TEMPOROMANDIBULAR JOINT AND RELATED - Upper and lower teeth DO NOT meet directly in

STRUCTURES a straight path

- Oral Physiology ● They meet in an angle
● Deals with the masticatory system - Position of longitudinal forces of teeth is NOT
in a straight path
Functional Occlusion System ● Also angulated
○ Reduces forces of mastications

Bones of Cranial Base

- NOT FUSED
- Connected by fibers and ligaments
- When masticatory forces are exerted in the
upper arch → bones FLEX OR EXTENDS
- Teeth is NOT fixed in the alveolar bone
● Attached via Periodontal Ligaments
○ Acts as a shock absorber for the
teeth
- Masticatory forces are minimized to a tolerable
amount to prevent trauma to brain
- Dentition - Extension of Bone → stretches the dura of the
● Supporting Structures brain → effect on the pumping factor of CSF is
○ Maxilla enhanced
○ Mandible ● Hard Diet
- TMJ ○ Smarter
● Responsible for jaw movements ● Soft Diet
- Neuromuscular ○ Bobo-er?
● Controls movement of the jaw ○ Dumb :(

- Glenoid Fossa
● Very thin → 2-3 millimeters
- TMJ
● Movement of lower jaw

- Biting Force = 60-80 kilograms

● Teeth are given a design that can reduce
masticatory forces
The Temporomandibular Joint Physiologic Characteristics of the Teeth
- Growth
● Initiation
○ Usually evident on the 6th week of
intrauterine life
● Proliferation
● Histodifferentiation and
Morphodifferentiation
○ To form enamel and dentin
● Apposition or Critical Calcification
○ To form structures of the teeth
- Calcification

0
● Nolla’s Stages of Tooth Calcification
○ Dr. Nolla
■ Cranio-facial growth
○ Stage 1: Presence of Crypt
■ Round masses in upper and
lower jaw
■ NOT identifiable in
radiographs
- Opening of Mouth
○ Stage 2: Initial Calcification
● Condyle moves down and forward
■ Signs of calcification
- Articular Disc
● Upper Teeth → At
● Acts as shock absorber between the 2
the bottom of the
bones (temporal bone and condyle)

=
round masses
● Lower Teeth → On
top of the round
masses
● Calcification of
enamel undergoing
development of
teeth
■ After 6 months to 1 year
○ Stage 3: One third of crown
completed
■ After 6 months to 1 year

Is
' ■ Increase in amount of
calcification
Alveolo-Dental Structures ■ One third of crown is
calcified
○ Stage 4: Two thirds of crown
completed
■ After 6 months to 1 year
■ Increase in amount of
213 calcification
■ Two third of crown is
calcified
○ Stage 5: Crown almost completed
-

■ After 6 months to 1 year

■ Increase in amount of
calcification
○ Stage 6: Crown completed
■ After 6 months to 1 year
■ Fully calcified tooth crown
○ Stage 7: One third of root
completed
■ After 6 months to 1 year
Is
'
■ One third of root is
calcified
○ Stage 8: Two thirds of root
completed
■ After 6 months to 1 year
■ Two thirds of root calcified
43 ■ Crown of the tooth is
0exposed in the oral cavity
○ Stage 9: Root almost completed
■ After 6 months to 1 year
■ APEX IS STILL OPEN
■ Tooth is already in Lateral Cephalic X-Ray
occlusion with its opposing
-

○ Stage 10: Apical end of root

completed
■ After 6 months to 1 year
■ Root is completely formed
○ 3 most important stages
■ Stage 2
● Confirmation that
the round masses
are tooth structures
because of
calcification
■ Stage 6 Panoramic X Ray
● Tooth will start its
eruptive movement
because of the
growth of the roots
that push the
crowns occlusally
■ Stage 8
● Tooth will start
showing in the oral
cavity (pierces the - If patient is younger → both primary and
oral mucosa so that permanent dentition are seen
the crown is shown ● Mixed dentition (6-7 years of age)
in the oral cavity)
- Eruption in dimension to the middle and
● Tooth starts its eruptive movement when
-
upper facial heights
crown is completed ● Normal adults→ all 3 are proportioned

gmm
○ Stage 6 (equal)
○ Because of the development of ○ Lower facial part becomes shorter
the roots when there is a loss of teeth
○ Root increases its length → crown ● Attrition DOES NOT shorten the lower
moves occlusally facial height
● Active Eruption , ,, my guy,,, , ,w,,, man, ○ Because of a compensating
mechanism → Passive Eruption
■ Alveolar bone grows with
the teeth
■ Tooth grows occlusally
carrying the alveolar bone
■ Tooth will become
● Passive Eruption EXPOSURE OF CROWN THON
-

tooth ①
supraerupted if there is no
○ Attrition I
opposing
○ Lost of opposing
● Parameters of Eruption
● Time of Eruption
● Sequence of Eruption
- Resorption and Exfoliation of Primary Teeth
● Primary teeth ONLY
- Attrition
● Due to mastication
-

● Attrition in enamel of occlusal surfaces

○ Decrease crown length of tooth

Total Length of the Face

- Upper Facial Height Chronology of Tooth Development (Permanent
● Forehead Dentition)
● Soft tissue nasion to the hairline at top
- Middle Facial Height
● Soft tissue nasion to the base of the nose
● Occupied by eyes and the nasal area
○ Also parts of the maxillary bone
- Lower Facial Height
● Base of the nose to the lower tip of the
chin
● Dictated by
○ Height of maxillary and mandibular
bone
○ Eruption of upper and lower set of
teeth
● Children → lower facial height is shorter
than middle and upper facial heights
○ As teeth develops in occlusion,
lower facial height becomes equal
- Root Canal Therapy cannot be done on a tooth ■ May become impacted or
that has an open apex (root)
-
malposed
● Apex should be closed first - Eruption of Maxillary Incisors
○ Using Calcium Hydroxide ● Can erupt labially, at the level of the
○ Remove debris or dead pulp → deciduous incisors, or lingually
clean the canal → apply Calcium ○ Normal: Labially to the deciduous
Hydroxide to the apex area → wait incisors
for the root apex to be completed ■ To attain a positive overjet
● If it erupts lingually → negative overjet
Favorable Sequence of Eruption for Permanent (anterior crossbite or Class 3)
Dentition ○ Upper incisors are lingual to the
lower incisors
● If it erupts exactly at the level of the
deciduous incisors
○ Edge to edge overjet
○ Tip of the upper and lower incisors
will be pointing at each other
- Eruption of Mandibular Incisors
● Erupts lingually to the deciduous incisors
→ positive overjet
○ Lower incisors will be behind the
lingual surface of the upper
- Favorable Sequence of Eruption (Maxillary) incisors
● First Molar 6 ● If it erupts labially to the deciduous
● Central Incisor I incisors → negative overjet (anterior
● Lateral Incisor 2 crossbite)
● First Premolar 4 ○ Lower incisor will be in front of
● Second Premolar

:
upper incisor
○ Leeway Space is small → about 1.6 ● If it erupts at the level of the deciduous
mm incisors → negative overjet (anterior
● Canine crossbite)
● Second Molar 7 ○ Lower incisor will be in front of
● Third Molar 8
upper incisor
- Favorable Sequence of Eruption (Mandibular) - How incisors are being aligned as a person
● First Molar 6
grows
● Central Incisor I
● Dental arch is growing
● Lateral Incisor 2
● Teeth move mesially
● Canine 3 ● Fibers of the teeth pull each other
● First Premolar
● Second Premolar :
● Second Molar 7

● Third Molar 8
● Leeway Space is big → about 3.1 mm
- Eruption of Second Premolar and Mesial Cusp?
of Second Molar
● When second molar erupts, it usually
pushes the first molar mesially
○ May block the eruption of second
premolar
- When incisors erupt, they are either lingual or ● General Characteristics
labial to the deciduous incisors
● Upper incisors are usually rotated and
○ Crown proportion
○ Molar relationship ↓ - ¥Em¥%ÑP
"

flared distally ■ Ideal: Flush Terminal Plane

- Tongue pushes teeth labially and buccally ■ Distal surface of lower
● Front teeth forward deciduous second molar is
● Posterior teeth sideward in line with the distal
● If it pushes upward → change in surface of the upper
occlusion or position of the teeth deciduous second molar
○ Will not be in the Neutral Zone ○ Anterior interdental spaces and
○ Upper arch may become primate spaces
constricted and upper anterior ■ Upper primate space
teeth will flare forward ● Big spaces
- Lips will push the teeth lingually or palatally ● At the back of the
- Muscles of the cheek will push teeth medially lateral incisor
- Continuous push from tongue, lips, and cheeks (between the distal
will align teeth in an area wherein their forces surface of the lateral
will be equal incisor and mesial
● Area is called the NEUTRAL ZONE surface of the upper
○ Outward forces = inward forces deciduous canine)
○ Teeth will be stabilized and will not ■ Lower Primate Space
move anymore under normal ● Interdental Spaces
conditions in the lower teeth
● Distal to the
deciduous canine
(between the distal
surface of the
deciduous canine
and the mesial
surface of the
deciduous first
molar)
● Bigger space
● Present in primate
families → Apes

Dentitional Period and Occlusal Development

- Primary Dentitional Period
● 6 months to 5 years
○ Starts when the first deciduous
molar erupts
● Start from 6 months
● Completed at 24 to 30 months
● Ends when the first permanent molars
-

erupt
○ 5 - 5 ½ years of age -

= =
 ■ Spaces appear little by little ● Significance of Primary Dentition
when jaw increases its size
○ Overbite and overjet ☒" •
■ Overjet
● Horizontal overlap
#
■ Overbite
● Vertical overlap

○ Arch perimeter, width, and length

are established
○ Arch Perimeter
■ Measured from the distal
.

surface of the second

-

deciduous molar passing

through the contacts of the
neighboring teeth and
going to the other side until
the line reach the distal
surface of the second
deciduous molar on the
other side
○ Wider mesiodistally than ○ Arch Length
occluso-gingivally in proportion ■ Line going anteriorly from
-

than permanent dentition second deciduous molar to

the other side until it gets
NOTE: 3 Kinds of Molar Relationship → to the contact points of the
Deciduous Dentition two Central Incisors
- Distal Step ○ Arch Width
- Flush Terminal Plane ■ From the tip of the groove
-

