introduction to temporomandibular joint disorders

1. Temporomandibular disorders
TMDs
Abdusalam Alrmali
OMFS
BDS, DDS IMP,MDS,FICOI, FAIOI
MEMBER OF IADR
MEMBER OF AO
MEMBER OF ICOI
MEMBER OF WAUPS

3. Definition
• TMD is a collective term.
• function of the masticatory muscles and the jaw
joint.
• About 60-70 % of the population
• 25 % of these are aware of them
• only 5 % seeks treatment
(Dimitroulis et al. 1995).

4. Non odontogenic toothache
When the toothache is not of
dental origin

5. DO NOTING !

6. Referred Pain
• Pain is felt outside the sensory distribution of
the primary source of pain
• Central convergence Multiple peripheral
nerves synapse on common central pathways

7. Misdiagnosis

8. What’s The Point?
SUCCESSFUL
TREATMENT DEPENDS
ON MAKING THE
CORRECT DIAGNOSIS

10. Many Factors Can Initiate Orofacial
Pain

11. Felt in the ear, pharynx, tonsil, posterior aspect
of the tongue, and postmandibular areas
Not Impacted
Third molar

12. Types of Pain
• Musculoskeletal Pain
• Myogenic Pain, TMJ
• Neurovascular Pain
• Migraine Headache
• Neuropathic Pain
• Post-traumatic Neuropathy
• Trigeminal neuroglia

17. •If a dental source of the pain is not
found, no dental treatment should be
initiated

18. The most commoncauses of temporomandibulardisorders(TMDs)are muscular
disorders, which are commonly referredto as myofascialpainanddysfunction.
Thesemuscular disorders are generally managedwell with a varietyof reversible
nonsurgical treatment methods.
Othercauses of temporomandibular pain or dysfunction are articular in origin.
These causes includeinternal derangement and osteoarthritis, rheumatoidarthritis,
chronic recurrent dislocation, ankylosis,neoplasia, andinfection.
N.B: TMDs are eitherarticular or muscularor both.

19. Muscular
• Muscle spasm
• Myofacial pain
Articular:
• internal derangement
• and osteoarthritis,
• rheumatoid arthritis,
• chronic recurrent
• dislocation,
• ankylosis,
• neoplasia, and
infection.

20. Components

21. Anatomy
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22. • Mandibular condyle
• Articular surfaces of Temporal
bone
• Capsule
• Articular disc
• Ligaments
• Muscular component

23. Articular Disc

24. Jeffrey Tucker, D.C., D.A.C.R.B.24

26. Movements
• Rotational / hinge movement in first 20-25mm
of mouth opening
• Translational movement after that when the
mouth is excessively opened.

27. Mouth closed Mouth open

29. RELATIONS
Posteriorly - parotid gland
Superficial temporal vessels
Auriculotemporal nerve

30. TMJ liagments

31. blood supply & nerve supply :

32. Muscles of mastication:

33. Action for each muscle :
􀂄Masseter
Elevation, protrusion
􀂄 Temporalis
Elevation, retrusion
􀂄 Medial pterygoid
Elevation, protrusion,lateral movement
􀂄 Lateral pterygoid
– inferior belly 􀂄 Opening, protrusion,
– superior belly􀂄 Active during clenching

37. Definition
A collection of clinical problems affecting
the TMJs / muscles of mastication
A major cause of non-dental pain (both
acute and chronic)
A musculo-skeletal problem
Not just one disorder
Related disorders with common
symptoms

38. Etiology :
• Current Approach to Etiology of TMD
• 􀂐 Trauma
• Macrotrauma (direct/indirect)
• Microtrauma
• 􀂐 Anatomical Factors
• Skeletal/ Occlusal Relations
• 􀂐 Pathophysiological Factors
• Systemic/ Local Factors
• 􀂐 Psychosocial factors
• As many as 75 % of patients with TMJ
disorders have a
• significant psychological abnormality.

39. TMDS
Muscular Articular

40. MOST COMMON TMDs
• Myofascial pain and dysfunction
• Internal derangement
• Osteoarthrosis & RA
• Dislocation
• Ankylosis

41. TMD Research Diagnostic Criteria
• GROUP I : Muscle disorders:
• Myofascial pain
• Myofascial pain with limited opening
• GROUP II : Disc Displacements :
• DD With reduction
• DD Without reduction with limited opening
• DD Without reduction without limited opening
• GROUP III : Arthralgia, Arthritis, Arthrosis:
• Arthralgia
• Osteoarthritis of the TMD
• Osteoarthrosis of the TMD

42. MYOFASCIAL PAIN AND DYSFUNCTION
• Refers to a group of poorly defined
muscle disorders (eg, fibromyalgia)
characterized by diffuse facial pain
and episodic limited jaw opening
• May result from parafunctional habits
and significant relationship to
psychophysiologic disorders such as
stress or depression

43. Myofascial pain:
• Cause
• Muscle stress or overload, emotional stress &
deep pain→trigger points
• 􀂐 Clinical features
• Trigger point → constant deep pain → central
excitatory effects referred pain

