TMJ pathology thieories

1. TMJ Pathology
Islam Kassem,BDS,MSc,MFDS RCS Ed,MOMS RCPS Glasg,FFD RCSI
Consultant Oral & Maxillofacial Surgeon

3. Fundamentals Of
Occlusion

4. The Temporo-Mandibular Joints

5. Why Is Occlusion Important ?
• Assist in diagnosis
• Planning in restorative care
To minimize failure
Ensure predictable outcome by minimising loads on teeth
Managing the environment so that we get the minimal amount
of surprises (Similar to wearing a car seatbelt), the less the
patient has to adapt the better.

6. Definitions
OCCLUSION
A relationship between the masticatory surfaces of the
maxillary and mandibular teeth
The relationship between tooth contacts and mandibular
movements

7. Centric Occlusion
Relationship of the mandible to the maxilla when the
teeth are in maximum occlusal contact, irrespective
of the position or alignment of the condyle-disk
assemblies.
The relationship between the maxilla and mandible
when the teeth are maximally meshed with the
mandible in its most cranial position

8. Centric Relation
A relationship of the mandible to the skull where the
condyle is in an anteriorly, superiorly braced position
along the articular eminence of the glenoid fossa,
with the articular disc interposed between the
Condyle and eminence.

9. Mandibular Movements
• Mandibular movements occur around three axes
a) Horizontal axis
b) Vertical axis
c) Sagittal axis

10. Horizontal Axis (Rotation)
This movement occurs in the sagittal plane when the
mandible in centric relation makes a purely
rotational opening and closing border movement
around the transverse horizontal axis, which extends
through both condyles.

11. Vertical axis (Rotation)
This movement occurs in the horizontal plane when
the mandible moves into a lateral excursion. The
center for this rotation is a vertical axis extending
through the rotating or working-side condyle.

12. Working side
• The side towards which the mandible moves during
excursion OR Mandible moving toward the cheek
• Working side condyle pivots within the socket and is
better supported.
Balancing side (Non working side)
• The side opposite to the direction in which the mandible
moves OR Mandible moving toward the tongue
• Balancing side condyle has a downward orbiting path
and is more prone to injury or damage.

13. Balancing Side
Condyle has downward path
Mandible and TMJ
Working Side
Condyle pivots
Movement direction

14. Sagittal Axis
This movement occurs when mandible moves to working
side, the condyle on the opposite side (Non working side)
travels forward and downwards simultaneously. When
viewed in the frontal plane, this produces a downward arc
on the non working side, rotating about an anteroposterior
(sagittal) axis passing through the other condyle

15. Pure Hinge Movement
It occurs as the result of the condyles rotating in the
lower compartments of the temporomandibular
joints within a 10- to 13-degree arc, which creates a
20- to 25-mm separation of the anterior teeth

16. • Occurs when the mandible moves forward (protrusion)
• Teeth, condyles, and rami, all move in the same
direction and to the same degree.
• Occurs within the superior cavity of the joint
Translation Movement

17. Maximum Opening
(Translation & Rotation)
Occurs in the upper compartment of the joint as the
mandible drops down farther . Then the horizontal axis of
rotation shifts to the area of the mandibular foramen, as
the condyles translate forward and downward while
continuing to rotate.

18. Protrusive Position
When the mandible slides forward so that the
maxillary and mandibular anterior teeth are
in an end-to-end relationship, it is in a
protrusive position.

19. Bennett Movement
It is defined as “the bodily lateral
movement/ lateral shift of mandible resulting
from movements of condyles along lateral
inclines of mandibular fossa during lateral
jaw movement”
Dr Norman Bennett

20. Bennett Angle
The angle formed between the sagittal plane and
the average path of advancing condyle as viewed in
the horizontal plane during lateral mandibular
movements.
Average range is 7.5-12.8 degree
WSCBSC
Sagittal plane
Bennett angle

21. Posterior Determinant of Occlusion
TMJ – Temporomandibular Joint
Bony surfaces
The dentist has no control on the
posterior determinants i.e. TMJ

22. Anterior Determinant of Occlusion
Teeth
• Incisors
• Canines
• Premolars
• Molars

23. Posterior teeth
Provide vertical stops
Guide mandible to CO
Anterior teeth
Guide mandible in protrusive, retrusive and lateral
excursions
The closer the tooth located to a determinant , more it will
be influenced by it.
Anterior Determinants Of Occlusion

25. Occlusal Interferences
• Interferences are undesirable occlusal contacts that may
produce mandibular deviation during closure to maximum
intercuspation or may hinder smooth passage to and from
the intercuspal position .
• These can be of following types
a) Centric
b) Working
c) Non working
d) Protrusive

26. Centric Interferences
It is a premature contact that occurs when the
mandible closes with the condyles in their optimum
position in the glenoid fossae (CR) . It will cause
deflection of the mandible in a posterior, anterior,
and/or lateral direction

27. Working Side Interference
It occurs when there is contact between the
maxillary and mandibular posterior teeth on the
same side of the arches as the direction in which the
mandible has moved. If that contact is heavy enough
to dis-occlude anterior teeth, it is an interference .

28. • It is an occlusal contact between maxillary and
mandibular teeth on the side of the arches opposite the
direction in which the mandible has moved in a lateral
excursion .
• It has the potential for damaging the teeth, PDL, MOM
and TMJ due to changes in the mandibular leverage, the
placement of forces outside the long axes of teeth and
disruption of normal muscle function.
Non-Working Side Interference

29. Protrusive Interference
• It is a premature contact occurring between the mesial
aspects of mandibular posterior teeth and the distal
aspects of maxillary posterior teeth .
• The proximity of the teeth to the muscles and the
oblique forces make them potentially destructive.
• They also interfere with the patient's ability to incise
properly

30. Ideal vs Pathologic
Occlusion

31. Ideal Occlusion
An ideal occlusion should provide comfort and function in
a predictable way.
1) Ideal occlusion at tooth level
Cusp tip to fossa or cusp to marginal ridge contact – i.e no incline
contacts
2) Ideal occlusion at articulatory system level
Posterior stability, Anterior guidance, Lack of posterior interferences.
3) Ideal occlusion at patient level
Within the adaptability of the rest of the articulatory system.

32. Features Of Ideal Occlusion
A) Anterior Guidance:
• In lateral excursions of the mandible, working-
side contacts (preferably on the canines)
disocclude or separate the nonworking teeth
instantly.
• In protrusive excursions, anterior tooth contacts
will disocclude the posterior teeth.

33. Protrusive Guidance
Excursive Guidance

34. Features Of Ideal Occlusion
B) Posterior stability:
Enough posterior teeth in each arch with solid and stable
contacts in appropriate positions to evenly distribute loads and
to allow the mandible to close in a reproducible CO. Posterior
teeth contact more heavily than anterior teeth
It is enhanced by tall cusp – deep fossa
Maintains teeth position
CO or ICP is easily reproduced
Increased masticatory function
Signs of lack of PS, drifting, fremitus, fractured rest, mobility & wear

35. Lack Of Posterior Stability

36. C) Absence of posterior interferences
Features Of Ideal Occlusion
The non-working side

37. D) Centric Occlusion is achieved at centric
relation position
E) Occlusal loads are axially transmitted
through
the teeth
Features Of Ideal Occlusion

38. Organization Of Occlusion
• There are three recognized concepts that
describe how teeth should contact in
various mandibular positions
1. Bilateral balanced occlusion
2. Unilateral Balanced occlusion
(Group function)
3. Mutually protected occlusion
(Canine protected)

39. Bilateral Balanced Occlusion
• It dictates that a maximum number of
teeth should contact in all excursive
positions of the mandible.
• Use for complete denture occlusal scheme
as contacts on non-working side prevent
tipping of the denture
• Not used for fixed prosthodontics, as very
difficult to achieve

40. Unilateral Balanced Occlusion
• Also called group function
• It requires teeth on the working side to be
in contact in lateral excursion and teeth on
the non-working side are free of any
contact.
• Avoids destructive , oblique forces on the
non-working side.
• Prevents wear of maxillary palatal and
mandibular buccal cusps

41. Mutually Protected Occlusion
• Also called canine protected occlusion
• Anterior teeth overlap prevents the posterior
teeth from making any contact on either the
working or the nonworking sides during mandibular
excursions.
• Anterior teeth bear all the load and the posterior
teeth are dis-occluded during excursions.
Protecting the posterior teeth
• In CO, posterior teeth direct forces through their
long axis and anterior teeth are slightly in or out
of contact. Protecting the anterior teeth.

