[Otalgia and tinnitus in patients with craniomandibular dysfunctions]

AIMS OF THE STUDY

The high prevalence of ear, nose, and throat symptoms in patients with craniomandibular disorders seems to depend on the connection between both phenomena. The present study evaluates the connection between craniomandibular disorders (CMD) and otalgia or tinnitus, investigates the correlation between specific diagnoses of CMD with otalgia or tinnitus, and estimates the effects of treatment of CMD on these ear symptoms.

PATIENTS AND METHODS

The information from case histories, clinical examinations, and treatment results of 221 patients with CMD were coded and evaluated by computer. All patients received conservative treatment with occlusal splints, training in self-observation of parafunction, massage of the masticatory muscles, and heat therapy. At least 1 year after the first examination, all patients were reevaluated. According to their complaints, the patients could be divided into three groups: (1) CMD patients without ear symptoms (n = 134 = 61%), (2) CMD patients with otalgia (n = 80 = 37%), and (3) CMD patients with tinnitus (n = 8 = 3.8%) (one patient with tinnitus and otalgia).

RESULTS

Otalgia correlated significantly with CMD and the specific CMD diagnoses of anterior disk displacement (ADD) without reduction and osteoarthrosis. Of the reevaluated patients with otalgia, 90% had no ear pain and 10% reported reduced or less frequent ear pain. Only one of the eight cases with tinnitus noted reduced noises; the remaining seven perceived no influence on their ear noises from therapy.

CONCLUSIONS

Due to the treatment results, otalgia has to be interpreted as a possible symptom of CMD and not as a separate diagnosis.

Dental and skeletal changes associated with long-term mandibular advancement

STUDY OBJECTIVES

Little is known of the possible dental or skeletal side effects following the use of mandibular advancement in the treatment of obstructive sleep apnea. A study has subsequently been designed to investigate these issues.

DESIGN

100 consecutively treated medically referred patients were reviewed cephalometrically in 6-month intervals (6-30 months) following mandibular advancement therapy.

SETTING

Orthodontic Private Practice.

PATIENTS

87 males, 13 females (mean age 49 years, SD 8.5, range 33-74 years).

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

Reference points and planes in the cranial base, maxilla, and mandible were digitized with a reflex metrograph and their means converted to linear and angular measurements. Significant changes following mandibular advancement were observed in lower face height, vertical condylar position, incisor angulation, overbite, and overjet. Skeletal changes were attributed to a vertical repositioning of the mandibular condyle relative to the cranial base and were present at the first review period (6 months). Dental changes occurred later with treatment with the most significant changes occurring at the final review period (30 months) which resulted in a 4.9 degrees proclination of the mandibular incisors and a reduction in overbite of 1.82mm.

CONCLUSION

The data suggests that long-term use of mandibular advancement can cause dental and skeletal changes which may be progressive over time. As many consider mandibular advancement a treatment for life, it is strongly recommended that all patients be fully informed of the potential for such changes prior to treatment and undergo mandatory dental reviews with long-term mandibular advancement.

Oral habits among adolescent girls and their association with symptoms of temporomandibular disorders

AIM

To evaluate the contribution of certain parafunctional activities to the presence of temporomandibular disorder (TMD) symptoms among teenage girls, with special emphasis to gum chewing and jaw play.

METHODS

A total of 323 girls, aged 15-16 years, were randomly selected from a religious junior high school. The girls responded to a questionnaire on oral habits and TMD symptoms.

RESULTS

Gum chewing was a very prevalent habit (62.4%), performed daily (mean chewing time 3.95 h day-1). Girls who chewed intensively (more than 4 h day-1) showed associations with pain in the ear area during function and at rest, as well as with joint noises. Jaw play, although reported by only 14.3%, was significantly associated with pain in the ear area during function and at rest, feeling of tiredness of the jaw while chewing, joint noises, catch and lock. All oral parafunctions, except chewing gum, were associated with jaw play and with each other.

CONCLUSIONS

Jaw play was the most detrimental habit in TMD; intensive gum chewing was a potentially contributing factor for joint noises and pain. Oral parafunctions (except chewing gum) were significantly associated between themselves and suggest a behavioural pattern of "jaw hyperactivity".

