The Optimum Temporo-Mandibular Joint Condyle Position in Clinical Practice.
The Optimum Temporo-Mandibular Joint Condyle Position in Clinical Practice.
The Optimum Temporo-Mandibular Joint Condyle Position in Clinical Practice.
Questions
1. Where is It?
2. How is This Determined?
3. How is This Achieved?
4. What Constitutes Dysfunction?
5. How is Dysfunction Diagnosed?
6. How is Dysfunction Treated?
ticulating areas within the joint are in- sule as well as into the neck of the any further superiorly than the thick-
nervated, are vascularized and have condyie, and the attachment of the ness of the disk in a healthy joint. The
a synovial lining.'^ These areas in- right and left collateral ligaments articular disk serves as a shock ab-
clude the periphery of the disk as (Figs. 7 and 8). The relationship of sorber, it helps to reduce wear, and
well as anteriorly or posteriorly to the the disk to the condyie is controlled it fills the incongruous spaces be-
articular portion of the disk. The col- by these structures. It must be re- tween the condyie and the posterior
lateral ligaments, usually attached membered that disks come in vary- slope of the eminence^ (Fig. 11). The
above the attachment of the capsule, ing sizes and shapes (Figs. 9 and 10|. osseous irregularities of these struc-
are highly innervated, vascularized, Disks can undergo remodeling, tures are compensated for by the
and covered with synovial lining. hyperplastic, and/or metoplostic disk and thus help to stabilize the
The stability of the disk is provided by changes throughout life. When the joint.
the lateral pterygoid muscle, the condyie is seated by muscle action
upper belly attaching into the cap- across the joint, it cannot be seated
Fig. 4 in fhe dried skull, the roof of the fossa is shown to be very
thin.
Figure 8
Figure 10
The Optimum Position of fhe Condyle articulation, fhe articulating bones fained fhrough muscle spindle reflex
are kept in sharp contact by the mus- activity, and during function it is
The optimum condylar posifion is the cles thaf move fhe articulation (Fig. maintained by fhe muscles that pro-
structural or anatomical position (in a 14). As fhe condyle-disk assembly vide the movement. During swallow-
healthy joint) of the condyle with ifs moves, fhe muscles that act across ing, chewing, speaking, and all other
biconcave disk braced against the fhe joint confrol how the condyle is movemenfs the muscle activity main-
eminence in on anferior superior di- going fo be related with its disk tains contact of the condyle wifh ifs
rection (Fig. 12). Ideally, an optimum against the posferior slope of fhe disk against fhe articular eminence.
condylar disk position occurs wifh eminence. DeBrul has also stated Most pafients have the ability to
optimum integrated muscle activity fhat a well integrated neuromuscular adapt fo structural irregularities or
as well as with maximum occlusal sysfem attempts fo maintain confacf imperfections. Neuromuscular adap-
stability (Fig. 13). across fhis joinf as if does in oil fafions usually come first and fhen
Clinicians do nof determine the op- joints.' osseous changes can occur, particu-
timum posifion of fhe condyle in the On opening the arficular disk rotates larly if fhere is o prolonged, chronic
healthy joint. Certainly x-rays do nof. posteriorly as the condyle comes for- neuromuscular adaptation. This, of
The physiology of fhe stomatog- ward. As fhe condyle goes back- course, is modified by the patient's
nathic sysfem determines if.® The ward on closing, fhe disk rotates an- ability fo cape wifh stress. A number
muscle action wifh ligamentous sup- teriorly (Fig. 15). There is a changing of patients can adapt fo occlusions
port or resfriction determines the op- relationship of the surface of the con- that are ofher fhan ideal and wifh
timum posifion of fhe condyle, and dyle to the inferior biconcave surface condylar positions that are other
the dentist has liftle, if any, confrol ot the disk and the superior bicon- than optimum. The histologisfs tell us
over It in mosf patients. Neurologi- cave aspect of this disk to the convex that fhe fibrous connective fissue disk
cally, fhe input from fhe feefh, fhe surfoce of the articular eminence. has the propensity to undergo
muscles, the capsule, and also from The relationship of the disk fo the change and adapt to some new
fhe CNS determine the optimum condyle changes as muscle activity equilibrium.'° Fig. 16 shows a dis-
posifion of the condyle. Sicher's Law moinfalns sharp contacf of fhe bones placed disk thot appears fo be un-
states that, in all movements of an of fhe articulation. At rest if is main- dergoing o change in the attachment
Structurol Position
Möller
Sicher's Law:
In All Movements of an Articulation, the
Articulating Bones Are Kept in Sharp Contact
by the Muscles That Move The Articulation.
