Clinical management of temporomandibular disorders: controlling bruxism and temporomandibular joint load Penanganan klinis gangguan temporomandibula: pengendalian bruksisma dan beban sendi temporomandibula


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  Shogo Minagi: Clinical management of temporomandibular disorders: controlling bruxism and tmj load

Clinical management of temporomandibular disorders: controlling bruxism

and temporomandibular joint load

Penanganan klinis gangguan temporomandibula: pengendalian bruksisma dan

beban sendi temporomandibula Shogo Minagi

  Department of Occlusal and Oral Functional Rehabilitation Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama University, 2-5-1 Shikata-cho, Okayama 700-8525 Japan


Langkah pertama penatalaksanaan klinis dari gangguan temporomandibula (GTM) adalah membedakan sumber

masalah, mengklasifikasi menjadi masalah dari otot atau sendi, yang telah dipahami menjadi proses yang penting.


Meskipun mekanisme yang tepat untuk gejala atau patologi kondisi tersebut sampai saat ini belum diklarifikasi,

parafungsi atau hiperfungsi otot telah disadari memainkan peranan penting dalam etiologi GTM. Pembebanan

mekanis yang berlebih ke sendi temporomandibula (STM) telah dilaporkan menjadi salah satu faktor yang mungkin

menyebabkan perkembangan osteoartritis. Gaya-gaya ini dapat dikenakan melalui parafungsi mandibula seperti

bruksima saat tidur atau kebiasaan mengkertakkan gigi. Untuk kontrol klinis dari bruksisma saat tidur, telah

dikembangkan sebuah piranti palatal yang tebal yang menutupi palatum dan tidak menutupi permukaan oklusal.

Dalam kajian pustaka ini juga telah dibahas mengenai implikasi klinis dari hubungan antara oklusi, mastikasi dan


  Kata kunci: oklusi, balancing side, mediotrusif, TMJ, epidemiologi ABSTRACT

The first step of clinical management of the temporomandibular disorders (TMD) is to distinguish the origin of

problem, to classify into myogeneous and joint problems, which have been regarded to be an important process.

Although the precise mechanisms for the symptoms or pathology of these conditions have not yet been clarified,

muscular parafunction or hyperfunction has been regarded to play an important role in the etiology of TMD. Excess

mechanical loading to the temporomandibular joint (TMJ) has been reported to be one of the possible causes for the

development of osteoarthritis. These forces might be exerted through mandibular parafunctions like sleep bruxism or

tooth contacting habit. For clinical control of sleep bruxism, a thick palatal appliance which fills the palate and does

not cover the occlusal surface have been developed. In this review article, clinical implication of the relationship

between occlusion, mastication and bruxism have also been discussed.

  Key words: occlusion, balancing-side, mediotrusive, TMJ, epidemiology

Correspondence: Shogo Minagi, Department of Occlusal and Oral Functional Rehabilitation, Graduate School of

Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Okayama 700-8525,

Japan. E-mail:; Tel: +81-86-235-6685, Fax: +81-86-235-6689.


INTRODUCTION controversial issue especially in relation to TMD.

  The first step of clinical management of the Many opinions have been presented in the temporomandibular disorders (TMD), is to literature during the past century especially distinguish the origin of the problem, classify into regarding several points of view: i.e. 1) occlusion myogeneous and joint problems, which has been as an aggravating factor of mandibular regarded to be an important process. Although parafunction, 2) occlusion as a controlling factor precise mechanisms for the symptoms or of mechanical stress distribution, and 3) others. pathology of these conditions have not yet been Excess mechanical loading to the clarified, muscular parafunction or hyperfunction temporomandibular joint (TMJ) has been reported has been regarded to play an important role in the to be one of the possible causes for the 1-2 etiology of TMD. development of osteoarthritis. These forces

  On the other hand, occlusion has been a might be exerted through mandibular

  B f palatal splint. 4 B: baseline; nce; TN: thin appliance; TK: medium thick appliance. en compared to the baseline

  When focused on controlling factor of the m to masticatory system, ba would be playing an impo studies of balancing-side ce. 3 A. Occlusal view of a thick palatal appliance in po faces. B. Median sagittal section of a thick palatal appli

  position. The appliance ppliance. The appliance A

  on the occlusion as a mechanical stress exerted , balancing-side occlusion portant role. In historical de occlusion, it has been

  ancing-side occlusion and l survey

  hich were horseshoe type appliance (TN), thick medium thick appliance and reported that TK was designs as shown in Fig.3. target were TMJ and not would be appropriate to irst choice modality, as the erted to TMJ would be atory muscle activities.

