Tomislav Badel

A quantitative analysis of splint therapy of displaced temporomandibular joint disc

OBJECTIVES The effects of the Michigan splint on the change in disc displacement (DD) as well as the position of the condyles were determined by metrical analysis using magnetic resonance imaging (MRI). METHODS Twenty-five patients with clinical DD symptoms were treated by means of the Michigan splint, and an assessment of the effects of the splint was conducted or verified by MRI before and during the period of therapy, 5 months follow-up. The positions of the condyles and the disc were calculated from the MRI in the parasagittal plane. RESULTS There were no changes in the positions of the disc and condyles in the physiological joints of the patients (n=23) prior to and during the time the splint was in place (p>0.05). The splint achieved a DD decrease (p<0.05), and pain was eliminated in 69.2% of the DD joints with reduction (n=13). As far as the DD joints without reduction (n=13) are concerned, pain was eliminated in 74.9% of the joints, that is, without any change in the positions of the disc and condyles (p>0.05). CONCLUSIONS The evaluation of the Michigan splint therapy showed that it has no influence in the repositioning of the DD joints without reduction, but the DD joints with reduction have a limited positive effect. In both forms of these displacements, conditions for the elimination of the clinical symptoms are created.

Digital orthopantomograms in osteoporosis detection: mandibular density and mandibular radiographic indices as skeletal BMD predictors

OBJECTIVES To determine the correlation of skeletal bone mineral density (BMD) with mandibular density and mandibular radiographic indices estimated on digital panoramic radiographs. METHODS Study comprised 112 female subjects older than 45 years. Digital panoramic radiographs were taken, and patients were referred to densitometric measuring (dual energy X-ray absorptiometry) of BMD in the hip bones and lumbar spine regions (L1-L4). On the radiographs, mandibular bone density was estimated and the following indices were measured by the DIGORA(®) software (Soredex, Tuusula, Finland): mental index (MI), gonial index (GI), antegonial index (AI), panoramic mandibular index (PMI) and alveolar crest resorption degree (M/M). Mandibular cortical index (MCI) was visually estimated. RESULTS Mandibular density and visual index MCI are significant predictors of hip and spine BMD. Mandibular density was marked by a significant square trend: it decreased until the age of 54 years and remained constant until the age of 64 years when it started to increase. Significant correlations were found between MI, AI and PMI values and BMD in the hip but not in the lumbar spine region. The GI and M/M values did not show statistically significant correlations with BMD of either region. CONCLUSIONS Mandibular bone density and mandibular radiographic indices are useful in detecting patients with decreased BMD. The applicability of orthopantomograms in diagnosing osteoporosis/osteopenia should be recognized as the potential greatest benefit of this everyday diagnostic method in dental practice.

Timing of emergence of the first primary tooth in preterm and full-term infants

Variations in the timing of emergence of primary teeth are under strong genetic control, but there is also a significant contribution from external factors. The aim of this study was to evaluate the influence of preterm birth, birth weight and length, and feeding practices during the first 6 months of life on the timing of emergence of the first primary tooth. Data on pregnancy duration, birth weight and length, feeding practice, time of emergence and first emerged primary tooth were collected by electronic questionnaires. The study included 409 parents and 592 children of both genders. The sample was divided into two groups according to pregnancy duration (<37 weeks and ≥37 weeks), three groups according to feeding practice (exclusively breastfed, exclusively bottle fed, and a combination of breast feeding and bottle feeding), three groups by birth length (<50, 50-53, >53cm), and four groups by birth weight (<1500, 1500-2500, 2501-3500, >3500g). Data were analyzed considering chronological and postmenstrual age-which is the gestational age plus the infants chronological age at the month of emergence of the first primary tooth. The mean time of first primary tooth emergence was 7.55±2.67 months when chronological age was considered. The first emerged tooth in most cases was a lower incisor (82.33%). There was a statistically significant difference in the timing of the first tooth emergence between preterm and full-term groups when chronological age was considered (p<0.005). However, no difference was found when age was adjusted. The age of emergence of the first tooth differed significantly when feeding, weight, and length groups (p<0. 05) were taken into account. In conclusion, the study indicates that shortened gestational age and very low birth weight are predictors for later ages of emergence of the first primary tooth.

Measurements of the sagittal condylar inclination: intraindividual variations

Abstract Aims: Sagittal condylar inclination is an important parameter during fabrication of prosthetic restorations. Existing data about intraindividual variations of sagittal condylar inclination are scarce. The purpose of this study was to investigate intra- and interindividual variations of the sagittal condylar inclination, depending on the position of the condyle in the temporomandibular joint. Methodology: The study included 51 subjects with Angle’s Class I occlusion (21–32 years of age, mean 25·1). Measurements were done using an electronic axiograph. After a paraocclusal tray was fixed in the mouth, every subject had to make three protrusive movements, from which the device’s software calculated the mean left and mean right sagittal condylar path. The mean left and right condylar path of each subject was divided into three equal sequences, based on whole condylar path length. Condylar inclination values for the first, second and third movement sequences were calculated. Results: Results showed significant differences between movement sequences (P<0·05). For the left joint, condylar inclination values in the first condylar movement sequence demonstrated, on the average, 14·4% higher values compared to the second movement sequence, and 39·2% higher values than in the third movement sequence. For the right joint, the first condylar movement sequence demonstrated, on the average, 15·8% higher values compared to the second movement sequence, and 41·5% higher values than the third movement sequence. Conclusions: Results suggest that condylar movement in the sagittal direction is not uniform. Mean left and mean right condylar inclination values do not necessarily describe the actual condylar path, nor do they give adequate information for articulator setup. Left–right side condylar inclination differences greater than 10° can be considered as normal.

Within-Subject Reliability and between-Subject Variability of Oxidative Stress Markers in Saliva of Healthy Subjects: A Longitudinal Pilot Study

The present study evaluated diurnal variations and day-to-day fluctuations of salivary oxidative stress (OS) markers in healthy adult individuals. Whole unstimulated saliva was collected at 2 time intervals over 3 consecutive days. Glutathione peroxidase (GPX), superoxide dismutase (SOD), total antioxidant capacity (TAC), and uric acid (UA) were analyzed using spectrophotometric methods, while 8-hydroxydeoxyguanosine (8-OHdG) and malondialdehyde (MDA) were determined using immunoassays. No significant differences for salivary OS markers between men and women were observed. For all examined OS markers, no significant day-to-day variations were demonstrated. Significant diurnal variations were found in salivary GPX, TAC and MDA levels. For SOD, TAC, GPX, and UA, good-to-moderate intraindividual coefficients of variations (CVs) were observed in more than 75% of the subjects. For MDA and 8-OHdG, intraindividual CVs > 35% were observed in 60% and 40% of the subjects, respectively. Between-subject variance was wide for all examined OS markers (CV% 30.08%–85.70%). Due to high intraindividual variability in the salivary concentrations of MDA and 8-OHdG, those markers cannot be reliably verified based on single measurements and multiple measurements over several days would provide more reliable information. Salivary SOD, TAC, GPX, and UA proved stable across three days of measurement. Trial Registration. ClinicalTrials.gov NCT03029494. Registered on 2017-01-19.

Temporomandibular Disorders and Orthodontic Treatment – A Review with a Reported Clinical Case

Temporomandibular disorders (TMDs) are musculoskeletal disorders which affect the structures of the stomatognathic system. They include two separate entities of functional disorders: masticatory muscles disorder (tendomyopathy) and temporomandibular joint (TMJ) disorder (anterior disc displacement, osteoarthritis). Their shared symptomatology is pain related to masticatory muscles and/or TMJs, limited mouth opening and pathological noise in the TMJs (clicking, crepitations). In general, TMDs are considered to be multifactorial disorders with pain as the most pronounced symptom and the main reason for patients (from 75 – 90% female) to seek medical help. As the musculoskeletal form of the disorder and due to clinically pronounced pain, TMDs include a biopsychosocial component which is an important factor in creating a clinical picture, wherein the chronic aspect of musculoskeletal pain makes the relatively moderate clinical picture much worse. Therefore, like in many other musculoskeletal disorders in the body, their etiopathology is considered nonspecific, which is to say, they have an idiopathic cause on the level of the patient – individual. Clinical examinations, particularly manual examination techniques, are an integral part of TMD diagnostics and they serve to determine the indication for imaging techniques. Magnetic resonance imaging (MRI) has become the gold standard in diagnopstics and differential diagnostics of TMDs because it shows both hard and soft tissues of the TMJ (primarily of the disc) as well as joint effusion. Since the etiology of TMDs is mostly unknown, the indicated treatment methods are mostly symptomatic, noninvasive and reversible. These methods include the well known occlusal splint, physical therapy, cognitive-behavioral methods, acupuncture in cases of chronic pain and psychological treatment. Masticatory muscles and, especially, TMJs are directly connected to occlusal relations and due to that, TMDs are in correlation with occlusal disorders, ranging from obvious occlusal anomalies, variations of static and dynamic occlusal relations to loss of teeth. The Michigan type of the occlusal splint as the most widely used non-permissive splint serves as reversible initial treatment. Definitive occlusal treatment is not recommended for TMD patients as well as prosthodontic appliances and orthodontic treatments. Namely, orthodontic treatment by itself is not confirmed as a potential etiopathogenic factor of TMDs but it should not be performed in patients with a painful form of TMD. All irreversible and relatively long and expensive occlusal treatments, including orthodontic treatment, are never indicated without prior initial treatments. Manual examination techniques can be used as screening methods for detecting clinical symptoms of TMDs. Although a possibility of TMDs prevention is considered, the orthodontic, prosthodontic or any other form have not been scientifically proven because there is no consensus on the factors which cause TMD. Long-term follow-ups of patients undergoing orthodontic treatments did not show subsequent appearance of TMD and certain occlusal variables (cross bite, Angle class II/1, etc.) do not dominate the overall sample of TMD patients. In the review of literature, there is a clinical case described regarding a 5 year follow-up of a 26-year-old female patient who sought specialist prosthodontic help due to pain in the right TMJ and clicking in the left one with limited mouth opening. From patient history: 7 months ago a general dental practitioner referred her to an orthodontist due to clicking in the same joint and the specialist started treatment with a bimaxillary removable appliance (bionator). Namely, the patient previously had Angle class II/1 (prognate jaw) with a horizontal overlap of 11 mm and non-matching medial line of 1 mm. However, the patient did not realize at first that the pain in the TMJ was not being treated and the orthodontist did not realize that her intention was not to treat the orthodontic anomaly. In the course of orthodontic treatment her right TMJ became painful. The orthodontic appliance fixated the occlusion in an anterior (protrusive) position wherein the posterior teeth were in non-occlusion. A clinical examination confirmed the patient’s symptoms (left with reduction, right without reduction) and the anteriorly displaced disc was identified by MRI in habitual closed mouth position, a protrusive position conditioned by the orthodontic appliance and open mouth position. Besides stopping the orthodontic treatment, the patient initially wore the Michigan splint around 5 months and, after a year, still had pain in the right TMJ, with evident chronic character of pain. TMD treatment continued at home by physical therapy and oral exercises. At a recall 5 years later, the patient did not have pain in the TMJs and only felt discomfort in the right TMJ during wide mouth opening with clinically evidenced minor crepitations. MRI showed no change in the anterior disc displacement bilaterally with osteoarthritic changes in the right joint. Now, she does not have esthetic or functional needs for orthodontic treatment. In conclusion, TMD hinders orthodontic treatment and a prior initial treatment is necessary. Orthodontic treatment does not cause TMD symptoms in previously asymptomatic persons. Occlusal variables as well as anomalies and tooth loss have a limited proven direct connection with TMD appearance.

Relationship Between Osteonecrosis of the Jaw and Bisphosphonate Treatment

Povezanost osteonekroze čeljusti i terapije bisfosfonatima Terapija bisfosfonatima i njezina etiopatogenetska povezanost s aseptičkom osteonekrozom čeljusti važan je javnozdravstveni problem današnjice. Svrha je rada pregledom suvremene znanstvene literature utvrditi posljedice višestrukog djelovanja bisfosfonata (antiosteoklastična aktivnost, citotoksičnost na meka i koštana tkiva, antiangiogeneza, genski čimbenici, poremećena ravnoteža između osteoklasta i osteoblasta). Terapija bisfosfonatima jedan je od najčešćih uzroka razvoja osteonekroze čeljusti. Epidemiološki podaci pokazuju da se javlja u bolesnika koji su uzimali jedan ili kombinanciju nitrogenih bisfosfonata. Najvažniji čimbenici rizika za ovu nuspojavu su vrsta bisfosfonata (napose visokopotentni pamidronat i zoledronat koji se daju intravenski), njihova doza i duljina medikacije te vrsta bolesti zbog koje se propisuje terapija. Pojava osteonekroze čeljusti zabilježena je uglavnom u onkoloških bolesnika i u samo 5 % bolesnika s osteoporozom koji su liječeni bisfosfonatima. U patogenezi osteonekroze povezane s bisfosfonatima važno je, sa stajališta dentalnomedicinske prakse, dobro opće oralno zdravlje jer se osteonekroza javlja napose nakon prethodnoga parodontološkog i oralnokirurškog zahvata. Relationship Between Osteonecrosis of the Jaw and Bisphosphonate Treatment Bisphosphonate treatment and its aetiopathogenic association with aseptic osteonecrosis of the jaw is one of the more prominent public health issues today. The aim of this review is to see into the mechanisms of bisphosphonate effects on bones described in literature (anti-osteoclastic activity, cytotoxicity, antiangiogenesis, genetic factors, and imbalance between osteoclasts and osteoblasts). Bisphosphonate treatment is the dominant cause of jaw necrosis. Epidemiological data show an exclusive incidence of osteonecrosis of the jaw in patients who took one or a combination of nitrogen-containing bisphosphonates. Risk factors vary by the bisphosphonate potency (particularly risky are the highly potent pamidronate and zoledronate, which are given intravenously), dosage, duration of treatment, and the illness. Jaw necrosis is most common in oncology patients, and only 5 % in patients with osteoporosis. From a dental-medical point of view, a good oral health is important because osteonecrosis often appears after a periodontal or oral surgical procedure.

Salivary Oxidant/Antioxidant Status in Chronic Temporomandibular Disorders Is Dependent on Source and Intensity of Pain – A Pilot Study

Temporomandibular disorders (TMD) have been associated with altered salivary oxidative status, but the relation with pain source and pain severity isn’t clarified. With the aim to assess their interaction with TMD, we compared levels of selected salivary oxidative stress (OS) markers (glutathione peroxidase, superoxide dismutase, total antioxidant capacity (TAC), uric acid, 8-hydroxydeoxyguanosine, malondialdehyde) and salivary cortisol (SC) as a stress indicator, between 20 TMD patients and 15 healthy control subjects. In order to record differences relating to pain source and severity, patients were respectively classified according to specific diagnoses (myofascial pain or disc displacement (DD)), and pain intensity (high or low). TAC was significantly higher in TMD patients than in controls (morning p = 0.015; afternoon p = 0.005). Significant differences were also observed when TAC levels between high-intensity pain patients and controls were compared, as well as between DD patients and controls. In logistic regression analysis, higher levels of TAC were related to DD (morning OR: 1.66, 95%CI: 1.05–2.64, p = 0.029; afternoon OR: 2.10, 95%CI: 1.11–3.98, p = 0.021) and to high-intensity pain (morning OR: 1.81, 95%CI: 1.04–3.15, p = 0.037; afternoon OR: 1.79, 95%CI: 1.02–3.14, p = 0.043). We also found that morning SC was positively correlated with antioxidant parameters in TMD patients. Our data suggest compensatory mechanism as response to higher level of stress. This stress could be extrinsic and lead toward TMD, or intrinsic, emerging from established TMD, or could be both. The intensity and the source of pain should be considered important factors in future investigations evaluating salivary OS markers in TMD patients.

Diagnostics and Management of Temporomandibular Joint Disorder - A Reported Case with a Review of Literature

Department of Removable Prosthodontics, School of Dental Medicine, University of Zagreb, Zagreb, Croatia 2Department of Dental Anthropology, School of Dental Medicine, University of Zagreb, Zagreb, Croatia 3Department of Diagnostic and Interventional Radiology, Clinical Hospital Center “Sestre milosrdnice”, University of Zagreb, Zagreb, Croatia

Centric slide in different Angle's classes of occlusion

The purpose of this study was to test the possible differences in centric slide values between different Angles classes of occlusion. The study included 98 participants divided into four groups: Angles class I, Angles class II, subdivision 1, Angles class II, subdivision 2 and Angles class III. All recordings were obtained using an ultrasound jaw tracking device with six degrees of freedom. The distance between the maximum intercuspation (reference position) and the centric occlusion was recorded at the condylar level. Anteroposterior, superoinferior and transversal distance of the centric slide were calculated for each participant, and the data were statistically analyzed (analysis of variance and Newman-Keuls post hoc test). No statistically significant difference was found in the anteroposterior and transversal distance of the centric slide between tested groups, while Angles class II, subdivision 2 showed smaller vertical amount of the centric slide compared to Angles class I and class II, subdivision 1. None of the 98 participants showed coincidence of centric occlusion and maximum intercuspation. Our results suggest that coincidence of the maximum intercuspation with the centric occlusion should not be expected. Smaller extent of the vertical distance of the centric slide could be morphological and a functional expression characteristic of the Angles class II, subdivision 2.