Fig. 16 Specimen depicting on onteriorly displaced disk that oppears to hove un-
dergone metaplostic chonge af the junction of the thick posterior band or rim and
the posterior attachment or bilominor zone (from Solberg and Hannson).
oreo of the thick posterior band and been defined as the relationship of most of the force, in part relieving the
the bilaminar zone or posterior liga- the mandible to the maxilla when the joints and muscles of maintaining
ment (Fig. 16). The previously vascu- condyles are in the most posterior stobility. The dentist should provide
lar, innervated portion now has be- superior unstrained positions in the the patient with structural and func-
come avascular and noninnervoted. glenoid fossae from which lateral tional stability between the occlusion
It can become articulating tissue, not movements can be made at any de- and joints as well as with neuromus-
as an optimum joint with optimum gree of jaw separation." Stated cular harmony. Centric jaw relation is
function, but pain free and with rela- more simply, the centric relation jaw reproducible. Reproducibility does
tively normal function. This concept is position is the relationship when the not necessarily make it valid phys-
important relative to definitive treat- mandible is in the most posterior iologically, even though it may be
ment planning. Understanding that hinge axis border position to the convenient. It is acceptable phys-
as clinicians we do not necessarily cranium.^^ Thus it is on the rotational iologically, however, as the end point
have to recapture even/ disk either arch of closure. As has been pointed of closure as measured in milli-
surgically or otherwise is important. out rather clearly, this is an abnormal seconds. It is stable orthopedically.
There are a large number of patients movement and occurs only when the The mandibular muscles tend to seat
that can be successfully managed off mandible is being manipulated by the condyles back and up in the
the disk. the dentist; in fact, patients can actu- fossa on swallowing and at the end
ally be trained to open on the hinge of the chewing stroke on the working
Determining the Optimum Condylar axis. It is not normal movement. Any side'^ (Fig. 20). Patients function in
Position normal functional movement has a centric relation if it is available, that
certoin amount of translation when is, if there are no interferences pre-
The optimum condylar position is de-
the patient opens. It is a border po- venting the closure. After involved re-
termined physiologically. It is the
sition that is used to relate casts.'''"'^ storative, prosthodontic, orthodontic
physiologic position of the condyle
The craniomandibular articulation is and/or orthognathic treatment pa-
with its attached biconcave disk
the only joint system with a rigid end tients unknowingly utilize the posi-
against the eminence in the direction
point of dosure.^'^ As a patient is tion.
of the muscle action across that joint
functioning in an intraborder posi- The stomatognathic system is in a
(Fig. 17). The patient's own function,
tion, the teeth come together at a constant state of flux and the fact that
the physiology of the stomotognathic
rigid end point or border position. the patient develops a new man-
system, will determine the position in
The dentist can retrude the mandible dibular position of a few tenths of a
a healthy, normal functioning joint
into the hinge rotation and seat the millimeter as measured in the con-
hence the term "physiologic condy-
condyles at the same time. The state dyle with time does not invalidate the
lar position."
of the art clinically is to aid the action concept of centric relation. It simply
of the elevator muscles, bracing the helps to prove that the stomatog-
Achieving the Optimum Condylar condyles against the posterior slope nathic system is a dynamic system.