  B ru xi sm e p isod es/ h r .10, No.1, Februari 2011:1-5

  he end of treatment. 3 were observed between latal appliance groups alatal appliance group

  Fig.3. Effect of design of p HS: horseshoe type applianc thick appliance; Med: m

  A B

  DISCUSSION Classification of balanci related epidemiological su

  parafunctions like sleep brux contacting habit. This review arti clinical management of TMD and is mainly from our research resul

  . Hasegawa et al., 4 t of different design of palatal appliance, whic appliance (HS), thin a appliance (TK) and me (Med), on sleep bruxism a most effective in these des Even when treatment targ masticatory muscles, it w use this appliance as a first origin of the force exer generated by the masticator

  This has long been TMD clinic at the l. A clinical study pain alleviation on hown in Fig.2. 3 This ted especially at the

  bruxism or tooth rticle focuses on the and its consequence sults. of sleep bruxism, a s developed. 3 The does not cover the not alter the occlusal

  Dentofasial, Vol.10

  Fig.2. Pain alleviation rate at the Note that statistical differences were the no treatment and the thick palat (p< 0.05) and between the thick pala

  A B

  Fig.1. Thick palatal appliance does not cover occlusal surfac fills the palatal cavity.

  For the clinical control of thick palatal appliance was appliance fills the palate and doe occlusal surface, thus would not condition as shown in Fig.1. Thi the first choice modality in TM Okayama University Hospital. revealed significant effect of pa myogeneous TMD patient as show clinical effect could be expected first phase of the treatment. H made EMG study on the effect of

  LITERATURE REVIEW Controlling sleep bruxism

  • Significant difference when condition. (p < 0.05).

  Shogo Minagi: Clinical managemen

  reported that classification of th occlusion might have been resulting in the conflict of the investigation employing a c balancing-side occlusion was classification incorporated the functional force exerted to ma Balancing-side occlusal contact during mandibular lateral excu were classified into the following First, simultaneous balancing-si side contact (without clenching). as the presence of balancing-si that occurred simultaneously with on the working (contralateral) sid excursive jaw movement. This performed without any clenching balancing-side protective contac only). This was defined as balancing-side molar contact ( and/or second molar) in a position that existed only clenching force was exerted. D the mandible was in the can position. Then, no balancing-side without clenching). This was absence of any balancing-side toot either a lateral excursive mov clenching) or in a canine edge- (with moderate clenching). The balancing-side contact (no work This was defined as the presence molar contact without any occlus working (contralateral) side du excursive jaw movement. This performed without any clenching

  • side and working- ng). This was defined
  • side molar contact ith occlusal contact side during a lateral his movement was hing force. Second, ontact (with clenching s the presence of t (mandibular first lateral excursive when moderate

  Epidemiologic survey using achieved according to the cl number and percent of balanc patterns per side and per age w the prevalences of TMJ sounds ( of the balancing-side contact gr exclusive balancing-side contac number of the subjects is not enoug in Fig. 4. Temporomandibular joi balancing-side protective conta prevalence of TMJ noise and show relationship. On the contrary, l between TMJ noise and the age TMJ with no balancing-side con TMJ with simultaneous balanc

  ment of temporomandibular disorders: controlling bruxism

  of the balancing-side n incomplete thus their effect. 5-6 An classification of as achieved. 1 The the concept of masticatory system. ct patterns observed cursive movements ing four groups.

  . During clenching, anine edge-to-edge ide contact (with or as defined as the tooth contact during movement (without dge-to edge position

  The last, exclusive orking-side contact). nce of balancing-side lusal contact on the during a lateral his movement was hing force. ng 430 subjects was classification. The ancing-side contact were analyzed and unds (per side) in three groups (except for ontact group, as the enough) are shown joint with ipsilateral ontact showed low showed no positive , linear correlation ge was observed in contact (p<0.001). ancing-side contact showed higher noise pr young age, showing slig with age. From these r induced balancing side co play a protective role components.

  Following the abov magnetic resonance imag the relationship betw displacement (ADD) of T occlusal contact was achie four patients who visited Dental School Hospital see problems were selected diagnosis for the patients in dysfunction syndrome derangement of the TMJ a but did not include traumatic joint diseases joints 70 were excluded fr as the disc position could by the MRI. Occlusal ex 52 sides showed simul contact, 7 sides showed with clenching only and balancing-side contact wit Articular disc displacemen 101 sides of 138 joints, an of 37 sides of the joints normal. As shown in Fig simultaneous balancing-sid in disc displacement g pattern of the three occlu different between the disc non disc displacement gro the comparison of these

  Fig.4. Prevalence of TMJ so side occlusal contact groups. ism and tmj load

  prevalence especially in light negative correlation e results, the clenching- contact was suggested to ole for ipsilateral TMJ bove described results, aging (MRI) analysis on etween anterior disc of TMJ and balancing-side hieved. 8-9 One hundred and ited Okayama University seeking treatment for TMJ ted for this trial. The s included myofascial pain e (MPD), internal

  J and osteoarthritis of TMJ growth abnormalities, s or neuralgias. Of 208 d from further examination ld not be clearly identified examination of 138 sides, ultaneous balancing-side ed balancing-side contact nd 79 sides showed no with or without clenching. ent could be observed for and articular disc position ints were regarded to be

  Fig.5, high prevalence of

  sounds in three balancing- ps. 1

  • side contact was observed group. The prevalence clusions was significantly sc displacement group and group (p<0.05). Moreover, e data with our previous

  Dentofasial, Vol.10, No.1, Februari 2011:1-5 . 5 60 80 Disc displacem ent ( + ) Disc displacem ent ( -) 51.5% 60 80 73.0%

  44.6% ) (% 40 40 e nc ale 18.9% ev

  Pr 20 4.0% 20 8.1% p < 0.05

  Fig.5. Prevalence of balancing-side occlusion in articular disc displacement group and non- 9 10 displacement group. Note the significant difference of the distribution pattern (p<0.05). technique reported elsewhere.

