Temporomandibular Disorders and Bruxism

Lecture 1 - The new definition of bruxism: which clinical implications?

According to Prof. Manfredini, bruxism is a hot topic nowadays and we can notice that more than 250 publications per year can be counted on this subject. In this first lecture of the video course, participants will discover a recently published new definition of bruxism that has resulted in the adoption of new therapeutic strategies to assess patients and manage them clinically. Prof. Manfredini will explain to participants that bruxism is not a pathology but it’s a behavior, a muscle activity that could be a sign of certain psychological personality or a sign of disrupting sleep conditions. In the final part of the lecture, a new multidimensional bruxism evaluation system will be presented and the differences between different type of bruxism will be discussed.

In particular, this lecture focuses on the following topics:

• What’s bruxism: dental and neurological perspective
• Updated definition of bruxism (2018)
• Which are the cause and the consequences of bruxism?

• The advantages of the Multiple-P treatment
• Different phenotype of bruxism and bruxers
• Correlation between sleep apnea and bruxism
• STAB: Standardized Tools for the Assessment of Bruxism

Duration: 44 min

Lecture 2 - TMJ physiopathology and the overload concept

In this video the lecturer will analyse TMJ basic concepts, the relationship between dental occlusion and bruxism, the overload theory and the treatment implications. Participants will discover that musculoskeletal symptoms are not linked to occlusion but are linked to an overload problem and they will notice that psyche and anxiety traits are TMJ leading factors.

In particular, this lecture focuses on the following topics:

• Temporomandibular disorders cardinal symptoms
• Temporomandibular disorders general features
• A key factor: the absence of relationship between TMD and occlusion
• Joint sounds, functional limitations and pain presence analysis

Duration: 42 min

Lecture 3 - Fundamentals of TMD management

Thanks to this video lecture participants will discover the features and the benefits of the Multiple-P treatment, a clinical protocol based on pep talk, physiotherapy, psychology, plates and pills. Prof. Manfredini will show participants how to teach patients how to properly move their mandible through the adoption of special physiotherapeutic protocols, how drugs can be prescribed to induce muscles relaxation, how do oral appliances work and finally he will illustrate different cognitive-behavioral strategies to relax muscles.

In particular, this lecture focuses on the following topics:

• General principles of treatment: pain control, rest and function restoring
• Why to adopt a patient-centered treatment?

• Drugs prescription: analgesics, antidepressant, sedative and hypnotics
• Basic principles of orthopedic medicine
• How to measure the emotional overload by adopting cognitive-behavioral treatments
• The biopsychosocial model of pain

Duration: 45 min

Lecture 4 - TMJ imaging

Several techniques to diagnose TMJ disorders will be discussed in detail in this video lecture; Rx, arthrography, spiral tomography and, moreover, the magnetic resonance will be described as useful instruments to visualize the soft tissues, to obtain disc images and to easily visualize the disc. Prof. Manfredini will show participants how to diagnose disc displacements and soft tissues’ inflammations by reading in a proper way the MRI. Participants will discover that there are several ways to read an MRI and the recent and innovative dynamic MRI protocol will be analysed in a step-by-step way. In the last part of this presentation, Prof. Manfredini will explain that it is only correct to prescribe an MRI in those particular clinical cases where something abnormal is expected or where a diagnosis could not be reached due to the absence of clear symptoms.

In particular, this lecture focuses on the following topics:

• How to read an MRI: different visualizations, relation between the TMJ condyle and the TMJ disc
• The visualization of the lateral pterygoid muscle insertion on the TMJ capsule
• Classification concerning the 3D position of the disc (Tasaki classification 1996)
• What can we see thanks to MR
• Is?

