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Functional preprosthetic treatment

Mark Schmitter, Prof. Dr. med. dent.

Functional exploration in patients with prostheses 16% of the population presents functional
is essential. On the one hand, the possible alterations of the stomatognathic system that
alterations detected during the examination can require treatment2. It follows that approximately 1
guide the planning of the new prosthesis and, on in 6 adults need treatment. There is a very high
the other hand, the documentation of the findings probability that some of them go to the dental
is important not only for medical-legal office and receive a prosthetic treatment without
considerations, but also for evolutionary control. previously detecting the existing symptoms or
The clinical examination should be a systematic taking into account the treatment needs. This
procedure that is easy to learn. It must be possible situation favors the appearance of complications
to carry out quickly and according to scientific in relation to the new prosthesis and may also
foundations. The RDC/TMD (Research Diagnostic have medico-legal consequences. Hence the
Criteria for Temporomandibular Disorders) importance of carrying out and documenting a
examination protocol meets the aforementioned functional examination before planning
requirements. In complex clinical pictures that are treatment, and starting the corresponding therapy
accompanied by joint involvement, magnetic if appropriate. However, it is worth asking what is
resonance imaging is recommended rather than the most appropriate exploration and what are
other imaging techniques. the most effective therapeutic options in daily
practice.

(Quintessenz.2009;60(11):1295-301)
Clinical and functional diagnostic examination

It is recommended to carry out a functional diagnostic

exploration in the framework of the pre-prosthetic
study, especially in large-scale rehabilitations that
Introduction
modify the intermaxillary relationship. Different
Functional disorders of the stomatognathic protocols and forms are available for this type of
system have their origin in the masticatory examination, which can create confusion: which form
muscles, in the temporomandibular joints or in should be used? What conditions can be diagnosed
associated structures. Pain, limited jaw mobility, through these examinations? In addition to the "Clinical
and temporomandibular joint noises may be Functional Status of the Working Group for Functional
symptoms of a functional disorder. Some recent Analysis of the German Dental Society (DGZMK)", the
studies showed that approximately one "Research Diagnostic Criteria for Temporomandibular
Disorders (RDC/TMD)" is also useful. It is a reliable
protocol, internationally recognized7.19, which can be
downloaded free of charge from the Internet also in
Correspondence: M. Schmitter. German (www.rdc-tmdinternational.org; fig. 1). As in
Polyclinic of Prosthodontics. Clinic of Dentistry, Oral and other protocols, in this examination protocol muscle
Maxillofacial Medicine of the Heidelberg University Clinic.
Im Neuenheimer Feld 400, 69120 Heidelberg, Germany. groups are also palpated (Fig. 2), temporomandibular
Email: [email protected] joint noises are identified, and
236 Quintessence (ed. esp.) Volume 24, Number 5, 2011
Figure 1.Home page of the
International RDC/TMD
Consortium website with
all the information
saria and the tra
the protocols
tion in differ

Therefore, functional limitations may or

origin in pain, but painless decrease
Oral opening can also negatively influence
the patient's daily life. In summary,
omandibular discomfort considerably affects
the quality of life related to oral health.

imaging tests
Magnetic resonance imaging (MRI) should be
considered in patients presenting with functional
pain of joint origin and resistant to long-term
treatment or temporomandibular joint swelling of
Figure 2.Unilateral palpation of the musculature on the unknown etiology. With zero radiation exposure and
right and left side separately.
good hard-tissue/soft-tissue contrast, this procedure
allows accurate assessment of disc position and
condyle shape (Fig. 3). In patients with anterior disc
measure mandibular mobility during physical displacement with reduction, in whom the aim is to
examination. In this context, special attention is paid to stabilize the reduction by means of a prosthesis, it
the appearance of pain. However, the protocol does not seems logical to check the location of the disc in the
include the evaluation of occlusion, so this point should non-click position using MRI before making the final
be taken into account, although there is no unanimity prosthesis in that position once a period of time has
regarding the importance of occlusion in the passed. probationary period with a provisional.
appearance and maintenance of functional disorders.3. Other imaging techniques are not suitable for the
An inexperienced examiner will not need more than 15 diagnosis of functional disorders of the
min to carry out the examination. Regardless of the type temporomandibular joint, since they do not provide
of protocol used, it should allow distinguishing between a sufficiently contrasted image of the soft tissues,
arthrogenic and myogenic functional disorders. The their interpretation is complicated (Fig. 4) and they
guiding symptoms that justify an intervention mainly are accompanied by considerable exposure to the
include pain and functional limitations, but joint noises radiation. Caution should also be exercised when
are excluded as the only symptom. The pain can appear interpreting panoramic radiographs, as the presence
both at rest and with movement. Pain on movement of projection phenomena makes it difficult or
may or may not be associated with exertion (chewing, impossible to accurately assess the shape of the
biting, condyle.14.18.
Quintessence (ed. esp.) Volume 24, Number 5, 2011 237
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articular tuberosity
auditory canal
condyle (alteration
Shape)
articular disc
(shifted to
in front of)

mandibular ramus
upward

Figure 3.ima 4.ra

zamiento disc stico d
in the form of

Figure 5.Initial situation prior to a bite increase. Figure 6.Provisional bite augmentation with a splint.

Functional therapy interventions within provisional and reversible bite before carrying out the
pre-prosthetic treatment definitive rehabilitation with a prosthesis.

