Temporo mandibular pathologies and dysfunctions
Over the last 10 years, doctors have considerably increased their interest in the complex relationship between the teeth, joints and muscles of the Stomatognathic system that can also play a fundamental role in symptoms in areas not of dental competence. Clinical and scientific experience has shown that these dynamic factors play a controlling role not only on dental problems, influencing problems at a distance. Recurring headaches (muscle tension headaches), pain in the neck and spine, are often related to problems of dental origin, sometimes not even evident to the dentist himself. The BTS TMJOINT evaluation is able to carry out a screening of patients whose problems are treatable by the dentist (including headaches, joint pain, postural disorders).
It improves the diagnosis and correction of occlusal interferences by integrating the synchromiographic analysis of neuromuscular stability to the traditional mechanical and morphological assessment.
Through the static and dynamic analysis of the activity of the masticatory muscles, BTS TMJOINT provides valuable information for planning dental interventions and for evaluating their effectiveness. With BTS TMJOINT the stability of the neuromuscular system becomes a further, important reference factor for improving prostheses and rehabilitation interventions. BTS TMJOINT uses synchromiographic analysis to perform a functional assessment of dental occlusion using validated indexes published in scientific literature.
MANDIBULAR CERVIC SKULL DISORDERS
By cranio-cervico-mandibular disorder (DCCM) we mean a series of affections
of the stomato-gnatic apparatus with multi-factor etiology, characterized by a neuromuscular imbalance that particularly affects the chewing muscles and the neck muscles, but which often also involves the muscles of the entire vertebral rachis, resulting in an alteration of the entire structure bodily.
The causes of DCCMs can be different. A bad match of the teeth often causes malposition of the mandibular condyles. However, malocclusion is not the only cause to be considered. There are other extrastomatognathic factors which, by inducing an alteration in the tone of the cervical muscles, have unfavorable biomechanical repercussions on the TMJ (temporomandibular joint). Distracting trauma of the cervical spine (whiplash syndrome) frequently represents events triggering a DCCM. Vision disorders must also be carefully evaluated, as a functional alteration of the oculomotor muscles is often concomitant with a dystonia of the masticatory muscles and of the nuchal muscles. Alterations of the breech support lead to functional adaptations of the spine and therefore also of the cervical tract. This determines the need to investigate various spheres: stomatognathic, ocular, orthopedic, being able to find alterations in all districts with global adaptive significance.
Before the disease manifests itself, a certain individual tolerance threshold must be exceeded. There is, in fact, a first phase of neuromuscular adaptation that allows to bear, within certain limits, abnormal conditions or stimuli, guaranteeing joint and muscle function within the normal limits. At this point, if triggering factors act on an ATM that works in compensatory conditions, joint dysfunction occurs. The triggering factors are represented by physical and psychological trauma or changes in the occlusion.
The clinical picture of DCCM is mainly characterized by craniofacial localization pain, prevalent in the preauricular area, frequently associated with oto-vestibular signs and symptoms, such as: tinnitus, sense of full ear and dizziness. The pain of DCCM is rarely well localized, very often it radiates in the mandibular, frontal, nuchal, cervical and brachial areas. Among the general signs dominates an asthenia present already upon awakening, difficulty falling asleep with nocturnal windows or grinding. This clinical picture is entirely nonspecific, however, an important symptom that characterizes DCCM is pain in the region of the TMJ spontaneous or on palpation that can radiate to the temples, ears, jaws, cheeks and tongue. Local pain originates from inflammation of the joint tissues. Radiated pain arises from a muscle spasm.
What relationship do they have with body posture?
Following the most current medical-scientific knowledge on the subject, in our Center the DCCMs are framed in the context of postural alterations, since the mandibular posture is closely linked to that of the body. The misalignment of the shoulders and pelvis, the body rotations, the slight lateral flexion of the head and all that is noticed in the postural imbalance that
accompanies the DCCM, they are the reflection of a permanent change in the basic tone of certain muscle groups or of all the muscles of the body which has negative biomechanical consequences at the level of all joints, as the altered muscle function leads to an altered dynamics articulate. This occurs in a peculiar way in the TMJ, since this is a bilateral joint, in which the right and left are connected by a single bone which is the mandible. The dysfunction of the neck muscles and masticatory muscles causes an alteration of the dynamics of the temporomandibular joint, in relation to the fact that the external pterygoid muscle is inserted on the anterior edge of the articular disc. If there is dysfunction of the masticatory muscles, a unilateral contraction of the external pterygoid determines a dislocation of the articular disc and therefore a modification of its relationship with the condyle. The altered joint dynamics over time induces morphological and degenerative changes in the joint heads.
How is the diagnosis made?
Our experience has led us to emphasize the importance of a complete, reproducible and easily monitored diagnostic path that must not neglect any clinical data. Only from a correct diagnostic approach can an effective and lasting therapy result. The diagnostic activity is carried out following precise protocols and using the most modern equipment in order to frame these pathologies in the most complete way possible. The clinical investigation is supported and integrated with the data deriving from the following instrumental examinations:
Mandibular kinesiography, which is the recording in the three planes of the space of the mandibular movements and evaluates the mandibular dynamics.
Baropodometry, which is the recording of pressure loads on the support polygon and evaluates the breech support.
