Nyeri TMJ TMJ Pain

Yuliati Departemen Biology Oral

FKG UNAIR

Sistem Sensoris Somatik

• Sensasi sensoris somatik

rasa raba, vibrasi, 2-point discrimination, rasa tekan, propiosepsi → serat Aβ → medulla spinalis

rasa nyeri, panas & dingin ( nosisepsi ) → serat Aδ atau tipe C medulla spinalis

• Sinyal nyeri melewati 2 jaras otak

traktus neospinotalamikus → nyeri cepat

traktus paleospinotalamikus → nyeri lambat, kronis

Chapter 46 Sensory Receptors, Neuronal Circuits for Processing Information 573

transmit only impulses. Therefore, how is it that different nerve fibers transmit different modalities ofsensation?

The answer is that each nerve tract terminates at aspecific point in the central nervous system, and the type of sensation felt when a nerve fiber is stimu-lated is determined by the point in the nervous systemto which the fiber leads. For instance, if a pain fiber is stimulated, the person perceives pain regardless of what type of stimulus excites the fiber. The stimuluscan be electricity, overheating of the fiber, crushing of the fiber, or stimulation of the pain nerve ending by damage to the tissue cells. In all these instances,the person perceives pain. Likewise, if a touch fiber isstimulated by electrical excitation of a touch receptoror in any other way, the person perceives touchbecause touch fibers lead to specific touch areas in the brain. Similarly, fibers from the retina of the eyeterminate in the vision areas of the brain, fibers fromthe ear terminate in the auditory areas of the brain,and temperature fibers terminate in the temperatureareas.

This specificity of nerve fibers for transmitting onlyone modality of sensation is called the labeled lineprinciple.

Transduction of SensoryStimuli into Nerve Impulses

Local Electrical Currents at NerveEndings—Receptor Potentials

All sensory receptors have one feature in common.Whatever the type of stimulus that excites the recep-tor, its immediate effect is to change the membrane

Free nerveendings

Expanded tipreceptor

Tactile hair

Paciniancorpuscle

Meissner’scorpuscle

Krause’scorpuscle

Ruffini’send-organ

Golgi tendonapparatus

Musclespindle

Figure 46–1

Several types of somatic sensory nerve endings.

Table 46–1

Classification of Sensory Receptors

I. MechanoreceptorsSkin tactile sensibilities (epidermis and dermis)

Free nerve endingsExpanded tip endings

Merkel’s discsPlus several other variants

Spray endingsRuffini’s endingsEncapsulated endings

Meissner’s corpusclesKrause’s corpuscles

Hair end-organsDeep tissue sensibilities

Free nerve endingsExpanded tip endingsSpray endings

Ruffini’s endingsEncapsulated endings

Pacinian corpusclesPlus a few other variants

Muscle endingsMuscle spindlesGolgi tendon receptors

HearingSound receptors of cochlea

EquilibriumVestibular receptors

Arterial pressureBaroreceptors of carotid sinuses and aorta

II. ThermoreceptorsCold

Cold receptorsWarmth

Warm receptorsIII. Nociceptors

PainFree nerve endings

IV. Electromagnetic receptorsVision

RodsCones

V. ChemoreceptorsTaste

Receptors of taste budsSmell

Receptors of olfactory epitheliumArterial oxygen

Receptors of aortic and carotid bodiesOsmolality

Neurons in or near supraoptic nucleiBlood CO2

Receptors in or on surface of medulla and in aortic and carotid bodies

Blood glucose, amino acids, fatty acidsReceptors in hypothalamus

Chapter 46 Sensory Receptors, Neuronal Circuits for Processing Information 573

transmit only impulses. Therefore, how is it that different nerve fibers transmit different modalities ofsensation?

The answer is that each nerve tract terminates at aspecific point in the central nervous system, and the type of sensation felt when a nerve fiber is stimu-lated is determined by the point in the nervous systemto which the fiber leads. For instance, if a pain fiber is stimulated, the person perceives pain regardless of what type of stimulus excites the fiber. The stimuluscan be electricity, overheating of the fiber, crushing of the fiber, or stimulation of the pain nerve ending by damage to the tissue cells. In all these instances,the person perceives pain. Likewise, if a touch fiber isstimulated by electrical excitation of a touch receptoror in any other way, the person perceives touchbecause touch fibers lead to specific touch areas in the brain. Similarly, fibers from the retina of the eyeterminate in the vision areas of the brain, fibers fromthe ear terminate in the auditory areas of the brain,and temperature fibers terminate in the temperatureareas.

