Manual of Temporomandibular Disorders

The Authors Edward F. Wright, DDS, MS, is a Professor in the Department of Comprehensive Dentistry at the University of Texas Health Science Center-San Antonio (UTHSCSA) in San Antonio, Texas, USA. Gary D. Klasser, DMD, is a Professor in the Department of Diagnostic Sciences at Louisiana State University, School of Dentistry, as well as the Director of the LSU Orofacial Pain Continuum in New Orleans, Louisiana, USA.

Preface xiii

About the Companion Website xv

Introduction 1

References 3

Part I Initial Evaluation 5

References 7

1 Patient Interview 9

Summary 25

References 25

2 Review of the “Initial Patient Questionnaire” 29

3 Clinical Examination 35

3.1 Range of Motion 36

3.2 TMJ Noise 39

3.3 TMD Palpations 40

3.4 Intraoral Examination 57

3.4.1 Occlusal Changes 57

3.4.2 Temporomandibular Disorder Pain Caused by a Tooth 58

3.4.3 Tooth Pain Without Local Pathology 61

3.5 Additional Evaluations 63

References 65

4 Imaging 69

4.1 Plain Radiographs 70

4.2 Panoramic Radiograph 70

4.3 Axially Corrected Sagittal Tomography 71

4.4 CT 71

4.5 CBCT 72

4.6 MRI 72

4.7 Arthrography 72

4.8 Ultrasound 72

4.9 Imaging Strategies 73

4.10 Imaging Recommendations 73

References 76

5 TMD Diagnostic Categories 79

5.1 TMJ Disorders 80

5.1.1 Joint Pain 80

5.1.1.1 Arthralgia 80

5.1.1.2 Arthritis 80

5.1.2 Joint Disorders 80

5.1.2.1 Disc–Condyle Complex Disorders 80

5.1.2.2 Other Hypomobility Disorders 85

5.1.2.3 Hypermobility Disorders 86

5.1.3 Joint Diseases 87

5.1.3.1 Degenerative Joint Disease 87

5.1.3.2 Condylysis/Idiopathic Condylar Resorption 87

5.1.3.3 Osteochondritis Dissecans 87

5.1.3.4 Osteonecrosis 87

5.1.3.5 Systemic Arthritides 87

5.1.3.6 Neoplasm 88

5.1.3.7 Synovial Chondromatosis 88

5.1.4 Fractures 88

5.1.5 Congenital/Developmental Disorders 88

5.1.5.1 Aplasia 88

5.1.5.2 Hypoplasia 88

5.1.5.3 Hyperplasia 88

5.2 Masticatory Muscle Disorders 88

5.2.1 Muscle Pain Limited to the Orofacial Region 88

5.2.1.1 Myalgia 88

5.2.1.2 Tendonitis 89

5.2.1.3 Myositis 89

5.2.1.4 Spasm 90

5.2.2 Contracture 90

5.2.3 Hypertrophy 91

5.2.4 Neoplasm 91

5.2.5 Movement Disorders 91

5.2.5.1 Orofacial Dyskinesia 91

5.2.5.2 Oromandibular Dystonia 91

5.2.6 Masticatory Muscle Pain Attributed to Systemic/Central Disorders 91

5.2.6.1 Fibromyalgia 91

5.3 Headache Disorders 91

5.3.1 Headache Attributed to TMD 91

5.4 Associated Structures 91

5.4.1 Coronoid Hyperplasia 91

References 92

6 Contributing Factors 95

References 99

Part II Common Acute TMD Conditions and Therapies 101

7 TMD Secondary to Trauma 103

References 106

8 TMD Secondary to Dental Treatment 107

8.1 Preventing Aggravation from Dental Treatment 110

8.2 Medial Pterygoid Muscle Pain 112

8.3 Inability to Close into MI 114

8.4 Occlusal Interference Sequelae 116

8.5 OSA Appliances 118

References 119

9 Lateral Pterygoid Spasm 123

References 127

10 Intermittent and Continuous Forms of TMJ Disc Displacement Without Reduction with Limited Opening 129

10.1 Intermittent Disorder (Disc Displacement with Reduction with Intermittent Locking) 131

10.2 Continuous Disorder (Disc Displacement Without Reduction with Limited Opening, Also Known as Closed Lock) 134

References 140

11 TMJ Subluxation and Luxation 145

References 148

Part III Occlusal Appliance Therapy 149

References 151

12 Stabilization Appliance 153

12.1 Mandibular Positions and Interocclusal Record 155

12.2 Physical Variables 159

12.2.1 Full or Partial Coverage 159

12.2.2 Maxillary or Mandibular 160

12.2.3 Hard, Intermediate, or Soft Material 162

12.2.4 Thick or Thin 168

12.2.5 Appliance or Clasp Retention 169

12.2.6 Summary of Physical Variables 170

12.3 Appliance Adjustments 171

12.3.1 Internal Adjustments 171

12.3.2 Internal Reline 174

12.3.3 External Adjustments 176

12.3.4 External Reline 182

12.3.5 Appliance Repair 185

12.4 Appliance Examples 188

12.4.1 Pressure‐Cured Mandibular Acrylic Stabilization Appliance 188

12.4.2 Maxillary Acrylic Stabilization Appliance 191

12.4.3 Hard Thermomolded Stabilization Appliance 192

12.4.4 Impak Stabilization Appliance 195

12.4.5 Dual Laminate Thermomolded Stabilization Appliance 196

12.4.6 Soft Thermomolded Stabilization Appliance 197

12.5 Appliance Management 200

References 205

13 Anterior Positioning Appliance 209

13.1 Mandibular Position and Interocclusal Record 211