Locating the centric relation prematurity with a computerized occlusal analysis system

Locating the first tooth contact that interferes with freedom of movement in and out of centric relation has been the diagnostic and treatment objective of most occlusal therapies. The centric relation prematurity can be located by various methods, which involve operator-guided mandibular positioning combined with the patient's subjective assessment of his or her perceived first tooth contact. The method known as bimanual manipulation has been widely recognized and accepted as a predictable method of determining and verifying the centric relation position. The first occlusal contact that results when the mandible is closed on a correct centric relation axis is known as the centric relation prematurity. An alternative procedure combines bimanual manipulation with the simultaneous recording of the sequence of resultant tooth contacts using a computerized occlusal analysis system. This alternative offers a significant improvement in the precision of locating the first tooth contact. This article describes a method of identifying the first tooth contact while not relying on the patient's subjective assessment of his or her perceived occlusal feel.

[Masticatory system pain-dysfunction syndrome at the University Hospital Center in Yaounde, Cameroon--a study in 1994]

TMJD is a painful syndrome. Carrying a patient suffering of this syndrome is above all to relieve him of pain. The treatment of TMJD is therefore primary the treatment of pain, but as it is known, pain is just a physiologic phenomenon. It can be found in a particular way in between the person. The personality and his culture and this demand the person who treats to treat without going to therapeutical express and to consider the social context in which the patient lives. In the treatment of TMJD, we know how to give good dental treatment. We know how to prescribe muscle relaxants, anti-anxiety drugs and anaesthetics but the psychological aspect remains, according to my humble opinion, as the most favouring factor which we should absolutely consider in case of patient who does not present any occlusal aetiology. This patient should rather be oriented towards a specialist in psychotherapy or towards a post traumatic psychological recuperation which is done in "Life Center for Women" for example.

A review of the evidence for overlap among unexplained clinical conditions

PURPOSE

Unexplained clinical conditions share features, including symptoms (fatigue, pain), disability out of proportion to physical examination findings, inconsistent demonstration of laboratory abnormalities, and an association with "stress" and psychosocial factors. This literature review examines the nature and extent of the overlap among these unexplained clinical conditions and the limitations of previous research.

DATA SOURCES

English-language articles were identified by a search of the MEDLINE database from 1966 to January 2001 by using individual syndromes and their hallmark symptoms as search terms.

STUDY SELECTION

Studies that assessed patients with at least one unexplained clinical condition and that included information on symptoms, overlap with other unexplained clinical conditions, or physiologic markers. Conditions examined were the chronic fatigue syndrome, fibromyalgia, the irritable bowel syndrome, multiple chemical sensitivity, temporomandibular disorder, tension headache, interstitial cystitis, and the postconcussion syndrome.

DATA EXTRACTION

Information on authorship, patient and control groups, eligibility criteria, case definitions, study methods, and major findings.

DATA SYNTHESIS

Many similarities were apparent in case definition and symptoms, and the proportion of patients with one unexplained clinical condition meeting criteria for a second unexplained condition was striking. Tender points on physical examination and decreased pain threshold and tolerance were the most frequent and consistent objective findings. A major shortcoming of all proposed explanatory models is their inability to account for the occurrence of unexplained clinical conditions in many affected patients.

CONCLUSIONS

Overlap between unexplained clinical conditions is substantial. Most studies are limited by methodologic problems, such as case definition and the selection and recruitment of case-patients and controls.

Temporomandibular disorders in relation to craniofacial dimensions, head posture and bite force in children selected for orthodontic treatment

The present study examined the associations between craniofacial dimensions, head posture, bite force, and symptoms and signs of temporomandibular disorders (TMD). The sample comprised 96 children (51F, 45M) aged 7-13 years, sequentially admitted for orthodontic treatment of malocclusions entailing health risks. Symptoms and signs of TMD were assessed by 37 variables describing the occurrence of headache and facial pain, clicking, jaw mobility, tenderness of muscles and joints, and the Helkimo Anamnestic and Dysfunction indices. Craniofacial dimensions (33 variables), and head and cervical posture (nine variables) were recorded from lateral cephalometric radiographs taken with the subject standing with the head in a standardized posture (mirror position). Dental arch widths were measured on plaster casts and bite force was measured at the first molars on each side by means of a pressure transducer. Associations were assessed by Spearman correlations and multiple stepwise logistic regression analyses. The magnitudes of the significant associations were generally low to moderate. On average, temporomandibular joint (TMJ) dysfunction was seen in connection with a marked forward inclination of the upper cervical spine and an increased craniocervical angulation, but no firm conclusion could be made regarding any particular craniofacial morphology in children with symptoms and signs of TMJ dysfunction. Muscle tenderness was associated with a 'long face' type of craniofacial morphology and a lower bite force. Headache was associated with a larger maxillary length and increased maxillary prognathism. A high score on Helkimo's Clinical Dysfunction Index was associated with smaller values of a number of vertical, horizontal, and transversal linear craniofacial dimensions and a lower bite force.