This specificity of nerve fibers for transmitting onlyone modality of sensation is called the labeled lineprinciple.

Transduction of SensoryStimuli into Nerve Impulses

Local Electrical Currents at NerveEndings—Receptor Potentials

All sensory receptors have one feature in common.Whatever the type of stimulus that excites the recep-tor, its immediate effect is to change the membrane

Free nerveendings

Expanded tipreceptor

Tactile hair

Paciniancorpuscle

Meissner’scorpuscle

Krause’scorpuscle

Ruffini’send-organ

Golgi tendonapparatus

Musclespindle

Figure 46–1

Several types of somatic sensory nerve endings.

Table 46–1

Classification of Sensory Receptors

I. MechanoreceptorsSkin tactile sensibilities (epidermis and dermis)

Free nerve endingsExpanded tip endings

Merkel’s discsPlus several other variants

Spray endingsRuffini’s endingsEncapsulated endings

Meissner’s corpusclesKrause’s corpuscles

Hair end-organsDeep tissue sensibilities

Free nerve endingsExpanded tip endingsSpray endings

Ruffini’s endingsEncapsulated endings

Pacinian corpusclesPlus a few other variants

Muscle endingsMuscle spindlesGolgi tendon receptors

HearingSound receptors of cochlea

EquilibriumVestibular receptors

Arterial pressureBaroreceptors of carotid sinuses and aorta

II. ThermoreceptorsCold

Cold receptorsWarmth

Warm receptorsIII. Nociceptors

PainFree nerve endings

IV. Electromagnetic receptorsVision

RodsCones

V. ChemoreceptorsTaste

Receptors of taste budsSmell

Receptors of olfactory epitheliumArterial oxygen

Receptors of aortic and carotid bodiesOsmolality

Neurons in or near supraoptic nucleiBlood CO2

Receptors in or on surface of medulla and in aortic and carotid bodies

Blood glucose, amino acids, fatty acidsReceptors in hypothalamus

Chapter 46 Sensory Receptors, Neuronal Circuits for Processing Information 573

transmit only impulses. Therefore, how is it that different nerve fibers transmit different modalities ofsensation?

The answer is that each nerve tract terminates at aspecific point in the central nervous system, and the type of sensation felt when a nerve fiber is stimu-lated is determined by the point in the nervous systemto which the fiber leads. For instance, if a pain fiber is stimulated, the person perceives pain regardless of what type of stimulus excites the fiber. The stimuluscan be electricity, overheating of the fiber, crushing of the fiber, or stimulation of the pain nerve ending by damage to the tissue cells. In all these instances,the person perceives pain. Likewise, if a touch fiber isstimulated by electrical excitation of a touch receptoror in any other way, the person perceives touchbecause touch fibers lead to specific touch areas in the brain. Similarly, fibers from the retina of the eyeterminate in the vision areas of the brain, fibers fromthe ear terminate in the auditory areas of the brain,and temperature fibers terminate in the temperatureareas.

This specificity of nerve fibers for transmitting onlyone modality of sensation is called the labeled lineprinciple.

Transduction of SensoryStimuli into Nerve Impulses

Local Electrical Currents at NerveEndings—Receptor Potentials

All sensory receptors have one feature in common.Whatever the type of stimulus that excites the recep-tor, its immediate effect is to change the membrane

Free nerveendings

Expanded tipreceptor

Tactile hair

Paciniancorpuscle

Meissner’scorpuscle

Krause’scorpuscle

Ruffini’send-organ

Golgi tendonapparatus

Musclespindle

Figure 46–1

Several types of somatic sensory nerve endings.