42. Guidance
Describes the influenced path the mandible
takes as a result of the contacting surfaces
of the teeth. Depending on the contact and
shape of the teeth they should be in
harmony

43. Protrusive Guidance
Influenced path the mandible takes as a
result of a forward thrust

44. Lateral Guidance
• Canine
• Describes the way in
which lateral excursions
are affected by tooth to
tooth contacts involving
the canine teeth only
resulting in disclusion of
the posterior teeth

45. Lateral Guidance
• Group function
• When lateral
excursions are guided
by more than one tooth
other than the canines

46. Hanau’s Quint
By modifying the following five factors, a scheme of occlusion
can be developed that will suit a particular patient best.
1. Condylar guidance
2. Incisal guidance
3. Occlusal plane orientation
4. Compensating curves
5. Height of the Cusp
Except for the condylar guidance, all other factors can be modified during the
fabrication of a prosthesis and the anterior guidance plays a predominant
role.

47. Anterior Guidance
• Guidance produced by the teeth themselves and not the
temporomandibular joint (can be on any tooth)
• The influence of contacting surfaces of anterior teeth on
mandibular movements.
• The influence of contacting surfaces of the guide pin
and anterior guide table on articulator movements.
• The fabrication of a relationship of the anterior teeth
preventing the posterior tooth contact in all eccentric
mandibular movements.

48. Effects Of Anatomic
Determinants Of Occlusion

49. Protrusive Incisal Path
The track of the incisal edges
of the mandibular teeth from
maximum intercuspation to
edge-to-edge occlusion.

50. Protrusive Incisal Path Angle
The angle formed by the protrusive incisal path and the
horizontal reference plane is the protrusive incisal path
inclination. It ranges from 50 – 70 degrees and is often
5-10º steeper than the sagittal condylar guidance.

51. Incisal Guide Angle
The angle formed with the horizontal
plane of occlusion and a line in the
sagittal plane between the incisal
edges of maxillary & mandibular
central incisors when the teeth are
in maximum intercuspation.
The angle formed in the sagittal plane
between the horizontal plane and
the slope of the incisal guide table.

52. Importance of Anterior Guidance
Opening and closing of the mandible is simply a rotation of
the condyles in the articular fossae.

53. Importance of Anterior Guidance
As anterior guidance is normally steeper than the condylar guidance,
the anterior teeth guide the mandible downwards during protrusive
or lateral movement
and ..

54. Importance of Anterior Guidance
(during protrusive movement)
.. produces dis-occlusion or separation of the posterior
teeth.

55. Importance of Anterior Guidance
(during lateral movement)
N.W.SW.S
C.G.O
Group Function

56. Importance of Anterior Guidance
Anterior guidance is linked to the combination of
horizontal & vertical overlap of the anterior teeth
and
can affect the occlusal surface morphology of
the posterior teeth.

57. Inter-relationship with Vertical & Horizontal Overlap of
the Anterior teeth
Anterior guidance can be made steeper by either increasing the
vertical overlap (overbite) ‘A-B’, or by reducing the horizontal
overlap (over jet) ‘C-A’ of the anterior teeth.
Anterior guidance can be made shallow by either decreasing the
overbite ‘B-A’ or increasing the over jet ‘A-C’ of the ant. teeth.

58. Condylar Guidance & Posterior tooth Morphology
(without considering the role of A.G.)
Shallow condylar guidance normally requires shallow cusp
angle or short cusp height and steeper condylar guidance
requires steep cusp angle or longer cusp height.

59. Condylar side-shift & Posterior tooth Morphology
(without considering the role of A.G.)
‘side shift +’ ‘No side shift’
Similarly, in the presence of an immediate lateral side shift during
lateral movement (Bennett’s movement) the cusp height and
cusp angle should be shallow.

60. Influence of Anterior Guidance on
Posterior tooth Morphology

61. Influence A.G. on Posterior tooth Morphology
(Effect of Overbite)
Greater overbite produces more
disocclusion hence permits
longer cusp height
Less overbite – less disocclusion
– shorter Cusp height.

62. Influence of A.G. on Posterior tooth Morphology
(Effect of Over jet)
Greater over jet necessitates
shorter cusp height.
Less over jet allows for long
cusp height.

63. Influence of A.G. on Posterior tooth Morphology
Summarizing,
greater anterior guidance allows posterior teeth to
have longer cusp height
&
smaller anterior guidance requires posterior teeth to
have shorter cusp height.