Temporomandibular disorders in adults with repaired cleft lip and palate: a comparison with controls

The purpose of this study was to investigate the prevalence of temporomandibular disorders (TMD), and assess psycho-social distress in adult subjects with repaired complete cleft lip and palate (CLP). Sixty-three adults (42 males and 21 females, mean age 24.2 years, range 19.5-29.2) with repaired CLP (CLP group) were compared with a group of 66 adults without cleft (non-cleft group, 49 males and 17 females, mean age 25.5 years, range 20.2-29.9). All subjects underwent a clinical TMD examination, which followed the guidelines in the Research Diagnostic Criteria for TMD (RDC/TMD). Jaw function was assessed by evaluating answers to the mandibular function impairment questionnaire (MFIQ). Tension-type headache was diagnosed according to the International Headache Society (IHS) classification. Psychological status was assessed using the depression score and the non-specific physical symptom score with subscales of the Revised Symptom Checklist-90 (SCL-90-R). The prevalence of reported pain in the face, jaws and/or TMJs was 14 and 9 per cent for the CLP and non-cleft group, respectively, and did not differ significantly between the groups. The CLP group exhibited a significantly reduced jaw-opening pattern (P < 0.001) and a higher frequency of crossbites (P < 0.05) compared with the non-cleft group. Whilst jaw function was similar in both groups, a few items, e.g. speech and drinking, were significantly more impaired (P < 0.01) in the CLP group than in the non-cleft group. There were no significant differences between the two groups concerning tension-type headache or psycho-social distress. The study found that overall TMD pain or psycho-social distress was not more common in this CLP group than in a non-cleft group.

Tooth wear and loss: symptomatological and rehabilitating treatments

The authors report a clinical case that presented tooth wear and absence, with painful muscular and articular symptomatology, and also alteration in deglutition, mastication and speech. The clinical procedures used were re-establishment of vertical dimension of occlusion, mandibular centric relations, and occlusal contacts through therapeutic removable partial dentures. The condyle position was analyzed in habitual occlusion and in occlusion with dentures, through transcranial radiographs of the temporomandibular joints. Oral rehabilitation was achieved with dental restoration and removable partial dentures.

Does orthodontics damage faces?

With the increasing provision of orthodontic care in this country, certain practitioners have raised concerns regarding the use of elective extractions and retraction mechanics, especially the effects on the facial profile and the TMJ. The non-extraction versus extraction debate spans the history of orthodontics, and the concepts of facial attractiveness are subject to change as fashions change. Within the realms of evidence-based practice, there is little or no evidence to suggest that the philosophies and mechanics of contemporary orthodontics, in the vast majority of cases, cause damage to the profile or are directly linked to the development of TMJ dysfunction.

[Comparison of treatment options for myogenous temporomandibular dysfunction]

A randomized clinical trial which included a follow-up of one year was applied to 118 myogenous TMD-patients. The therapies investigated were: physiotherapy of the masticatory system or splint therapy for patients without occlusal interferences, and occlusal adjustment therapy or the combination of splint and occlusal adjustment therapy for patients with pronounced occlusal interferences. Counseling, which yielded a reduction of 27% of the scored pain intensity, will most likely eliminate any further need for treatment of patients with a low level of myogenous TMD signs and symptoms. Otherwise, physiotherapy might be preferred as a starting option with respect to splint therapy because of 1. A similar efficacy; 2. A shorter treatment duration so that either chronic facial pain is earlier relieved or a patient can undergo a second type of therapy earlier; and 3. Lower costs. One third of the patients selected had pronounced occlusal interferences. Using stringent criteria it might be possible to apply occlusal adjustment therapy without involvement of splint therapy yielding a similar therapy efficacy and with advantages of a shorter treatment duration and lower costs. All types of therapy diminished not only facial pain but also pain of neck and shoulder areas.

Oral symptoms and signs in elderly patients with type 2 diabetes mellitus. A focus on diabetic neuropathy

OBJECTIVE

We investigated oral disorders and compared the findings with the occurrence of neuropathy in type 2 diabetes mellitus.

STUDY DESIGN

Mucosal diseases, tooth loss, and temporomandibular joint dysfunction were examined in 45 patients with long-term type 2 diabetes mellitus and in 77 control subjects. The occurrence of neuropathy was evaluated by neurophysiologic tests.