Table 46–1

Classification of Sensory Receptors

I. MechanoreceptorsSkin tactile sensibilities (epidermis and dermis)

Free nerve endingsExpanded tip endings

Merkel’s discsPlus several other variants

Spray endingsRuffini’s endingsEncapsulated endings

Meissner’s corpusclesKrause’s corpuscles

Hair end-organsDeep tissue sensibilities

Free nerve endingsExpanded tip endingsSpray endings

Ruffini’s endingsEncapsulated endings

Pacinian corpusclesPlus a few other variants

Muscle endingsMuscle spindlesGolgi tendon receptors

HearingSound receptors of cochlea

EquilibriumVestibular receptors

Arterial pressureBaroreceptors of carotid sinuses and aorta

II. ThermoreceptorsCold

Cold receptorsWarmth

Warm receptorsIII. Nociceptors

PainFree nerve endings

IV. Electromagnetic receptorsVision

RodsCones

V. ChemoreceptorsTaste

Receptors of taste budsSmell

Receptors of olfactory epitheliumArterial oxygen

Receptors of aortic and carotid bodiesOsmolality

Neurons in or near supraoptic nucleiBlood CO2

Receptors in or on surface of medulla and in aortic and carotid bodies

Blood glucose, amino acids, fatty acidsReceptors in hypothalamus

Penjalaran Sinyal

• ‘Fast-pain’ ( nyeri cepat, tajam ) Rangsangan mekanik atau suhu → serat Aδ ( 6-30 m/dtk ) Lokalisasi pada bagian tubuh lebih pasti Melibatkan reseptor raba Jaras melewati Traktus Neospinotalamikus → brainstem & talamus

Neurotransmiter : Glutamat • ‘Slow-pain’ ( nyeri lambat, kronik )

Rangsangan kimiawi, mekanis/suhu persisten → serat C ( 0,5-2 m/dtk )

Jaras Traktus Paleospinotalamikus

→ juga menjalarkan sinyal serabut serat Aδ Neurotransmiter : Substan P

Glutamat Neurotransmiter serat Aδ

Disekresi : medulla spinalis pada ujung2 serabut nyeri saraf AδSifat : eksitasi

Mula kerja : segera

Durasi kerja : beberapa milidetik

Substan PNeurotransmiter serat C

Mula kerja : lebih lambat drpd Glutamat ( bbrp detik sd menit )

Disekresi : medulla spinalis pada ujung2 serabut nyeri saraf C

Jalur Somatosensoris pada Sistem Saraf

556 Unit IX The Nervous System: A. General Principles and Sensory Physiology

Motor Part of the Nervous System—Effectors

The most important eventual role of the nervoussystem is to control the various bodily activities. Thisis achieved by controlling (1) contraction of appropri-ate skeletal muscles throughout the body, (2) contrac-tion of smooth muscle in the internal organs, and (3) secretion of active chemical substances by bothexocrine and endocrine glands in many parts of thebody. These activities are collectively called motorfunctions of the nervous system, and the muscles andglands are called effectors because they are the actualanatomical structures that perform the functions dic-tated by the nerve signals.

Figure 45–3 shows the “skeletal” motor nerve axis ofthe nervous system for controlling skeletal muscle con-traction. Operating parallel to this axis is anothersystem, called the autonomic nervous system, for con-

trolling smooth muscles, glands, and other internalbodily systems; this is discussed in Chapter 60.

Note in Figure 45–3 that the skeletal muscles can becontrolled from many levels of the central nervoussystem, including (1) the spinal cord; (2) the reticularsubstance of the medulla, pons, and mesencephalon;(3) the basal ganglia; (4) the cerebellum; and (5) themotor cortex. Each of these areas plays its own spe-cific role, the lower regions concerned primarily withautomatic, instantaneous muscle responses to sensorystimuli, and the higher regions with deliberatecomplex muscle movements controlled by the thoughtprocesses of the brain.

Processing of Information—“Integrative” Function of the Nervous System

One of the most important functions of the nervoussystem is to process incoming information in such away that appropriate mental and motor responses willoccur. More than 99 per cent of all sensory informa-tion is discarded by the brain as irrelevant and unim-portant. For instance, one is ordinarily unaware of the

Brain

Spinal cordSecond-orderneurons

Axon

Synapses

Cell body

Dendrites

Figure 45–1

Structure of a large neuron in the brain, showing its important func-tional parts. (Redrawn from Guyton AC: Basic Neuroscience:Anatomy and Physiology. Philadelphia: WB Saunders Co, 1987.)

Golgi tendonapparatus

Cerebellum

Motor cortex

Thalamus

BulboreticularformationPons

Somesthetic areas

Medulla

Spinal cord

Skin

Pain, cold,warmth (Freenerve ending)

Pressure(Pacinian corpuscle)(Expanded tipreceptor)

Touch(Meissner's corpuscle)

Muscle spindle

Kinesthetic receptor

Joint

Muscle

Figure 45–2

Somatosensory axis of the nervous system.

• Termasuk sensasi sensoris somatik

• Dapat dirasakan oleh hewan tingkat rendah → human

• Sensasi yg phemomenal : sesuatu yg dibutuhkan tetap ada tapi harus dieliminasi

• Respons nyeri :• intensitas ( ringan, sedang, berat )• sifat rangsangan• memori

Rasa Nyer i

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Cortex Cerebri sisi kiri ( hemispher kiri )

Cortex cerebri adalah lapisan paling luar otak , merupakan lapisan paling tebal – serta mencerminkan intelegensia

Pusatintelegensi

Pusatvisual

Pusat kontraksi otot

Pusat bicara

Cortex cerebri

1. Pusat persepsi dan interpretasi sistem sensoris somatik.

2. Pusat pengendalian sistem motorik somatik ( gerakan anggota tubuh ).

3. Pusat intelegensia.

4. Pusat penglihatan, pendengaran, bicara, taste / pengecapan.

Reseptor

• Reseptor nyeri ( nosiseptor ) - free nerve endings - axon saraf sensoris : Aδ ( fast pain ) → mekanis, termal tipe C ( slow pain ) → kimiawi, mekanis & termal (persisten) tersebar hampir di seluruh tubuh → termasuk daerah muka ( facial ) dan dental

• Reseptor somatosensorik daerah kepala dilayani n. trigeminus divisi somatosensoris

Rangsangan yg dapat menimbulkan nyeri: mekanik, kimiawi, termal, elektrik, tissue ischemia, skeletal muscle spasm

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• Beberapa bahan yang dapat menimbulkan nyeri๏ Bradikinin๏ Serotonin๏ Histamin๏ Prostaglandin๏ Leukotrien๏ Substance P๏ Enzim proteolitik๏ ion K yg berlebihan๏ asam atau basa yang berlebihan

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permeabilitas membran nosiseptor ↑

influks ion Na+

potensial aksi (impuls) membran neuron

medulla spinalis

Trauma/kerusakan jaringan

pengeluaran ion K+, sintesa prostaglandin

& bradikinin

Keradangan Jaringan Infeksi - Non infeksi

sekresi peptida (substan P)

merangsang mast cell, platelet, kapiler

inflammatory agents( Histamin, bradikinin, serotonin,

platelets factors )

Input sensoris: - kulit fasial - mukosa oral - geligi - pembuluh darah kranial - otot - TMJ

Impuls Nyeri S.S.A I : Gyrus Postcentralis

Thalamus

Tr.Spinothalamicus

Medulla SpinalisFree nerve endings

Aδ / C

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Klasifikasi Nyeri ( berdasarkan etiologi )

A. Nyeri Fisiologik• Nyeri tjd krn rangsangan, singkat dan tidak merusak jaringan

• Korelasi positif antara stimuli dan persepsi nyeri

B. Nyeri Inflamasi / Nosiseptif• Terjadi akibat keluarnya mediator inflamasi yg mengaktivasi nosiseptor

C. Nyeri Neuropatik• Nyeri yang didahului/disebabkan oleh lesi (trauma, toksin, gangguan

metabolik) atau disfungsi primer sistem saraf

• Tidak berhubungan dg aktivasi nosiseptor

D. Nyeri Psikogenik• Nyeri yg tidak berhubungan dg nyeri nosiseptif maupun nyeri neuropatik

• Didapatkan simptom psikologisCopyright©yuliati

The discovery that norepinephrine can block pain transmissionled to studies directed at the combined administration of opi-oids and clonidine, a central-acting !-adrenergic agonist forsome types of pain relief.

Serotonin also has been identified as a neuromodulator inthe NRM medullary nuclei that project to the spinal cord. It hasbeen shown that tricyclic antidepressant compounds, such asamitriptyline, have analgesic properties independent of theirantidepressant effects. These drugs, which enhance the effectsof serotonin by blocking its presynaptic uptake, have beenfound to be effective in the management of certain types ofchronic pain.11

Endogenous Analgesic Mechanisms. There is evidence that theendogenous opioid peptides, morphine-like substances syn-thesized in many regions of the CNS including the spinal cordand PAG, modulate pain in the CNS. Three families of opioidpeptides have been identified—the enkephalins, endorphins,and dynorphins. Although the endogenous opioid peptides ap-pear to function as neurotransmitters, their full significance inpain control and other physiologic functions is not completelyunderstood. Probably of greater importance in understandingmechanisms of pain control has been the characterization ofreceptors that bind the endogenous opioid peptides. The iden-tification of these receptors has facilitated a more thorough un-derstanding of the actions of available opioid drugs, such asmorphine, and it also has facilitated ongoing research into thedevelopment of newer preparations that are more effective inrelieving pain and have fewer side effects.

Pain Threshold and TolerancePain threshold and tolerance affect an individual’s response toa painful stimulus. Although the terms often are used inter-changeably, pain threshold and pain tolerance have distinctmeanings. Pain threshold is closely associated with tissue dam-age and the point at which a stimulus is perceived as painful.Pain tolerance relates more to the total pain experience; it is de-fined as the maximum intensity or duration of pain that a per-son is willing to endure before the person wants somethingdone about the pain. Psychological, familial, cultural, and en-vironmental factors significantly influence the amount of paina person is willing to tolerate. The threshold to pain is fairlyuniform from one person to another, whereas pain tolerance isextremely variable.12 Separation and identification of the roleof each of these two aspects of pain continue to pose funda-mental problems for the pain management team and for painresearchers.

Types of PainThe most widely accepted classifications of pain are accordingto source or location, referral, and duration (acute or chronic).Classification based on associated medical diagnosis (e.g., sur-gery, trauma, cancer, sickle cell disease, fibromyalgia) is usefulin planning appropriate interventions.

Cutaneous and Deep Somatic PainCutaneous pain arises from superficial structures, such as theskin and subcutaneous tissues. A paper cut on the finger is anexample of easily localized superficial, or cutaneous, pain. It is

a sharp, bright pain with a burning quality and may be abruptor slow in onset. It can be localized accurately and may be dis-tributed along the dermatomes. Because there is an overlap ofnerve fiber distribution between the dermatomes, the bound-aries of pain frequently are not as clear-cut as the dermatomaldiagrams indicate.

Deep somatic pain originates in deep body structures, suchas the periosteum, muscles, tendons, joints, and blood vessels.This pain is more diffuse than cutaneous pain. Various stimuli,such as strong pressure exerted on bone, ischemia to a muscle,and tissue damage, can produce deep somatic pain. This isthe type of pain a person experiences from a sprained ankle.Radiation of pain from the original site of injury can occur. Forexample, damage to a nerve root can cause a person to experi-ence pain radiating along its fiber distribution.

Visceral PainVisceral, or splanchnic, pain has its origin in the visceral organs.Common examples of visceral pain are renal colic, pain causedby cholecystitis, pain associated with acute appendicitis, andpeptic ulcer pain. Although the viscera are diffusely and richlyinnervated, cutting or burning of viscera, as opposed to similarnoxious stimuli applied to cutaneous or superficial structures,is unlikely to cause pain. Instead, strong abnormal contractionsof the gastrointestinal system, distention, or ischemia affectingthe walls of the viscera can induce severe visceral pain. Anyonewho has had severe gastrointestinal distress or ureteral colic canreadily attest to the misery involved.

735Chapter 39: Pain

KEY CONCEPTS

TYPES OF PAIN

! Pain can be classified according to location, site ofreferral, and duration.

! Cutaneous pain is a sharp, burning pain that has itsorigin in the skin or subcutaneous tissues.

! Deep pain is a more diffuse and throbbing pain thatoriginates in structures such as the muscles, bones,and tendons and radiates to the surrounding tissues.

! Visceral pain is a diffuse and poorly defined pain thatresults from stretching, distention, or ischemia oftissues in a body organ.

! Referred pain is pain that originates at a visceral sitebut is perceived as originating in part of the bodywall that is innervated by neurons entering the samesegment of the nervous system.

! Acute pain usually results from tissue damage and is characterized by autonomic nervous systemresponses.

! Chronic pain is persistent pain that is accompaniedby loss of appetite, sleep disturbances, depression,and other debilitating responses.

Beberapa Tipe Nyeri

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• Orofacial pain merupakan istilah umum nyeri daerah oral & fasial

• Meliputi sejumlah kelainan klinis termasuk pada otot mastikasi atau temporomandibular joint.

• Tipe nyeri orofasial : nyeri inflamasi dan neuropatik

• Etiologi akut : terutama dental pain ( pulpa, jar.periodontal ) kronis : sebag.besar dari otot, tendon TMJ

What is Orofacial Pain ?

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TMJ Dysfunction

• Merupakan salah satu penyebab facial pain

• Terjadi saat hubungan sendi rahang keluar ligamen,

menyebabkan RA dan RB pada posisi tidak seimbang

• Patogenesis : distal displacement

mandibulare overclosure

• TMJ pain terjadi akibat ketidakseimbangan aktivitas otot rahang

& spasme otot

• Struktur yg diperiksa:

otot, sendi Temporomandibular, geligi

• Simptom

1. Jaringan keras

a. Rahang : clicking, nyeri otot daerah pipi,

gerakan rahang / lidah tak terkontrol

b. Geligi : clenching, grinding at night,

ke-ausan gigi belakang

2. Jaringan lunak

a. Mulut : discomfort, gangguan membuka mulut,

hilangnya kemampuan membuka mulut dg pelan ( smothly )

deviasi rahang pada satu sisi saat buka mulut, tidak dapat menggigit ( open bite )

b. Tenggorokan : gangguan menelan, laringitis,

perubahan suara, sering batuk merasa ada benda asing di tenggorokan

c. Masalah pada leher : penurunan gerak leher, nyeri

• Etiologi

1. Teeth grinding & teeth clenching kebiasaan tidak disadari, nyeri saat bangun tidur

2. Kebiasaan mengunyah permen karet / menghisap ibu jari

3. Maloklusi restorasi

4. Mengunyah satu sisi

5. Trauma rahang riwayat kecelakaan ( patah tulang rahang atau fasial )

6. Stres memicu sistem saraf

7. Pekerjaan misal : kebiasaan memegang gagang telepon antara

bahu & kepala

Gejala lain

a. Sakit kepala keluhan sakit saat membuka rahang

b. Nyeri telinga bagian depan/dalam telinga, tidak ada infeksi

c. Pusing ( belum jelas )

d. Rasa penuh pada telinga terutama saat take off & landing pesawat diduga disfungsi Eustachian tube

e. Tinnitus ( suara bising dlm telinga )

1. Mengukur pembukaan inter-insisal ( mm )

2. Mengukur gerak lateral & protusif ( mm )

3. Memperhatikan koordinasi & simetri saat membuka & menutup mulut

4. Memperhatikan ada tidaknya suara TMJ ( mis : clicking )

5. Palpasi TMJ dari arah lateral & posterior ( dari eksternal auditory meatus )

Prosedur Pemeriksaan Klinis

6. Palpasi otot elevator & depressor

7. Evaluasi ada tidaknya prematur kontak

8. Memperhatikan pola oklusal

9. Evaluasi skeletal symmetries dari kranial / fasial

10. Mencatat overjet, overbite & garis median ( mm )

Penjalaran Impuls TMJ Pain

S.S.A I : Gyrus Postcentralis

Thalamus

Tr.Spinothalamicus

Medulla Spinalis Free nerve endings pada disk parenkim TMJ

Aδ / C

Persepsi Nyeri TMJ

• Spasme otot → Iskemia

• Hambatan suplai darah jaringan

• Peningkatan metabolisme

• Timbunan asam laktat → aktivitas metabolisme anaerob

• Bahan metabolit - bradikinin, enzim proteolitik → kerusakan jaringan

Spasme Otot - Iskemia Jaringan

Terdiri atas 2 Fase

Prinsip :

1. Dimulai setelah diagnosis

2. Diutamakan terapi konservatif

3. Didahului dengan terapi yang bersifat reversibel,

terapi iireversibel hanya bila diperlukan

Terapi / Tata laksana TMJ Pain

Fase Pertama

Tujuan : a. mengatasi keluhan utama, b. mengembalikan Range of Motion ( ROM ) mandibula, c. mengembalikan kondili pada posisi normal, d. rehabilitasi otot yg fatique & cedera , e. membangkitkan semangat penderita memecahkan masalahnya ( faktor psikogenik ), f. memperbaiki postur tubuh.

Fase Kedua Merupakan lanjutan fase pertama, jika diperlukan terapi lanjutan untuk menstabilkan kondisi perawatan fase 1.

1. Istirahat menggurangi aktivitas rahang ( menghindari mkn-an dg konsistensi keras/kenyal, tidak membuka mulut lebar )

2. Stress reduction & management program

3. Biofeedback penderita mengatur tonus ototnya sendiri ( mengatur kontraksi - relaksasi otot )

4. Physical therapy antara lain : perubahan postural ( koreksi posisi mandibula ) pemijatan

terapi panas ( melancarkan sirkulasi ) muscle exercise dll

Fase Pertama

Fase Kedua

1. Equilibration grinding oklusal yg berkontak berat efektif pada penderita tanpa spasme otot & tidak banyak gigi hilang

2. Orthodonsi mengharmoniskan hubungan sendi dg mengkoreksi geligi

3. Overlays

4. Rekonstruksi ( Restorasi, Replacing ) gigi belakang aus akibat pengunaan atau akibat karies

5. Pembedahan

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