Screening for temporomandibular disorders in dental practice

A simple screening procedure to determine evidence of a temporomandibular disorder (TMD) in a patient is presented. The current view is that dentists are responsible for the recognition and management of these disorders. The dentist should therefore perform a TMD screening examination on every patient and document the patient's functional status. If this is not known then it is impossible to discuss with the patient the possible implications of proposed dental treatment which could potentially worsen a pre-existing TMD. Unless functional status is documented and informed consent obtained from the patient prior to proceeding with dental treatment, the dentist may be held liable should TMD problems develop during or after the treatment.

[Preventive prosthetics and gnathology]

In daily practice the dentist is constantly confronted with dentitions which do not measure up to the (idealized) parameters of a theoretically ideal occlusion. In many cases there is a healthy situation which should be maintained. Changes to the occlusion and/or prosthetic treatment should only take place if they are predicted, beforehand to contribute to solving relevant problems. Clinical application of preventive measures in relation to the function of the masticatory system as well as prosthetic treatment are discussed.

Prosthetic rehabilitation in temporomandibular disorder and orofacial pain patients. Clinical problem solving

Good clinical decision making represents an integral part of quality care. A definition of the dental problem and its significance from a dental point of view, in combination with a good working hypothesis of the nature of the concurrent TMD condition are prerequisites of any successful clinical problem solving. It is hoped that, with time, we will be in a position to call upon hard data on the probability and utility of successful outcome for each treatment alternative. This will bring the needed structure and scientific validity to a terribly complex albeit clinically important problem.

A new osteotomy for the correction of mandibular prognathism: techniques and rationale of the intraoral vertico-sagittal ramus osteotomy

The sagittal split ramus osteotomy (SSRO) and the intraoral vertical ramus osteotomy (IVRO) are long established methods for correcting mandibular prognathism, each having its own advantages. However, both procedures have the same disadvantage: the potential for postoperative condylar displacement. The displacement of the condyle is mainly due to the fact that the osteotomy plane is not parallel to the original sagittal plane in which the mandible is repositioned. The author has developed a new ramus osteotomy since 1985 in which the osteotomy plane is theoretically parallel to the original sagittal plane and thereby attempting to decrease the incidence of condylar displacement. This osteotomy was designed additionally to decrease neurosensory disturbances and has the advantages of both methods, and therefore has been named 'intraoral vertico-sagittal ramus osteotomy (IVSRO)'. Initial experience with the 24 prognathic patients operated on by means of the IVSRO indicated excellent clinical results. It has been noted clinically that the IVSRO is very effective in reducing postoperative iatrogenic TMJ symptoms and in treating preoperative TMJ symptoms. It has the additional effect of reducing neurosensory disturbances. This osteotomy seems to be more applicable in mandibular prognathism with excessive flaring of the ramus, particularly that associated with TMJ dysfunction, because the IVSRO has a 'condylotomy effect' and its splitting plane diverges less from the original sagittal plane than that of the SSRO and the IVRO.

Prevention in orthodontics--a review

Increasing numbers of patients are being orthodontically treated by specialist and general dental practitioners, after postgraduate courses and clinical assistantships. The potential for iatrogenic damage to the teeth and supporting structures has, therefore, also increased. This paper examines these problems and outlines measures for their prevention.

Etiologic theory and prevention of temporomandibular joint disorders: reaction paper

The treatment of patients with temporomandibular joint pain and dysfunction remains a controversial issue. Strong evidence exists that the occlusion of the teeth may not be a significant contributor to the overall etiology of the disorder. This now presents clinicians and researchers with a problem. What factors are responsible for the pain and dysfunction? Today, no solid evidence exists to substantiate the etiology of this disorder.