  . 6 70 60 Clinical implication of the relationship between occlusion mastication and bruxism 11 50 Our recent study on the preference of 40 chewing side (PCS) revealed that in asymptomatic ( % ) subjects with ADD, a significant predominance of n c e 30 the PCS on the ipsilateral side of ADD was le a v 20 observed during the mastication of hard food, and P re 10 no correlation was found between unilateral ADD and PCS for the soft food. This suggests that daily mandibular function might be regulated by Balancing-side Protective Contact Simultaneous Balancing caused by ADD. As mentioned above, ADD itself Contact No Balancing contact unconscious pain or uncomfortableness of TMJ Dental school student (n= 860) TMD group (n= 138) p < 0.0001 occlusion. would be related to some specific condition of

  CONCLUSION Fig.6. Prevalence of balancing-side occlusion in dental 9 Epidemiological and experimental data listed school student and TMD group. Note the significant

  above suggest the importance of occlusion as a difference of the distribution pattern (p<0.0001). 1,12 mechanical stress distributing factor. Considering study using 860 subjects research on balancing- clinical settings, the role of occlusion might be side occlusion revealed that the prevalence of negligible only when the total force amount, simultaneous balancing-side occlusal contact was which would be generated by masticatory muscles significantly higher and the prevalence of during functional and parafunctional activities, balancing-side protective contact was significantly were small. However, when mandibular lower in patient group (p<0.0001) (Fig. 6). parafunctional activity is high, resulting in certain

  From the results of this study, it was amount of mechanical loading to stomatognathic suggested that the high prevalence of system, occlusion would play an important role simultaneous balancing-side occlusal contact in especially in distributing the resultant force. patient group was mainly caused by the disc displacement of the TMJ side, where no REFERENCES

  1. Minagi S, Watanabe H, Sato T, Tsuru H.

  balancing-side occlusal contact could have been

  Relationship between balancing-side occlusal

  observed until the disc displaced. The importance

  contact patterns and temporomandibular joint

  of the balancing-side in articular disc

  sounds in humans: proposition of the concept of

  displacement might be indirectly supported by the

  balancing-side protection. J Craniomandib Disord

  mandibular movement utilized in the manipulation

  Shogo Minagi: Clinical management of temporomandibular disorders: controlling bruxism and tmj load 1990; 4(4):251-6.

  2. Satsuma H, Saito N, Hamanishi C, Hashima M, Tanaka S. Alpha and epsilon isozymes of protein kinase C in the chondrocytes in normal and early osteoarthritic articular cartilage. Calcified Tissue Int 1996; 58(3):192-4.

  3. Minagi S, Shimamura M, Sato T, Natsuaki N, Ohta M. Effect of a thick palatal appliance on muscular symptoms in craniomandibular disorders: a preliminary study. Cranio 2001; 19(1):42-7.

  4. Hasegawa K, Okamoto M, Nishigawa G, Oki K, Minagi S. The design of non-occlusal intraoral appliances on hard palate and their effect on masseter muscle activity during sleep. Cranio 2007; 25(1):8-15.

  5. Marklund S, Wänman A. A century of controversy regarding the benefit or detriment of occlusal contacts on the mediotrusive side. J Oral Rehabil 2000; 27:553-62.

  Mediotrusive tooth guidance and temporomandibular joint sounds in non-patients and patients. J Oral Rehabil 1996; 23(10):686-98.

  7. Minagi S, Ohtsuki H, Sato T, Ishii A. Effect of balancing-side occlusion on the ipsilateral TMJ dynamics under clenching. J Oral Rehabil 1997; 24(1):57-62.

  8. Ohta M, Minagi S, Sato T, Okamoto M, Shimamura M. Magnetic resonance imaging analysis on the relationship between anterior disc displacement and balancing-side occlusal contact. J Oral Rehabil 2003; 30:(1):30-3.

  9. Minagi S. Effect of occlusion on TMJ as a mechanical stress regulator. In Proceeding of the 3 rd symposium by 18 th committee of occlusion “occlusion and TMD” (Kobayashi Y, editor). Science Council of Japan, Tokyo; 2004. pp.39-47. (in Japanese).

  10. Minagi S, Nozaki S, Sato T, Tsuru H. A manipulation technique for treatment of anterior disk displacement without reduction. J Prosthet Dent 1991; 65: 686-91.

  11. Ratnasari A, Hasegawa K, Oki K, Kawakami S, Yanagi Y, Asaumi J-I, Minagi S. Manifestation of preferred chewing side for hard food on TMJ disc displacement side. J Oral Rehabil 2010 (in press).

6. Christensen LV, Donegan SJ, McKay DC.

  12. Minagi S. Balancing-side occlusion and TMJ. Dent in Japan 2007; 43: 183-8.

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