ABSTRACT
http://dx.doi.org/10.1590/1678-775720150295
Occlusal changes secondary to tem porom andibular
j oint condit ions: a crit ical review and im plicat ions
for clinical pract ice
Waleska CALDAS1, Ana Cláudia de Castro Ferreira CONTI2, Guilherme JANSON1, Paulo César Rodrigues CONTI3
1- Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento de Odontopediatria, Ortodontia e Saúde Coletiva, Bauru, São Paulo, Brasil. 2- Universidade Norte do Paraná, Departamento de Ortodontia, Londrina, Paraná, Brasil.
3- Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento de Prótese e Periodontia, Bauru, São Paulo, Brasil.
Corresponding address: Waleska Caldas - R. Dr. Roberto Barroso, 1351 - São Francisco - Curitiba - PR - Brazil - 80520-070 - Phone: +55 41 96679262 -
Fax: +55 14 33388353 - e-mail: [email protected]
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he r elat ionship bet w een Tem por om andibular Disor der s ( TMD) and m alocclusion is an ext rem ely crit ical issue in dent ist ry. Cont rary t o t he old concept t hat m alocclusion causes70'RFFOXVDOFKDQJHVHVSHFLDOO\WKRVHREVHUYHGDVVXGGHQPD\EHVHFRQGDU\DQGUHÀHFW
j oint or m uscle disor der s due t o t he obvious connect ion bet w een t hese st r uct ur es and t he dent al occlusion. Obj ect ives: The aim of t his ar t icle is t o pr esent t he m ost com m only occlusal changes secondar y t o TMD. Met hods: The clinical pr esent at ion of t hese condit ions is discussed. Det ails r egar ding diagnosis, t r eat m ent , and follow- up of pat ient s pr esent ing TMD pr ior or dur ing t r eat m ent ar e also pr esent ed. Conclusions: All plans for ir r ever sible t herapy should be pr eceded by a m et iculous analysis of TMD signs and sym pt om s in such a way t hat pat ient s ar e not subm it t ed t o ir r ever sible t r eat m ent , based on an unt r ue occlusal r elat ionship, secondar y t o ar t icular and/ or m uscular disor der s. When pr esent , TMD sym pt om s m ust always be cont r olled t o r eest ablish a “ nor m al” occlusion and allow pr oper t r eat m ent st rat egy.
Ke y w or ds: Tem por om andibular j oint disor der s. Malocclusion. Diagnosis.
I N TROD UCTI ON
The r elat ionship bet w een Tem por om andibular Disor der s ( TMD) and m alocclusion is an ext r em ely cr it ical issue in dent ist r y. I n t he 1980s, a law suit declar ed t hat or t hodont ic t r eat m ent was t he m ain cause of TMD236LQFHWKHQDVLJQL¿FDQWQXPEHU of st udies have been conduct ed t o invest igat e t his associat ion.
I n t h e p a st , st u d i e s h a v e su g g e st e d t h a t m al o ccl u si o n an d o ccl u sal i n t er f er en ces w er e m ain fact or s in TMD developm ent , t hus, validat ing
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t r ea t m en t o f t h e d i so r d er9 , 2 5. Ba sed o n t h a t , occlusal adj ust m ent s, full m out h r ehabilit at ion and or t hodont ic t r eat m ent becam e ver y popular as t he t r eat m ent of choice for TMD.
How ev er, m ost r ecen t st u d i es h av e sh ow n no differ ence in r elat ion t o signs and sym pt om s o f TM D a m o n g s u b j e c t s w i t h m a l o c c l u s i o n
an d t h ose w it h n or m al occlu sion3 , 2 0 as w ell as bet w een or t hodont ically t r eat ed and non- t r eat ed individuals3,13.