- Mesial Step of the deciduous second

molar on one side to the tip
✓ 2ND Mouth _ First
Mouth
of the groove of the
deciduous second molar on
the other side

NOTE: For permanent dentition, mesial surface

of first molar is used
● Arch Length decreases in Permanent
dentition

- Mixed Dentitional Period

● Transitional Period
● From 6 years to 13 years
○ When the permanent first molar
erupts
○ Ends when all primary teeth are
exfoliated
● Early Mixed Molar Relationship
○ Distal flaring of upper anteriors unless the
■ Ugly duckling stage deciduous molars
■ Solution: Relieved when the and canines in front
permanent maxillary canine of them will exfoliate
erupts
● Occupies the
primate space and
pushes the
permanent lateral
incisors because of
its wide mesiodistal
width
● Lips and tongue will
try to derotate distal
flaring of the upper
incisors → put them
in the Neutral Zone
where everything NOTE: Deciduous molar and canine has WIDER
will be aligned mesiodistal width
● Rotation of teeth are ● Maxillary → 1.3 mm excess (Leeway
being aligned → Lips Space)
and tongue tries to ○ Deciduous → 22.6 mm
derotate the central ○ Permanent → 21.3 mm
and lateral incisor to ● Mandibular → 3.1 mm excess (Leeway
the neutral zone Space)
○ End to end (or cusp to cusp) molar ○ Deciduous → 23.7 mm
relationship ○ Permanent → 20.6 mm
■ When the first permanent ● Leeway Space will be used by the mesial
-

molar erupts, there is no drifting of the permanent first molar

-

space in front of them → no ○ Permanent First molar → moves

adjustment in its position mesially
● Erupts distal to the ● Leeway Space is bigger in the mandibular
primary second arch → permanent mandibular first molar
molars will move more mesially than permanent
● Lower first molar maxillary first molar → cusp tip of the
cannot move permanent upper first molar will fall on
mesially → cusp to the mesiobuccal groove of the permanent
groove relationship lower first molar → CLASS 1 Permanent
because of the Dentition
presence of the ■ Normal: Class 1
deciduous second ● Cusp of upper first
molars which are in molar should fit in
Flush Terminal Plane the mesiobuccal
■ End to end to Class 1 groove of the lower
Relationship first permanent
● First permanent molar
molars CANNOT ● Lower first
establish a Class 1 permanent molar
 should be more ■ There is no space for the
anterior than upper alignment of the permanent
permanent first lower incisors because the
molar (not possible primate space is not readily
because of the available for them
deciduous second ● No space for the
molars → first alignment
permanent molar
cannot move
mesially)
■ Relieved when permanent
first molar erupts → will
push the primary second
molar anteriorly → mesial
step
● Leeway space is
bigger in the
mandible →
mandibular molars
will move mesially ■ Relieved by the help of the
and forward to forces from the tongue and
occupy the Leeway lips
Space → ■ Solution:
relationship ● Mandibular Incisors
becomes Cusp to and Canines
Groove reposition
○ Transient anterior crowding of themselves distally
lower anterior teeth to occupy the
■ CAUSE: Combined Primate Space →
mesiodistal widths of lower more space for the
permanent incisors is permanent incisors
usually bigger than the ● Late Mixed
combined mesiodistal ○ Space closed because of the
widths of the deciduous erupting canine
incisors → INSUFFICIENT ○ Crossbite or negative overbite
SPACE → erupted ○ Zero overbite
permanent incisors ○ Posterior overbite
become crowded - Permanent Dentitional Period
● The negative space ● General Characteristics
is called INCISOR ○ Normal surface contact
LIABILITY ■ Proximal surfaces of each
■ Incisors are not well aligned adjacent teeth should be in
because the primate space contact with each other
is distal to the primary ○ Normal cuspid to fossa
canine (unlike in upper relationship
primate space where it is ■ Cusps should fall on the
located in the mesial fossa
surface of the canine) ○ Normal triangular ridge to
embrasure or groove contact
 ■ Cusp of every premolar or
molar should fall on the
embrasure or groove or
fossa
■ There is an interdigitation
of teeth in the permanent
dentition
● NOT SEEN in mixed
dentition
● Ideal Molar Relationship in Permanent
Dentition
○ CLASS I → Mesiobuccal cusp of
the upper first molar should 3 = Ideal Molar Relationship
occlude with mesiobuccal groove 4 = will result in a Plunger Cusp
of the lower first molar ● Food will be stuck in the embrasure
■ Cusp to groove relationship between the lower permanent first molar
● Classification of Cusps According to and lower permanent second molar
Function
○ Stamp Cuspids 2) Crown Angulation (Tip)
■ Functional Cusps - Mesiodistal angulation of the tooth
■ Palatal cusps of the molars - Cervical portion of the crown is more distal
and premolars (for upper than the incisal portion of the crown
teeth) - Incisors → 5 degrees
■ Buccal cusps of molars and
premolars (for lower teeth)
○ Shear Cuspids
■ Nonfunctional Cusps
■ Buccal cusps of molars and
premolars (for upper teeth)
■ Lingual cusps of the molars
and premolars (for lower
teeth)

Six Keys to Occlusion According to Lawrence

Andrew

1) Molar Relationship
- Mesiobuccal Cusp of the Upper Permanent
First Molar occludes with the Mesiobuccal
Groove of the Lower First Molar
- Distal surface of the Distobuccal Cusp of the 3) Crown Inclination
Upper Permanent First Molar occludes with the - Inclination of the tooth in the labiolingual
Mesial Slope of the Mesiobuccal Cusp of Lower dimension or buccolingual dimension
Second Permanent Molar - Cervical portion of the incisors is more lingual
or palatal than the incisal portion of the crown
- Inclination → 7 degrees
● Labiolingual Inclination or Buccolingual
Inclination
● Torque
4) Rotations
- Each tooth should have a slight rotation 6) Occlusal Plane

=
EXCEPT CANINE - Flat to a slightly concave in the mandibular arch
● Canine ● Slight Curve of Spee → 5 degrees
○ Has the biggest rotation ● Seen in Figure B
○ Junction between the incisor area - Too concave → Figure A
to posterior area - Too convex → Figure C
- Mild rotations
● If big → will displace other tooth

5) Tight Contacts
- All teeth should have tight contacts
- Area without tight contact
● Food will be stuck or entrapped A = Curve of Spee
● Gingiva and bones will move apically B = Curve of Wilson
● Bone will resorb C = Sphere of Monson (combination of A and B)
Normal Buccolingual Relationship Incisor Liability
- 8-9 years old
- 1.6 mm in the mandible
● Difference in width between permanent
mandibular incisors and the combined
mesiodistal width of deciduous
mandibular incisors
- Negative space in the lower incisor area
- Main cause of transient lower incisor crowding

- Upper permanent molars overlaps the lower

permanent molars
- Lingual Cusp of upper molars occlude with the
Central Fossa of lower molars

Significance of ABC Contacts

- Concept of Tripodization
How to overcome incisor liability?
● Fulfilled by molars
- Slight increase in arch width
- A Contact
● Slight lifting in the crowding of lower
● Contact with the palatal slope of the
anterior area
buccal cusp of the upper permanent
- Labial positioning of permanent incisor relative
molar
to primary incisor
● Contact with buccal slope of the buccal
● Because of the forces from the tongue
cusp of the lower permanent molar
● More space in the labial area
- B Contact
- Repositioning of canines in the mandibular
● Contact between the buccal slope of the
arch
palatal cusp of the upper permanent
● Primate space is distal to the mandibular
molar and the lingual slope of the buccal
primary canines
cusp of the lower permanent molar
● When permanent mandibular canine
● Receives the most stress and pressure
erupts, it moves distally to occupy the
during biting
primate space → more spaces for the
● Contact that maintains the vertical
mandibular incisors
dimension of occlusion
- Continued development of the arches improves
- C Contact
spacing
● Contact between the palatal slope of the
● Continuous development and
palatal cusp of the upper permanent
enlargement of arches → gives mores
molar and the buccal slope of the lingual
space for alignment
cusp of the lower permanent molar
- Function of Tooth Contacts
● Prevent horizontal or lateral drift of the
teeth buccolingually
● Prevent mesial and distal drifting
 - Class 1 Molar Relationship
● Mesiobuccal cusp of the upper first molar
should occlude with mesiobuccal groove
of the lower first molar
- Class 2 Molar Relationship
● Mesiobuccal cusp of the upper first molar
falls mesial to the mesiobuccal groove of
the lower first molar
● Maxillary bone is more forward than
Mandibular Bone -4
- Class 3 Molar Relationship
● Mesiobuccal cusp of the upper first molar
falls distal to the mesiobuccal groove of
the lower first molar

Bone Movement During Development

- Flush Terminal Plane
● Ideal Molar Relationship for Deciduous
Dentition
● Maxilla grows more than the Mandible →
Class 2 MAXIMA > MANDIBUT
● Harmony in the growth of the Maxilla and
the Mandible → End to end → Class 1
● Mandible grows more than Maxilla →
Class 3 MANDIBUT > MAXIMA
- Mesial Step
● Maxilla and Mandible grow normally →
Class 1
● Mandible continues to have more growth - During Bone Development
than Maxilla → Class 3 ● There is bone deposition and resorption
- Distal Step ○ Referred to as DRIFT
● ALWAYS CLASS 2

Different Types of Malocclusion

● + → bone deposition (at the back of the

mandible)
● - → bone resorption (in the anterior
border of the mandible)
● Result: Body of mandible will increase its
length
○ This type of bone growth is called
DRIFT
 ■ Bone movement during ● Example:
growth ○ In the mandible
- Bone deposition in the superior and posterior ■ Bones surrounding the
border of Maxilla → Maxilla will move down and inferior alveolar nerve,
forward → DISPLACEMENT mental nerve, and teeth
● 2 Types of Bone Displacement Movement ■ Symphysis
or Bodily Movement of the Bone ○ In the maxilla
○ Primary Displacement ■ Bones surrounding the
■ Deposition at the superior greater palatine nerve,
border → bone will move incisive nerve, midpalatal
bodily suture, and the teeth
○ Secondary Displacement
■ Bone is pushed by the
deposition of bone from its
neighboring bone
■ Maxilla is being pushed by
the deposition of bone
around it