64. Influence of A.G. on Posterior tooth Morphology
By increasing the anterior guidance angle to compensate for
inadequate or shallow condylar guidance, it is possible to
increase the cusp height of the posterior teeth.

65. Influence of A.G. on Posterior tooth Morphology
Similarly, increasing the anterior guidance will permit
lengthening of the cusp that otherwise have to be
shorter in the presence of pronounced immediate
lateral translation of the condyles.

66. The importance of occlusion in
oral function and dysfunction

67. Mastication
Lundeen, Gibbs, 1972-1985

68. Influence of food

69. Influence of tooth morphology

70. Influence of age

71. Influence of jaw relationship
P. Proeschel (1988, 2006)
➢Different chewing patterns :

72. Soft food – Tough food

73. Angle Class

74. Cross bite

75. Reversed sequencing

76. Conclusion
➢Differences between groups with different
(mal)occlusions or tooth morphology
DO exist…..
But are they important …?

77. Bite force
M. Bakke (2006)
➢“Objective measure” of one parameter
➢Relatively simple measurement

78. Maximum Bite Force
➢Unilateral molars : 300-600 N
➢Premolars : 70 %
➢Front teeth : 40 %
➢Bilateral molars : 140 % - 200 % (PVDF)
➢Maximum (Eskimo’s) : 1750 N (Waugh 1937)
Hagberg 1987, Bakke et al 1989,
Ferrario et al 2004, Tortopidis et al 1998

79. Maximum bite force
➢Depends on number of teeth
➢Gender difference
➢Importance of motivation and cooperation
Rugh and Solberg 1972

80. Maximum bite force
➢Influence of pain : arthritis or TMD results in
decrease of 40 % (Wenneberg et al 1995, Stohler 1999)
➢Correlated to PPT (Hansdottir and Bakke 2004)

81. Maximum bite force
➢Influence of age (constant from 20-50 y,
decreases later, Bakke et al 1990)
➢Decreases with increasing facial height,
gonial angle,… (Ingerval & Helkimo 1978, Throckmorton et al
1980, Proffitt et al 1983, Braun et al 1995)
➢No influence of tooth decay or loss of
periodontal support (Miyaura et al 1999, Morita et al 2003)

82. Maximum bite force
➢Dentures....
..and implant-support helps…
(Bakke et al 2002, Van Kampen et al 2002)

83. Malocclusion and bite force
➢Negative influence of :
- overjet on incisal MBF (Ahlberg et al 2003)
- unilateral cross-bite (Sonnesen et al 2001)
- open bite (Bakke & Michler 1991)

84. Conclusions
➢Occlusal contact area seems most
correlated, more than malocclusion
➢But…does it matter,since
- only 10-20 % of variation explained
(while e.g. thickness of masseter explains 55 %...)
- normal chewing forces are only 15-30 % of
MBF….

85. Masticatory ability and performance
P.H. Buschang
➢Anatomical (occlusal contact area,
malocclusion …); physiological (muscle
strength, training, gender,…) and
psychological components interplay in
mastication, and deficiencies in one part can
be compensated for by others
➢“Masticatory performance” is an objective
measure, directly linked to food breakdown,
nutrition, digestion

86. Masticatory performance
➢Particle size distribution of (test-)food,
chewed a standard number of cycles
➢Methodology : fractional sieving
➢Typical food (peanuts, carrot, bread,…)
Optosil, or specially developed test-foods

87. Masticatory performance is influenced
by :
➢Number of teeth/occluding units (but
subjects with missing teeth do not chew
longer…)( Helkimo et al 1978, Yurkstas et al 1965, Henrikson et
al 1998)
➢Patients with dentures increase the number
of chewing strokes and wait longer to
swallow (? Corrected for age )
➢Mixed dentition : increase in early, decrease
in late phase

88. MP and malocclusion
➢Less potent effect than mutilated dentition
➢In cross-sectional studie, MP of Class III
patients is up to 60 % lower (English et al 2002,
Lundberg et al 1974, Zhou and Fu 1995). MP of Class II is
30 to 40 % lower (Henrikson et al 1998) but Median
Particle Size (MPS) was not significantly
different (Toro et al 2006)

89. MP and malocclusion
➢After a predetermined number of chewing
cycles (20,30,40) , the Median Particle Size
is larger in subjects with ICON (index for
complexity, outcome,need) < 43 than > 43
➢ but no differences in particle distribution or
masticatory frequency (Ngom 2007)

90. MP and digestion
➢Animal experiments clearly indicate relation
between food particle size and digestion
(Gyimesi et al 1972)
➢In man, also incompletely chewed food is
digested. In elder persons, MP has been
linked to GI-problems : 49 % of patients
without posterior teeth have gastritis vs
6 % when no teeth are missing (Mumma 1970)

91. CONCLUSIONS
➢Malocclusion influences the chewing cycle
➢Number of occlusal contacts and units
influences the maximum bite force
➢Class II and III patients have a lower
masticatory performance
but….
➢Probably not of clinical significance in non-
compromised patients

93. Diseases and Disorders of theTMJ
The TMJ is susceptible to all conditions that
affect other joints
ankylosis, arthritis, trauma, dislocations,
developmental anomalies and neoplasms
Psychosocial factors are extremely
controversial
Somatoform disorder, drug seeking, malingering,
“need” for illness

94. Muscular Disorders (Myofascial Pain
Disorders) are the most common cause of
TMJ pain
High psychosocial component?
many patient with “high stress level”
poor habits including gum chewing, bruxism, hard
candy chewing
poor dentition

95. MPD, continued
unilateral dull, aching pain
worse with use (gum, candy, bruxism)
associated HA’s, otalgia, T/HL, burning tongue

96. Myofascial Pain Disorder, Cont.
Six categories
Myositis
acute inflammation with pain, edema and decreased
ROM. Usually secondary to overuse, but infection or
trauma seen
TX: rest, NSAIDs, Abx as needed
Muscle Spasm
acute contraction from overuse, overstreching
Tx: rest, NSAIDs, massage, heat, relaxants

97. Contracture
end stage of untreated muscle spasm
due to fibrosis of muscle and connective tissue
Tx: NSAIDs, massage, vigorous physical therapy,
occasional surgical release of scar tissue
Hysterical trismus
decreased ROM
psychosocial etiology
more common in females

98. Fibromyalgia
diffuse, systemic process with firm, painful bands
(trigger points)
usually seen in weight bearing muscles
often associated sleep disturbance
more common in females
Diagnostic criteria
trigger points
known path of pain for trigger points
reproducible

99. Collagen vascular disorders
SLE
autoimmune, butterfly rash, fever, rheumatoid arthritis
Dx with high ESR, positive ANA and a false-positive VDRL
Scleroderma
autoimmune characterized with gradual muscle and joint pain,
tightening of skin
limited jaw expansion with pain may be initial presentation

100. Sjogren’s Syndrome
autoimmune
xerostomia, xeropthalmia with keratitis
sometimes see muscle and joint pain , including the
TMJ
diagnose with minor salivary gland biopsy

101. Treatment is divided into four phases
Phase I (four weeks, 50% will improve)
educate the patient about muscle fatigue
explain referred pain
“oral” hygiene: no gum chewing, candy chewing, jaw
clenching
soft diet
NSAIDs (usually ibuprofen)
muscle relaxants (benzos)

102. Phase II (four weeks-25% more improve)
Continue NSAIDs, benzos
add bite appliance (splint)
decrease effects of bruxism
“splints” the muscles of mastication
improves occlusion while wearing, allowing more natural jaw
position
usually worn at night, may be worn during day
once relief obtained, d/c meds first. If remains asymptomatic, d/c splints.
may continue with prn splinting

103. Phase III: (four weeks-15% improved)
continue NSAIDs, bite appliance
add either ultrasonic therapy, electrogalvanic
stimulation or biofeedback
no one modality superior
Phase IV: TMJ Center
multidisciplinary approach utilizing psychological
counseling, medications, trigger point injections and
physical therapy

104. Joint Disorders
Joint Disorders are the second most
common cause of temporomandibular pain
Include internal derangements,
degenerative joint disease, developmental
anomalies, trauma, arthritis, ankylosis and
neoplasms

105. Cardinal features are jaw popping (clicking)
and pain
50% of the population has a jaw pop, which
usually occurs with opening (between 10-20 mm)
may elicit a history of “lock” jaw
advanced disorders may not present with a jaw
click, but a history can usually be found

106. Internal Derangement
the most common joint disorder
involves the abnormal repositioning of the disc
disc location is usually anteromedial
four types of derangements

107. Internal Derangement Types
Type IA
popping over the joint without associated pain
(50% of normal subjects)
Type IB
popping over the joint with pain
due to chronic streching of capsular ligaments
and tendons

108. Type II
similar to type IB, but a history of “lock jaw” can
be elicited
closed lock vs open lock
Type III
a persistent lock, usually closed
No click on PE!

109. Tx of Internal Derangements
Type I and II
similar to myofascial disorders: NSAIDs,
anxiolytics/relaxers, “oral” hygiene and appliances
if necessary for four weeks
progression of symptoms may require surgical
intervention
main goal is lysis of adhesion and repositioning of disc
open vs arthroscopic

110. Tx of Internal Derangements
Type III
usually requires general anesthesia to mobilize
jaw
agressive medical and physical therapy is
initiated, including a bite appliance
if no improvement after 3 weeks, surgery is
indicated to lyse adhesions and/or reposition disc

111. Congenital Anomalies
Fairly rare
Important to identify
absence of growth plates leads to severe
deformities
condylar agenesis, condylar hypoplasia,
condylar hyperplasia and hemifacial
microsomia most common

112. Condylar agenesis
the absence of all or portions of condylar process,
coronoid process, ramus or mandible
other first and second arch anomalies seen
early treatment maximizes condylar growth
a costocondral graft may help with facial development

113. Condylar hypoplasia
usually developmental secondary to trauma or
infection
most common facial deformity is shortening of
mandible
jaw deviates towards affected side
Tx for child: costochondral graft
Tx for adult: shorten normal side of lengthen
involved side

114. Condylar Hyperplasia
an idiopathic, progressive overgrowth of mandible
deviation of jaw away from affected side
presents in 2nd decade
Treat by condylectomy

115. Traumatic Injuries
Fractures of the condyle and subcondyle
are common
unilateral fracture involves deviation of jaw
towards affected side with or without open bite
Tx: MMF with early mobilization
bilateral fracture usually has anterior open bite
often requires ORIF of one side with MMF

116. Dislocation of the TMJ
Acute dislocation
new onset Type III derangement, surgery of the
mouth
treatment is reduction under anesthesia
Chronic dislocation
usually secondary to abnormally lax tendons
Tx: sclerosing agents, capsulorraphy, myotomy
of lateral pterygoid

117. Ankylosis of the TMJ
Defn: the obliteration of the joint space with
abnormal bony morphology
etiologies include prolonged MMF, infection,
trauma, DJD
False ankylosis: an extracapsular condition
from an abnormally large coronoid process,
zygomatic arch or scar tissue

118. Treatment
Child: a costochondral graft to help establish a
growth plate
Adult: prosthetic replacement
the new joint should be established at highest point on
ramus for maximal mandibular height
an interpositional material is needed to prevent fusion
PT must be aggressive and long term

119. Arthritis of the TMJ
The most frequent pathologic change of the
TMJ
Most are asymptomatic
Rheumatoid arthritis
usually seen in other joints prior to TMJ
when present, both joints usually affected
early radiographic changes include joint space
narrowing without bony changes

120. Rheumatoid Arthritis, Continued
late radiographic changes may involve complete
obliteration of space with bony involvement and
even ankylosis
end stage disease results in anterior open bite
Juvenile RA may progress to destruction of the
growth plate, requiring costochondral graft

121. Rheumatoid Arthritis, continued
Treatment
NSAIDs, penicillamine, gold
Surgery limited to severe JRA and ankylosis
Degenerative Arthritis
“wear and tear” of the joints
most asymptomatic

122. Degenerative Arthritis, Continued
Primary Degenerative arthritis
“wear and tear” - usually in older people
asymptomatic or mild symptoms
Secondary Degenerative arthritis
due to trauma, infection and bruxism
symptoms severe
radiographic findings include osteophytes an derosion
of the condylar surface

123. Dejenerative Arthritis, continued
Treatment is initially similar to myofascial
disorders, including NSAIDs, benzos and “oral”
hygiene. Bite appliance may be necessary
After 3-6 months, surgery is considered
lysis of adhesions, osteophyte removal
condylar shave. Resorption of the condyle is a known
complication

124. Neoplasms of the TMJ
Uncommon
Usually benign
chondromas, osteomas, osteochondromas
fibrous dysplasia, giant cell reparative granuloma
and chondroblastoma rare
Malignant tumors such as fibrosarcoma and
chondrosarcoma very rare
Radioresistant