RESULTS

Of patients with diabetes, 56% suffered from dry mouth and 18% from glossodynia; of controls, correspondingly, 36% and 7% (P <.05); 2 or more mucosal lesions were detected in 42% and 20%, respectively (P =. 008). Temporomandibular joint dysfunction was found in 27% of subjects with diabetes and in 16% of control subjects. Peripheral neuropathy was present in 42% of patients with diabetes and in none of the controls (P <.01), and autonomic parasympathetic neuropathy in 54% and 31%, respectively (P =.02). Peripheral and autonomic parasympathetic neuropathies were independent risk factors for tooth loss and temporomandibular dysfunction.

CONCLUSIONS

Diabetic neuropathy was found to be associated with tooth loss and temporomandibular joint dysfunction.

Headache as a manifestation of otolaryngologic disease

Headache can be caused by a multitude of factors, but experienced physicians accustomed to treating patients with headache are adept at making an accurate diagnosis. Occasionally, however, a patient has an unusual presentation of headache or facial pain. In these cases, it can be difficult to classify the etiology of the headache despite the performance of a thorough physical examination and the acquisition of appropriate diagnostic tests. Awareness of some of the otolaryngologic diseases that can manifest as facial pain or headache may help the physician better diagnose and treat this complex problem.

Presence of orofacial pain and temporomandibular disorder in fibromyalgia. A study by questionnaire

The objective of this study was to evaluate subjective symptoms from the temporomandibular system in patients with fibromyalgia. Two hundred and thirty-seven individuals with fibromyalgia affiliated to the Stockholm Rheumatologic Association were included in the study. A questionnaire about symptoms of temporomandibular disorders (TMD) was mailed and returned by 191 (81%). The participants reported frequent and severe symptoms of TMD, 94% reported local pain from the temporomandibular system with a mean duration of 12 years. The most frequent sites were the temple, temporomandibular joint and neck regions. General body pain had a significantly longer duration than TMD, which indicates that fibromyalgia starts in other parts of the body and later extends to the temporomandibular region. The severity of general pain scored significantly higher than local pain, but there was a significant positive correlation between the two conditions. High frequency, 73-78 %, of headache, facial pain and tiredness of the jaws was found and about fifty percent of the patients also complained about difficulties to open the mouth and to chew. Fibromyalgia is thus a probable cause of TMD. In conclusion this study shows that patients with fibromyalgia often suffer from symptoms of TMD, and that the intensity of the pain is correlated to general body pain. These findings indicate that fibromyalgia is one of the causes of TMD.

Symptoms and signs of temporomandibular disorders before, during and after orthodontic treatment

The relationship between orthodontic treatment and symptoms and signs of temporomandibular disorders (TMD) was studied prospectively and longitudinally in 65 adolescent girls with Class II malocclusion. The subjects received orthodontic fixed appliance treatment with the straight-wire technique combined with or without extractions and were examined for symptoms and signs of TMD before, during, after, and finally one year post-treatment. Both symptoms and signs of TMD showed considerable fluctuations over the three-year period within the individuals. The general tendency was a decreased prevalence of symptoms of TMD over the three years. The prevalence of pain on mandibular movement and tenderness to palpation of the masticatory muscles was significantly less common during and after orthodontic treatment than before. Clinically registered TMJ clicking increased slightly over the three year period. One orthodontic treatment effect when normalizing Class II malocclusions with fixed appliances was a decreased prevalence of functional occlusal interferences. We concluded that the orthodontic treatment either with or without tooth extractions did not increase the risk for TMD or worsen pre-treatment signs of TMD. Subjects with Class II malocclusion and pre-treatment signs of TMD of muscular origin seemed rather to benefit functionally from orthodontic treatment in a three-year perspective.

[Treatment of bruxism: physiotherapeutic approach]

Epidemiological and experimental studies suggest that there is a relationship between bruxism and pain in the orofacial region, and between bruxism and restricted mandibular movements. However, the exact nature of this relationship remains unclear. Therefore, up till now, the following working hypothesis is used: bruxism can lead to (chronic) pain complaints and restricted mandibular movements, when its intensity exceeds the adaptation capacity of the musculoskeletal structures. In that case, the aims of physical therapy treatment are twofold: to decrease symptoms, such as pain ('symptom therapy'), and to teach the patient to recognise and reduce the bruxism ('behavioral therapy'). Techniques used for symptom treatment are massage and stretching exercises. For the behavioral therapy exercises and myofeedback are often used.