Position of the eminentia. Thus there is a rota- Dentists are not treating articulators;
tion of the mandible which seats the they ore treating human beings. De-
In healthy functioning joints the pa-
condyles in an anterior superior po- pending upon the complexity of the
tients themselves achieve optimum
sition as the mandible is simultane- treatment involved, they must use
condylar position for us unless we as
ously retruded (Fig. 19). Dowson's some sort of anatomical aid, that is a
clinicians confuse them. If there is
technique of achieving this clinically semiadjustable or a fully adjustable
dysfunction or pathology, however, it
is certainly one of the most repeat- articulator. They would the like to
can become difficult. The condyle
able types of manipulations.'^ relate an upper cast to the articulator
disk position is determined by muscle
Joint stability is maximal as occlusion as the teeth are related to the pa-
action until movement into maximum
occurs. Joint stability is provided by tient's skull and, utilizing some sort of
intercuspation (Fig. 18). The teeth
a bilaterally symmetrical occlusion. recording media, try to relate the
then influence condylar position.
The occlusion of the teeth absorbs lower cast in the same spacial
Centric relationship has traditionally
Condyiar Seating
Muscle Action During Closing Pulls Condyle
Disk Complex Upward and Backward
I Along Slippery Incline
TMS Dysfunctions can cause secondary organic anterior and medial to the condyie
changes (Fig. 21 ). Organic problems cause the condyie to articulate on
As reported by the American can be articular problems such as in- the nonorticulating portion (pos-
Academy of Craniomandibular Dis- ternal derangements or pathological terior attachment) of the disk (Fig.
orders in the Journol of Prosthetic processes (for example osteoar- 22). During surgery the disk does not
Dentistry, temporomandibuiar or thritis) or they can be non- or periar- always appear normal; rather, it can
craniomandibular disorders are clas- ticular conditions seen as muscle be folded, wrinkled, or macerated. A
sified into categories of organic (true and/or occlusal problems. closed lock condition occurs when it
physical problems) and nonorganic There can be many changes in the is impossible to reduce the articulat-
(psychological) problems. Further, optimum condylar position as o re- ing portion of the disk (Figs. 23 and
unfortunately, when a psychological, sult of articular problems that relate 24). This anterior mass of soft tissue
or nonorganic, problem continues to internal derangements. Displaced prevents the normal range of transla-
for a long enough period of time, it disks with their articulating portion tion of the condyie. Many times there
already have been fears, perfora- should surgical management be even more loading occurs, and this
tions, and other types of structural considered. tends to push the disk anteriorly in
changes within the disk. With o se- Nonarticular conditions include some patients (Figs. 26 and 27). Thus
verely stretched or torn posterior at- these occlusal conditions: loss of the beginning of a displaced disk
tachment, it will most likely be impos- posterior support, a "distal thrust" of may result from this occlusal (struc-
sible to "recapture" the disk (Fig. fhe mandible causing a compression tural) problem. Also, with increased
25). If able to perform o repair, the posteriorly in the joint, ond posterior parafunctional activity the elevator
surgeon will never recreate o normal supra-contacts or fulcrums causing a muscles can force the condyles
joint, just as the orthopedic surgeon distraction in the joint. A loss of verti- superiorly, and the lateral pterygoids
cannot recreate a normal knee. Only cal support in the occlusion can can chonge the relationship of the
if nonsurgical approaches are un- cause a compression in the joints. disk, resulting in a tendency to de-
successful in controlling poin or if se- When this occurs, with an increased velop an anterior displaced disk.
vere limitation in movement remains hyperactivity of the elevator muscles. The clinical support for the belief that
Distraction
(power stroke
ogainst Disk Rotation
resistance (I muscle activity)
Fig. 34 During distraction the lateral pterygoid muscle reflexly changes fhe disk-condyle relationship attempting to mointain contact af the articulation structures.