• Effective prescription of MR
• Is and different disc TMD diagnosis
• Clinical correlates of imaging findings

Duration: 46 min

Lecture 5 - TMJ arthrocentesis

This last theoretical lecture of the video course will be dedicated to the single-needle strategy to perform arthrocentesis of the TMJ. Prof. Manfredini will explain the reasons why one-needle technique has replaced the two-needle one and will show several clinical videos thanks to which participants will appreciate the advantages of this innovative clinical treatment that allows to have an injection and ejection of the fluid from inside to outside the TMJ capsule (hyaluronic acid or other drugs) with the very same needle.

In particular, this lecture focuses on the following topics:

• The advantages of the single-needle technique
• The correct area for the hyaluronic acid injection
• Research findings comparing single and multiple-needle techniques
• Comparison between different protocols for arthrocentesis
• How to optimize the benefits and reduce the invasivity of the treatment?

Clinical cases: crepiting joints and tooth wear due to mechanical attrition

Duration: 17 min

Lecture 6 - Temporomandibular disorders and orofacial pain in the everyday practice - Part IThis theoretical lesson focuses on the three categories in which orofacial pains are divided depending on the origin of the pain: dentoalveolar, musculoskeletal or neurological. Prof. Daniele Manfredini discusses the signs and symptoms of TMD and shows several brief clinical cases to let participants appreciate his working philosophy. The clinical cases focus on the relation between clicks and cracks, occlusion and the features of MR

Is.

In particular, this lesson focuses on the following topics:

• Is the function warranted by self-control of the muscles or by the oral appliances?
• The very first full TMJ prosthetic replacement
• Disc displacement with reduction and deviation of the mandible
• Is there a way to relate the mandible click to a malocclusion?

Duration: 1 h 05 min

Lecture 7 - Temporomandibular disorders and orofacial pain in the everyday practice - Part II

In this lesson, Prof. Manfredini illustrates how to easily unlock a patient’s mandible in a situation of pain, how to manage patients with intermittent locking, and how to deal with crepitus. There‘s also time to discuss the effectiveness of imaging and the arbitrary use of clinical instruments.

In particular, this lesson focuses on the following topics:

• Axis I vs Axis II
• Orthodontic finalization phase
• Crepiting joints management
• How to mobilize the mandible

Duration: 53 min

Lecture 8 - 1st Clinical video: Burning mouth syndrome diagnostic protocol

In this first clinical video, Prof. Manfredini shows how to conduct the dialogue with the patient to collect the necessary information to reach a diagnosis in a professional, fast and targeted way. Participants will appreciate the quality and the precision of Prof. Manfredini’s questions; according to the lecturer, the Burning Mouth Syndrome diagnosis was pretty straightforward and didn’t require any special instrument. One of the most important phases of the diagnostic procedure shown in this clinical video is the interaction between the patient and the clinician: it was fundamental for him to understand that there was no correlation between the Burning Mouth Syndrome and the occlusion or other teeth-related problems. In situations of physical weakness, in fact, small interventions can activate the nerve cells in the mouth and cause widespread burning in the mouth.

In particular, this lesson focuses on the following topics:

• How to guide the patient during the history taking phase • How to improve your skills concerning medical history collection
• What is a neuropathic form of orofacial pain?

Which drug should be prescribed in case of Burning Mouth Syndrome?

Duration: 15 min

Lecture 9 - 2nd Clinical video: Open mouth syndrome diagnostic protocol

In this clinical video, Prof. Manfredini deals with a patient that started feeling her mandible locked immediately after a dental treatment for caries removal, and that has since had difficulty opening her mouth. The lecturer explains that the Open Mouth Syndrome condition is related with the position of the temporomandibular joint disc but also with muscle overload, tension and anxiety. Participants will understand that in these cases the treatment must be based on a cognitive and behavioral approach; the patient, in fact, is experiencing a period of stress and it is the clinician’s responsibility to make her understand that her anxiety is the trigger for her pain. Prof. Manfredini demonstrates the relevance of Bruxapp, a useful application to let patients gain cognitive awareness of their anxiety traits.