The craniocervical connection: a retrospective analysis of 300 whiplash patients with cervical and temporomandibular disorders

Because the concept of whiplash as a causative factor for temporomandibular disorders (TMD) is highly controversial, we decided to do a retrospective analysis of patients treated in our office who had sustained whiplash injuries and were treated for cervical and temporomandibular disorders. The records of 300 patients with TMD preceded by a motor vehicle accident were examined retrospectively. The most common presenting symptoms, in order, were: jaw pain, neck pain, post-traumatic headache, jaw fatigue, and severe temporomandibular joint (TMJ) clicking. The most common TMD diagnoses were: masseter trigger points, closing jaw muscle hyperactivity, TMJ synovitis, opening jaw muscle hyperactivity, and advanced TMJ disk derangement. Based primarily on the physical examination, we concluded that the TMJ and surrounding musculature should be examined similarly to other joints, with no preconceived notion that TMD pathology after whiplash is unlikely.

[Bruxism and temporomandibular disorders]

Bruxism is generally regarded as an important predisposing as well as an initiating factor in temporomandibular disorders. Many studies have demonstrated an association between bruxism and symptoms and signs of temporomandibular disorders, in adults as well as in children. However, a causal relationship has not been established. Currently, the most probable hypothesis is that other factors, reducing the adaptive capacity of the temporomandibular joint and associated tissues, have to be present for bruxism to play an initiating role.

TMD: it's our responsibility! Part Two

Dentists modify and construct occlusions. This occurs on a daily basis in the disciplines of restorative, fixed and removable prosthetics and orthodontics. These procedures influence the TMJ, the muscles of mastication, the supporting structure of the teeth and the teeth as well. Dentists have an opportunity to not only objectively analyze how they all interrelate, but to create a physiological harmonious relationship. This will reduce a traumatic occlusion to one that is within the histological adaptive range for the tissue to accommodate. This knowledge can be applied to not only help patientsí pain and dysfunction, but to ensure confidence that dentists are not going to be responsible for iatrogenic results. The future of dentistry is not only being able to effectively deal with TMD but to prevent the problems. Management of mandibular whiplash and migraine headaches are also becoming our responsibility. Dentists are the specialists of occlusion. With the technology available to render this quality of care, they must fulfill their obligation to the public, take responsibility and continue to increase their capability. This approach to dentistry provides a new "window of opportunity" as its many applications have yet to be explored.

Need for occlusal therapy and prosthodontic treatment in the management of temporomandibular disorders. Part I. Occlusal interferences and occlusal adjustment

This review, divided into two parts, evaluates the literature on the relationship between dental occlusion and temporomandibular disorders (TMD) and the need for occlusal therapy in the management of TMD. The first part of the review focuses on the aetiological importance of occlusal interferences and the place of occlusal adjustment in the management and prevention of signs and symptoms of TMD. This has long been a controversial issue, which has not yet been resolved. The literature does not give strong support for the role of occlusion in the aetiology of TMD. Experienced clinicians also repudiate the need for occlusal adjustment in the management of TMD, whereas (less experienced) general dentists adhere to a concept focusing on the occlusion in diagnosis and treatment of TMD. There is a consensus that generalized prophylactic occlusal adjustment is not justified. There is an obvious need for research with evidence-based methods, to be able to answer the many remaining questions in this field.

Bleaching and temporomandibular disorder using a half tray design: a clinical report

A maxillary soft, custom-fitted tray was fabricated for a patient to perform nightguard vital bleaching. Treatment was interrupted after the patient experienced pain in the temporomandibular joint area shortly after wearing the bleaching prosthesis. The tray was trimmed so the labial, incisal and buccal cusps were covered and Sc) the patient had complete tooth-to-tooth contact in the maximum intercuspal position. The prosthesis proved to be retentive even without the presence of the bleaching material. The thick, sticky bleaching material was contained in the half tray design and the tray was held in place. The patient was able to continue the bleaching process for the 2-week duration necessary to achieve successful lightening of the teeth without further TMD symptoms.

Prevalence and patterns of nocturnal bruxofacets on stabilization splints in temporomandibular disorder patients

The purpose of this study was to investigate the prevalence of nocturnal bruxism, the characteristics of bruxofacets, and the reduction of symptoms in temporomandibular disorder (TMD) patients. The study involved the observation of bruxofacets on a stabilization splint. Twenty-six patients (22 women and 4 men, 16-54 years of age) with signs and symptoms of TMD were given an initial examination before using a splint, and then at intervals of one, three, six and ten weeks after a stabilization splint was first used. In 88% of the patients (n = 23) active shiny facets or scratches caused by nocturnal bruxism appeared on the occlusal surface of splints within ten weeks. In 52% of the 23 patients these facets were created by bilateral mandibular excursions, in 35% by small lateral movements, and in 13% by unilateral excursions. Subjective pain and the Craniomandibular Index in patients had decreased after ten weeks (p < 0.001), but a reduction of symptoms did not differ according to the patterns of the bruxofacets. It was concluded that most TMD patients have a parafunctional habit, namely bruxism. Further research is needed to produce more convincing evidence of a true cause-and-effect relationship between nocturnal bruxism and TMD.