2 Areas of Bone Growth in Facial Bones

- Growth Sites
● Area of bone that has bone deposition
● All over the bone
- Growth Centers
● Cell division is present
-
○ To increase the number of - Spheno-occipital Synchondroses
bone-forming cells and to increase ● Biggest growth center
bone mass ● Tissue -separating force
○ Presence of tissue-separating ○ Separates the base of the
force sphenoid bone and the base of
● Specialized sites where bone increases occipital bone
its size due to cell division ● Responsible for growth of cranial base
(anteroposteriorly)
- Direction of bone movement during growth
● Maxilla → downward and forward
 ○ Because the maxilla is connected - Maximum Intercuspation
to other bones in its upper and ● Refers to the position of the mandible
posterior parts when the teeth are brought to full
● Mandible → downward and forward interdigitation
○ Bone deposition and increase in ● Full interdigitation of the upper and lower
bone mass is somewhere near the teeth (premolars and molars)
condylar area → will push the ● Maximum Cusp to Fossa Relationship
mandible down and forward ○ Under centric occlusion
- Centric Occlusion
Concepts of Occlusion ● Maximum intercuspation
- Balanced Occlusion ● Positioning of the upper and lower arch
● When biting and gliding from left to right into a cusp to fossa relationship
○ Almost all teeth (molars and ● Immediate maximum intercuspation
premolars) contact each other when biting
○ VERY RARE ○ Centric Relation coincides with
- Mutual Protection the Centric Occlusion
● When biting, the posterior teeth protects ● Needing to glide to achieve maximum
the dental arch intercuspation

:
● Molars and premolars control the “bite” ○ Discrepancy in Centric Relation
● We can only chew at lower set of anterior and Centric Occlusion
teeth behind the upper anterior teeth ■ If discrepancy is around 2
○ Anterior Teeth mm, the tissues around will
■ Controls the jaw movement adapt
of the lateral excursion ■ Beyond 2 mm → possibility
● Posterior Teeth of patient to experience
○ Accepts the load symptoms
● When gliding ● Tightness of jaw
○ Upper and lower teeth on the sides ● Pain in the jaw
make contact ● Muscle pain
■ Sign of Multiple Group ● Chipping of off
Function Occlusal Contacts enamel in the tooth
○ If only the CANINES can make a ● Discomfort or pain in
contact the joint
■ Premolar and molar are - Centric Relation of Occlusion
MALOCCLUDED ● Position wherein the Centric Relation and
■ “Canine protected Centric Occlusion coincides
occlusion” - Physiologic Rest Position
● Upper and lower arch are NOT in contact
Basic Mandibular Positions ● Jaw arch moves down to relax
- Centric Relation ○ Mouth is slightly opened
● Lower jaw automatically centers itself ● “Emma” = physiologic rest position
when biting ● Tip of the Nose to the Tip of the Chin
● Controlled by Neuromuscular System ○ Vertical height of the face during
○ Decides where the lower jaw will rest position
position itself to the upper jaw ○ Physiologic Rest Position (PRP)
● Maximum Mandibular Relationship ● PRP-VDO = FWS
○ Physiologic Rest Position (slightly
opened mouth) - Vertical
Dimension of Occlusion (while
 biting or maximum intercuspation)
= Free Way Space
■
■ Approximately 2 to 4 mm
■ 6 mm and above → bigger
than normal → speech is
affected (a lot of air comes
out)
■ Less than 2 mm → speech
is affected (tongue can’t
move properly) → less air
coming out

SALIVARY GLANDS

Major Salivary Glands

- Parotid Gland Properties of Saliva
● Stensen’s Duct - 99% water and 1% inorganic and organic
- Submandibular Gland material
● Wharton's Duct - pH
○ Near the base of the tongue (at the ● 5.6 to 7.6 pH
back) - Gravity
● Between the lower first and second molar ● 1.002 to 1.008 specific gravity
- Sublingual Gland - Frothy, colorless or slightly opalescent,
● Bartolin’s Duct odorless
○ At the lateral of the lingual frenum ● Odor → infection or disease
(at the back of lower incisors) ○ Decomposition or degradation of
tissues = release of SULFUR
Minor Salivary Glands ■ Sulfur releases bad odor to
- Scattered in the tongue, palate, and buccal
=

the body
mucosa - Secretion
- Mucous Glands ● 1 to 1.5 liters a day
● Glossopalatine Glands ○ Saliva is being recycled
● Palatine Glands
● Anterior ⅔ of the tongue Types of Saliva
● Posterior ⅓ of the tongue - Pure or Active Saliva
- Mixed Glands ● Stimulated saliva ✓ PHYSICAL MONTAG
, PSYCHOLOGICAL
● Retromolar ○ When chewing
● Labial ○ When thinking about food
● Buccal Mucosa ● Clear and colorless
- Serous Glands ● Has more SEROUS CELLS
● Salivary protein

=
- Resting or Mixed Saliva
● Amylase ● Frothy
- Von Ebner Gland ● Viscous
● Beside circumvallate papilla of the ● Has more MUCOUS CELLS
tongue ● During sleeping
● Main purpose is to clean the papilla from
any food debris
● Secretes watery or serous saliva
Cells Wound
- Serous Cells - Accelerate - Epidermal
healing
● Has zymogen granules wound healing growth factor
factor
- Mucous Cells
● Has mucous cells
Bicarbonate
Functions of Saliva - Neutralize the esophageal content that
contains HCl
Function Effect Component Sialin
- Lubrication - Raises pH of dental plaque after exposure to
- Water fermentable carbohydrate
proofing
- Lavage - Glycoprotein Water
Protection - Dissolves particles of food → release
● Washing - Mucin
medium molecules
- Pellicle ● Molecules come into contact with taste
Formation buds → ability to taste food or recognize
the taste of the food
- Maintains pH
unsuitable for - Phosphate Gustin
microbial - Bicarbonate - Helps in the maturation of the taste buds
Buffering
colonization - Sialin
- Neutralizes ● Protein Tastebuds
acid - NOT functional until maturation

- Water Glycoprotein
- Bolus
- Phosphate - Thrive to seal with the pellicle
formation
- Carbonate
- Neutralizes
Digestion - Protease Immunoglobulin A
esophageal
- Lipase - neutralizes bacteria
contents
- Ribonuclease
- Digest starch
- Amylase Lysozyme
- Enzyme
- Solution of - Kills microbes
molecules ● Breaks down bacterial cell wall
- Water
Taste - Taste bud
- Gustin
growth and Lactoferrin
maturation - Protein that binds with Iron in the oral cavity
● Iron is needed for any living metabolism
- Barrier - Glycoprotein
- Immunoglobulin
- Starves the bacteria
Antimicrobia - Antibodies A
l - Hostile - Lysozyme Calcium and Phosphate
environment - Lactoferrin - For calcification
- Maintains tooth integrity and promote enamel
- Calcium maturation
Tooth - Enamel - Newly erupted teeth are NOT YET calcified
- Phosphate
Integrity maturation
Epidermal Growth Factor - Statherin
- Promotes proliferation of epithelium to cover ● Prevents formation of calcified masses
the wound - Proline Rich Proteins
● Acidic
Masticatory Salivary Reflex ● Inhibits CaPO4 nucleation
- When we chew food, masticatory muscles and ● Prevents calcular deposits
jaw are moved → saliva is stimulated
Salivary Proteins With Antimicrobial Action
Gustatory Salivary Reflex - Immunoglobulin
- When food particles are broken down, saliva ● Aggregation
will be released automatically ● Aggregates with the microorganism →
- Presence of food → will be broken down into kills microorganism
molecules → molecules will come into contact - Mucin
with taste buds → saliva is released ● Agglutination
● Agglutinates the microorganism → kills
2 Parts of Autonomic Nervous System microorganism
- Lysosome
1) Sympathetic ● Autolysis
- Noradrenaline or norepinephrine ● Breaks the cell membrane or cell wall of
- Constricts salivary gland duct microorganism
- Decrease secretion ○ Bacteria
- Fight or flight response ○ Fungus
- Receptors ○ Contents of cytoplasm will come
● Alpha Receptors out → microorganism will die
○ Vasoconstriction - Lactoferrin
○ Located in the smooth muscle of ● Will compete by binding with the Iron
salivary glands content in the oral cavity
■ Constricts → flow of saliva ○ If the microorganism doesn’t have
decrease Iron for its metabolism, it will die
● Beta Receptors - Peroxidase
○ Vasodilation ● Block essential metabolic process of
○ Located in blood vessels of microorganisms → microorganism will
muscles die
○ Noradrenaline + Beta Receptors →
blood vessels in the muscle will Growth Factors in Saliva
DILATE → increase blood - Epidermal Growth factors
● Usually present in the smooth muscle of ● Wound healing
blood vessels and ducts of glands ● Stimulate the epithelial cells or
fibroblasts to secrete collagen fibers or
2) Parasympathetic other components of connective tissue
- Acetylcholine ○ To repair the damaged part of skin
- Dilates salivary duct or dermis
- Relax = Increase secretion of saliva - Nerve Growth Factor (NGF)
● Stimulates ganglionic factor to repair
Calcium Binding Protein damaged nerves
- To prevent accumulation of calcular deposits in ● When chewing:
the salivary gland ducts, teeth, and other parts ○ Nerves are getting damaged but
of the oral cavity are easily repaired immediately
- Calcular deposit → pain
- Transforming Growth Factor ■ Lactobacillus acidophilus,
● Differentiation and growth Staphylococcus aureus,
● Undifferentiated mesenchymal cells → and Streptococcus mutans
specialized cell ● Individual will most
○ In order to secrete a material that likely develop tooth
is necessary for a growth of a decay
certain tissue or part of the body ● Caries-producing
○ Undifferentiated mesenchymal bacteria in the oral
cells become fibroblast → cavity
fibroblast secretes collagen to - Chemical Test
build up damaged tissue ● Fluoride
- Fibroblast Growth Factor ○ For 7-14 days only
● Wound healing ■ If all bacteria are killed →
● Stimulate a Fibroblast to mature fungal infection will occur
○ Mature fibroblast can secrete ○ Normal fluoride → can protect
collagen to repair wound or teeth
damaged tissues ○ High Fluoride → can destroy the
enamel
Diagnostic Tests ■ Especially for pregnant
- Calorimeter Test women and infants
● Caries susceptibility test ● Can kill the
● Hyd Ion Test ameloblasts →
○ Indicate pH destroy enamel
○ Pink, brown, blue ○ Low Fluoride → Fluoride therapy
○ Litmus Paper
■ Acidic → Red Growth Factors in Saliva
■ Basic → Blue - Epidermal Growth Factor
■ Neutral → Brown ● Wound healing effect
○ Saliva should NOT be acidic ● Mucosal defense barrier
■ Acidic = caries formation - Nerve Growth Factor
● Methyl Red Test ● Stimulating effect on ganglionic factor
○ Acts as disclosing solution ● Recovers the injured nerve
○ For identification of plaque - Transforming Growth Factor
○ Binds with the starch or plaque in ● Causes cell differentiation and growth
the teeth - Fibroblast Growth Factor
○ Plaque turns to RED or PINK ● To stimulate fibroblast to mature
● Snyder Test ○ So they can deposit material for
○ Tests the acidity of the saliva repair of connective tissue
○ Chew food → inoculate test 24, 48, (collagen)
or 72 hours ● Regulator of wound healing
■ If it turns YELLOW→ acidic
- Microbial Test Mouth and Clinical Examination
● Bacteriologic Test
○ Put saliva in a medium 1. Soft Tissue
○ Observe and examine microbial - Posterior
growth - Superior
■ Identify what - Lateral
microorganism is - Anterior
predominant
2. Individual Tooth Examination (DMFT) ■ Actually a Nervous Tissue
- Decayed Missing Filled Charting → a kind of proprioceptor
● Some teeth are missing, decayed, or filled - When muscles RELAX
● Muscle length INCREASES
Mastication ○ Contains Muscle Spindle
- Position of the jaw while chewing is ● Muscle Spindle
automatically placed in its position ○ Located along the length of the
- 2 Controls of Mastication muscle
● Voluntary Movements ○ Relaxed → lengthens →
○ Result of deliberate effort and will stimulated
to chew ○ Sends impulse to the Trigeminal
● Reflex Movements Reflex Center → Central Nervous
○ Programmed in Central Pattern System
Generator (CPG) ● CNS and Trigeminal Reflex Center
○ Fine-ture voluntary movements ○ Sends reflex to Extrafusal Muscle
○ Learned and inherited Fibers to contract → to relieve the
○ Automatically happen when there the muscle spindle from
is a presence of food in the oral stretching activity
cavity
○ Involves not only the contraction NOTE: All voluntary muscles are attached in the
of the muscles and the control of bone by a TENDON
the CNS but also by the influence ● Contains Golgi Tendon
of some proprioceptors that is ○ A form of proprioceptor
related to the parts of the body ○ Stimulated by the contraction of
responsible for mastication Extrafusal Muscle Fibers
○ Will complain or be stimulated
■ Sends impulse to the
Trigeminal Reflex Center →
Central Nervous System
○ CNS and Trigeminal Reflex Center
■ Sends reflex to Extrafusal
Muscle Fibers to stop the
contraction and relax the
muscle → to relieve the
golgi tendon from
stretching activity →
muscle will relax again
○ Once relaxed → muscle spindle
lengthens → CYCLE OF
2 Groups of Muscle Fibers CONTRACTION/RELAXATION
- Extrafusal Muscle Fibers
● Composed of muscle fibers that are Reflex Movements
capable of contracting - Stretch Reflex From Muscle Spindles
● Actual contracting fibers of a muscle ● When the muscle spindle is stimulated
- Intrafusal Muscle Fibers (when the muscle is overstretched), it
● Example: stimulates contraction of the muscle
○ Muscle Spindle ○ Maintain the posture of the jaw in
■ NOT a muscle tissue its rest position
- Periodontal Reflex - Opening Phase
● Give sensation about pressure on the ● Downward with slight lateral movement
teeth of the mandible
○ Because of the presence of ● Food can get in
Pacinian Corpuscles ● Occurs when the food enters the Occlusal
■ Located in Periodontal Table
Ligament Area (Periodontal ○ Occlusal surfaces of molars and
Space) premolars
● Guide teeth into occlusion during the - Closing Phase
grinding phase as teeth slide across each ● Crushing Phase
other towards occlusal position ○ Initial upward movement of
● Guides jaw movement mandible
- Tendon Organ Reflexes ● Grinding Phase
● Monitor the force exerted by a number of ○ Lower jaw with lateral motions to
different motor units during weak grind food
contractions
● Extrafusal Muscle contracts → Tendon NOTE: Cycles are being repeated until the food is
Organ becomes stimulated → CNS → simplified into a condition of where they are
Extrafusal Muscle Fibers relax capable of being swallowed
- Joint Reflexes
● Signal extremes of movement that
oppose movement of the jaw beyond safe
limit
○ Opening
○ Protrusion
○ Lateral excursion
● Prevent damages of the ligaments and
other tissues related to the
Temporo-mandibular Joint (TMJ)
- Cyclical Movements
● Rhythmic and well-controlled functional
mandibular movements due to the
proprioceptors and nociceptors that
receive stimuli
○ Monitors the movement of the jaw
● Cyclical movement of the jaw during
chewing
● Prevents jaw movements that can be
damaging to the joint and ligaments

Chewing Stroke
- Basic unit of mastication
- Represents each cycle of opening and closing
movements of the mandible
- Has 2 Phases
● Opening Phase
● Closing Phase
Tooth Contacts During Mastication - Tooth (Biting Force)
- Single Tooth Contact ● Incisor
● Tooth Contact B ○ 13.2-23.1 kg
○ Strongest Contact ● Molar
○ Maintains the vertical dimension ○ 41.3-89.8 kg
of occlusion - Type of Food
● Occurs in the maximum intercuspal ● Hard food
position ○ Mandibular Sling Muscle
- Gliding Tooth Contact ■ Composed of:
● Occurs as the cuspal inclines of the ● Masseter Muscle
stamp cusp pass by each other during the ● Medial Pterygoid
opening (56%) and grinding phase (60%) Muscle
of mastication ■ Carry the mandible like a
● Stamp Cusp sling
○ Functional cusp or centric cusp ■ Activated in eating hard
● Palatal Cusp food
○ Stamp cusp in the Maxillary Molars ● Soft Food
● Buccal Cusp ○ Strong force is not needed
○ Stamp cusp of Mandibular Molars ○ Temporalis Muscle
- Age and Diet
Stages of Mastication ● Middle age people
- Incision Stage ○ Strongest biting force
● Performed by incisors to cut food into ● Younger and older people
smaller pieces ○ Weaker biting force
- Direct Crushing Stage - Dentition
● After cutting, the food will go to the ● Dentulous
occlusal table (occlusal surfaces of ○ Complete set of teeth = stronger
molars) biting force
● Buccal inclines of maxillary stamp cusps ● Edentulous
pass over lingual inclines of mandibular ○ Weakest biting force
stamp cusps to tear food into morsels ● Partial edentulous
● Food will be ground and the fluid content ○ Weaker biting force
of the food will be squeezed out - Craniofacial Morphology
○ Chemical content will go the oral ● Brachycephalic
cavity and comes into contact with ○ Have square face or wider face ☐
taste buds ● Dolichocephalic
■ If taste is sensed, more ○ Have longer face 0
saliva will be produced ● Mesocephalic
- Trituration Stage
● Performed by molars to grind food ready
0
○ Have ovoid or oval face
- Masticatory Muscle Size
for swallowing ● Masseter
○ Wide and bulky = stronger biting
Factors that Affect Forces of Mastication force
- Gender
● Female
○ 35.8-44.4 kg
● Male
○ 53.6-64.4 kg → stronger in general
Factors that Affect Chewing Stroke ● Approximately before 2 years old
- Quality and Quantity of Tooth Contacts - Mature or Somatic Swallowing
● More teeth = more tooth contacts = small ● Teeth is present
chewing strokes ● Requires maximum intercuspation
● More complete teeth = lesser chewing ○ Mandible is stabilized by maximum
strokes intercuspation of teeth
● Complete set of teeth = lesser chewing ■ Most important tooth
strokes contact: Single tooth
● Missing teeth = more number of chewing contact (Tooth Contact B)
stroke to masticate the food ■ Mandible will not go up too
● Bad Occlusion = less tooth contacts = much
more number of chewing stroke to ○ Normal Oral Seal
masticate the food ● Lips
- Occlusal Condition of Teeth ○ Don't have to close tightly to
● Flat occlusal table prevent food from coming out
○ Broader chewing stroke ○ Food is combined in the oral cavity
● Tall cusps with deep fossa ○ Lips are relaxed
○ Predominantly vertical chewing I ● Tongue:
stroke ○ Positioned in the hard palate
- TMJ ○ Not between the upper and
● Normal TMJ anterior teeth
○ Well rounded strokes with definite ○ Purpose:
borders and less repeated ■ To serve as a stimulus for
● Painful TMJ the maxillary bone to
○ Repeated pattern and shorter develop/grow
strokes
○ Slower and irregular pattern Stages of Swallowing
■ Jaw will try to avoid the - Bucco-pharyngeal Phase
pain ● Voluntary movement from oral cavity to
pharynx (oropharynx)
Types of Swallowing ● Space of Donder
- Infantile or Visceral Swallowing ○ Where tongue moves the food
● For infants → no teeth yet ○ Space at the dorsal of the tongue
● Mandible is stabilized by placing the ○ Where the bolus is placed
tongue forward and between the gum ○ Space between tongue and palate
pads when the tongue is elevated
● Tongue ● Ends when tongue goes down in the
○ Tongue is interposed between the pharyngeal area
upper and lower gum pads → - Pharyngo-esophageal Phase
Mandible is stabilized ● Known as Glosso-pharyngeal Phase
■ Because mandible may go ● Involuntary movement from pharynx to
up more → gives strain to esophagus
TMJ ● Epiglottis
● Lips ○ Most important structure to
○ Tend to exert pressure in the prevent choking
upper and lower lips to close ○ Located in the pharyngeal area
○ No teeth yet = food will come out ○ Closes the oropharynx
● Occurs until posterior primary teeth erupt ○ Closes the airway (trachea) during
to assume somatic or mature swallow swallowing
 ■ Prevent food from coming MASTICATORY MUSCLES
in - Divided into 2 groups:
● During Choking ● Elevator Muscles
○ Food enters the larynx therefore ○ Muscles that elevate the lower jaw
bolus blocks larynx ○ Closes the mouth
- Esophagus to Stomach ○ Called as Sling Muscles
● Peristaltic movement of esophagus → ○ Masseter (Right)
stomach ■ Has 2 bellies
● Involuntary ● Outer Oblique
● Regurgitation ● Inner Vertical
○ Movement of bolus from ■ Origin:
esophagus to oral cavity ● Zygomatic area
○ Food is mixed with hydrochloric ■ Insertion
acid in the stomach ● Inferior border of the
■ If regurgitated, it can etch mandible
the enamel → susceptible ○ Medial Pterygoid Muscle
to caries ■ Internal surface of the
● Vomiting ramus of the mandible
○ Chyme ■ Origin
■ Water in the stomach that ● Pterygoid fossa
has hydrochloric acid ■ Insertion:
○ Movement of chyme from stomach ● Medial surface of
to esophagus to oral cavity the mandibular
○ Pressure is in stomach angle
● GERD (Gastro-esophageal Reflux ● Depression Muscles
Disease) ○ Depresses the jaw
○ Chronic condition where the ○ Open the mouth
content of the esophagus and
stomach goes back to the oral
cavity
○ Acidic content goes back to oral
cavity → etch the enamel and
dentin → tooth decay
○ Oral significance
■ Increase susceptibility to
caries (acid reflux)

Frequency of Swallowing
- Approximately 590 times a day NOTE: Movement of the jaw can be related to the
● 146 → while eating direction of the fibers of the muscle
● 394 → between meals while awake
● 50 → while sleeping - Temporalis Muscle
- Unique Features ● 3 parts
● Occurs as early as intrauterine life ○ Anterior
● Occurs at the end of respiratory phase ■ Anteriorly directed fibers
● Occurs even in the absence of food ■ Contracts → mandible goes
● Most frequently repeated activity of the up and forward
masticatory system ○ Middle
■ Vertically directed fibers
 ■ Contracts → mandible goes - Superior Belly of Lateral Pterygoid Muscle
upward ● Origin:
○ Posterior ○ Infratemporal surface of the
■ Posteriorly directed fibers greater sphenoid wing
■ Contracts → brings ● Insertion:
mandible backward ○ Articular capsule of the TMJ
● Origin ○ Disc of the TMJ
○ Temporal fossa ○ Neck of the condyle
○ Lateral surface of the skull ● Contraction
● Insertion ○ Does NOT move mandible
○ Coronoid Process ○ Puts some tension in the articular
○ Anterior border of the ascending disc
ramus ○ Active when the lower jaw is
elevating/closing
■ There is a risk that the
articular disc will move too
much backward (this
muscle prevents the
articular disc from moving
too much backward)
- Inferior Belly of Lateral Pterygoid Muscle
● Origin:
○ Outer surface of the lateral
pterygoid plate
● Insertion
○ Neck of the mandibular condyle
- Medial Pterygoid Muscle ● Contraction
● Origin ○ Brings the neck of the condyle
○ Pterygoid Fossa forward
● Insertion ■ Down and forward
○ Medial surface of the mandibular ○ Opens the jaw
angle (angle of the mandible)

- Suprahyoid Muscles
● Muscles on top of the hyoid bone
● Digastric Muscle
- Anterior Belly of the Digastric Muscle
● Origin 1 Masseter Muscle
○ Fossa on the lingual surface of the
mandible 2 Medial Pterygoid Muscle
● Insertion
○ Intermediate tendon attached to 3 Anterior Temporalis
the hyoid bone
● Contraction 4 Medial Temporalis
○ Elevates the hyoid bone
5 Posterior Temporalis
- Posterior Belly of the Digastric Muscle
● Origin 6 Inferior Belly of the Lateral Pterygoid
○ Mastoid notch (medial to the Muscle
mastoid process)
● Insertion 7 Superior Belly of the Lateral Pterygoid
○ Intermediate tendon attached to Muscle
the hyoid bone
● Contraction 8 Anterior Digastric Muscle
○ Brings mandible backward
9 Hyoid Bone

10 Posterior Digastric Muscle

11 Suprahyoid Muscle

12 Infrahyoid Muscles

Movements of the Jaw

- Elevation of the jaw requires contraction of
● Medial Pterygoid
● Posterior Temporalis
● Masseter
- When opening the mouth
● Contraction of
○ Anterior Digastric
○ Lateral Pterygoid
○ Mylohyoid
● Depressors of the Jaw
- Lateral Movement of the Jaw - Retrude the Mandible
● Moving the jaw to one side ● Move the mandible backward
● Contraction of ● Posterior Temporalis
○ Lateral Pterygoid ● Posterior Digastric
○ Medial Pterygoid ● Suprahyoid Muscles
○ Anterior Temporalis
○ Medial Temporalis
● Move lower jaw to the left side
○ Lateral Pterygoid on the right side
○ Medial Pterygoid on the right side
○ Anterior Temporalis on the right
side
○ Medial Temporalis on the right side
○ Muscles of the left side should
relax

- Posture or tonicity of jaw muscles is under

the activity of the extrafusal fibers of the
masticatory muscles
● Under the influence of proprioceptors in
the muscle
○ Muscle Spindle
○ Golgi Tendon
● Muscle is relaxed too much
- Protrude the Lower Jaw ○ Muscle Spindle will send
● Lateral Pterygoid information to the brain to
○ Left and right contract the extrafusal muscle
○ Inferior Belly fibers
○ Superior Belly DO NOT CAUSE ● Muscle is contracted too much
MANDIBULAR MOVEMENT ○ Golgi Tendon will be stimulated to
● Medial Pterygoid send impulses to the Trigeminal
○ Both left and right Reflex Center or to the Central
● Masseter Nervous System to stop the
● Anterior Temporalis contraction
■ Makes the extrafusal fibers
relax
The Temporomandibular Joint (TMJ)

- TMJ’s part in the temporal bone

● Sphenous part
● Squamous part
● Petrous part
- Roof of TMJ
● Glenoid Fossa of Temporal Bone
○ Within the Glenoid Fossa and the
Head of the Mandibular Condyle is
the Disc
■ Disc is composed of dense
fibrous connective tissue
● VERY THIN
● When Glenoid Fossa is cracked →
intracranial hemorrhage

Coronal Section of the TMJ

- AD = Articular Disc - Accessory Ligaments
● Attached to the neck or head of the ● Prevents the excessive downward
condyle medially by the Medial Discal movement of the mandible → protects
Ligament and laterally by the Lateral the mandible
Discal Movement ● Sphenomandibular Ligament
● Condyle moves when the jaw moves ○ Origin
● Disc should always follow the condyle ■ Sphenoid Bone
because it is attached to the condyle ○ Insertion
● Divides the TMJ into 2 ■ Medial part of the ramus of
○ Superior Compartment or the mandible (near the
Superior Joint Cavity lingular process of the
○ Inferior Compartment or Inferior mandible)
Joint Cavity ● Stylomandibular Ligament
● No blood or nerve supply ○ Origin
○ Gets nutrition from the Synovial ■ Styloid Process
Fluid ○ Insertion
- CL = Capsular Ligament ■ Angle of the mandible
● Lines or encloses the whole TMJ ○ Action:
- Synovial Fluid
● Inside the TMJ
● Present in both compartments
● Comes from the epithelium of the
synovial membrane
- Synovial Membrane
● Lines the whole TMJ
○ Temporal Bone Wall
○ Condylar Wall

- Condyle is restricted in its posterior movement

● By the Temporomandibular Ligament
○ Prevents the condyle from moving
backward too much
■ During opening of the
mouth
- 2 Groups of Fibers of the Temporomandibular
Ligament
● Outer Oblique Fibers
● Inner Horizontal Fibers
Temporomandibular Joint cut from Articular
Disc to the Condyle

Optimum Orthopedically Stable Joint Position

(CR)
- Condyle should be pointing at the isthmus of
- Transitions from cartilage to bone
the disc
- Articular Zone
- 3 Parts of the Disc
● First layer
● Anterior Band
● Contains less cells
○ Thick
● Cartilage loses cells → cells become
● Middle Part
black
○ Isthmus
- Proliferative Zone
○ Very thin
● Composed of numerous cells
● Posterior Part
- Articular Disk
○ Posterior Band
● Made up of dense fibrous connective
○ Thicker
tissue
- Condyle
● Made up of fibrocartilage
- Fibrocartilaginous Zone
● Bone transforms into a cartilage

Cartilage Matrix
- Usually made up of Collagen
- Collagen Network
● Made up of
○ Collagen fibrils
○ Hyaluronic Acid
■ Combines collagen fibrils
○ Monomer
○ Interstitial Fluid
- Connective tissue is made up of collagen
● Bone
● Cartilage
Biomechanics of the Temporomandibular Joint BORDER MOVEMENTS OF THE MANDIBLE
- Disc is attached anterosuperiorly
● Some fibers of the disc goes to the
Superior Lateral Pterygoid
● When the lower jaw closes, it prevents
the posterior displacement of the disc
- Disc is attached anteroinferiorly
● Some fibers of the disc goes to the
capsule
- Posterosuperior attachment of the Disc
● Fibers goes into the Petrotympanic
Fissure
Intercuspal Position (ICP)
○ MENISCUMALLEOLAR LIGAMENT
- Tip of the lower incisor is touching the lingual
or PINTO’S LIGAMENT
surface of upper central incisors
● Goes to the middle ear
- Molars are at maximum
○ Attaches to the Malleolar
interdigitation/intercuspation
Ligament
- Formed by the movement of the jaw to the tip
○ Attaches to the Malleus of the Ear
of the lower incisor
- Posteroinferior attachment of the Disc
- Condyle is located concentrically in the glenoid
● Comes from the posterior part of the disc
fossa
→ goes downward → inserts into the
● When jaw is lowered backward → condyle
neck of the condyle or near the head of
also moves backward
the condyle
- Bilaminar Zone
- Retrodiscal Tissue
● Tissues in between the posterosuperior
and the posteroinferior attachments
● At the back of the disc
● Contains blood vessels, nerves, and
lymphatics
● When inflamed → Retrodiscitis
○ Pain in the ear area when biting →
Retrodiscal Pain Retruded Contact Position (RCP)
■ Because of the pressure of - Lower jaw is moved backward
the condyle in the area ● Cannot move in a straight way
○ Has to go downward and backward
■ Because the posterior
teeth have their cuspal
inclines
● they have to
overcome their
cuspal inclines first
before going
backward
Terminal Hinge Axis Movement
- Open the mouth: At about 25-27 mm
● Lower jaw will make a straight or slightly
curved path
○ From RCP

NOTE: Condyle moves for every mandibular

movement
- From 0 to 25 or 27 mm
Biomechanics of the Temporomandibular Joint ● Condyle rotates in its longitudinal axis
● Rotates in the condylar axis
- After 25 or 27 mm
● Limit of temporomandibular ligament is
reached
● Condyle will translate (move bodily) in the
glenoid fossa
○ Maximum opening

3→4
● Condyle has to translate (move bodily)

Temporomandibular Ligament
- Condyle rotates when mouth is open
● Rotation has a limit → suspension of the Border movement of Mandible at Lateral View
pull of the Temporomandibular Ligament - Mouth closes
- When the length of the Temporomandibular ● Mouth will make a maximum protrusive
Ligament is already reached movement
● Neck of Condyle cannot move backward ○ Condylar position of maximum
anymore opening
■ Condyle almost reaches the
articular tubercle of glenoid
fossa
● Mouth will return to ICP
○ Condyle returns to center of
glenoid fossa
Centric Occlusion
- Myocentric
● Usually the first contact
● From Myocentric → Centric Occlusion
● Within 2 mm → acceptable

- Maximum Protrusion
● Pull of the Lateral Pterygoid at the left
and right side are equal
● To achieve Maximum Lateral Movement of
Horizontal Border Movement
the Jaw to the Right
- Intercuspal Position (ICP)
- Maximum Lateral Movement
● After ICP, the lower jaw will be moved
● Move backward → achieve RCP
backward
○ To achieve Retruded Contact
NOTE: All functional movements of the lower jaw
Position (RCP)
starts from ICP
- Retruded Contact Position (RCP)
● Lower jaw is moved maximally to the left
- When chewing:
○ CANNOT MOVE DIRECTLY TO THE
● Movement of jaw is far from ICP
LEFT
● As food particles become smaller →
■ Has to move forward and to
range of mandibular movement becomes
the left
smaller → LATE CHEWING (LC) →
● Because of the limit
Swallow
of the muscles of
mastication
(especially the
Lateral Pterygoid
Muscle)
- Maximum Lateral Movement of the Lower Jaw
to the Left
● Jaw has to be moved forward
○ But because of the balance of the
left and right side (especially the
Lateral Pterygoid Muscle), it
cannot be moved forward directly
■ Has to move forward and
medially until it reaches
maximum protrusion ● EC = Early Chewing
● EEP = Edge to Edge Position
Frontal Border Movement
- Starts at ICP
- Lower jaw is moved maximally to the left
● CANNOT MOVE DIRECTLY TO THE LEFT
○ Lower jaw has to move downward
■ Because the presence of
cuspal inclines (has to be
overcome first)
■ Lower teeth must
overcome their cuspal
inclines and the cuspal
inclines of upper teeth
- Lower jaw is moved downward
● CANNOT MOVE DIRECTLY DOWNWARD
○ Because of the balance of the pull
of the masticatory muscles
■ Lateral Pterygoid Muscles
● Has to move slowly towards the midline
- At maximum opening, mandible should be at
the middle
- When jaw is moved to the right
● It moves upward and to the right
● Goes back to ICP

Labeled Anatomy → TMJ is beginning to open →

rotating against disc

Functional Movement of Lower Jaw

- When Chewing
● Becomes smaller as food particles
becomes smaller
TMJ still moving down and opening more
● Will not reach the Border Movement of
the Jaw
- Reading aloud
● Range of movement of the lower jaw is
smaller than during eating
- Border Movement
 Bennett Movement
- Unilateral movement of the mandible
- When lower jaw is moved to the right
● Condyle is supposed to move to the right
side also
● Left and right condyles will have different
movements
● Left condyle
○ Moves directly to the left
● Right condyle
TMJ at maximum extension ○ Will not move directly to the left
○ Should move forward and
Temporomandibular Joint Disorder downward before going to the
contralateral side
Normal TMJ ■ Because of the pull of the
horizontal and oblique
fibers of
Temporomandibular
Ligament

Disc Displacement

- Glenoid Fossa
● Dome-shaped
● Has an extension on the medial side
● No extensions on the lateral side(almost
no lateral wall)

Degenerative Joint Disease/Arthritis

 2 Kinds of Bennett Movement
- Immediate Side Shift
● Condyle can move abruptly towards the
opposite side
○ In a sharp angle
- Progressive Side Shift
● Condyle cannot move abruptly towards
the contralateral side
○ Because of the anatomy of glenoid
fossa

Proprioceptors
- Pacini Corpuscles (Left)
● Provide sensation for vibration and
pressure → mechanical stimulus
- Bulb of Krause (Middle)
● For detecting cold temperature
- Ru ni (Right)
● For detecting hot temperature

Lateral Condyle
- Cannot move medially to the right due to the
pull of the horizontal and outer oblique fiber of
temporomandibular ligament
Cerebral Cortex - Hypothalamus
- Recognize, interpret, and evaluate incoming ● Coordinates with Autonomic Nervous
impulses System (ANS)
- Determine the response through motor ● Fight or flight response
neurons ○ Sympathetic
- Decides what response it will give to a certain
stimulus Myostatic or Stretch Reflex
- Stimulus - Contract the stretched muscle
● Transferred from one neuron to another
through IMPULSES Nociceptive or Flexor Reflex
● Mechanical - Hard object suddenly bite during mastication
● Thermal
● Chemical Speech
- Impulse - Processes involved
● Reaches the cortex ● Respiration
○ Major physiology for speech
○ Air from lungs will hit the laryngeal
Brain Stem area where the vocal cords are
- Lower part of the brain located → makes a sound
- Maintain homeostasis and control ● Resonance
subconscious functions ○ Paranasal sinuses
- Has several areas ● Articulation
● Central Pattern Generator ○ Lips
● Reticular System ■ Come together and touch
● Limbic System to produce M, B, and P
● Hypothalamus sounds
- Central Pattern Generator ○ Teeth
● Pool of neurons to control precise timing ■ Incisal edges of anterior
of contraction and relaxation of teeth approximate each
protagonist and antagonist muscles other to produce ‘SH-’
● Example sound
○ During chewing ○ Tongue and palate
■ Muscle engram → learned ■ Tip of tongue touches
pattern palate behind incisors to
- Reticular System produce the D sound
● Central portion of brain stem ○ Tongue and Teeth
● Relay station to transmit sensory stimuli ■ Tongue touches upper
to cortex incisors to produce TH and
● Can also modify motor neuron activity S sound
from cortex to the peripheral side ○ Lip and Teeth
- Limbic System ■ Lower lip touches incisal
● Emotion edges of upper incisors to
● Amygdala make F and V sound
○ Anxiety ○ Tongue and Soft Palate
○ Fear ■ Posterior portion of tongue
● Septum and hippocampus touches soft palate to make
○ Anger K and G sound
 ● Verbalization Diagnosis and Management of Common
○ Predominantly controlled by the Temporomandibular Disorders
mind
Diagnostic Classification of TMD Adapted From
AAOP (1993)

A. Temporomandibular Joint Articular

Disorders

1) Congenital or Developmental Disorders

2) Disc Derangement Disorders

- Disc can be displaced
● Instead of being on top of the condyle →
it is displaced anteriorly
○ Anterior Disc Displacement
- Types of Displacement:
● Disc Displacement With Reduction
Biomechanics of the Temporomandibular Joint ○ When the patient opens mouth →
- Mandible moves = condyle also moves condyle moves down and forward
○ If the mouth is opened for more
Anatomy of the Temporomandibular Joint than 25 to 27 mm → condyles
- Disc is always on top of the condyle move more downward and forward
● Thin part of the disc ■ A CLICK can be felt
● Head of condyle will
overcome the
posterior band of
articular disc
■ Condyle will recapture the
disc
● When mouth is open
Biomechanics of the Normal Joint widely
● Disc Displacement Without Reduction
○ Disc can NO LONGER be
recaptured
■ Even if the condyle goes
downward and forward or
the mouth is opened widely
→ it CANNOT be
recaptured anymore by the
condyle
● Posterior Band has
been kicked out
already
● Disc is already
displaced without
reduction
 NEUROPHYSIOLOGY OF PAIN
3. Temporomandibular Joint Dislocation
Distinct Processes in the Neural Pathways of
B. Masticatory Muscle Disorders Pain
- Transduction
- Transmission
- Modulation
- Perception

Process:

3 Types of Stimulus for Pain

- Biochemical
- Thermal
- Mechanical
- Stimulus should exceed a physiologic limit
● If it exceeds, it can stimulate the
Anterior Disc Displacement With Reduction SENSORY RECEPTORS FOR PAIN →
NOCICEPTORS

Nociceptors
- Free nerve endings
- C fibers
- Stimulated by a stimulus

Altered Membrane Conformation

- Change in membrane permeability in the nerve
fibers
- Potassium → greater inside the cell
- Sodium → greater outside the cell
- Result:
Degenerative Joint Disease with Large ● Sodium outside of the cell goes in while
Perforation the Potassium goes out
○ By the process of OSMOSIS
Progressive Degeneration of Condyle ● Sodium goes to an area of LOWER
- Condyle contacting the Temporal Bone concentration
● Occurs when condyle moves downward
and forward Ionic Flow Transfer
● Hear a DRY CRACKING SOUND - Altered Membrane Conformation travels to the
○ Condyle is rubbing the Temporal whole length of nerve fibers
Bone
○ No more shock absorber because NOTE: Once the Altered Membrane
disc is destroyed Conformation reaches the END OF THE NERVE
- If the disc is anteriorly displaced and distorted FIBER
- Condyle is flattened by resorption ● Will produce a neurotransmitter
● Condyle rubs on the Temporal Bone
Transmitter Substances in Nociceptive Primary
Afferent
- Neurotransmitters released
 - Remaining pain or NECESSARY PAIN reaches
Slow Excitatory Neurotransmitter the Cerebral Cortex
- Substance P ● They are interpreted and perceived as
● Transfer is SLOW but LONG LASTING pain
○ Cortex → sends MOTOR or
Fast Excitatory Neurotransmitters EFFERENT impulses going back to
- Aspartate the area / peripheral side
- Glutamate
- ATP Pain Pathway for Odontogenic Pain
● All 3 produces a FAST excitation but NOT
LONG LASTING

NOTE: Once the Neurotransmitter is released at

POSTSYNAPTIC JUNCTION → the
neurotransmitter will act again on the receptor
of the PRESYNAPTIC JUNCTION in the next
nerve → causes DEPOLARIZATION → Altered
Membrane Conformation occurs again →
impulse will travel

Transduction
- Method where stimulus is converted into
impulse

Transmission
- Transfer of impulse to one end of a nerve fiber
to another end of a nerve fiber
- Transfer of impulse from one nerve fiber to
another nerve fiber

Pain Modulation / Pain Inhibition

- As the impulse travels from the peripheral
nerve to the spinal cord
- Before the impulse reaches the brain stem
going to the cortex
- Impulse should be filtered and modulated
● NOT ALL PAINFUL IMPULSES should
reach the brain
- Reduction of pain
- Occurs in the:
● Substantial Gelatinosa
○ In the lamina 1 and lamina 2 of the
dorsal horn of the spinal cord
- Other Mechanism:
● Release of ENDOGENOUS OPIOIDS
○ ENKEPHALINS and ENDORPHINS
○ When released → relieves pain

Perception
 - Once desired resorption of cartilage for
renewal is achieved
Layers of Cartilage ● An inhibitor of MMP should be secreted to
stop its activity
○ TIMMP

TIMMP
- Tissue Inhibitor of Matrix Metalloproteinase
- Balance of MMP and TIMMP → normal process
of bone/condylar remodelling and renewal
- More MMP = Less TIMMP
● Progressive resorption of condylar
cartilage
○ Leads to arthritis of condylar
cartilage
○ Can also happen in the condyle of
the femur → osteoarthritis

- Condylar cartilage cannot stay for a very long

time
- Head of condyle
● Surrounded by cartilage with several
layers
● CONDYLAR CARTILAGE → hould undergo
remodelling
○ If no remodelling → becomes stiff
and brittle → will crack or fracture
easily
● Renewal
○ Condylar cartilage should be
dissolved
■ Through an enzyme → MMP
Trismus
MMP
- Matrix Metalloproteinase
- Released in the cartilage
● Within a physiologic limit
○ So resorption of a condylar
cartilage will be controlled
- Dissolves the cartilage → new cartilage will
come out from the inner layer
● Renews the old cartilage
● Cartilage becomes strong
○ Less prone to breakage
- If the amount becomes MORE than the
physiologic limit
● Condylar resorption will become
progressive - No balance in the control of muscles
 ● Left Lateral Pterygoid muscle is not ● Arachidonic Acid is acted on by 2
working properly enzymes
○ Undergoes hyperactivity ○ Cyclooxygenase
○ Only Right Pterygoid Muscle is ■ Converted to Cyclic
working normally Endoperoxides
■ When opening the mouth ● Will be converted to
→ goes to the left side Prostaglandins and
- Treatment: Thromboxanes
● Therapy to the left inferior head of the ○ Lipoxygenase
Left Lateral Pterygoid Muscle ■ Converted to Leukotrienes
○ Muscle relaxes → muscle becomes ● Prostaglandin
active → normal opening of mouth ○ Pain producing substance
● Myofascial Release Technique ○ Reason why pain is produced when
○ Stretching the muscle having an injury
- Cause: - Ways to relieve pain in injury
● Trismus → muscle becomes hyperactive ● Take Aspirin or NSAID
○ Similar to cramps → muscle ○ Mefenamic Acids
spasms ■ Dolfenal
○ Inhibits the Cyclooxygenase
Pathways for the Synthesis of Eicosanoids Enzyme → Arachidonic Acid
cannot be converted to
Prostaglandin → no pain produced
○ Can result to Ulcers
● Taking Anti Inflammatory Steroids
○ Phospholipase A2 will be inhibited
→ Membrane Phospholipid cannot
be converted into Arachidonic
Acid
● COX 2 Inhibitors
○ Inhibits Cyclooxygenase 2
- Mechanism of how pain is produced during an ○ DOES NOT inhibit Cyclooxygenase
injury 1
● Mechanical stimulus ○ DOES NOT produce Ulcers
● Biochemical stimulus ○ Can induce cardiovascular events
● Thermal stimulus ○ Examples:
- Cell Membrane ■ Celecoxib
● First part of the cell that is affected ■ Etoricoxib
during injury ○ Can Induce cardiovascular events
- Process - Cyclooxygenase
● Cell membrane is injured ● Has 2 kinds
● Membrane phospholipids come out of the ○ Cyclooxygenase 1
cell → ■ In GIT inner lining
● Membrane phospholipids go into the ■ Responsible for the
interstitial tissues vasodilation of the blood
● Membrane Phospholipids are acted on by vessels in the inner lining of
Phospholipase A2 the GIT
● Phospholipase A2 will convert the ○ Cyclooxygenase 2
Membrane Phospholipid into Arachidonic ■ Preventing prostaglandin in
Acid the peripheral or injury side
 ● Both kinds are blocked when taking pain - Norepinephrine and Clonidine
medications → Aspirin - Serotonin
○ Pain is relieved but vasodilation of ● Can reduce pain if secreted in the
the blood vessels in the inner CENTRAL NERVOUS SYSTEM (CNS)
lining of the GIT is also decreased ● Can induce quality of sleep
→ not much blood flow in the GIT - Gamma Aminobutyric Acid (GABA)
inner lining - Reduces pain to have balance
■ There is also acidic content
in the GIT → inner lining of
GIT will be irritated →
patient will develop
hyperacidity → ulcer

Nociceptors
- Receptors for pain

Kinds of Nociceptors
- AƔ Mechanical Nociceptors
● Reacts to noxious mechanical stimuli
- C Polymodal Nocieptors
● Reacts to:
○ Mechanical Stimuli
○ Thermal Stimuli
○ Chemical Stimuli
● Polymodal → many modes
- Aβ Fibers
● Very few large fibers
● Respond to tissue damage
- Silent or Sleeping Nociceptors
● Inactive AƔ and C Polymodal Nociceptors
● Activated when there is an injury
● Inactive nociceptors become active
○ Numerous nociceptors → Transmitter Substances in Nociceptive Primary
sensitivity Afferent
- Transduction
Biochemical Stimulants of Pain ● Process in which the stimulus is
- Potassium Ions converted to an impulse
- Acetylcholine - Transmission
● Can cause stimulation of pain ● Impulse can reach the cortex for the
- Histamine interpretation of pain or any mechanical
- Serotonin stimulus (such as pressure)
● Can induce pain if secreted in SITE OF ● Pain will be transmitted from one end of a
INJURY or PERIPHERAL AREA nerve fiber to another end of nerve fiber
- Prostaglandins ○ Needs neurotransmitter
- Bradykinins - Slow Excitatory Neurotransmitter
- Lactic Acid ● Substance P
○ Released in the postsynaptic end
Pain Reducing Substances of nerve going to the presynaptic
- Opioids end of another nerve
 ○ Released SLOWLY
○ Stays for a LONGER TIME
■ Pain / impulse / effect is
sustained
- Fast Excitatory Neurotransmitter
● Aspartate
● Glutamate
● ATP
● Released in a FAST rate
● Stays in the synapse for a SHORT TIME
○ Seconds or minutes only

Pain Pathway for Odontogenic Pain

- Process
● Pain in the tooth
● Pain stimulus passes nociceptors
● In the nociceptors
○ Pain stimulus is converted to pain Acute or Chronic Pain
impulse Deep or Superficial Pain
■ Transduction Hyperalgesia and Allodynia
● Pain impulse travels to the first order Primary Pain and Secondary Pain
neuron → spinal cord Referred Pain
● Transferred to another set of fibers
○ Release of Neurotransmitter PAIN
○ Located in the postsynaptic end of - An unpleasant sensory and emotional
the nerve experience associated with actual or potential
● Neurotransmitter goes to the next fiber tissue damage or described in terms of such
through the presynaptic end damage
○ Stimulates the next fiber
■ Initiates impulse going
along the spinal cord to the
brain stem
● Brain stem transfer impulse to the next
nerve fiber going to the cortex
○ Third order neuron → cortex →
pain
○ Nerve fiber to the Cerebral Cortex
→ interpreted as Pain

- When injury occurs → transduction happens

● Poking = Mechanical Stimulus
● Stimulus will be converted to impulse
○ Done by nociceptors
- Impulse undergoes Translation
● Transfer from one end of a nerve fiber to
another end of a nerve fiber
- At one end, it will release neurotransmitters for Spinal Cord
pain - Has an area where many pain impulses will be
● Aspartate filtered or inhibited
● Glutamate ● Pain Inhibition System
● Potassium ● NOT ALL pain of the body should go into
● Lactic acid the cortex
● Released at the POSTSYNAPTIC - Lamina I and Lamina II of the Dorsal Horn of the
JUNCTION Spinal Cord
○ Neurotransmitters will make a ● Has an area called Substantia Gelatinosa
contact with the surface of the ○ Where pain inhibition occurs
next nerve → transduction ■ Operates through a process
happens (at the second nerve of Gate Control Theory
fiber) ○ Where several nerve fibers pass
■ Goes to the spinal cord and through
eventually to the cortex ■ Small Diameter
- Cerebral Cortex Unmyelinated Nerve Fibers
● Impulse is interpreted as pain ● Carries pain
● Emotional aspect takes place impulses
- First order neuron → second order neuron → ■ Large Diameter Myelinated
third order neuron (spinal cord) → cortex Nerve Fibers
● Carries Mechanical
Impulses →
Pressure

Gate Control Theory of Pain

- Pain impulses in Large Diameter Myelinated
Nerve Fibers
● TRAVELS FASTER
● Will reach the Substantia Gelatinosa
faster
○ Once it passed → it will lock the
gate
■ Impulses travelling through
the Small Diameter
Unmyelinated Fibers will be
 blocked and CANNOT PASS
through anymore
■ Impulses travelling the
Large Diameter Myelinated
Nerve Fibers will proceed
the Cortex
● Will reach the cortex ahead of time →
cortex will interpret the impulse as
MECHANICAL
● Pressure is recognized but pain was
blocked
TERMS RELATED TO PAIN ■ Touching of the lips will induce
pain
1) Acute or Chronic Pain
- Acute Pain 4) Primary Pain and Secondary Pain
● Manner of Onset: Sudden or Fast - Primary Pain
● Duration of Pain: Short Duration ● Source of Pain and Site of Pain
● Intensity of Pain: Higher intensity = more ○ Has the SAME location
severe pain ○ Example:
○ Moderate to severe pain ■ Tooth decay that involves the
- Chronic Pain pulp in the Lower Right Molar
● Manner of Onset: Little by Little ● Decay extends in the
○ Not Abrupt pulp = painful
○ Slow ● Source/Site of Pain:
● Duration of Pain: Long Duration Pulpal Irritation (Pulp)
● Intensity of Pain: Low intensity = less to - Secondary Pain
moderate pain ● Source of Pain and Site of Pain
○ Mild ○ Has DIFFERENT location
○ Example:
2) Deep or Superficial Pain ■ Patient has a painful trapezius
- Deep Pain muscle
● Locations ● Patient feels pain in the
○ Below or inside the skin head (Temporal and
○ Muscles Preauricular Region)
○ Internal Organs → Intestines ● Impulse is transmitted
● Pain is hard to localize because it is inside to the next (order of)
the body nerve fiber → synapse
- Superficial Pain → will be interpreted
● Locations as pain in the other
○ Exposed mucosa and skin area (not in the area
where is the source of
3) Hyperalgesia and Allodynia pain)
- Hyperalgesia
● There is INCREASED sensitivity or feeling of 5) Referred Pain
pain - An example of SECONDARY PAIN
● Stimulus is not that intense but the feeling - Site of pain is not the source of pain
of pain is exaggerated
● Example:
○ Cementoenamel Junction (CEJ)
■ Dentin is exposed
■ Pain when drinking COLD
WATER
● Should not be painful in
normal cases
● Hypersensitivity to pain
- Allodynia
● Area becomes too painful even if the
stimulus is NOT a pain producing stimulus
● Example:
○ Trigeminal Neuralgia
■ People cannot shave
Pain Pathways for Odontogenic Pain ● Neuritis = inflammation of the nerve
● Mono or poly
● Trigeminal Neuritis Secondary to Viral
Infection
○ Cause → viral infection

● Mononeuritis
○ Neural trauma
■ Injection trauma or crush
■ Cut of lingual or inferior
alveolar nerve
- Toothache in the lower first molar ○ Regional Bacterial or Fungal Infection
● Tooth has been irritating the nerve for a very ■ Sinusitis
long time ■ Dental abscess
● Nerve fiber will be used to release a ○ Virus infection
neurotransmitter in the nerve terminal ■ HSV
○ Will keep transmitting impulses to ■ CMV
the CNS ■ HZ
● CNS will interpret it as pain ■ Others
● NEUROPLASTICITY ○ Compression and abrasion of nerve
○ Pain PERSISTS even when tooth is because of
REMOVED ■ Tumors
■ Because nerve fibers has ■ Dentures
been conditioned to release ■ Implants
neurotransmitters ○ Localized to one area
● Metabolism of the ● Polyneuritis
nerve fiber has been ○ Has many locations
changed already ○ Diabetes
● Source of pain is not in ○ Immune-mediated
the tooth but in the ○ Nutritional
nerve fibers ○ Kidney
○ SECONDARY ○ Hypothyroid
PAIN ○ Alcohol toxins
● Non-odontogenic odontalia ● Neuritis Treatment Rx
○ Trauma = steroid
NOTE: Not all pain is caused by infection, ○ Viral = antivirals
inflammation, or injury ○ Bacterial = antibiotics
● Pain can come from the nerve itself ○ Fungal = antifungal
○ Toxin = remove toxin
OROFACIAL NEUROPATHIC DISORDERS ○ Systemic = treat disease
- Neuropathic Pain
● Atypical pain
● Pain coming from the nerve
- Trigeminal Neuritis
 ● Diagnosis ● Ophthalmic Branch
○ Acute onset steady pain in area of ○ Upper face
neuritis which fades as inflammation - Electric-like shock pain
or infection disappears - Diagnosis
● Episodic or brief sharp stabbing pain in a
neural division usually with a sensory trigger
● Mostly in elderly

Neuroma
- Severance or cutting of the nerve
● Nerve will sprout → very sensitive
○ Called as neuroma
- Area supplied by the neuroma will be very
sensitive
- Neuroma
● Bundle of nerve fibers which develop Vascular Decompression Surgery
subsequent to a nerve transection which are
very sensitive to touch and spontaneously
active
- Diagnosis
● Traumatic nerve injury followed by
anesthetic zone in nerve distribution and
eventual burning pain with electric-like pain
on touch
- Neuroma Treatment Rx
● Block of neuroma with
○ High dose local anesthetic
○ Corticosteroid
○ Other neurolytic agent - As the Trigeminal Nerve gives off its branches, an
○ Surgical resection or repair arterial loop becomes very near to the nerve
- Nerve Block Based Pain Control ● Result
● Peripheral pain which is blockable but not ○ Whenever the artery dilates or
surface constricts → irritates the nerve
● Lidocaine - 4% ■ Constricts during diastolic
● Methylprednisone blood pressure
● Ammonium Sulfate - 10% ■ Dilates during systolic blood
pressure
Trigeminal Neuralgia ● Will irritate the nerve
- Pain follows the branch of Trigeminal Nerve that is → pain
affected - Surgery
● Mandibular Branch ● Move the artery away from the nerve
○ Lower face
○ Lower Lips
○ Middle of the head
● Maxillary Branch
Neuralgia Treatment Rx CASES
- To alleviate pain
- Anticonvulsant drugs 1) Deflection
● Carbamazapine - Lower jaw always deflect to one side (left side)
○ Tegretol when opening the mouth
○ 200 mg - CAUSE: Left Lateral Pterygoid Muscle is having a
○ Disp 90 tablets hyperactivity or Trismus
○ Sig: 1 tab BID then TID - No balance in the control of muscles
○ After 4 days ● Left Lateral Pterygoid muscle is not working
■ Baseline liver function (SGOT, properly
SGPT) plus hematologic ○ Undergoes hyperactivity
screening (CBC with ○ Only Right Pterygoid Muscle is
differential white cell, platelet working normally
function test) prior to taking ■ When opening the mouth →
the medication and every 1-3 goes to the left side
months after - Treatment:
● At each time get ● Relax the Left Lateral Pterygoid Muscle
therapeutic level of ○ Remove hyperactivity
drug ● Therapy to the left inferior head of the Left
● Gabapentin Lateral Pterygoid Muscle
● Neurontin ○ Muscle relaxes → muscle becomes
● Lyrica active → normal opening of mouth
- Decompression surgery ● Myofascial Release Technique
- Neuroablation of Trigeminal Nerve ○ Stretching the muscle
- Dorsal Root Ganglion Neuroablation - Cause:
● Glycerol injection in GG ● Trismus → muscle becomes hyperactive
● Radiofrequency lysis ○ Similar to cramps → muscle spasms
○ Plasma therapy
● Gamma knife lysis
○ Cutting the nerve
○ Gamma knife penetrates the area
● Alcohol injection
○ Inject alcohol in the nerve fiber for it
to degenerate

Chronic Peripheral Neuropathy

Chronic Centralized Neuropathy
Complex Regional Pain Syndrome
- Orofacial Neuropathy with Sympathetic
Involvement

Other Poly-Neuropathies
- Burning Mouth Syndrome
- Post Herpetic Neuropathy 2) Deviation
- HIV Neuropathy - Lower jaw moves to one side before mouth can be
- Diabetic Neuropathy fully opened
● Returns to the midline when the mouth is
opened
- Cannot open the mouth widely
- Jaw cannot move side to side
- Moves to center at maximum opening
- Treatment ● Patient was asked to take membrane
● Manipulate the joints and stretch the stabilizers of nerves
muscles

3) Myofibrotic Contracture
- Di culty opening the mouth widely
- Even if the muscle of mastication is manipulated
or stretch → muscle is still TIGHT
- Treatment
● Manipulation of muscle
● Neurologist injected botox on the Masseter
Muscle
○ Botox → for stretching the skin and
muscles
- Hyperactivity of masticatory muscles → too tight
- Muscles become myofibrotic → patient cannot
open the mouth widely

4) Mandibular Dystonia
- Not voluntarily opening the mouth
● Mouth opens subconsciously
- Mouth subconsciously moves from side to side
- Disorder the Motor Neuron
● Constant impulse transmission
- Also called Oromandibular Dystonia
- Treatment;
● Neurologist injects muscle relaxant