Stabilometry, which is the recording of the oscillations made by the body’s pressure center and evaluates the function of the main postural receptors.
Surface electromyography that analyzes the functionality and balance of the main chewing muscles.
The integration of the data collected through the clinical-anamnestic investigation with the parameters extrapolated from the instrumental investigations allows to frame the patient in the most complete way possible, highlighting the type of functional alteration of the temporomandibular joints, the severity and the multiple causes of the neuro-myo-postural imbalance characteristic of DCCM.
What is the therapy?
The diagnostic complexity of DCCM, resulting from multifactorial etiopathogenesis, entails the need for multi-specialist collaboration. For the treatment of DCCM, individualized treatment plans are envisaged, following precise therapeutic protocols, based on the integration of targeted treatments, provided by various professionals who work in our Center in a coordinated manner. The global combined rehabilitation of the patient with DCCM provides first of all an accurate study and gnathological therapy which consist in the functional re-education of the mandibular kinetics and in the positioning of an occlusal release plate. The patient is appropriately instructed and motivated to correct any incorrect postural attitudes of the jaw, through muscle training and learning of the physiological mandibular kinetics. This leads to functional improvement through muscle rebalancing and therefore greater joint stability. An occlusal release plate is also positioned which is a small mobile device in transparent resin, which has the dual purpose of relaxing the chewing muscles and making any abnormal dental contacts evident. At the same time, the recovery of the physiological body structure is carried out through a manipulative therapy with direct intervention on the neuro-muscular proprioceptive system. The rebalancing of the functionality of the musculoskeletal system is subsequently consolidated through postural gymnastics which allows the patient to become aware of the new body structure and her active control, through targeted exercises. Other types of therapy may also be required based on the expressiveness of the pathology in the individual case:
- Speech therapy rehabilitation.
- Orthoptic rehabilitation.
- Breech therapy.
- Neuromioriabilitative therapy.
The therapy is constantly monitored through the computerized tools available in order to monitor in the most precise way the effectiveness and validity of the treatments performed.
The data provided by the electromyograph represent the missing piece that allows the doctor to complete the occlusal puzzle. In this way, with the obtaining of additional information the whole picture of the patient’s needs and the diagnosis of the doctor becomes clearer or and the related processing can be performed with greater safety. For an optimal diagnosis and therapy, the doctor must be able to measure the physiological phenomena that indicate the state of the occlusal function and its effect on muscles and joints not only of the Stomatognathic system, but also on the spine. An incorrectly placed occlusion will cause hypertonicity or hypotonicity of the chewing muscles and damage to the temporomandibular joint.
Electromyography provides the correct evaluation of these occlusal factors to give the doctor scientific and objective data on which to base the diagnoses and treatment programs and to monitor and document the results obtained.
With the use of bipolar surface electrodes, the electromyographic data can be detected on eight muscles simultaneously and in real time. The program allows the detection of data both at rest and in operation. The data collected on eight muscles can be viewed simultaneously giving the doctor a precise indication to process the diagnosis and therapy.
The examination lasts a total of half an hour and does not cause any discomfort to the patient.
How does it work
The patient is fitted with four probes on the temporal muscles and massetters which record muscle activity during two tightening tests lasting 5 seconds, with and without salivary rollers.
The results are displayed immediately through a clear graphical representation, easy to understand for both the doctor and the patient.
The doctor has the possibility to intervene without having to remove the probes from the patient’s face, thus being able to perform a further post-treatment evaluation. This procedure can be repeated numerous times within the same working session, showing the objective effectiveness of the treatment to which the patient is subjected.
Applications
Oral rehabilitation: Choice of treatment, evaluation of provisional and definitive
TMJ: Pre and post-splint, craniocervic mandibular malocclusion disorders
Orthodontics: Pre and post-treatment
Documentation and research: Treatment validation, biomechanical research
Forensic examinations: Appraisals, defense in case of litigation
Protocols
POC 4
By means of a quick test of the window frame, lasting 5 seconds in which the activity of the masseter and temporal muscles anterior, right and left, is acquired, it provides, as an immediate result, a percentage coefficient of overlap POC (index of the symmetrical distribution of the activity muscle, determined by the occlusion) and a torque coefficient TORS (to evaluate the possible presence of a mandibular toque), which allow to establish the role of the occlusion on the muscular balance.
Another index called IMPACT allows to evaluate the muscular work, providing information on the vertical occlusal dimension.
POC 6
Compared to the previous protocol, it adds 2 acquisition probes for the calculation of the indices relating to the sternocleidomastoid muscles, right and left. The effects of tooth contact on the neck muscles are evaluated.
CHEWING
Analyzes neuromuscular coordination during the chewing act. The chewing frequency, the Lissajous figure and the muscle symmetry index are calculated.
BIBLIOGRAPHICAL DATA AND REFERENCES:
TUFTS University School of Dental Medicine, Boston, MA (USA)
TUFTS University School of Dental Medicine is one of the most prestigious American dental schools and is the first center to use BTS TMJOINT. We thank Dr. Hiroshi Hirayama who, on the occasion of the presentation of the system, organized a technical-practical seminar on the use of BTS TMJOINT, with the aim of providing a first level of education to the students present.