[Iatrogenic effects of orthodontic therapy]

Iatrogenic effects of orthodontic treatment are root resorption, pulpal changes, decalcifications and white spots, gingival and periodontal changes, enamel surface changes, temporomandibular dysfunction, immunological reactions, pain and discomfort, and accidents. The authors discuss these items and give, if possible, tips to prevent or reduce these effects.

Temporomandibular joint dysfunction and occlusion in the mixed and permanent dentition

The aim of this study was to investigate the relation between occlusal factors: Angle classification, overbite, overjet, openbite, anterior and posterior crossbite, scissors bite or buccal crossbite and lateral openbite--and the presence of mandibular dysfunction in a sample of 359 Turkish children with mixed and permanent dentition. Z Test was used to compare the results. It was found that, Class III malocclusion in the permanent dentition and openbite, overbite = 0, overjet = 0, anterior-posterior crossbite in the mixed dentition were related with TMD.

[The clinical x-ray aspects of the diagnosis and treatment of the temporomandibular joint pain dysfunction syndrome]

Clinical and x-ray picture of the syndrome of painful dysfunction of the temporomandibular joint is described. Differential diagnosis of this syndrome and other articular diseases with similar clinical symptoms is presented. Treatment strategy is described in brief.

[Impaired occlusion is the main etiological factor in the occurrence of temporomandibular joint dysfunction]

A homogeneous group of 104 subjects aged 21-34 years was examined. Forty-nine (47%) subjects (study group) presented with symptoms of abnormalities of the masticatory muscles and temporomandibular joint, 58 subjects (53%) without such symptoms were controls. Clinical examination was carried out with evaluation of occlusion, Angle's [correction of Engle's] class, and analysis of dental contacts in the oral cavity in different types of occlusion. Disorders of occlusion were detected in 31% of controls and in 73% patients in the study group. Disorders of occlusion correlated with the number of symptoms of temporomandibular joint dysfunction. The detected super-contacts of teeth are the main etiological factors leading first to discoordination of the masticatory muscles and then to functional disorders of the temporomandibular joint.

Craniomandibular status and function in patients with habitual snoring and obstructive sleep apnoea after nocturnal treatment with a mandibular advancement splint: a 2-year follow-up

The aim of the investigation was to evaluate the status and function of the temporomandibular joint (TMJ) and masticatory system in patients with habitual snoring and obstructive apnoea after 2 years nocturnal treatment with a mandibular advancement splint. Thirty-two patients participated in the study, ranging from 43.0 to 79.8 years of age (mean 54.4 years, SD 8.78) at the start of treatment. All patients had been referred from the ENT department for treatment with a mandibular advancement splint. The acrylic splint advanced the mandible 50-70 per cent of maximal protrusion, opened 5 mm vertically, and was used 6-8 hours per night and 5-7 nights per week. Overjet, overbite, and molar relationship were measured on dental casts. The patients were asked to answer a questionnaire concerning symptoms of craniomandibular dysfunction (CMD). They were also clinically examined in a standardized manner, including registration of range of mandibular movements, TMJ sounds, pain on movement, and palpatory tenderness of the TMJ and the masticatory muscles. None of the patients showed more than five symptoms of dysfunction either at the start of or after 2 years of treatment. A decrease in the frequency of headache was found for nine of those 18 patients that reported headache (P = 0.004). A minor, but significant decrease in overjet and overbite was found and the molar relationship was also changed. It was concluded that 2 years' treatment with a mandibular advancement splint had no adverse effects on the craniomandibular status and function, but the observed occlusal changes requires further evaluation.

Arthrogryposis multiplex congenita in a patient with limited mouth opening: a case report

This report describes a case of arthrogryposis multiplex congenita and concomitant bruxism with limited mouth opening and pain in the temporomandibular joints (TMJ). A conservative treatment with a myorelaxing splint and physiotherapeutic exercises was prescribed resulting in improvement to the muscular and joint conditions and a reduction in pain.

Recent developments in understanding temporomandibular joint disorders. Part 1: Bone marrow abnormalities of the mandibular condyle

Improvements in diagnostic imaging of the temporomandibular joint in the past 20 years have shown that disk displacement is the most frequent abnormality in patients with joint pain and dysfunction. The aetiology of the pain is poorly understood. Recent studies with magnetic resonance imaging have demonstrated a number of other changes in the TMJ. In this paper I review the possible significance of alterations in the condylar bone marrow and its relationship to osteonecrosis.