In particular, this lesson focuses on the following topics:

• The features of the cognitive-behavioral approach
• How to teach your patients to relax
• How to take the bite size: impression technique

Duration: 33 min

Lecture 10 - 3rd Clinical video: How to build an oral appliance

In this clinical video, Prof. Manfredini illustrates the technical details to build an oral appliance that will be used by patients with TMD disorders for about two months, only during bedtime. In this way, patients will feel relief because the bite will act as a complement to the treatment, which remains based on a cognitive-behavioral or pharmacological approach. The shown bites are flat because there’s no need for repositioning teeth since TMD disorders are never correlated to occlusion. Prof. Manfredini shows the impression technique and explains that the appliance shouldn’t disturb the patient in terms of position and should fit properly with the sustaining teeth without any disturbances.

In particular, this lesson focuses on the following topics:

• Which are the required features to obtain a good appliance?
• Impression technique: filling the gap between the arches with hard resin
• How to determine the correct dimension of the bite?

Why don’t we need complex arrangements?

Duration: 03 min

Lecture 11 - 4th Clinical video: Closed lock: a follow-up visit

In this clinical video, Prof. Manfredini shows how to conduct a follow-up visit on a patient who, six months earlier, couldn’t open her mouth more than 2 centimetres and was experiencing intense pain. Participants will see how the patient states that the bite and the behavioral suggestions were really helpful (above all the use of Bruxapp, a mobile application devised by Dr. Luca Guarda Nardini). The main purpose of the follow-up visit is to check the contact points of the oral appliance and to give emotional reinforcements to patients who need them. The visit concludes with a muscle relaxation therapy using radiofrequency.

In particular, this lesson focuses on the following topics:

• How to check the contact points on the oral appliance? • Muscle relaxation therapy with radiofrequency
• The dialectical interaction and relaxation generated with the patient
• The management of musculoskeletal symptoms and psychological aspects

Duration: 10 min

Lecture 12 - 5th Clinical video: Arthrocentesis protocol

This clinical video shows an arthrocentesis of the right TMJ in a patient with TMJ arthrosis. Repeated arthrocentesis are useful for lubricating TMJ structures: this video intends to discuss this protocol step by step. Prof. Manfredini performs an intraoral anesthesia in the area of the lateral pterygoid and an extraoral anesthesia in the area of the glenoid fossa. Participants will have the chance to see the execution of the single-needle technique that consists in using the same needle for both the inflow and the outflow of the fluids (saline solution first and hyaluronic acid). Prof. Manfredini explains that the single-needle technique has important advantages as compared to the traditional two-needle technique because it is less invasive, less traumatic and more effective.

In particular, this lesson focuses on the following topics:

• Anesthetic protocol: intraoral and extraoral anesthesia
• How to enter the TMJ capsule with the needle
• Why is this intervention particularly helpful in third age patients?

Single-needle technique vs two-needle technique

Duration: 17 min

Lecture 13 - 6th Clinical video: Management of an unclear chief-complaint patient

In this clinical video, a patient complains of orofacial pain at the level of the jaw, especially while chewing. According to Prof. Manfredini, the symptoms are related to muscle fatigue and tension and lead to the hypothesis of tendinitis. Participants will understand how to manage a complex case with a not-so-clear chief complaint and no linear descriptors. Patient compliance in this case wasn’t perfect and Prof. Manfredini prescribed antiinflammatory drugs to relax the jaw muscles before bedtime. This is an interesting case for different diagnosis pathways and difficulties in interacting with the patient.

In particular, this lesson focuses on the following topics:

• How to interact with difficult patients
• How to explain the various treatment options as comprehensively as possible
• How to make a diagnosis when the patient is unable to properly describe the symptoms

Duration: 25 min

Lecture 14 - 7th Clinical video: arthrosis with no pain

In this clinical video, a patient displays a visible discrepancy between the right and the left side of her mandible when the mouth is open. The patient has no pain, so Prof. Manfredini diagnosed an arthrosis caused by a degeneration of the condyle and an anterior displacement of the disc, and the visit finished in that exact moment because, according to the lecturer, it is important to create non-patient. In fact, participants will discover that it’s absolutely normal to display an asymmetry between the right and left TMJ at a certain age.

In particular, this lesson focuses on the following topics:

• Why is it important to avoid treatment in patients without symptoms?
• TMJ asymmetry diagnosis
• How to read an MRI
• Why is the limitation not due to the disc position?

Duration: 06 min

Lecture 15 - 8th Clinical video: muscle tension, neuropathic pain and TMJ arthritis

During the medical history collection phase, the patient tells Prof. Manfredini that she started noticing an increasing crepitus at the level of the left TMJ over the past two years. This symptom is correlated to mild pain and difficulties in opening the mouth. This is a condition of degenerative joint disease of TMJ. In this clinical video, participants will see the execution of an arthrocentesis with the innovative singleneedle technique.

In particular, this lesson focuses on the following topics:

• How to regain a perfect physiological range of motion thanks to arthrocentesis
• Arthrocentesis protocol: anesthesia, inflow and outflow of the fluid
• Post-operative procedure: cortisone and control
• MRI to see the degeneration of the condylar head

Duration: 13 min

Lecture 16 - 9th Clinical video: facial pain and limited mouth opening

A patient that has already been referred to both a neurologist and a maxillofacial surgeon came to Prof. Manfredini’s observation complaining of a pain all around the face that started on the right side and then migrated to the left one. The patient suffers from a limited mouth opening condition related to muscle tension caused by her anxiety traits. The treatment is thus focused on a cognitive-behavioral approach with the goal of letting the patient gain awareness of her muscle tension.

In particular, this lesson focuses on the following topics:

• What’s the origin of orofacial pain symptoms?
• Why is the limitation related to anxiety traits and fear?
• The features and the advantages of Bruxapp (Bruxism Smart Application for devices)
• Digital impression recording

Duration: 12 min

Lecture 17 - 10th Clinical video: Oral appliances mechanism of action for TMJ disorders

A patient shows symptoms related to a tendinitis caused by an overuse of jaw muscles and an overload of the TMJ. Prof. Manfredini shows how to manufacture a flat oral appliance with no reposition goals in an easy and fast way. After two months, the patient is completely out of pain thanks to the combination of the cognitive-behavioral approach during wakefulness and the flat oral appliance during bedtime.

In particular, this lesson focuses on the following topics:

• Why don’t we need typical dental appliances?
• Oral appliance manufacturing procedures
• Oral appliance delivery phase
• Why prescribe a flat oral appliance to have optimal results in a very short time?

Duration: 05 min

Lecture 18 - 11th Clinical video: TMJ disorders clinical assessment

After collecting the patient’s medical history, Prof. Manfredini shows how to delve deeper into the clinical assessment by evaluating the TMJ and jaw muscles. From the TMJ palpation to the identification of the glenoid fossa, passing through the muscles palpation and the chewing text with cotton roles, every phase of the diagnostic procedure is shown in this clinical video. Participants will discover that the muscles are responsible of the pain in the majority of the cases because these patients have overload and overuse issues that cause tendons and muscles inflammation.

In particular, this lesson focuses on the following topics:

• Muscles and TMJ palpation
• Masseter and temporalis muscle palpation
• What is the key point of our clinical assessment?

Exclusion of any intraoral cause of orofacial pain

Duration: 15 min

Lecture 19 - 12th Clinical video

In this brief clinical video, Prof. Manfredini discusses the relationship between the masseter hypertrophy and the possible presence of temporomandibular disorders. The lecturer explains that the patient tends to face asymmetry and a masseter hypertrophy but with no symptoms, so there’s nothing else to do than tell the patient to relax because her problem of clenching and bracing is only relating to cognitivebehavioral aspects.

Duration: 03 min