13.2 Design and Adjustments 212

13.3 Appliance Management 213

References 216

Part IV Multidisciplinary Management Approach 219

References 221

14 Self‐Management Therapy 223

14.1 Self‐Management Instructions 224

14.2 Closure Muscle‐Stretching Exercise 230

14.3 Lateral Pterygoid Muscle‐Stretching Exercise 231

14.4 Posture Exercises 233

14.5 Controlling Awake Behaviors 234

References 238

15 Physical Medicine 241

15.1 Muscle Massage 242

15.2 Yoga 242

15.3 Trigger‐Point Compression 243

15.4 Trigger‐Point Injection 243

15.5 Botulinum Toxin Injections 244

15.6 Physical Therapy 244

15.7 Acupuncture 248

15.8 Chiropractics 249

References 250

16 Cognitive‐Behavioral Intervention 255

16.1 Controlling Awake Behaviors 259

16.2 Relaxation 261

16.3 Hypnotherapy (Hypnosis) 262

16.4 Biofeedback‐Assisted Relaxation 263

16.5 Stress Management 264

References 265

17 Pharmacological Management 269

17.1 Analgesics 270

17.2 Anti‐inflammatory Medications 271

17.2.1 Nonsteroidal Anti‐inflammatory Drugs (Ingested Form) 271

17.2.2 Steroidal Anti‐inflammatory Drugs 273

17.3 Muscle Relaxants 274

17.4 Anticonvulsant 275

17.5 Tricyclic Antidepressants 276

17.6 Topical Medications 278

17.6.1 OTC Topical Medications 278

17.6.2 Prescription Topical Medications 280

17.7 Nutritional Supplements 283

References 285

18 Other Dental Procedures 291

18.1 Occlusal Equilibration 294

18.2 Orthodontic–Orthognathic Therapy 296

18.3 Prosthodontic Therapy 297

18.4 TMJ Surgery and Implants 299

References 303

19 Integrating Multidisciplinary Therapies 309

19.1 Management Summaries and Clinical Implications 310

19.1.1 Self‐Management Therapy 310

19.1.2 Massage and Trigger‐Point Compression 310

19.1.3 Lateral Pterygoid Muscle‐Stretching Exercise 310

19.1.4 Closure Muscle‐Stretching Exercise 310

19.1.5 Posture Exercises 311

19.1.6 Occlusal Appliances 311

19.1.7 Physical Therapy 311

19.1.8 Yoga 312

19.1.9 Trigger‐Point Injections 312

19.1.10 Acupuncture 312

19.1.11 Chiropractics 312

19.1.12 Controlling Awake Parafunctional, Muscle‐Tightening, or Fatiguing Behaviors 313

19.1.13 Relaxation 313

19.1.14 Hypnotherapy (Hypnosis) 313

19.1.15 Biofeedback‐Assisted Relaxation 314

19.1.16 Stress Management 314

19.1.17 Pharmacological Management 314

19.1.18 Occlusal Therapy 315

19.1.19 TMJ Surgery 315

19.2 Integrating Conservative Therapies 316

19.3 TMD Refractory to Initial Therapy 320

19.4 Long‐Term Management 321

References 322

Part V Case Scenarios 327

V.1 Case 1: Symptomatic Irreversible Pulpitis Mimicking TMD Symptoms 329

V.2 Case 2: Tooth Pain: No TMD Pain 331

V.3 Case 3: Chronic Sinusitis 332

V.4 Case 4: Chronic Forehead Pain Referred from the Neck 333

V.5 Case 5: Myalgia Secondary to Sleep Parafunctional Behaviors 335

V.6 Case 6: Tooth Attrition: No Pain 336

V.7 Case 7: Myalgia Secondary to Awake Parafunctional Behaviors 337

V.8 Case 8: Medial Pterygoid Spasm 338

V.9 Case 9: Personal Stressors and Sleep Disturbances as Contributing Factors 339

V.10 Case 10: Fibromyalgia as a Contributing Factor 340

V.11 Case 11: TMJ Disc–Condyle Complex Disorders and When to Provide Therapy: no Pain 341

V.12 Case 12: TMJ Arthralgia 342

V.13 Case 13: TMJ Disc Displacement with Reduction with Intermittent Locking 343

V.14 Case 14: TMJ Disc Displacement Without Reduction with Limited Opening: Unlocked 345

V.15 Case 15: TMJ Disc Displacement Without Reduction with Limited Opening: Not Unlocked 346

V.16 Case 16: Osteitis Causing Inability to Open Wide 348

V.17 Case 17: Lateral Pterygoid Spasm 350

V.18 Case 18: Acute Exacerbation of TMD 352

V.19 Case 19: Multiple Forms of Head and Neck Pain After Crown Insertion 354

V.20 Case 20: Appliance That Positioned Condyles into Their “Proper Position” 355

References 357

Part VI Fundamentals of Clinical Studies 359

VI.1 Prominent Clinical Study Designs 359

VI.1.1 Case Report 359

VI.1.2 Case Series Study 360

VI.1.3 Cross‐Sectional Study 361

VI.1.4 Case‐Control Study 362

VI.1.5 Cohort Study 362

VI.1.6 Nonrandomized Clinical Trial 363

VI.1.7 Randomized Controlled Trial (RCT) 365

VI.2 Other Types of Publications 367

VI.2.1 Literature Reviews 367

VI.2.2 Systematic Reviews 367

VI.2.3 Meta‐Analyses 367

VI.2.4 Clinical Practice Guidelines 368

VI.3 Considerations in Assessing Clinical Trials 368

VI.4 Conclusions 368

References 369

Glossary 373

Index 377