The incidence of pain in the muscles of mastication in patients with fibromyalgia

This study recognizes the high incidence of temporomandibular symptoms in a group of patients with documented fibromyalgia. Findings indicate that the diagnosis and treatment of temporomandibular disorders and fibromyalgia have many similarities.

Managing bruxism and temporomandibular disorders using a centric relation occlusal device

This article discusses the rationale, indications, and fabrication of the centric relation occlusal (CRO) device in the management of bruxism and temporomandibular disorders. Five methods of fabricating occlusal devices are briefly discussed. Two methods, preferred by the authors, are discussed in detail, including the laboratory phase. One method uses heat-cured acrylic resin, and the other method uses a heat-vacuum machine, thermoplastic splint resin material, and autopolymerizing clear acrylic resin. The use of the CRO device in the successful management of bruxism and temporomandibular disorders has been previously documented in the literature. Some patients may not successfully adjust to the wearing of occlusal devices (splints), which are not well-defined in terms of occlusal morphology, anterior guidance, and their relativity to centric relation. This problem usually is overcome when the dentist uses precise skill in the fabrication and delivery of a CRO device with mutually protected articulation.

Case report of malocclusion with abnormal head posture and TMJ symptoms

Abnormal cervical muscle function can cause abnormal head posture, adversely affecting the development and morphology of the cervical spine and maxillofacial skeleton, which in turn leads to facial asymmetry and occlusal abnormality. There can be morphologic abnormalities of the mandibular fossa, condyle, ramus, and disk accompanying the imbalance of the cervical and masticatory muscles activities. Two normally growing Japanese female patients with Class II Division 1 malocclusion presented with TMJ symptoms and poor head posture as a result of abnormal sternocleidomastoid and trapezius cervical muscle activities. One patient underwent tenotomy of the two heads of the sternocleidomastoid muscle and the other patient did not. In addition to orthodontics, the 2 patients received physiotherapy of the cervical muscles during treatment. Both were treated with a functional appliance as a first step, followed by full multi-bracketed treatment to establish a stable form of occlusion and to improve facial esthetics with no head gear. This interdisciplinary treatment approach resulted in normalization of stomatognathic function, elimination of TMJ symptoms, and improvement of facial esthetics. In the growing patients, the significant response of the fossa, condyle, and ramus on the affected side during and after occlusal correction contributed to the improvement of cervical muscle activity. Based on the result, early occlusal improvement, combined with orthopedic surgery of the neck muscles or physiotherapy to achieve muscular balance of the neck and masticatory muscles, was found to be effective. Two patients illustrate the potential for promoting symmetric formation of the TMJ structures and normal jaw function, with favorable effects on posttreatment growth of the entire maxillofacial skeleton.

Role of temporomandibular disorders (TMD) in facial pain: occlusion, muscle and TMJ pain

Temporomandibular disorders (TMD) which comprise myogenic and arthralgic components have been reported to predispose subjects to headache and facial pain. The aim of this study was to evaluate the role of these components in patients with facial pain and to investigate the influence of treatment of TMD on pain of these patients. The subject group consisted of 25 patients suffering from facial pain. The clinical stomatognathic examination was performed before conservative treatment of TMD, and one-two weeks, three months and one year after treatment. The severity of TMD was assessed using the anamnestic (AI) and clinical dysfunction (DI) indices of Helkimo. The intensity of pain was evaluated on a numerical rating scale (NRS). According to clinical findings the patients were classified to following diagnostic subgroups: TMD myo (mainly myogenic), TMD arthro (mainly arthrogenous) and TMD comb (both myogenic and arthrogenous components involved). Fifteen patients were classified in the TMD myo group, nine in the TMD comb group and one in the TMD arthro group. The DI index decreased significantly one-two weeks after treatment and remained at this level at three month and one year follow-up examinations. At the first examination the TMD myo group had the highest level of NRS index, which decreased significantly during the time of follow-up, while no significant changes were found in other groups. Bruxism reported by the patient had a positive correlation with the amount of painful muscles on the right side at first examination. The results show that facial pain combined with TMD may be mostly of myogenic origin, and myogenic pain seems to have most favorable response to conservative treatment of TMD.