Loss of vertical dimension Changes in the existing jaw relationship

If the objective of prosthetic rehabilitation is to increase In all other changes in the intermaxillary relationship
the vertical dimension to solve a loss of it, an exhaustive (besides the bite increase in the loss of vertical
clinical functional analysis must be carried out (Fig. 5). In dimension) it is also advisable to carry out a
this context it is irrelevant whether the patient already provisional reversible adjustment of the "new bite"
wears a prosthesis that must be replaced or damaged before the definitive treatment. This is the case, for
natural teeth must be restored. example, in the prosthetic reduction treatment of an
Before proceeding with the definitive treatment of a loss anteriorly displaced disc with reduction.
of vertical dimension with a prosthesis, an increase in the
provisional bite will be made with a splint (fig. 6). This
myofascial pain
allows early detection of possible adaptation problems that
may arise and eliminate them by introducing modifications If the results of functional clinical examinations
to the splint. In exceptional cases, the provisional bite point to a diagnosis of myofascial pain, functional
augmentation may show that the patient does not tolerate treatment is recommended before starting
the elevation of the vertical dimension. This gives an idea of rehabilitation. For this, there are a series of more
the need to increase or less well-studied procedures: treatment
238 Quintessence (ed. esp.) Volume 24, Number 5, 2011
Figure 7.Anterior disc displacement with reduction (disc framed in red) (left: mouth closed, right: mouth open). This type of
displacement is characterized by clicks when opening and closing the mouth. Opening and closing are not usually painful.

I lie with splintseleven, physiotherapy12, trigger point Although the treatment is not curative in disc
infiltration1, botulinum toxin injection24, spray and displacements and changes in the shape of the condyle, it
stretch technique10, pharmacotherapy, acupuncture23, is possible to achieve adequate control of the symptoms. In
psychosocial interventions9, etc. In the dental practice, addition, for medical-legal reasons, it is recommended to
treatment with splints combined, if appropriate, with document the functional status of the TMJ before
pharmacological treatment has established itself as a proceeding with large-scale prosthetic rehabilitations.
non-invasive and reversible therapeutic option in the
majority of patients.6.17. Meanwhile, its mechanism of
Anterior disc displacement with reduction (fig. 7)
action has been studied and it has been found that the
change in the stimulation patterns of the masticatory In this case, with the mouth closed, the disc is
muscles plays an important role.15.16. placed in front of the condyle and returns to its
Other procedures have also shown therapeutic efficacy, normal position when the mouth is opened. It is
but are invasive (such as trigger point infiltration), common to perceive a click when opening or
expensive (psychosocial intervention), or understudied closing the mouth. Although this condition does
(such as acupuncture). However, it should not go not necessarily require treatment, it may be useful
unmentioned that in a small number of patients with to reduce disc displacement before a previously
chronic pain it is essential to integrate psychosocial scheduled oral rehabilitation (for example with a
interventions into the overall treatment. These types of hybrid prosthesis). For this, a protrusion splint is
interventions should be carried out by the corresponding made, free of clicks and, later, the new mandibular
specialists (such as clinical psychologists). The psychosocial position is stabilized by means of the prosthesis.
screening of these patients should be carried out using However, this procedure is not suitable for
specific questionnaires in the dental office, although it is patients who do not require a prosthesis of at
only for guidance and does not serve to establish a least one full arch.
diagnosis.

TMJ diseases
Anterior disc displacement without reduction (fig. 8)
In this type of pathology, disc displacements (with or
without reduction when opening the mouth) and The disc is placed in these cases in front of the condyle
changes in the shape of the condyle (such as those that both with the mouth open and with the mouth closed.
occur in osteoarthritis) stand out above all. However, Opening may be limited in the acute phase and any
other disorders, such as joint effusions, can also cause attempt to force the opening further may cause pain. Also,
functional disorders. These clinical pictures may be due when opening the mouth, the jaw deviates towards the
to other rarer causes (such as free bodies). affected side. From a therapeutic point of view, the

Quintessence (ed. esp.) Volume 24, Number 5, 2011 239

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Figure 8.des fallen and

open mouth) e sharp
mandibular. AND or, but
by det

Figure 9.TMJ osteoarthritis (right: normal condyle). If the picture is accompanied by pain, it is TMJ osteoarthritis in the active
phase. On clinical examination, movements of the temporomandibular joint are often accompanied by a grinding noise.

options are limited and none of them is curative. On the In the absence of symptoms, therapeutic
one hand, invasive procedures are available13, whose intervention is undoubtedly not necessary, but it is
efficacy is also debatable and, on the other hand, of possible that this group of patients develops
non-invasive procedures such as treatment with splints discomfort more frequently after prosthetic
22. Due to the situation of permanent anterior rehabilitation. Patients should be informed of this
displacement of the disc, the evolution of the symptoms possibility if positive data are identified in the history.
depends to a great extent on the adaptability of the TMJ
structures.
TMJ osteoarthritis (fig. 9)
Interestingly, many of the patients with anterior disc
displacement without reduction do not present any of Osteoarthritis is accompanied by a change in the shape
the symptoms described.twenty. During the interview to of the articular condyle and is a relatively frequent
obtain the anamnesis, and also through specific finding in representative random samples of patients.5.
questionnaires, important data suggestive of the In this situation, a discrepancy between the diagnosis
existence of anterior disc displacement without and the symptoms is often found, that is, many patients
reduction (such as a limited mouth opening in the past) present clear signs of osteoarthritis (in imaging tests),
can be collected. This underscores the importance of but do not report any type of discomfort. By contrast,
paying special attention to the history. other patients show only mild signs (in
240 Quintessence (ed. esp.) Volume 24, Number 5, 2011
 ATM

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