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The Neurological Aspects of the Trigeminal Cranial Complex and Its Role in the TMJ Dysfunction…
MRI of TMJ in patients with Tourette syndrome. (a) Patient JG went from 105 tics/3min to 4 tics/3min after
Fig. 7
increasing volumetric spacing within the TM joint. Courtesy Dr. Anthony Sims. (b) Patient BH went from 15 tics/3min
to 2 tics/3min after increasing volumetric spacing within the TM joint. Courtesy Dr. Anthony Sims. (c) Patient HL went
from 60 tic/3min to 2 tics/3min after increasing volumetric spacing within the TM joint. (Courtesy Dr. Anthony Sims)
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10 Summary
As has been described meticulously above, there
are many neurologic connections between the trigeminal nerve nucleus and other elements of the
central nervous system in the brain stem and
spine. These connections set the stage for the
possible mechanisms of temporomandibular joint
dysfunction and related movement disorders. An
understanding of this neuroanatomy, combined
with clinical observation, can assist in the diagnosis and treatment of those movement disorders
which may benet from the treatment of TMDs.
Suggested Reading
1. Rosenberg RN, Pascual JM, editors. Rosenberg’s
molecular and genetic basis of neurological and psy-
chiatric disease. 5th ed; 2015.
2. Casale J, Giwa AO.Embryology, branchial arches. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2022. https://www.ncbi.nlm.nih.gov/
books/NBK538487/.
3. Lee WY, Okeson JP, Lindroth J. The relationship
between forward head posture and temporomandibu-
lar disorders. J Orofac Pain. 1995;9(2):161–7.
4. Manning KA, Evinger C. Different forms of
blinks and their two-stage control. Exp Brain
Res. 1986;64(3):579–88. https://doi.org/10.1007/
BF00340495.
A Journey toUnderstanding
andTreating TMD/Craniofacial
Pain: Rediscovering theStructure
Often Overlooked inOrthodontics
andFacial Orthopedics: TheTMJ
LidiaYavich
1 Introduction
As a specialist in orthodontics and facial orthopedics and a specialist in temporomandibular disorder (TMD) and orofacial pain, I work primarily
with patients seeking pain relief. As our clinic deals
with TMJ pathologies, the prevalence of TMD will
not be discussed here. How orthodontics and facial
orthopedics can cause TMD will not be discussed.
The pathogenesis of TMD is far from settled, even
with all the studies that cases have generated.
What is important is the discussion about what
procedures can cause TMD and the importance to
evaluate the situation of the temporomandibular
joints in patients before beginning any therapy.
When patients are evaluated, it is important to know
whether they have undergone orthodontic and/or
orthopedic treatments, to be aware of the signs and
symptoms, and to look at patient posture and movements. A good history, clinical examination, and
images help to differentiate the lesions that affect
the TMJ.It is fundamental to distinguish the cases
that can benet from routine orthodontics and the
cases that need to be referred to other specialists
and/or need to have a multidisciplinary team.
Orthodontists and facial orthopedists are professionals who have general training in dentistry and
extensive specialized education to diagnose, pre-
L. Yavich (*)
SBPAT, The Brazilian Society for Diagnosis and
Treatment of Temporomandibular Joint Pathologies,
Attending, Clinica My, Porto Allege, RS, Brazil
vent, control, and treat anomalies in the form, position, relationship, and function of dento- maxillofac
ial structures. This is an integral part of patient care,
making diagnoses on the early or late detection of
the disease and monitoring the response to treatment. Many patients who seek malocclusion correction present with noise and pain in the TMJs.
Their TMJ images show facets and erosions, and
these patients feel more pain when retrodiscal palpation is performed. Many who nish orthodontics
and/or facial orthopedics treatments have clicks in
the TMJ, signs of joint wear in images, and pain in
the retrodiscal palpation.
In training, the temporomandibular joint, which
connects the jaw with the skull, the most used of all
articulations, is wholly ignored. This joint performs
different functions such as chewing, swallowing,
speaking, and breathing. Just like all the other
synovial joints of our body, the TMJ can also suffer
from different diseases. What differentiates the
TMJ and makes it unique when compared to the
other synovial joints of the body is that in addition
to all the structures that the other synovial joints
have, such as the capsule, ligaments, and others, the
TMJ is also subordinated to the teeth (occlusion).
Primary pathologies of the temporomandibular joint can affect the occlusal relationship,
change the spatial alignment of the joint, and
affect all of its body alignment. Infections and
trauma can initiate processes that sometimes
cause permanent damage to TMJ ligaments, even
in cases where the teeth are aesthetically aligned
and in an occlusal relationship that seems healthy.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
B. C. Stack Jr. et al. (eds.), Craniofacial Pain, https://doi.org/10.1007/978-3-031-57563-1_11
185
186
L. Yavich
Technological advances have allowed for a
deeper understanding of the pathologies that
affect the temporomandibular joint. The images
of nuclear magnetic resonance (NMR or MRI)
and bioinstrumentation have been migrated to the
realm of clinicians, no longer being the exclusive
domain of the investigators. These advances play
a fundamental role together with the clinical
examination, carefully integrated with the history
and pathophysiology of the patient.
2 Pain
Controlling pain in a patient with temporomandibular dysfunction is crucial. Presently, it is also
possible in certain cases to improve damaged
structures as well. The evaluation of the TMJ and
the diagnosis of its pathologies must be an inseparable part of all elds of dentistry. Examining
the curricula of different universities of the world
today, TMD is not included or, if it is, it is very
abbreviated. Embryology, morphology, and neurological and proprioceptive connections are
studied but there is often nothing about the
pathologies and/or joint dysfunctions. In this
education, TMJ is often a “ghost,” and its pathologies and dysfunction are not discussed.
One frequent question encountered is: How
many of our patients that present for malocclusion correction or prosthodontics, or just simple
clinical procedures, have among other things, a
clicking TMJ, signs of wear in any TMJ images,
limitation in opening the mouth, and/or pain during retrodiscal palpation? How many patients
that nish orthodontics or facial orthopedic treatments continue with or develop the signs and
symptoms during or after treatment? For many
practitioners, the answer would be none because
they did not check for that.
3 Training
Many are trained as a dentist, an orthodontist,
and a facial orthopedist as though the TMJ did
not exist. Training may presume that no pathology affects the head of the mandible or its mor-
phology. Many believe that a “good occlusion”
was a guarantee of healthy joints. The famous
quote of the philosopher Giacomo Leopardi,
“Ignorance is the greatest source of happi-
ness,” can be a painful lesson. Continuing with
the analysis of my training, everything depended
on my diagnosis, my ability, my knowledge to
balance the occlusion, the cognizance of the most
modern techniques, understanding of the latest
generation of materials, and the biological
response of the patient.
3.1 Where wastheTMJ inthis
Planning? Without Considering
theTMJ, There Is No Diagnosis!
Without knowing what the status of the foundation, can one effectively balance the occlusion?
That is, considering occlusion like the relation of
the arches, without muscles, joints, and neural
innervation. Without considering the TMJ, the
knowledge of the most modern techniques and
the latest generation of materials is like constructing a beautiful building without having any
awareness of the ground, like a project without an
engineer or an architect. The temporomandibular
joint was an abstract entity. The vast majority of
the anatomy texts assumed that the head of the
mandible has no pathology in its localization nor
in its size or shape. This does not coincide with
new technologies and diagnostic methods.
Temporomandibular joints can be affected by
local and systemic pathologies, trauma, autoimmune diseases, and occlusal problems.
A functional lesion is one which presents an
alteration of the function without an anatomical
change. An organic lesion however is one which
presents with anatomical alterations. How can
one determine anything without images? Imaging
is the only method for obtaining visual
information about the joint’s tissues and is fundamental to differentiate the lesions that affect the
TMJ.It is not uncommon to see publications in
orthodontics and facial orthopedics where panoramic radiographs do not show the condyles
considering that they are not an important part of
a diagnosis; even in many international meetings
A Journey to Understanding and Treating TMD/Craniofacial Pain: Rediscovering the Structure Often…
187
and conferences, the panoramic radiographs do
not show the condyles. Panoramic radiographs
are not the ideal images for TMJ, but in many
cases, they can show that a problem exists; therefore they need to be investigated deeper.
4 A New Look at Familiar Basic
Images
4.1 Panoramic Radiograph
Every orthodontist requests a panoramic radiograph which, as its name indicates, gives a general scenario of odontogenic and maxilofacial
alterations. Some structural alterations of the
mandibular condyles can be identied as asymmetries, erosions, large osteophytes, and fractures. Comparing both images in Fig. 1a with
Fig. 1 Comparative
example of panoramic
radiographs with healthy
heads of the mandible
(a) and pathological
heads of the mandible
(b)
a
round condyles beside image (Fig. 1b) where the
condyles present asymmetries and erosions demonstrates the utility of the panorex. The panoramic radiograph alone is not adequate to treat
TMJ pathologies as more accurate information is
needed. The panoramic radiograph image is still
a good image and one from where to begin evaluation of the TMJ.
With the use of cone beam CT, the panoramic
radiograph obtained through tomography and the
conventional panoramic radiograph have different image qualities because they have different
acquisition principles. Conventional panoramic
radiography (Fig. 2a) is an imaging technique
with a specic device with a cutting zone in
which the structures that are within the zone are
clearly visible in the image. It has diagnostic
capacity. The panoramic radiograph (Fig. 2b)
obtained through tomography has no diagnostic
b
188
L. Yavich
a
b
Fig. 2 Comparative example of a conventional panoramic radiograph (a) and a panoramic radiograph obtained through
tomography (b)
value. It is a reconstruction of a tomographic
volume.
In many publications and conference presentations, the mandibular heads are omitted from
images of cases showing the before and after
treatment (Fig. 3). One cannot specify whether
the orthodontic mechanics produced the joint
alteration shown in the image. For the patient
who consulted after treatment due to an open
bite, little joint pain, and signicant loss of balance, everything needs to be investigated. One
cannot disregard portions of images as if they
were insignicant. One should consider the panoramic radiograph as a rst clue of TMD looking
at it in an in-depth way.
lar fossa, and also the articular eminence. This is
the basic reference in the eld, and its signicance may be compared to that of panoramic
radiography for general dentistry or a modied
panoramic radiography for TMJ.A comparative
example of a plain lm is with healthy heads of
the mandible (Fig. 4a) and with pathological
heads of the mandible Fig. 4b. Different pathologies can cause three-dimensional joint changes.
They are a product of different etiologies. These
“tridimensional anatomical variations” provoke
morpho- functional pathologies.
One cannot call these joint changes an “adaptation” where it does not increase the system efciency or improve health. Different cuts of
mandibular condyles in the closed mouth position
show severe structural alterations of the mandible
4.2 TMJ Plain Films
heads. Image (Fig. 5a) without coloring and
image (Fig.5b) with color to mark the condylar
Plain lms allow one to observe the joint’s bony
components: the head of the mandible, the articu-
geometry are not compatible with optimal
mechanics of the temporomandibular joint.
A Journey to Understanding and Treating TMD/Craniofacial Pain: Rediscovering the Structure Often…
a
b
189
1a 2b
Fig. 3 Comparison of a panoramic radiograph before (a)
and (b) after orthodontic treatment. Cross section of the
comparative condyles with image inversion to highlight
the deformation of the mandibular condyle and the articular eminence (1a) before treatment and (2b) after
treatment
190
L. Yavich
a
b
Fig. 4 TMJ plain lms: right and left TMJ, open and closed mouth, color highlighted
Congruence of articular surfaces is a basic biomechanical principle of any synovial joint. Anatomy
is the platform where physiology acts. Many of
the lesions that are labeled as functional assessed
only with a clinical exam are organic joint lesions.
It is necessary to understand that differences
in structures caused by several etiological agents
produce diverse effects on muscle performance,
soft tissues, and sensory response, even when
the patient is in occlusion. Let us consider in
Fig.6 a patient that came in the middle of the
orthodontic treatment with this image of signicantly deformed condyles. In this specic case,
did the treating dentist know the joint situation
before initiating orthodontic treatment? If the
colleague was not aware of this situation, this is
a problem. If the professional knew of this condition, there is a problem. In this specic case,
the patient was diagnosed with lupus.
Oftentimes, these images can give us a rst clue
that can be impactful since the sooner a disease
like lupus is diagnosed, the greater the chance of
its control. In a 9-year-old patient, it is easy to
see only the crossbite without considering the
resorption of the left condyle, which requires a
thorough investigation (Fig.7).
A Journey to Understanding and Treating TMD/Craniofacial Pain: Rediscovering the Structure Often…
a
b
191
Fig. 5 TMJ plain lms: different distorted shapes of mandible heads
There are a number of local and systemic factors or diseases that can cause mandibular condylar resorption. This condition can create occlusal
and skeletal instability, dentofacial deformities,
TMJ dysfunction, and pain. In Fig.8, the ideal
structural shape of the condyles is shown.
However, the patient’s TMJ plain lms show a
very different shape in that both condyles are
deformed. This rst image cannot be considered
a normal nding as the corresponding plain lms
belong to a patient in profound pain. When joint
structures undergo anatomical changes, an imbalanced system is inevitable.
gies, but also noticing new data that was not
previously considered. One of the fundamental
things to be changed in documentation is the
request for photos of the patient’s entire body:
front, back, right, and left proles, and not exclusively photos of the patient’s head (Fig. 9). Do
not forget that the head is joined to the rest of the
body! It is very important to evaluate posture.
Orthodontists and facial orthopedists do not
treat posture like other professionals, but it is fundamental to have the insight to assess the postural
problems that can be observed in TMD patients.
Many of these problems may have descending
triggers from the oromandibular complex, and,
with this awareness, patients can be directed to
4.3 Clinical Documentation
trained professionals to make precise diagnoses
and to improve posture. Posture is bidirectional
Documentation in the study of patients can
change many times in a career based on professional growth and introduction of new technolo-
from ascended and descendent pathways. As for
the descendent pathway, craniomandibular intervention is decisive.
192
L. Yavich
Fig. 6 Photographic records of a frontal view and right
and left lateral views in maximum intercuspation in the
middle of orthodontic treatment, together with a pan-
Observable postural images:
• Uneven shoulder height
• Lateral tilt and cervical rotation to the right
• Cervical straightening
• Cervical anteriorization
• Gluteal line parallel to the scapular line
• Uneven anterior superior iliac spines
• Dorsal curve rectication
Physiotherapists like to assess the patient’s
posture in a natural stance and not with aligned
feet, but, for dentists, it is very difcult to compare the natural posture from day to day.
4.4 Structural Misalignment
Related toTemporomandibular
Joint Pathology
4.4.1 Intraoral photographs
This patient underwent orthodontic treatment, and
one can observe a beautiful alignment of the teeth,
oramic radiograph (above) showing the mandibular condyles with signicant erosions
class 1 molar and canine, and aligned dental midlines. Despite the aesthetic result, she had difculty in opening her mouth; severe headaches;
pain in the back of the neck, in the forehead, in
both shoulders, and in both temporomandibular
joints; as well as vertigo. In a quick analysis of the
patient’s teeth, in Fig.10, some questions arise:
• Does the wear on the lower incisors stand out?
• Did this wear exist before the treatment?
• Can the wear represent a misplaced incisor
guide?
The colleague who treated the patient placed
her in permanent retainers on the worn lower and
upper incisors. This is also appreciated in the
lower dental photographs and also in the panoramic radiograph (Fig.11a). Why would upper
incisors need retaining if they do not have periodontal problems, and why would they open?
Does the habitual closing trajectory coincide
with the closing neuromuscular trajectory? These
A Journey to Understanding and Treating TMD/Craniofacial Pain: Rediscovering the Structure Often…
193
Fig. 7 Photographic records of a frontal, right, and left lateral views in maximum intercuspation in a patient in mixed
dentition. The panoramic radiograph (below) shows the left mandibular condyle with signicant resorption
are some of the questions that should be asked.
“When we believed that we had all the answers,
all of a sudden, all the questions changed,” Mario
Benedetti.
Signicant distortions cannot be seen in the
mandible heads in the panoramic X-ray
(Fig.11a). It is important to understand that the
panoramic radiograph can sometimes show distortions but not always. In this case, it is notice-
Mandibular retrusion, whether caused by iatrogenesis, trauma, or malocclusion, often results in
otalgia (ear pain) due to excessive compression
of the retrodiscal tissues. Mandibular retrusion
invades the retrodiscal tissue, impairs TMJ
metabolism, reduces the blood supply of the
TMJ, wears down the posterior band of the articular disc, and stretches TMJ ligaments.
Fundamental questions:
able only in the laminography. In the TMJ
panoramic radiography of the same patient, the
posterior displacement of the right and left mandibular condyles in the joint cavity with consequent reduction of the joint space is clearly
visible. One can also notice the alteration of the
growth axis in both mandibular condyles (greenstick fracture), more evident in the left condyle
• Was the mandibular retrusion present before
the orthodontic treatment?
• Was the mandibular retrusion a result of the
orthodontic treatment?
• How and in what tridimensional location were
the temporomandibular joints before the
treatment?
(highlighted in red); greenstick fractures will be
explained further in a following section.
Pain can occur due to the posteriorizing of the
condyle and anteriorization of the disc when
compression of the retrodiscal tissue occurs.
These are important questions not only
because of legal issues but also for the health of
patients. It is important to highlight that in these
images, the structural alterations do not appear in