The incidence and influence of abnormal styloid conditions on the etiology of craniomandibular functional disorders

This study aimed to examine the incidence and influence of craniomandibular functional disorders caused by abnormal styloid-stylohyoid chains. Seven hundred sixty-five patients with temporomandibular joint (TMJ) disorders were divided into two groups (with and without radiographically visible abnormal styloid conditions). In the group with abnormal stylohyoid conditions, the etiology of TMJ disorders was further subdivided into poly-, oligo- and monoetiological factors, and, after this classification, evaluated regarding a clear, possible or unlikely involvement of abnormal stylohyoid conditions in TMJ disorders. One hundred thirty-six out of 765 patients presented abnormal styloid-stylohyoid chains. One hundred five of the patients (77.2%) demonstrated polyetiological causes of TMJ symptoms with an unlikely involvement of the abnormal styloid-stylohyoid chain. Twenty-nine of the patients (21.3%) showed oligoetiological causes with possible involvement of the abnormal styloid-stylohyoid chain. In two patients (1.5%), the abnormal styloid conditions showed up as the only definite cause of TMJ symptoms (monoetiological). Detailed knowledge of variations and possible effects of suprahyoid structures is important for an accurate diagnosis of TMJ disorders. All in all, the incidence of a stylohyoid involvement in TMJ disorders is very low. However, after an initial subdivision into abnormal and normal stylohyoid conditions, the incidence of pathological stylohyoid chains gains significant importance in the etiology of TMJ disorders.

A clinical study of specific signs and symptoms of CMD in bruxers classified by the degree of severity

Two hundred and seventy-six CMD patients referred consecutively for diagnosis and treatment over a period of four years were assessed. Two hundred and eleven were classified as bruxers according to the use of a questionnaire and clinical examination. One hundred (47.39%) presented clinical characteristics of mild bruxers, 66 (31.27%) presented moderate bruxism and 45 (21.32%) demonstrated severe bruxism. Severe bruxers presented the lowest degree of jaw opening (39.21 mm) and highest prevalence of capsulitis (97.77%), retrodiskal pain (84.44%) and disk-attachment pain (48.88%). As compared to the mild and moderate groups, severe bruxers also demonstrated significantly higher prevalence of protective splinting and transient locking or recent history of intermittent locking, masticatory pain, reciprocal clicking and signs and symptoms of Myofascial Pain Dysfunction Syndrome (MPDS). Because higher prevalence of specific muscle and joint disorders were observed in bruxers and such prevalence was progressive from the mild to the moderate and severe group, it may be concluded that bruxing behavior is a significant factor in the etiology and progression of muscle and joint disorders. Based on the review of the literature, the analysis of our data in comparison to other studies allowed us to conclude that severe bruxers are more impaired by muscular and joint disorders as compared to mild and moderate bruxers.

Sliding plates on complete dentures as a treatment of temporomandibular disorder: a case report

This work presents a case report of a woman, aged 62, who presented with signs and symptoms of temporomandibular disorder (TMD). The patient reported pain in the masticatory system and examination showed a reduction in the occlusal vertical dimension (OVD). She was treated with complete dentures incorporating a modification to the posterior regions developed by the authors and which were termed "sliding plates." Through analysis of photographs taken of the patient prior to the extraction of the patient's natural dentition, sliding plates were utilized to reestablish the OVD. The sliding plates also allowed for unrestricted eccentric mandibular movements, thereby accelerating the neuromuscular deprogramming and making it possible for the mandible to adopt a more physiologic position. The dentures reduced the pain and were well-accepted by the patient. Therefore, sliding plates may be of great benefit to completely edentulous patients with painful symptoms that result from alterations in the OVD and inappropriate condylar positioning.

The effects of sustained incisal clenching on the temporomandibular joint space

OBJECTIVE

To determine the effect of sustained incisal clenching on the width of the temporomandibular joint space.

METHODS

Nine normal subjects clenched on an anterior appliance for 10 min at 49 N. Sagittal tomograms were obtained during comfortable closure in the intercuspal position (ICP) (ICP-Before), comfortable closure on bite force transducer without clenching (BFT-Before), start of clenching (BFT-0), end of 5 min clenching (BFT-5), end of 10 min clenching (BFT-10), comfortable closure on the bite force transducer immediately after clenching (BFT-After) and comfortable closure in ICP after clenching (ICP-After). Joint space dimensions were automatically measured by a computerized image analysis system.

RESULTS

The minimum joint space dimension was significantly reduced at BFT-5 (P = 0.0381), BFT-10 (P = 0.0019) and BFT-After (P = 0.0053) in relation to BFT-Before. The condylar position was also significantly shifted upward at BFT-0 (P = 0.0422), BFT-5 (P = 0.0005), BFT-10 (P = 0.0001), and BFT-After (P = 0.0004) in relation to BFT-Before.

CONCLUSION

Sustained incisal clenching at 49 N causes significant anterior joint space reduction. We believe this is due to marked compression of the articular cartilage and disc.