Temporal Muscle Syndrome (TMS)

Oral Communication presented at the 1st.  Interdisciplinary Forum Meeting of Oral and Craniofacial Pain: “Functional Traumatic Pathologies: MMI and TMS”. 
Authors: Larena-Avellaneda Mesa J., Durán Porto A., Ferreiro Calavia J., Ferrer Torregrosa I. and Siemens Barreto S., Oviedo, February 18-20, 2010.

The cause of TMS is an impingement of the temporal muscle inside the zygomatic orifice when performing certain movements or protrusive positions at chewing, talking, doing physical exercise, etc., and in general any posture that involves neck flexion such as reading, using computers, etc.

1.      TMS palpation.

Characterized by tension headaches and spontaneous pain or on palpation in the cheekbone area, in the mandibular coronoid process, and lack of stability, dizziness or vertigo. Pain can radiate to the TMJ, ear, eye, temple, nape, etc. It can be unilateral or bilateral. Some patients tell in the anamnesis that it hurts around the cheekbone.

2      Temporal muscle after separating masseter and zygomatic arch.

It is anatomically singular that temporal muscle “reaches its geatest thickness”(Sicher and Tandler) inside of a bone orifice, zygomatic orifice, and performing functional complex movements such as chewing and depending also on the dental joint which is the one that marks to the masticatory muscles the mechanical characteristics of such movements. Another peculiarity is the presence of adipose mass that helps to slide through the zygomatic orifice. Morphologically we can find temporal muscle hypertrophy and/or decrease of zygomatic orifice diameter, but experience has proven us that in the majority of cases a noticeable morphological alteration is not seen and movements and mandibular positions are the common cause of impingement.

Most of these patients with headaches and dizziness came with the wrong migraine diagnosis, Meniere or cervical problems. First, do not relate their symptoms to the masticatory system and second, for that they have heard and have been told by other specialists, they don’t even doubt it, to the extent that during anamnesis, when being asked to tell us what they “feel” that it isn’t normal from the neck up, most of them don’t tell us who suffer from headaches and dizziness since many years because they have assumed that their headaches and dizziness are chronic and for life, that don’t heal and that is another diseases diagnosis which has nothing to do with the visit to their dentist.

Here, it’s appropiate that we clarify why it has come to this situation. In our opinion , traumatologists have failed to address their pathologies at cranial level, bones, muscles, and temporomandibular joints, anatomical space has been left without  giving the correct approach at stomatologic or dentistry level. We, advised by traumatologists, have applied their concepts and terminology to understand patients in their symptoms explanations and diagnosing traumatologic pathologies clearly. This must be added to the complexity of static and dynamic analysis of the dental joint to evaluate functional alterations of the masticatory system, so it requires the knowledge of our specialty because occlusal treatments and functional aparathology will be the means that will use to solve these traumatologic pathologies.

TMS is related to the usual chewing and sleeping side, so the patient usually eats and sleeps by the pain side. SMT connection with usual chewing side is logical since being that hypertrophied musculature the most used in such unilateral function. It also matches with the sleeping side according to the theory of pulvinism,  patient leans over that side of the pillow and sometimes is the fact that either puts his hand under the pillow or between the face and the pillow.

In order to explore the pain, we perform an extra-and intraoral palpation. Extraoral palpation is done by placing thumb fingertip on the mandibular ramus anterior edge just under the cheekbone, and asking the patient to open his mouth very slowly. We’ll be feeling how mandible slides down until palpating coronoid process and from here palpation of temporal tendon insertion becomes very painful. First one side and the other one after to compare them.

            3  TMS extraoral palpation.

For intraoral palpation, we place the index fingertip, with half open mouth, on the mandibular inner side as high as possible trying to reach the zygomatic orifice lower part in the infratemporal fossa region and then we ask the patient to start opening the mouth very slowly and we will feel how it approaches to the coronoid process and temporal muscle tendon, increasing the pain just by pressing upward during palpation.

It will be in this painfula area where will inject anesthesia if we want to test the dissapearance of painful symptomatology and instability.

To evaluate instability we use Romberg’s test and we can see if the patient oscillates or falls when closing eyes. If it’s positive, patient oscillates towards the pain side. In practice patient tells us that he can not, doesn’t dare closing the eyes while is washing his head in the shower.

Another test is to inject anesthesia into the pain area inside the zygomatic orifice and check that pain disappears within seconds and Romberg’s test it becomes negative.

We must consider whether the patient has double occlusion because it has increased its vertical dimension at maximum intercuspidation, MMI when closing, and also protruded mandible position in addition to produce impingement, in the zygomatic orifice.

Another dynamic analysis that we perform is asking the patient from close denture position to move forward as much as possible, without losing contact with upper teeth and in straight line without deviating to the sides. It’s normal for lower teeth to leave an space between the upper ones, aprotrusionat least 7-8 mms.We’ll verify limitation of this movement.

4. Mandible in protrusive maximum opening in centric occlusion.

Once diagnosed with uni or bilateral TMS, treatment will begin to balance its occlusion restoring its normal vertical dimension, eliminate MMI in closure and cancel protrusion.
We explain to the patient that the mandibular movements he should avoid are the ones that involve a protrusion and above all if they are accompained by neck flexion.
And finally we must use an Inverted Equilibrator to eliminate the possibility of protruding mandible involuntarily when talking, working, making efforts, etc.

5. Inverted Equilibrator.

 6. Inverted Equilibrator in mouth.

I. Dynamic.
B. Temporal Muscle Syndrome (SMT) : at the zygomatic orifice
-a.At the opening :
-by unilateral or bilateral coronoid process hyperplasia.
-Decrease of zygomatic orifice.
-b.On  one laterality or lateralities.
-c.On the protrusive.
-a.In a unilateral TMJ subluxation. Pathogenesis of TMJ subluxation: unilateral mastication and functional and occlusal imbalance.In both cases the TMJ that suffers the most is the usual chewing side.  
II. Static. Postural. Pressure habits: MMI and/or TMS.
A.    Passive:
-1. Lying on the sleeping side.
-2. Pillowing.
    B.  Active:
          -1. When performing any kind of physical exercise that invloves protrusion: sport,
                phonation, etc.
          -2. When performing any kind of physical exercise that involves neck flexion:use
                of computers, reading, sewing, etc.

TMS image by bilateral coronoid process hyperplasia.

1 comment: