Occlusion Test 1

Crossover displays extended lateral movements that smoothly transfer occlusal contact from the ______ to the ______

Canine to incisors

Central Pain

Caused by tumor/CNS disturbance Pain felt in peripheral structures w/ systemic conditions (nausea, balance disorders)

Ideal tooth contact results in a resultant vector of force that is received by which muscles?

Temporalis masseter medial pterygoid

orofacial pain -list the acute types -list the chronic types

acute -protective co-contraction -local muscle soreness -myospasm -myofacial pain chronic -myofacial pain -centrally mediated myalgia -fibromyalgia

Posterior digastric fxn

depresses Mn

Suffering

how individuals react to the perception of pain

Describe the Manipulation of the Superior Lateral Pterygoid M

pt bites on tongue blade bilaterally overstretches m fibers painful if muscle soreness

Central excitatory effect -clinical manifestation if afferent neurons are involved

*referred pain reported* stimulating site of pain --> no effect stimulating source of pain --> ↑pain LA block at source --> eliminates pain at site + source

Projected Pain

Neurologic disturbance --> pain to peripheral distribution of same nerve (Nerve entrapment)

5 major factors of TMD etiology

Occlusal Emotional stress Deep pain Parafunction Trauma pt ADAPTABILITY = key

Describe the Manipulation of the inferior Lateral pterygoid

Pt protrudes against resistance - pain/burning = muscle fatigue

Temporalis fxn

elevation + Retraction

Meniscus

fibrocartilage crescent wedge attached to 1 side of the articular capsule + unattached on the other

Protective Co-Contracting

normal CNS response to injury --> alters fxn to protect injured area LA block at *source* --> removes pain at site/source

Fxn of masseter

slight protrusion + elevation deep fibers stabilize the condyle against the articular eminence

Fibromyalgia

widespread musculoskeletal pain w/ tenderness in 11/18 specific tender point sites throughout the body pain in 3/4 quadrants of the body lasts >3mon

left lateral movement -working side -balancing/non-working side

working = left side of arch balancing/non-working = right side

partially stretched muscle spindles results in

↓stretch needed to elicit a reflex action ↑muscle tonicity ↑muscle fatigue ↑tonicity - ↑inter-articular P of TMJ

Sleep cycle

4 stages non-REM --> REM non-REM -stage 1 = α wave -stage 2 = α wave -stage 3 = Δ wave -stage 4 = Δ wave

Normal sleep cycle is _______ min Most pts average ________ sleep cycles/night

60-90min 4-6 sleep cycles/night

TMJ Innervation

75% = auriculotemporal additional = deep temporal + masseteric (V3 branches)

Group function articulation

>/= 1 posterior teeth + some anterior teeth, are in some contact during the complete extent of lateral movement Secondary occlusal scheme/most practical approach More common in older pts

Ideal occlusion is when ____ + ____ occur smultaneously

CR + MI

The _________ ligament allows anterior/posterior movement of the condyle + rotation of the disc in the condyle

Collateral discal ligaments

the _______ ligament is responsible for hinge opening of the TMJ b/w condyle + disc the position of the ______ ligament limits pure hinge axis rotation

Collateral discal ligaments TM ligament

Temporomandibular ligament -inner horizontal portion fxn -outer oblique portion fxn

IHP = limits condyle + disc posterior movement OOP = limits rotational opening

Collateral Discal ligaments -list -characteristics

Medial discal ligament + lateral discal ligament True ligaments - collagenous CT doesn't stretch vascular + N supply

The myotactic jaw reflex (myotactic stretch reflex) maintains

Muscle tone + resting position of the jaw

The bite plane of the deprogrammer must be positioned

Perpendicular to the long axis of Mn teeth

TMJ Vascular supply

Posterior = superficial temporal A Anteriorly = middle meningeal A Inferiorly = internal maxillary A Other = deep auricular, anterior tympanic + ascending pharyngeal A

mutually protected occlusion

Posteriors accept heavy forces through their long axis (vertical force) closer to fulcrum -protects anteriors (labial inclination) during closure anteriors favor eccentric Mn excursions -protects posteriors by guiding Mn in excursions receiving lateral forces

List the muscle of mastication elevators

Pterygomasseteric sling masseter medial pterygoid

80% pts awakened during ______ will remember dreams

REM

Capsular ligament limits what movement?

Rotation translation posterior movement

80% of Lateral pterygoid muscle fibers are?

Slow Twitch Type 1 Muscle Fibers

TMD Predisposition regarding -steepness of articular eminence -condyle fossa morphology -joint laxity

Steeper eminence = more rotation = ↑ risk of ligament elongation flat condyles = more vulnerable joint laxity (↑ Estrogen) = ↑TMJ clicking

List the accessory ligaments supporting the TMJ + Mn. What is their fxn?

Stylomandibular ligament - limits excessive Mn protrusion sphenomandibular ligament - slightly limits lateral Mn movement

The TMJ is divided into what 2 systems? What is their fxn?

Superior = Condyle disc complex functioning against the Mn fossa -fxn = *Translation* (free sliding movement) Inferior = Condyle disc complex -fxn = *Rotation*

Central excitatory effect -clinical manifestation if autonomic neurons are involved

Variations of BF blanching reddening of tissue puffy/dry eyelids stuffy/runny nose

Ideal tooth contact relationships requires what? What is the resultant vector of force/most efficient direction of power stroke

adequate Mx overlap w/ Mn occlusal forces exerted down the long axis of posterior teeth All Mx/Mn teeth w/ simultaneous contact -posteriors dominate over anteriors -anteriors have "passive" contact

What causes referred ear pain w/ inflammation of the retrodiscal tissue

anterior wall of bony portion of ear canal = thin

The ________ guides all Mn movement

articular eminence angle (steep/flat)

List the types of heterotopic pain

central pain projected pain referred pain

Capsular ligament

contains the condyle + synovial fluid in the glenoid fossa OOP + IHP reinforces the lateral aspect

List the types of macrotrauma

direct trauma -open mouth -closed mouth indirect trauma -whiplash

Lateral pterygoid - superior head fxn

eccentric contraction w/ closing progressively active w/ Mn closing

Macrotrauma to TMJ -indirect (whiplash)

eccentric m contraction --> sudden/forced m lengthening --> condyles forced excessively forward

Signs of bruxism

excessive tooth wear, mobility, + fracture scalloped tongue/ridge mucosa masseter + temporalis hypertrophy wide PDL

Crossover

extreme Mn lateral movement when the Mn Cn's cusp tip "crosses over" Mx Cn's cusp tip while maintaining tooth contact b/w the Mx + Mn arch outside normal envelope of fxn critical to success of anterior restorations

The medial pole of the Mn fossa serves as a stop for?

force of elevator muscles (especially medial force of medial pterygoid)

In microtrauma - small, excessive loading forces --> ______ + _____

fragmentation of collagen fibers + chondromalacia

Functional forces v parafunctional forces regarding -influence of protective reflexes -pathologic effects

functional -protective reflexes present -unlikely pathologic effects parafunctional -obtunded protective reflexes -pathologic effects likely

Functional activity v parafunctional activity regarding -direction of force -Mn position -Type of muscle contraction

functional -vertical force -Centric occlusion -Isotonic Parafunctional -horizontal force -eccentric movements -Isometric

The _____, _____, + _____ are primarily responsible for a pt's emotional stage

hypothalamus reticular system limbic system

Pain behavior

individual's audible + visible actions to communicate his/her suffering to others

Most Mn movement occurs in the temporomandibular's disc _______ + _______ region

intermediate zone (thinnest) + anterior region

Myospasm (Tonic contraction myalgia)

involuntary CNS induced tonic muscle contraction - sudden shortening of a muscle

Chronic pain

lasts longer than healing + has no protective value!! destructive to the human spirit + quality of Life

Slow Twitch Type 1 Muscle Fibers

light resistance work aimed at muscular endurance ↑mitochondrial + vascular content + ↑[myoglobin] Resistant to fatigue May brace the condyle for long period of time w/o difficulty

______ is the most common muscle pain seen by dentists

local muscle soreness

Trigger point

localized area in m tissue/tendinous attachment felt as painful taut bands

Masticatory system -major fxns -secondary fxns

major -mastication -swallowing -speech secondary -aids respiration -aids emotion expression

Macrotrauma to TMJ -direct closed mouth

may cause adhesions due to altered articular surfaces

medial discal ligament v lateral discal ligament

medial = attaches medial edge of disc w/ medial pole lateral = attaches lateral edge of disc to lateral pole

Medial pole of the fossa allows ______ The lateral pole of the fossa must ________

medial pole = rotation in a fixed axis while not being parallel lateral pole = translates while the medial pole rotates

articular disc v meniscus

meniscus -extends freely into joint spaces -does NOT divide a joint cavity - isolating the synovial fluid -*passive fxn* to facilitate movement b/w bony parts -does NOT serve as a determinant of joint movement

Descending inhibitory system

modulates impulses (pain) to the cortex by assisting the brainstem in suppressing this input (5HT) important mechanisms for pain modulation

Polysomnogram

monitors brain activity, skeletal muscle activation, eye movement and heart rhythm during sleep

Macrotrauma to TMJ -Direct open mouth

most dangerous condyle suddenly displaced from fossa

Centric Relation

most orthopedically stable TMJ position = condyles in the articular fossa are in their most superior anterior position w/ disc properly interposed

Local Muscle Soreness (non-inflammatory myalgia)

muscle's 1st response to continued protective Co-contraction represents a change in local m environment due to excessive muscle use/direct tissue damage by IA block

Central excitatory effect

neurons carrying nociceptive input to CNS --> stimulates other interneurons either by.... -NT accumulation + spillage to other neurons -convergence of neurons on 1 synapse - can't localize pain continuous deep pain --> excites unassociated neurons

Central Pattern Generator

neurons controlling rhythmic m activity (breathing/walking/chewing) precise timing b/w antagonistic m feedback from PDL, tongue, lips, + teeth

Leaf gauge

occlusal stop in anterior section to give a fulcrum effect removed until 1st contact obtained

Heterotopic pain

occurs in an abnormal anatomic position (source = deep structures, not skin/gingiva)

Myotactic Jaw Reflect (myotactic stretch reflex)

only monosynaptic jaw reflex maintains m tone + resting jaw position protects masticatory system from sudden m stretching maintains stability of musculoskeletal system w/ muscle tonicity SoRTS

Myospasm -clinical characteristics

pain at rest increased pain w/ fxn tenderness to palpation muscle tightness structural dysfxn in occlusion

The articular surface of the _____ condyle is > ______ condyle. The _________ condylar head has most of the articulation b/w the condylar head, articular disc, + fossa

posterior condyle > anterior condyle anterior condylar head

The ______ border of the articular disc is thicker v the ______ border

posterior is thicker

TMJ's nociceptive reflex

protective Polysynaptic reflex to noxious stimuli (*sudden + heavy functional forces*) sudden tooth overload --> antagonistic inhibition

Central excitatory effect -clinical manifestation if efferent neurons are involved

protective co-contraction reported

Acute pain

provides protection from environment (nociceptive reflex) basic to survival!!!

What happens when CR does not coincide w/ MI/ICP/CO

pts have a slide MI = endpoint of the slide 1st occlusal contact in CR (>/= 2 posterior teeth) --> continued closure --> slides on posterior's inclines condyles are more anterior, superior, + lateral than ideal

Clinical rules for referred pain in H+N

rarely crosses the midline (unless origin is in the midline) lamination (M to M, incisors to incisors)

Myofacial Pain (Trigger point myalgia)

regional myalgic pain local areas of firm, hypersensitive bands of m tissue (Trigger points)

Anterior deprogrammer

relaxes muscles to capture the best CR record inhibits posterior tooth contact elevator muscles guide condyles to CR

Muscle contractile activity is controlled by what?

release + rapid Ca absorption stored in the SR AP --> CA release damage to SR w/ CA spillage --> sustained contraction as long as ATP is available

Non-REM fxn

restores body system fxns (RNA, proteins, NT, vital macromolecules) Physical rest

REM fxn

restores fxn in brainstem + cerebral cortex emotions are dealt + smoothed out Psychic rest

Protective Co-Contracting -clinical manifestations

restricted Mn movement secondary to pain Range of motion = almost normal, slow opening No pain at rest muscle weakness - tire quickly w/ chewing

Bruxism in children

self-limiting not associated to ↑bruxism risk in adulthood

Referred Pain

sensations felt not w/ involved nerve but in other branches/different nerve

Suggested cause of trigger points

sensitization of N endings by algogenic substances

Chondromalacia

softening of the articular surface

Source of pain v site of pain

source = actual origin site = where pt feels pain

Primary pain

source = site ex = toothache

Central excitatory effect -key symptoms

symptoms = unilateral (dry eye on 1 side)

Medial pterygoid fxn

unilateral contraction mediotrusive action + protrusion

Pain

unpleasant sensory + emotional experience associated w/ actual/potential tissue damage

CR axial loading occurs when?

when cusp tip to flat surface (fossa/marginal ridge) = perpendicular to long axis OR when cusp tip contacts 3 points in opposing fossa