두개하악장애의 진단 및 치료지침
Standard of care for Craniomandibular disorders
정성창,
소속 상세정보
정성창 ( ) - 서울대학교 치과대학 구강진단학교실
KMID : 0386219890010010037
Abstract
대만지역 청소년에 대한 두개하악장애의 역학연구
A survey on the health of the masticatory system had been performed in 1987 on 3,681 junior college students (2,307 boys and 1,644 girls) at different parts of Taiwan area. Their ages ranged from 15 to 23 years with the mean age of 18.8 years in boys and 18.4 years in girls. Examination and palpation of the TM joints and head and neck muscles were done by five trained dentists.
Occlusal status such as presence and position of decay, missing, attrition, cross bite, and centric and eccentric tooth contacts were recorded. Molar classification, range of jaw movement and the teeth that contact during eccentric movement were also observed. Questionaire on present and past experience on head and neck pain, joint clicking, limitation of jaw opening, bruxism, clenching, as well as the psychoemotional status was answered by the examinees. Students who had one or more of the following signs were categorized as symptomatic: 1) tenderness at TM joint, 2) tenderness at masticatory muscle, 3) clicking at TM joint, and 4) restricted jaw movement with pain.
It was found that the incidence of pain and dysfunction of the TM joints ad muscles was 59.1%(boys 56.9%, vs, girls 61.2%, p<0.01>. Among them, 14.9% had joint clicking, 33.6% had joint pain and 35.0% had muscle tenderness.
Muscle tenderness was found most often at lateral pterygoid muscles (37.0%). Only 0.8% of the students had both clicking at joint and pain at joint and / or muscle. In the symptomatic group, distorted and exaggerated curve of Spee, lateral and vertical components of centric sliding, and deeper overbite were more often found. However, the number of missing teeth, attrition, type of lateral guidance, molar and canine classification, crowding and spacing as well as dental cross bite were not significantly different between the two groups. There were more right chewers in the total examinees, however no difference in side dominant was seen between the two groups. Opening and closing click occurred more often at left joint (p<0.05) and opening click occurred more often then closing click (p< 0.01).
Analysis of the psychoemotional questionaire revealed a significantly higher score on anxiety, tension, stress and depression in symptomatic group while not on test anxiety and type A personality scores. Headache, bruxism, clenching, parafunctional oral habit and experience of previous dental treatment were more often reported in the symptomatic group.
The above findings suggested a high incidence of CMD in youths of Taiwan although the severity of the syndrome and demands for treatment were not as high. A similar survey on CMD in younger students (10-18 years) performed one year ago revealed a 40% incidence with equal change between boys and girls. It seems that the incidence of CMD increases with the age, and the increases is more significant in girls. Some dental occlusional and psychoemotional status had close relationship with the existence of CMD, thus suggested a multifactorial origin of the syndrome.
두개하악장애 발병에 대한 교합의 역할
There are many thoughts on the etiology of the craniomandibular disorder. But out of all these thoughts, the idea that occlusal problems are onsetting factors is tremendously interesting to dentists.
In order to clarify the relation between craniomandibular disorder and occlusal problems we have tried the follwing analysis. Seven normal adults were subjected to a 0.1 mm unilateral experimental occlusal interference consisting of a Class I gold inlay on the lower first molar. Date such as the EMG of the masseter and mental muscles, electro-encephalograms, restoratory waves, electro-cardiograms, electro-occlograms were taken through night using wireless telemeter before the insertion of occlusal interference, a week after the insertion and a week after the removal of the occlusal interference. Together with these data daily clinical observation, condylar positions and psychoendocraine secretions were also analy2ed. From the study it was suggested that occlusal interference could initiate sleep disorder, alter the function of the autonomic nervous system, increase the frequency and the degree of bruxism with accompanying emotional strees, cause the displacement of the condyle increase the tension of the muscles, and create the onset of dysfunctional symptoms. Therefore, I would think that for the onset of craniomandibular disorder occlusal problems may play an extremely important role.
악관절 기능장애와 교합치료
Treatment modalities of temporomandibular disorder are complex because it has multifactorial etiology. The proper management of the patient suffering from temporomandibular disorder must start the establishment of a working diagnosis, confirmation of that diagnosis, and finally by the indicated treatment irreversible treatment is considered only after the patient´s symptoms have been relieved and articulation has been stabilized.
Occlusal treatments include occlusal splint, occlusal adjustment, restorative therapy and full mouth rehabilitation. This presentation will deal with significance and effectiveness of occlusal splint, procedures of occlusal adjustment and full mouth rehabilitation through the clinical cases.
