Rehabilitation of The Temporo
July 10, 2022 | Author: Anonymous | Category: N/A
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Description
Rehabilitation of the temporo-mandibular temporo -mandibular disfunction with mobilizing personalized surgical
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devices Prof. Dr. Câmpian Radu Septimiu
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Discipline of Oral Rehabilitation, Oral Health and Management
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Faculty of Dentistry
University of Medicine and Pharmacy "Iuliu Haţieganu" Cluj Napoca
Temporomandibular joint
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TMJ 1. The temporomeniscal frenum 2. The mandibular fossa 3. Articular menisc
4. The articular tuber 5. Superior articular cavity 6. Anterior meniscal ligament 7. Lateral pterygoid muscles 8. External hearing duct 9. The joint capsule 10. Posterior meniscal ligament 11. Mandibular condyle 12. Inferior articular cavity 13. The synovial membrane (Coendoz S. - 2000 - Lausanne)
TMJ luxation
TMJ luxation/laxity- recommendations?
When you perform an extraction, and assistant has to hold the inferior arcade so as not to be
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pushed too low and dislocate it partially.
The treatment should be performed with the patient's mouth not completely open.
Vocal rest, soft food as much as possible
Mento-cephalic bandage to keep the joint at rest. r est.
Anti-inflammatory medicines if the joint is painful- 2 weeks
Risk of relapse is still there
The patient shouldn't open the mouth too much because they will surely get a partial
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dislocation.
Anatomy
Shape?
Vascularisation?
Synovial fluid- nutrients, lubricating fluids for the TMJ
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Synovial fluid excess?
Lateral pterygoid muscle
Palpation- in the vestibule of the tuberosity- in the fornix
Pain?- muscle contraction
TMJ symptoms
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1,2,3,4…
Conditions of TMJ pathology
Premature contacts,
Occlusion disorders,
Traumas,
Growth defects,
Ankylosis?- bone bridges,
Fillings quality- occlusion,
Prosthetic work quality.
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Conditions of TMJ pathology- patient’s tolerance
Conditions of TMJ pathology- adapt mechanism
Premature contact- avoidance- chewing on the other ot her side
Overstressed area- pathological abrasions.
Occlusal trauma
Periodontal disease- gingival retraction- periodontal space expands- the lamina dura may
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thicken- mobility
Algodysfunctional syndrome
The psychological state of the patient
The psychical pressure accumulated over the day- para-functions that reduce this adaptability.
ADS?
ADS- treatment
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Persistent muscle damage, chronic c hronic inflammation induce mandibular hypomobility.
Treat the cause
Pain control- muscle relaxation
Mouthguard- disorientation- erase the previous engram and rest the muscles
Release the teeth from occlusion
Thermo-polymerizable acrylate- a smooth surface
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Until the symptoms disappear- except eating period
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ADS treatment- medication
25 milligrams amitriptyline- anxiolytic- patient’s tolerance
Muscle relaxants- Midocalm, 50 to 400 milligram tablets
Start with 3x50 mg/day
TMJ pathology
Diagnosis and treatment are difficult by their complexity.
3 main components- the dental arches, the t he muscles and the joint.
Meniscus damage is intracapsular damage.
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MRI- the articular disk.
Radiography- mouth closed/mouth open- compare the space- enlargement/narrowing
Inflammatory/degenerative Inflammatory/d egenerative pathology
Semiological expression of the disease occurs by breaking the balance
ADS pain
Pains in other areas- the frontal area, the retroauricular, the interscapular vertebral, the
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shoulder, the submandibular areas hurt
Migraines
# trigeminal neuralgia
Palpation- the auditory duct
Alternatively
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Opening and closing of the oral cavity- crackle vibrations v ibrations
Assessment of therapeutic conduct
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1. Symptomatic treatments- for the acute phase 2. Etiological Treatments- irreversible
Etiological Treatments- irreversible
Selective polishing- premature contacts and improper occlusion
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30-40 microns articulation paper- fine
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! Vertical dimension
Only in the enamel
Orthodontic treatment
Secondary therapy
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It is a definitive therapy (Okeson Jeffrez P.) 1. Gnatological treatment 2. Pain treatment 3. Psychotropic treatment
4. Functional treatment and kinetotherapy 5. Infiltrative painkiller substances treatment 6. Balneophysiotherapy 7. Pharmacological treatment
Mouth opening limitation- etiology
1. Temporary constriction – trismus- reversible- inflammatory pathology, trauma
2. Permanent constriction
osteoarticular - articular
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- extra-articular: vicious callus,
tumor causes, post-irradiation,
idiopathic coronoid hypertrophy
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soft tissues - scarring folds (posttrauma- burns, surgery)
- calcified hematomas of the temporal muscle
- progressive osseous myositis
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mixed - post traumatic sequelae
(CHU Grenoble - 1995)
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3. Temporo-mandibular ankylosis
Mouth opening limitation- etiology
1. Temporary constriction - trismus
2. Permanent constriction
osteoarticular - articular
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- extra-articular: vicious callus,
tumor causes, post-irradiation,
idiopathic coronoid hypertrophy
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soft tissues - scarring folds (posttrauma- burns, surgery)
- calcified hematomas of the temporal muscle
- progressive osseous myositis
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mixed - post traumatic sequelae
(CHU Grenoble - 1995)
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3. Temporo-mandibular ankylosis- no bone bridges, but bone blocks
Trismus treatment
Myogimnastics- painful
Open the incisors area
Spoon, plug, syringe, cork stopper, spiral wood wedges - to the back area and front area
Clinic tmj disorders
Oral cavity opening limitation treatment
Surgery-last
- kineto-therapeutic methods (active mobilization, myogymnastics, massage)
- Mechanotherapy with prefabricated dental mouth gags, manufactured mobilizers, serial
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ones, and individual mobilizers
Serial mobilizers
Improvised Mobilizers: Plug, washcloth, spiral wood cone, syringe, wedges
Prefabricated Mobilizers:
Pons-Martin – universal inflatable mouth gag
Lebedinski - elastic drive and indicator of the mouth opening amplitude
Heister - acts as a lever by activating a screw, rubber-coated arms.