Etiologic theory and the prevention of temporomandibular disorders

Over the last 75 years, a variety of etiologic factors has been suggested as the cause of pain and dysfunction in the temporomandibular system. The earliest and still-popular etiologic theory proposed that temporomandibular disorders are induced by abnormal structure, usually described as a malocclusion of the teeth or jaws. The fact that this theory was based on mechanical concepts, ignored biologic diversity, and had limited factual experimental evidence to support it as well as extensive evidence in opposition did not seem to matter to its proponents. In the late 1960's and early 1970's, the structural occlusal model for TM Disorders was challenged and has yielded ground to a more multifactorial model of TMD causation. Other etiologic factors for TM disorders--such as anatomical susceptibility of TM tissues to trauma, polyarthritic diseases, joint laxity, repetitive parafunctional behaviors, and stress-related muscle dysfunction--need to be recognized and quantified. Unfortunately, many practicing dentists demonstrate a very poor understanding of and often fail to recognize these etiologic factors as agents that produce TM disorders. This failure is largely due to the fact that the dental profession has spent the last 90 years dealing with a variety of misconceptions about the etiology of temporomandibular disorders. In the 1990's, one of the more formidable challenges we face is acquiring the ability to segregate and define validly the specific TM Disorder of concern and then correctly identify and measure the specific etiologic factors that produce it. Until these problems are solved, it is unlikely that we will be able to prevent disease of the TM apparatus.

[The Pontic. Preventive consideration of pontic design]

When fixed partial dentures are provided for edentulous areas of the alveolar ridge, the previously impaired masticatory and phonetic functions as well as esthetics are restored immediately; in the long run, the restoration helps to stabilize the occlusion, thus maintaining the integrity of the temporomandibular joints and the neuromuscular system. The reabsorption of connective tissues following the loss of teeth as well as the changes in the dimensions of edentulous areas that occur over time will have to be taken into account in that the basic shape of the tooth or teeth to be replaced needs to be modified. Pontics usually present a larger surface than natural teeth; on this surface, plaque may accumulate. The self-cleaning mechanisms are ineffective on the surfaces facing the adjacent teeth or the tissues of the alveolar ridge. For this reason, the pontics and their flexible or rigid connectors to the abutments must be considered the weakest parts of the restoration. The long-term success of the restoration, once periodontal treatment and optimum prosthodontic care have been provided, depends on whether considerations of periodontal prevention played a role in the design of the restoration and on postinsertion periodontal care.

Diagnosis and prevention of temporomandibular joint (TMJ) or odontostomatognathic (OSG) injury in dental practice

Malpractice lawsuit cases due to temporomandibular joint/soft tissue injuries following dental therapy are increasing. Therefore, dentists and their staffs must know how to recognize, document and avoid any possible aggravation or precipitation of TMJ disorder. TMJ anatomy, biomechanics and mechanisms of TMJ injuries are presented. Etiological factors such as psychological factors, parafunctional activities, malocclusion, trauma, iatrogenic causes, systemic conditions, developmental disorders, neoplastic growth or medications are discussed. Preventive measures addressed include: history-taking, patient examination, complete records, the assessment of the patient's general condition, documentation of pre-existing findings, informing and educating the patient, performing only the necessary procedures, modifying appointments, selecting less traumatic dental techniques, avoiding sudden occlusal alterations and preparedness to handle unwanted complications.

[Justification of the needs and a trial of establishing of the principles of prophylaxis of functional disturbances in the stomatognathic system]

The author indicates a dramatic rise in the number of patients with signs of dysfunction of the masticatory system which are one of the main social problems in modern stomatology. Including of dysfunction signs into the range of periodic stomatological examinations is postulated, and the principles of prevention of these disturbances are described. For the realisation of these aims it would be indicated to organize special scientific units, to introduce proper training of students and dentists as well as medical students, and to set up specialization in this branch of stomatology. In the treatment, especially in cases complicated with headaches and pain of the eyes, ears, spine and muscles in the vicinity, and with trigeminal neuralgia, a far reaching cooperation is needed of highly specialized stomatologists with the specialists from other branches of medicine.

Preventing adverse effects on the temporomandibular joint through orthodontic treatment

The temporomandibular joint is one of the most complicated working assemblies in the human body. We are just now beginning to understand it and give it the respect and careful treatment it deserves as an integral functioning part of the dental anatomy. No orthodontic procedure can be performed in isolation without considering its possible effect on the temporomandibular joint. Therefore, the following recommendations are made for diagnosis and treatment planning. Etiologic factors that might cause upward and backward pressures on the mandible should be reduced as much as possible. Mechanotherapy that may cause upward and backward pressures on the condyles is not recommended. Final detailed correction of dental abnormalities should always consider optimal temporomandibular health and function. Retention procedures should be planned to provide a proper path of closure to minimize or prevent possible retrogressive posttreatment changes. It is the author's hope that the hypotheses and suggestions in on TMJ problems and on the preventive role of orthodontics in the patient's treatment.