I n ear lier 1990s, w ell conduct ed st udies have dem onst rat ed t hat som e occlusal/ skelet al fact or s, su ch as an t er ior open bit e, u n ilat er al post er ior cr ossbit e, over j et gr eat er t han 6- 7 m m , absence
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( CR) t o m axim um int er cuspat ion ( MI ) discr epancy gr eat er t han 2 m m could be consider ed occlusal r isk fact or s for TMD14,16,24. How ever, m ost of t he people pr esent ing t hese alt erat ions hav e nev er ex per ience any TMD sy m pt om s. An appr opr iat e adapt at ion capacit y is probably able t o com pensat e possible sm all alt erat ions in funct ion, cr eat ed by t he pr esence of t he m alocclusion18.
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var iables. I n ot her w or ds, it cannot be est ablished w h i ch v a r i a b l e ( o ccl u sa l ch a n g e s a n d TMD ) d e v e l o p e d f i r st . To e st a b l i sh a ca u se - e f f e ct r elat ionship, pr ospect ive longit udinal st udies w it h lar ge and r epr esent at ive sam ples ar e needed, but ar e not yet available.
T h u s , c o n t r a r y t o t h e o l d c o n c e p t t h a t m alocclusion causes TMD, it m ay be t hat , due t o t he obvious connect ion bet w een t hese st r uct ur es and t he dent al occlusion, occlusal changes, especially t hose suddenly obser ved, m ay be secondar y and
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m uscle disor der s15.
An acut e m alocclusion r efer s t o any sudden change in t he occlusal r elat ionship t hat has been developed by a disorder24. This m ay be a m om ent ary or pr olonged condit ion29.
Som e of t he m ost com m only TMJ condit ions associat ed w it h occlusal changes ar e j oint effusion
GXHWRLQÀDPPDWLRQ15 and condylar degenerat ion processes associat ed or not wit h syst em ic problem s2.
Th e aim of t h is ar t icle is t o p r esen t som e co n d i t i o n s o f o ccl u sal ch an g es, seco n d ar y t o t em por om andibular j oint condit ions, int r oducing t he dent al pr ofessional t o t he gr eat im por t ance of t heir r ecognit ion and of t he evaluat ion of signs and sym pt om s of TMD pr ior t o t r eat m ent planning.
O C C L U S A L C H A N G E S S E C O N D A R Y T O TEM POROM AN D I BULAR D I SORD ERS
The developm ent of a m alocclusion, associat ed w it h signs and sym pt om s of TMD, is an unusual com p lain t in an or t h od on t ic clin ical p r act ice1 8. When an occlusal alt erat ion is caused by TMD, t h e r esu lt in g m an d ib u lar p osit ion an d occlu sal r elat ionship depends on t he TMJ st r uct ur es and/ or m uscles involved24. Pat ient s can dem onst rat e any of a num ber of clinical condit ions t hat int erfere wit h t heir com for t and abilit y t o funct ion5.
I t is, t her efor e, essent ial in t his scenar io t hat
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b ef o r e b eg i n n i n g a n y t r ea t m en t p l a n n i n g , i n su ch a w ay t h at pat ien t s ar e n ot su bm it t ed t o ir r ev er sib le t r eat m en t ( or t h od on t ic t r eat m en t , occlu sal ad j u st m en t , p r ost h et ic r eh ab ilit at ion , o r t h o g n at h i c su r g er y ) , b ased o n an u n st ab l e occlusal r elat ionship, pr oduced by ar t icular and/ or m u scu lar dist u r ban ces. Th e im plem en t at ion of im m ediat e t r eat m ent w ould not only br ing no
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but it could also aggravat e TMD sever it y.
Th e clin ical pr esen t at ion of m ost com m on ly occlusal changes secondary t o signs and sym pt om s of TMD is fur t her discussed.
An t e r ior ope n bit e ( AOB)
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in pat ient s w it h TMJ degenerat ive diseases.