44. DIGAMMATIC RERESENTATION OF
ETIOLOGY OF MPDS
PSYCHOPHYSIOLOGIC THEORY OF MPDS
(Modified by LASKIN in 1969)
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45. Ia-Myofascial pain:
Key: Painful muscles
Lateral pterygoid
Temporalis insertion

46. Diagnostic criteria :
• Regional dull, aching pain.
• Hyperirritable sites ( trigger points)
• 􀂐 Aggravated by movement
• 􀂐 >50% reduction of pain with vapocoolant
spray or l t LA

47. Accompanying signs and symptoms
• 􀂐 Muscle stiffness
• 􀂐 Ear symptoms
• 􀂐 Limited mouth opening
• 􀂐 Hyperalgesia in referral sites

49. Group I: Muscle Disorders
Ib-Myofascial pain with
limited opening:
Key: painful muscles +
limited movement
(interincisal opening +
OB)

50. Group II: Disc Displacements

51. INTERNAL DERANGEMENT
• Abnormal relationship of the articular disc to
the mandibular condyle, fossa,and articular
eminence, interfering with the smooth action
of the joint (Dolwick 1983)
• Is a localized mechanical fault within the joint
• Synonymous with disc displacement

52. DDWR

53. Group II: Disc Displacements
IIa-Disc displacement
(DD) with reduction:
Key:
Reproducible clicking

54. DDWOR

56. INTERNAL DERANGEMENT

57. Normal disc position Anterior disc
displacement
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58. Group II: Disc Displacements
IIb-DD without
reduction with limited
opening:
• Key:
limited movement
with small passive
stretch

59. Group II: Disc Displacements
IIc-Disc displacement
without reduction
without limited
opening:
Key:
History of previously
limited opening but
imaging needed to
confirm DD

60. Group III
IIIa-Arthralgia:
Key:
Painful TMJ
+ no crepitus

61. Group III
IIIb-Osteoarthritis:
Key:
Crepitus + painful TMJ
IIIc-Osteoarthrosis:
Key:
Crepitus + non painful
TMJ

62. OSTEOARTHROSIS
• Is a non painful, localized degenerative joint disease that
mainly affects bone and articular cartilage.
• It is often idiopathic, but predisposing factors such as old
age, repetitive trauma (bruxism), abnormal joint
posturing, or multiple surgical procedures may be
involved. If painful,then referred to as osteoarthritis

63. DEGENERATIVE CHANGES IN CONDYLE

64. Dislocation

65. Luxation and subluxation
Dislocation of the TMJ
– Luxation of the joint
– Subluxation
– Luxation  ‘acute’, due to a sudden traumatic
injury resulting in the fracture of the condyle.
– Yawning / wide opening of mouth
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66. Unilateral condylar dislocation
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67. Bilateral condylar dislocation
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68. Luxation & Subluxation
• C/f:
– Sudden locking and immobilization of the jaws.
– Prolonged spasmodic contraction of the temporal,
internal pterygoid and masseter muscles.
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69. Luxation & Subluxation
• Treatment:
– Relaxation of the muscles and then guiding the head of the
condyle under the articular eminence into its normal
position by an inferior and posterior pressure of the
thumbs in the mandibular molar area.
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70. Ankylosis

71. Ankylosis
–Fusion of head of the condyle  temporal bone.
• Etiology:
–Idiopathic
–Traumatic injuries
–Infection
–Rheumatoid arthritis
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72. Ankylosis
• C/f:
–1st decade
–Before 10 years
–M = F
–Unilateral /Bilateral
–In ability to open the jaws
–Pain, tenderness and malocclusion
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73. TRAUMA
Extravasation of blood into the joint space
haemarthrosis
Calcificatiion and obliteration of the joint space
Intra-capsular ankylosis Extra-capsular ankylosis
PATHOPHYSIOLOGY

76. Unilateral ankylosis
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77. Ankylosis
Intra-articular ankylosis Extra-articular ankylosis
-Destruction of the meniscus
-Flattening of the mandibular
fossa thickening of the head
of the condyle
-narrowing of the joint space
-Fibrous adhesion
External fibrous / osseous
encapsulation.
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78. Ankylosis
• R/F:
–Abnormal / irregular shape of the head of the
condyle
• Treatment:
–Surgical osteotomy / removal of section of bone
below the condyle.
–Fibrous ankylosis can be treated by functional
methods.
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80. Quiz
Diagnsis ???
• Constant diffuse unilateral pain
• Severe in the morning and worsens as day
progresses
• Radiates to cervical region, shoulders and back
• Limitation of jaw movement
• Deviation to the affected site
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81. Diagnostic questions
• Has the correct diagnosis been made?
• Is the diagnosis related principally to:
– muscle
– or TMJ
– or both?
• Any Predisposing, Precipitating or Prolonging
factors (e.g. life events, psychological conflicts, chronic pain
behaviour, parafunction, occlusal changes, trauma)?