두개하악장애에 대한 평가와 재평가를 위한 기계적 pantograph의 사용
Diagnosis and treatment of the craniomandibular disorder is still quite a controversial subject. Arthroscopy gives a direct view of the site and imaging devices such as X-rays including transcranials, tomograms, double contrasts and CAT scans, as well as MRI are some of tools, especially powerful in the diagnostic phase. However, the above have certain limitations, in areas of sophisticated skill, retardation, pain, artifact, risks of infection and cost.
The pantograph has been developed to record the patient´s mandibular movement in order to adjust the fully adjustable articulator. Shields and Clayton (1978) developed the PRI; pantographic reproducibility index. Mongini(1982) showed in his paper that condylar path changes according to the TMJ treatment. I have been using a mechanical type of pantograph (Denar, Stuart) not only in making diagnosis but also in the re-evaluation and as well as after the final (definitive) occlusal treatment.
The mechanical pantograph is a device with two pair of horizontal tables, which include both anterior and posterior horizontal tables and a couple of vertical (posterior) tables. In my view, in the anterior table we can see the coordination of the right and the left side muscles and TMJ, in the posterior horizontal table we can see the horizontal deviation of the protrusive and the orbiting paths and the smoothness of the rotation path. In all four horizontal tables we can see the muscle coordination. In the posterior vertical table we can see any disc-condyle interface problems. Clicking or disc displacement can occur three-dimensionally. With the pantograph we can sometimes observe the horizontal as well as vertical condyle deviation, I also use the pantograph to re-evaluate how well the retro-disc tissue has healed after repositioning procedures.
The pantograph however, also has some limitations: increased vertical dimension, loss of intercuspation and weight.
In this paper, I will present some of my clinical cases with pantographic documentation.
악관절 내장의 보존적 치료
The most common TMJ arthropathy is the TMj internal derangement (TMJ ID), which is characterized by a progressive anterior disk displacement relative to condyle. It its often associated with TMJ capsulitis and is attendant pain, tenderness, joint swelling, and restriction of mandibular movement.
We can modify Rasmussen´s classification of TMJ arthropathy (TMJ ID), and can divide it into five clinical stages, each one of which has specific signs and symptoms that can be helpful in establishing the diagnosis. Stage Ⅰ is characterized by clicking of the TMJ on opening and closing. Stage Ⅱ begins when the disk becomes anteriorly and medially lodged relative to the condyle, thereby blocking translation. Stage Ⅲ is characterized by on acute sustained closed-lock or intermittent open locking (subluxation). Stage Ⅳ is characterized by longstanding permanent disk displacement without reduction. Stage Ⅴ is characterized by the hard tissue remodeling with subsequent crepitation in the joint.
Diagnostic criteria, treatment planning, treatment option, treatment goals and prognosis of five clinical stages of TMJ ID and treatment flow for patients with TMJ ID will be presented.
악관절의 발생과 그 수술에 대한 임상적 평가
Temporomandibular joint consists of complex structures capable of various movements and shows interesting aspects in growth and development.
Therefore, the improper use of splints for treatments of temporomandibular disorders influences joint areas mechanically and results in the changes of pint tissues.
I will present the differences in structural development between human fetus and animal fetus. And we will see microscopic features about the influences to joint structures by responsive reactions of TMJ in patients.
In addition, I will evaluate and report the surgical managements and its results of fifty patients, I have operated for fifteen years and followed up.
Arthroscopy of the Temporomandibular Joint
Arthroscopy consists of the insertion of a rigid endoscope into a joint compartment for observation and therapeutic purposes. This procedure was first employed in the knee joint in 1918 by the orthopedic surgeon Prof. Takagi of Japan.
Subsequent development in technique and in instrumentation have enabled this method to be employed not only for visualization, but also for surgical procedures. Since the joint space of the temporomandibular joint is small, the indications for arthroscopy in the joint were very limited, but with development of a needle type riged fendoscope (Selfoscope, Olympus Co.) in 1974, we began applying this instrument for examination of the temporomandibular joint. With further developments of the needle arthroscope and accessory instruments, arthroscopy is now used for treatment of selected cases affecting the temporomandibular joint.
Arthroscopy of the temporomandibular joint has seen new progress including the recent organization of an international study group of arthroscopy of the temporomandibular joint(New York City, 1986), popularization of its clinical application in the United States and even wider use in Europe.
Present day professional interest in temporomandibular joing arthroscopy is taken not only in its clinical usefulness as a diagnostic procedure but also in great expectation of its possibility as a mode of treatment.
The background, possibilities limits of the temporomandibular joint arthroscopy will be presented.
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