Te m p o r o m a n d i b u l a r Jo i n t o s t e o a r t h r i t i s associat ed w it h funct ional over loading can lead t o j oint t issues collapse. I f t he j oint collapse occur s in bot h TMJs, condylar resorpt ion causes m orphologic br eakdow n of t he TMJs and a subsequent decr ease in r am u s h eig h t , w h ich r esu lt s in p r og r essiv e m an d ib u lar r et r u sion w it h an t er ior op en b it e. Th is m alocclu sion is called “ acqu ir ed open bit e associat ed w it h TMJ ost eoar t hr it is”26.
Tem porom andibular Joint degenerat ive diseases m ay be consequent t o syst em ic condit ions. I t has b een d em on st r at ed t h at r h eu m at oid ar t h r it is, am ong ot her reum at hological condit ions, can affect t he TMJ7,21. I ndividuals w it h t hese condit ions have less occlusal suppor t , m or e occlusal int er fer ences, gr eat er discr epancy bet w een Cent r ic Relat ion and Maxim um I nt er cuspat ion, and decr eased ver t ical over bit e. Ant er ior open bit e is, per haps, t he m ost
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t o r educed m axim um m out h opening capacit y26. I n pat ient s w it h such condit ions, ant er ior t eet h show w ear facet s and t he absence of m am elons on t he incisal edges, indicat ing t hat non- cont act ing t eet h of t hese pat ient s used t o be in cont act before2.
Pat ient s wit h TMJ ost eoart hrit is generally report s TMJ and m uscle pain, aggravat ed by j aw m ovem ent , an d j oin t cr ep it at ion1 2 , 1 8, con f ir m ed b y clin ical palpat ion and inspect ion.
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TMJ im ages and blood t est s ( r heum at oid fact or, eryt hrocyt e sedim ent at ion, ant inuclear ant ibodies) , especially w hen syst em ic condit ions ar e pr esent . Whenev er condy lar r esor pt ion is det ect ed, it is essen t ial t o d ef in e t h e st ag e of r esor p t ion t o invest igat e whet her t he dest ruct ive process is act ive or alr eady cam e t o a “ bur n out ” phase. Test s, such as com put ed t om ography ( CT) , m agnet ic resonance im age ( MRI ) and bone scint igraphy ar e useful t ools for t hat pur pose. Cone- beam CT is an excellent opt ion because of it s capacit y t o adequat ely det ect
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MRI , on t he ot her hand, allow s visualizat ion of t he disc posit ion and ar t icular car t ilage alt erat ions19.
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t he condyle and ar t icular em inence, ost eophyt es, ar t icular cyst s, and loss of t he j oint space18.
W h i l e t h e TMJ o st e o a r t h r i t i s ca n p r o d u ce r elat ively m inor open bit e changes fair ly slow ly, t he “ idiopat hic condy lar r esor pt ion”, a condit ion
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by hor m onal changes and ext er nal t r igger s, such as or t hognat hic sur ger y or ot her t raum as7, is, in com parison, m uch m ore aggressive and can lead t o sever e open bit e in a r elat ively shor t t im e21.
developm ent of condylar r esor pt ion in a 16- year-old fem ale pat ient , w it h past m edical hist or y of
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w it h a chief com plaint of TMJ pain, associat ed w it h a sev er e occlu sal r elat ion sh ip ch an ge ( an t er ior open bit e) .
The com put ed t om ography ( Figur e 1) clear ly show s t he advanced degr ee of condylar r esor pt ion, associat ed w it h t he pr esence of ost eophyt es and condylar er osions.
Sever e ant er ior open bit e, w it h t eet h cont act only in t he post er ior r egion ( Figur e 1) , is pr esent , r esult ing in funct ional pr oblem s such as chew ing
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Alt hough not a com m on com plaint30, progressive ant erior open bit e, as present ed here, should always be con sider ed as par t of t h e TMJ degen erat iv e disease pr ocess.
Un ila t e r a l post e r ior ope n bit e
A s s o c i a t e d w i t h u n i l a t e r a l c o n d y l a r r e sor pt ion
When condylar resorpt ion occurs unilat erally, an int rusion of t he condyle, associat ed wit h m andibular
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r esult is an ant er ior open bit e associat ed w it h a post er ior open bit e on t he cont ralat eral side, w it h occlusal cont act occur r ing only on t he post er ior r egion of t he affect ed side28.
I n Figur e 2, based on t he MRI , it is possible t o not e t he int egr it y of condyle cor t ical on t he r ight side and a high degr ee of condylar r esor pt ion on
t he left side in a 39- year- old pat ient , pr eviously subm it t ed t o or t hognat hic sur ger y. Left TMJ pain and sudden post er ior open bit e on t he r ight side w er e init ial com plaint s ( Figur e 3) .
Associa t e d w it h u n ila t e r a l j oin t e ffu sion
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can also lead t o occlusal alt erat ions. TMJ ret rodiscal t issu es ar e h igh ly vascu lar ized an d in n er vat ed, an d t h er ef or e su scept ible t o t h e in st allat ion of
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int o t he m andibular fossa. The out com e of t his condit ion is a sudden developm ent of ipsilat eral post er ior open bit e, and a st r ong cont act on t he canine r egion on t he opposit e side24. This m andible shift is accom panied by a low er m idline deviat ion ( Figur es 4 and 5) .
Pat ient s present ipsilat eral pain in t he preauricular r egion. I t is also im por t ant t o be awar e of m or e sever e disor der s t hat can cause sim ilar sym pt om s and develop m alocclusions such as TMJ t um or s or ear infect ions29.
Addit ionally, longit udinal st udies and r egr ession analysis of dat a w ould be useful for est ablishing which occlusal changes are due t o TMD, which t o our know ledge ar e st ill not available in t he lit erat ur e.
I nit ia l consult a t ion a nd t he pr e se nce of TM D sign s a n d sy m pt om s
Occlusal r elat ionship is fr equent ly dist ur bed by TMD m anifest at ions, as pr eviously m ent ioned, and t he dent al pr ofessionals m ust always be awar e of t he pr esence of such signs and sym pt om s pr ior t o any ir r ever sible pr ocedur e.
There are different prot ocols for t he assessm ent of signs and sym pt om s of TMD well est ablished in t he lit erat ur e, such as t he Resear ch Diagnost ic Cr it er ia
( RDC/ TMD)6 or t h e Helk im o in dices8. Alt h ou gh t hese pr ot ocols involve param et er s t hat ar e ver y
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disorders by specialist s in TMD and researches, t he assessm ent of possible signs and sym pt om s of TMD can be per for m ed in a r elat ively shor t t im e, w it h no
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t h e in it ial ex am in at ion . Su g g est ion s f or t h ese procedures are shown in Figure 6. These procedures allow t he clinician t o ident ify t he pr esence of t he
Figure 2- Magnetic resonance image evidencing integrity of condyle cortical on the right side (A) and a high degree of condylar resorption on the left side (B) of a patient presenting posterior open bite on the unaffected side
disor der and r efer t he pat ient t o a TMD specialist befor e st ar t ing any ir r ever sible t r eat m ent . Befor e t r eat m ent , pat ient s should always be asked about hist or y of sym pt om s of TMD such as TMJ noises, j aw locking, and pain in t he region of facial m uscles, j oint s or t em ple ar ea. Clinically, it is suggest ed t o inspect for t ender ness t o palpat ion on t he r egion of t he m asset er, ant er ior t em poralis m uscles, and in TMJ r egion. Assessm ent of m andibular act ive range of m ot ion ( AROM) , as w ell as inspect ion of j oint noises, should also be per for m ed.
An algor it hm is suggest ed ( Figur e 7) t o assist clinicians on how t o pr oceed w hen dealing w it h t hese sit uat ions. This algor it hm is based on t he
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f or or t h od on t ic t r eat m en t ( f u n ct ion al/ est h et ic com plaint s) or for TMJ/ m ast icat or y m uscles pain and dysfunct ion.