82. The group is recognized by one or
more of three principal clinical
features:
• 1. Pain associated with the
temporomandibular joint (TMJ) and/or the
masticatory muscles
• 2. Noises associated with the TMJ
• 3. Limitation of jaw movement.

83. Tenderness of the muscles or joints

84. CONTRALATERAL PAIN SUGGESTS ARTICULAR DISEASE

85. Noises
• The most common noise associated with the
TMJ is
• clicking (or snapping, cracking, bumping or
popping).
palpation or
auscultation.

88. Limitation of jaw movement
• A reasonable measure of the lower limit
• of interincisal opening for an adult with a class
1
• occlusion is 40 mm, measured between the
upper
• and lower incisal edges.
Hard end feelSoft end feel

89. Examination (1)
• Extra-oral
– asymmetry
– muscle tenderness and trigger points
– interincisal opening (3 measurements)
– TMJ tenderness
– clicking (opening/closing)
– crepitus

90. Diagnostic procedure
• Comprehensive
– history
– examination
– special investigations

91. History
• symptoms in order of severity
• detailed pain history
• previous treatment?
• history of clicking/locking?
• awareness of parafunction?
• other musculo-skeletal problems?
• other stress-related conditions?

92. Examination (2)
• Intra-oral
– muscle tenderness (lateral pterygoid, temporalis)
– tongue/cheek ridging
– dental problems

93. Examination (3)
• Occlusal examination
– signs of trauma from occlusion (facets, fractures, mobility,
drifting/tilting)
– anterior open bite
– lack of posterior support
– inharmonious RCP/ICP slide
– obvious occlusal interferences

94. Special Investigations (1)
• Radiographs
– periapicals
– OPG
– transcranial
– TMJ tomography

95. Special Investigations (2)
• Soft tissue imaging:
– MRI
– CAT
– Arthrography
• Psychological inventories

96. Investigations  TMJ
• TMJ imaging
–Panoramic radiographs
–Transcranial view
–Transpharyngeal view
–Transorbital view
–Reverse Towne’s view
–Submento-vertex (SMV) view
–Conventional tomography
–Arthrography www.indiandentalacademy.c
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97. –Computed tomography (CT)
–Magnetic resonance imaging (MRI)
–Arthroscopy
–Bone scan
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99. Treatment
•counselling
•occlusal splints
•occlusal adjustment
•physiotherapy
•pharmacotherapy
•psychotherapy

100. Counselling
• Reassurance and education
• Stress management
– habit modification
– lifestyle modification
– progressive relaxation
• Self-care:
– rest (during acute stage)
– jaw exercises
– moist heat and ice packs

101. Physiotherapy

102. PHYSICAL THERAPY

103. Pharmacotherapy
• Analgesics
– eg. asprin, paracetamol
• NSAIDs
– e.g. ibuprofen
• Antidepressants
– e.g. amitriptyline
• Muscle relaxants/tranquilisers
– e.g. diazepam

104. Pharmacotherapy - injections
• Corticosteroid
– e.g. TMJ injection with methyl prednisolone
• Local anaesthetic
– e.g. trigger point injection with 0.5% procaine

105. Psychotherapy
• Mouth and jaws prime focus for symbolic
portrayal of psychological conflicts
• Beware of becoming DIY psychiatrist
• Suitable referral may be difficult.

106. Occlusal splints
The best of many designs are:
• Soft splint
– initial treatment (with counselling and exercises)
• Stabilisation splint
– muscle and joint pain
• Anterior (re)positioning splint
– joint pain, clicking, intermittent locking,
secondary muscle symptoms

107. Occlusal splints
• general functions:
– alter occlusal relationships
– redistribute occlusal forces
– reduce bruxism
– reduce tooth wear and mobiltiy
– treat masticatory pain and dysfunction
– alter structural relationships in TMJ

108. The Soft Splint

109. Stabilisation splint

110. Anterior positioning splint
• decrease adverse joint loading
• alter condyle-disc relationship
• holds jaw forward with indentations
• guidance ramps
• wean off before 3m full time wear

111. Splint Problems
• Caries
• Gingivitis
• Psychological
dependence
• Unwanted tooth
movement

112. ARTHROSCOPY

114. HOLMLUND-
HELMSING LINE

115. Surgical management
• Minimum invasive
• Open : approaches
• Meniscoplasty , menisectomy
• Risk ??

116. SURGICAL APPROACHES
TO
TMJ

117. POST/ RETRO AURICULAR

118. ENDAURAL

119. SUBMANDIBULAR
RISDON’S APPROACH

120. POSTRAMAL /
HIND’S INCISION

121. PREAURICULAR
DINGMAN’S INCISION
Dingman and Grabb (1962)

122. PREAURICULAR
THOMA’S ANGULATED INCISION

123. BLAIR’S INVERVED HOCKYSTICK
INCISION
BLAIR & IVY 1936

126. PREAURICULAR INCISION

129. T H A N K
Y
O
U