Individual Mobilizers- manufactured in the dental office
Benoist Mobilizer
Darcissac Mobilizer
Rahn-Boucher Mobilizer
Rigault Mobilizer
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Voreaux Mobilizer
Principles of tmj individual mobilizers
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1. Force’s support is made on large surfaces, equivalent to dental arches 2. Active forces are located extraorally 3. The action of the forces is continuous, through rubber rings 4. The takeover and transmission of forces is performed by means of o f metal stems 5. The end of the stems are ar e located in a vertically axial caudal than the m mandibular andibular axis ends 6. The extremities of the mandible mandible stems lie in the sagitt sagittal al axis posterior than the extremities of the maxillary stems
Benoist's temporomandibular joint mobilizer
Individual mobilizer, obtained in the prosthesis and oro-maxillofacial surgical laboratory, with a
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wide range of applications and with multiple possibilities of modulation of active forces.
They act continuously as long as they are worn
Need of good compliance
Several times daily
Ptyalism- discomfort
Home therapy
Composition of the Benoist personalized mobilizer
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1. Mouthguard with or without palatal plate 2. The mandibular mouthguard 3. A maxillary metal stem located vertically and median 4. Two lateral and horizontal mandibular metal stems 5. Hooks for anchoring rubber rings- coloured differently for each movement
- unique
- rigid
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- vertical direction
- median
- 5 anchoring points.
- paired- one in on the right side and the other on the left side
- they’re horizontal
- they’re parallel with the occlusal plan
- they each present one attachment
- rigid
The Benoist mobilizer- how it’s made
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1. Impression of the two arcades:
# with standardized trays or with individual trays for each arcade # with individual vestibular trays (cases with acute limitations of the mouth opening amplitude) 1. Casting of hard plaster models 2. Manufacture of acrylate (and palatal plate) mouth gags 3. Modeling and fixing metal stems 4. Applying retention hooks.
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The Benoist mobilizer- how it’s made
The splint- checked not to create any discomfort, adaptation- reduce the thickness so that it can be inserted by the patient, then the patient must be present when the stems are mounted so as not to injure the soft parts.
The maxillary stem should be mounted so as not to compress on the lower lip or for the horizontal ones not to cause discomfort to the oral commissures.
Application of the elastic bands.
The mobilizer’s clinical try in
Application of the mouthguards and checking the presence of congruences - corrections c orrections are
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made if necessary
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Premature contact areas are eliminated Checking the correctness of the direction and position of the metallic stems as well a ass a
their relationship to facial soft parts
Checking (correcting) the direction of extraoral forces action
Extraoral forces dosage-pain-patient compliance
The rubber rings action mode
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1. Between the extremity of the maxillary stem and the paracomissural mand mandibular ibular hooks = the
vertical opening force of the mouth 2. Between the mandibular rod ends and the upper hooks of the maxillary rod = horizontal
protrusion forces of the mandible 3. Between the ends of the mandibular rods and the distal third hooks of the maxillary rod=
oblique, combined, opening and protruding mandible forces
Benoist mobilizers therapy
Daily exercises in 2 to 6 sessions; the duration of a working session is from 5-30 minutes
The duration and number of sessions are continuously increasing
Fatigue and muscle pain confirm the action of the device
The intensity of the forces is increasing, from 50 g to over 300 g.
Adjuvant Medication: Mydocalm 3x50 mg / day, Amitriptyline 2x25 mg / day and topical.
Therapy evaluation
Clinically
measure the inter-incisal distance between the two upper and lower incisal edges, or between
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the upper and lower interdental papillas- before the treatment t reatment
Monitor the results
Check-ups every other week, or at the latest every week and a half
Motivate the patient
Record the results in the patient's file.
Mobilizers
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- Continuous force action - Force direction can be modulated
- The intensity of the forces forces can be variable - Individual adaptation is very good - The treatment is accessible - The action is i s physiological - Device tolerance is very good - It requires multiple stages of execution - It can only be worn at home - It produces sialorheea and ptialism - The recovery time is relatively slow - Wearing the device remains at the discretion of the patient
Benoist mobilizers
Conclusions
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1. Surgical treatment of ankylosis and temporomandibular temporomandibular constriction should be complemented
by mobilizing devices. 2. The Benoist type mobilizer proved to be the most appropriate for this purpose. 3. The mode of action of this mobilizer is effective (extraoral elastic forces). 4. Forces can be modulated according to clinical necessities and particularities.
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