Accor d in g t o t h e su g g est ed p r ot ocol, w h en pat ient s com e for or t hodont ic t r eat m ent and signs of TMD ( not painful sy m pt om s) ar e det ect ed at baseline, it is essent ial t hat t he pat ient is infor m ed p r i o r t o t h e b e g i n n i n g o f t r e a t m e n t . Th i s i s im por t ant because, in case of pr ogr ess of signs t o sym pt om s during t he course of t reat m ent , pat ient s could consider t hat t he t r eat m ent was t he cause of t he disor der. I t is im por t ant at t his t im e t hat t he pract it ioner is able t o det ect any cont r ibut ing
Figure 5- Mandible shift accompanied by a lower midline deviation to the right side secondary to joint effusion on the opposite temporomandibular joint
fact or such as sleep or dayt im e br uxism / clenching, n a i l b i t i n g , ch e w i n g g u m , d e l e t e r i o u s sl e e p posit ion, am ong ot hers. A com plet e counseling and
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t o avoid t he pr ogr ession of signs as suggest ed by t he pr ot ocol of t he Am er ican Academ y of Or ofacial Pain ( AAOP)4. A few basic or ient at ions t hat can be given t o pat ient s w it h TMD signs ar e show n in Figur e 8.
Asy m p t om at ic j oin t click in g , on e t h e m ost com m on signs of TMD11,22, is one exam ple of t his sit uat ion. I t is a condit ion t hat usually do not require t r eat m ent27, but can pr ogr ess t o sym pt om s1 if t he pat ient has uncont r olled and per sist ent delet er ious parafunct ional habit s.
I n t h ese cases, or t h od on t ic t r eat m en t can b e in it iat ed . Th e p at ien t sh ou ld b e f r eq u en t ly r eassessed r eg ar d i n g t h e d et ect ed si g n s an d
r epeat edly h av e gen er al or ien t at ion on h ow t o avoid t he pr ogr ession of t he disor der. Addit ionally, p at ien t s m ay n ot r ep or t p ain on in it ial st ag es of degenerat iv e j oint diseases. When facing an occlusal change, as st at ed befor e, dent ist s should consider conduct ing fur t her invest igat ions on TMJ ( including im ages) .
On t he ot her hand, if a pat ient is looking for or t h od on t ic t r eat m en t , b u t also h as TMD an d t his is t he chief com plaint , it is v er y im por t ant t hat or t hodont ic t r eat m ent is not init iat ed. When pr esen t , sy m pt om s m u st be pr oper ly m an aged befor e t he init iat ion of or t hodont ic t herapy. This i s b eca u se, a s p r ev i o u sl y st a t ed , m a n y TMD m anifest at ions can r esult in an unst able occlusal r elat ionship, int er fer ing w it h a cor r ect t r eat m ent planning.
Wh en an y si g n s o r sy m p t o m s o f TMD ar e
a) ASK about the presence of joint noises, jaw locking and facial/head pain.
b) PERFORM muscle (masseter and anterior temporalis) and TMJ (lateral pole) palpation.
c) MEASURE mandibular active range of motion (AROM):
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Figure 6- Assessment of signs and symptoms of TMD
ob ser v ed , t h e p at ien t sh ou ld b e r ef er r ed t o a
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on TMD) for fur t her evaluat ion, diagnost ic, and m anagem ent . These pr ofessionals ar e pr epar ed t o conduct a differ ent ial diagnost ic and t o follow t he
pat ient dur ing t he or t hodont ic t r eat m ent or any occlusal t herapy.
Therapy usually follows a conservat ive t reat m ent pr ot ocol17, including phar m acot herapy, behavioral counseling ( Figur e 8) , hom e exer cises, phy sical
Figure 9- Protocol of management of patients presenting signs and symptoms of temporomandibular disorder during orthodontic treatment
1) Modify your diet
Try eating soft foods like soup, yogurt, mashed potatoes etc. Avoid eating hard foods or chewing for a long time. Do not chew gum!
2) Avoid opening the mouth wide
Avoid yawning, screaming, singing, and long sessions at the dentist.
3) Use hot compresses
Apply moist heat to the painful area for 20 minutes, two to four times a day.
4) Relax your jaw muscles
Try not clenching your teeth. Practice keeping your tongue on the roof of your mouth behind your front teeth. The rule is “lips together and teeth apart.”
5 Keep good posture
Maintaining good posture of head, neck, and back will help relax your jaw muscles.
6) Improve your sleep
Try to have a resting sleep. Avoid sleeping on your back or in other positions that stretch your jaw and neck muscles.
7) Practice aerobic exercises
Walking and water aerobics are excellent ways to help improve your pain and your overall health.
t h er apy, an d/ or in t r aor al applian ces1 8. To dat e, evidence based dent ist r y ( EBD) does not suppor t t herapies t hat pr om ot e com plex and ir r ever sible occlu sal ch an ges su ch as occlu sal adj u st m en t , or t h od on t ic t r eat m en t , f u n ct ion al or t h op ed ics, ort hognat hic surgery or prost het ic oral rehabilit at ion f o r t h e t r ea t m en t o f TMD1 0. Th i s d i scu ssi o n , how ever, is not w it hin t he scope of t his ar t icle.
On ce t h e p ai n h as b een r eso l v ed an d t h e con d it ion is st ab le ov er a r eason ab le am ou n t of t im e, in it iat ion of or t h od on t ic t h er ap y m ay be con sider ed1 8. Tr eat m en t plan m u st con sider possible v ulnerabilit ies of t he TMD pat ient such as asym pt om at ic ant er ior ly disc displacem ent or r em aining parafunct ional habit s.
D e v e lo p in g sig n s a n d sy m p t o m s o f TM D du r in g Or t h odon t ic t r e a t m e n t
TMD si g n s a n d sy m p t o m s a r e p a r t i cu l a r l y
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of or t h od on t ic t r eat m en t . Reg u lar or t h od on t ic t r eat m ent is done on adolescent s, a st age w hen t her e is a nat ural incr ease of m any cont r ibut ing fact or s for TMD such as t raum a, habit s, em ot ional st r essor s, et c. Hence, it is not uncom m on t hat , regardless of t he ort hodont ic m odalit ies, individuals develop t ransient signs/ sym pt om s at t hat life st age. I t is im por t an t t h at t h e or t h odon t ist n ot ify t h e pat ient t hat t hese pr oblem s ar e highly pr evalent in t he general populat ion and t hat t he et iology i s m u l t i f act or i al . Th er ef or e, i t i s n ot p ossi b l e t o est ab lish a cor r elat ion w it h t h e or t h od on t ic t herapy18.
Usu ally, t h e u se of b asic p h ar m acot h er ap y, such as m uscle r elax ant s ad non- st er oidal ant
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w it h counseling, physical t herapy and behavioral
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sig n s an d sy m p t om s. How ev er, if t h er e is an indicat ion for t he use of int raoral splint s as par t of t he m anagem ent st rat egy, t he or t hodont ic t herapy m ust be discont inued and r est ar t ed only aft er all sym pt om s w er e pr oper ly addr essed.
A prot ocol on how t o m anage pat ient s present ing signs and sy m pt om s of TMD dur ing or t hodont ic t r eat m ent is show n in Figur e 9.
CON CLUSI ON S
Based on t h e f act t h at t h er e is an ev id en t con n ect ion bet w een TMJ, m ast icat or y m u scles, and t he dent al occlusion, occlusal changes m ay
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for ir r ever sible t herapy, such as or t hodont ics or pr ost het ic r ehabilit at ion, should be pr eceded by a m et iculous analysis of TMD signs and sym pt om s. When pr esent , TMD sy m pt om s m ust alw ay s be cont r olled t o r eest ablish a nor m al occlusion and
allow pr oper t r eat m ent st rat egy.
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