Diagnosis disorders, and the dentist must be clude transcranial radiographs, to-
willing to spend the necessary time to mograms, corrected cephalometric
Dysfunction is diagnosed by means make a comprehensive history. This tomography, nuclear scanning, CAT
of diagnostic tests, good base line may require an hour or more of in- scanning, and magnetic resonance
records, and a good data base,^'"-^^ depth questioning and probing, imoging. The most typical film series
The following base line records A thorough ciinicai examination is the transcranial TMJ survey, which
should normally be mode for pa- should include the TMJ region and can be performed using x-ray equip-
tients suspected of having TMJ dys- mandibular function, the muscles of ment presently found in dental of-
function; medical and dental his- the head and neck, and the orol cav- fices,•'^^^ Transcranial films, how-
tories, clinical examination, radio- ity as well as an analysis of the occlu- ever, have some limitations; the dis-
graphic examination of the teeth and sion. This analysis should be per- advantages include distortion and
TMJ, and diagnostic casts. In addi- formed intraorally ond, when possi- lack of reproducibility.
tion, newer techniques of soft tissue ble, with properly mounted cosfs, There are presently more occurate
imaging, arthrography, ond man- Aiso, fhe newer electronic mandibu- techniques than transcranioi x-rays
dibular motion data can prove to be lor movement recording techniques of fhe temporomondibular ¡oint.
of important diagnostic value, may well prove to be of invaluable There are tomographic units on the
A thorough history may be the most diagnostic importance, market which take a corrected
important means of diagnosing TMJ Radiographic examination can in- cepholmetric tomogram, correcting
Treatment = Management
• Alleviate, Not Cure Symptoms
• Maintain Or Improve Signs
Fig. 35 Treatn
Treatment Goals
Educate And Assure Patient
i Hyperactivity Of Muscles
Stabilize Pasitian Of Candyles
i Parafunctianal Activity
Stabilize Occlusian, p.r.n.
Treatment Regimen
Treatment Modality
553 TMJ Patients, 1980-3
463 (84%)
500 456 (82%)
400
300
181
Ii
(33%)
200
56
(10%) 15
m
100
therapeutic muscle injections (Fig. fhis sfudy, there was an overall 94% tions of fheir symptoms after chewing
38). They were all placed on a 3, 6, improvement in sympfoms and a 6% hard foods or after an increase in
and 12 month recall program for as- lack of improvement. Only 12 of fhe tension due fo some stressful
patients who did not improve were episode. They had been trained dur-
sessment of fhe clinical results. Pa-
freafed surgically. To date, 11 of ing treatmenf fo understand the signs
fients without at least one recall ap-
fhose 12 pafienfs hove progressed and symptoms and could usually re-
pointment assessment were nof In-
satisfactorily. verse fheir renewed complaints
cluded in the tabulation of the resulfs.
Even though in fhe clinical studies themselves. The patients who had no
All patients were diagnosed, treated,
there was a significant group of pa- improvement or who were worse
and assessed by fhe same dentist
fients with partial improvement were referred for surgical carrection
(Figs. 39 and 40).
(51%), the overall symptom im- or for further medical consultation.
The patient progress was as follows:
provement was encouraging (94%). These results would compare favor-
43%, or 237 patients, reported total
The group that reported partial im- ably wifh fhe management of other
remission of their symptoms; 51 %, ar
provement should nof be considered orthopedic management problems
284 patients, reported partial remis-
as a failure. This group demon- in medicine.
sion; 5%, or 27 patients, were the
strated slight and even insignificant
same; and 1 %, or 5 patients, re-
signs of minor episodic exacerba-
ported they were worse (Fig. 40). In
500 —
400 —
300 205
100
^P^ 3 Mos.
6 Mos. 1 Yr. 2Yrs.
Patient Progress
553 TMJ Patients, 1980-3
•1
500
400
284
237 (51%)
300 (43%)
200 —
27
100 (5%) 5
(1%)
/ /
i
76
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