption of posterior
teeth (which is extremely unlikely if worn only at
night) and others have worried that the TMJs will
be overloaded without posterior support.

The potential dangers with long term use of

this appliance are permanent and irreversible
occlusal and even skeletal changes. Therefore,
this type of appliance should be used with
discretion, and only for short periods of time.

Figure 2: Traditional anterior bite plane

Figure 4: Anterior repositioning appliance
3- Minianterior appliances:
The concept of making an oral appliance that
engaged only a small number of maxillary
anterior teeth (usually 2-4 incisors) to allow 2-4
mandibular incisors to contact a platform.

5-

Figure 3: Minianterior appliance

4- Anterior repositioning appliance:
(orthopedic repositioning appliance)
purposefully alters the maxillomandibular
relationship so that the mandible assumes a
more anterior position. Originally, it was
supposed to be used to treat patients with
internal derangements (usually anterior disk
displacements with reduction). It was thought
that by altering the mandibular position in this
manner, anteriorly displaced disks could be
recaptured, after which the new condyle-disk
relationship could be stabilized through
comprehensive dental or surgical occlusal
procedures. Currently it is recommended that
they should be used primarily as a temporary
therapeutic measure to allow for symptomatic
control of painful internal derangements, but
not to permanently recapture the TMJ disk.
TMJ osteoarthritis 3

Posterior bite plane appliances:

They are customarily made to be worn on
the mandibular arch. The design is
bilateral hard acrylic resin platforms
located over the mandibular posterior
teeth (usually molars and premolars) and
connected with a lingual metal bar. The
purpose of this appliance is to produce
changes to the vertical dimension and
alter the horizontal maxillomandibular
relationship.

Figure 5: Posterior bite plane appliance

6-

Pivot appliances:
The pivoting appliance is constructed with
hard acrylic resin that covers either the
maxillary or mandibular arch and
incorporates a single posterior occlusal
contact in each quadrant.

This contact is placed as far posteriorly as

possible. The purpose of this design is to
reduce intra-articular pressure by condylar
distraction as the mandible fulcrums
around the pivot, resulting in an unl
oading of the articular surfaces of the joint.
This appliance was recommended for
patients with internal derangements and/or
osteoarthritis.

Figure 6: Pivot appliance

7- Hydrostatic appliance:
This unique appliance was designed by
Lerman82 over 30 years ago. In its original
form, it consisted of bilateral water-filled
plastic chambers attached to an acrylic
palatal appliance, and the patients posterior
teeth would occlude with these chambers.
Later this was modified to become a device
that could be retained under the upper lip,
while the fluid chambers could be positioned
between maxillary and mandibular posterior
teeth. The concept was that the mandible
would automatically find its ideal position
because the appliance was not directing
where the jaw should be. No independent
research has been offered to substantiate this
claim.

Botulinum Toxin in the treatment of

TMD:
BoNT-A products can be used to help
patients with bruxism, TMD, Masseteric
Hypertrophy, Trigeminal neuralgia. Proper
training in the use of BoNT-A neurotoxins is
essential. Some clinicians typically treat
bruxism and TMD patients with bilateral
injections of BoNT-A into the masseter and
temporalis muscles. Using the right amount
of BoNT-A will reduce the intensity of
contractions of these muscles of mastication
as well as give your patient full competence
for chewing, eating properly, and speaking.
The relief afforded to patients by BoNT-A
neurotoxins can help eliminate facial pain,
significantly reduce their TMD symptoms
and potentially improve periodontal
treatment outcomes by removing the bruxism
element.

Figure 8: Botulinum toxin

Intra-articular injections with
corticosteroids and sodium hyaluronate
It was found that intra-articular injection
with corticosteroids and sodium hyaluronate
seems to be an effective method for treating
TMJ disorders. However, further randomized
controlled clinical trials, with representative
samples and longer follow-up time must be
carried out in order to assess the real
effectiveness of this technique.

Figure 7: Hydrostatic appliance

TMJ osteoarthritis 4

Case Report:
Dr. Muhassad Hameed Al-Mudhaffer
42 yrs old female patient came to our oral
medicine clinic with the following
complaints:
-Pain at the lower right quadrant and the
TMJ region (during eating + opening of the
mouth)
-Limitation in her mouth opening
Clinically:
-Extra-orally: Joint clicking
-Intra-orally: Teeth no. 36 & 46 were
extracted several years ago, as a result, teeth
no. 37 & 47 have got shifted mesially; overeruption of opposing teeth has occurred as
well.

Figure 9: Shifting of the second molar mesially

Figure 10 : CT scan

OPG & CT scan have been taken:

Findings:
- Anterior lipping of the right condylar
head
- Bone outgrowth (osteophyte),
subchondral cyst & erosion in the left TMJ
- The whole problem was due to the
premature contact (resulted from the
mesially shifted 37 & 47) which worked as
a pivot point on which the occlusion forces
became concentrated on.
The mandible then shifts into another
position than its usual; to avoid that contact
resulting in disk displacement and bone on- bone contact (articular eminence to the
anterior surface of the condyle) <-- Right
side

Figure 11: OPG showing: Anterior lipping of the right condylar head. Bone outgrowth
(osteophyte), subchondral cyst & erosion in the left TMJ

TMJ osteoarthritis 5

References:

Figure 12: CT scan digitally

Figure 3: OPG

Treatment:
-Glucosamine 1*1
-Medrol 1*1 for 4 days
- Selective grinding (removing high spots,
interfering points)
-Occlusal splint therapy to allow muscles
in spasm to relax, protects the teeth and
jaws, and normalizes periodontal ligament
proprioception. It can also allow
repositioning of the condyles and jaws
into centric relation.

Figure 13: Stabilization splint

TMJ osteoarthritis 6

TMJ osteoarthritis: new approach to

diagnosis, Dr Carolyn Rando, UCL
institute of Archaeology. University
College London
Oral appliances in the management of
temporomandibular disorders Gary D.
Klasser, DMD,a and Charles S. Greene,
DDS,b Chicago, Illinois COLLEGE OF
DENTISTRY, UNIVERSITY OF
ILLINOIS, 2009
Botulinum Toxin for Frontline TMJ
Syndrome and Dental Therapeutic Treatment
A Peer-Reviewed Publication Written by
Louis Malcmacher DDS MAGD, 2012,
http://www.dentaleconomics.com/
Machado E, Bonotto D, Cunali PA. Intraarticular injections with corticosteroids and
sodium hyaluronate for treating
temporomandibular joint disorders: A
systematic review. Dental Press J Orthod.
2013