TMJ disorder and its management

1. TEMPOROMANDIBULAR
JOINT DISORDER AND ITS
MANAGEMENT
1
- Dr Priyanka Parihar

2. CONTENTS:
INTRODUCTION
TYPES OF JOINTS
COMPONENTS OF THE TMJ
MUSCLE OF THE JOINT
INNERVATIONS OF TMJ
VASCULARIZATION OF TMJ
CLASSIFICATION OF TMJ DISORDERS
ETIOLOGIC FACTORS
2

3. Treatment of Functional Disturbances of the Masticatory System
• Temporomandibular Disorders,
• Treatment of Masticatory Muscle Disorders
• Treatment of Temporomandibular Joint Disorders
• Treatment of Chronic Mandibular Hypomobility and Growth Disorders
• Occlusal Appliance Therapy
3
CONTENTS:

4. INTRODUCTION:
• Temporomandibular joint (TMJ) is
formed by the articulation of the
mandible and the temporal bone of
the cranium. It is located anteriorly
to the tragus of the ear, on the
lateral aspect of the face.
• It is a bicondylar joint in which the
condyles, located at the two ends of
the mandible.
4

5. TYPES OF JOINT:
• A joint is where two or more bones meet.
• Fibrous joint: Immovable,
Example: cranium, Radioulnar, Tibiofibular joint.
• Cartilaginous joint: slightly moveable
Example: vertebral column
• Synovial joint : freely moveable
example : knee joint , hip joint
5

6. • types of Synovial joint
1. Hinge joint
2. Pivot joint
3. Condyloid joint
4. Ball and socket joint
5. Gliding joint
6. Saddle joint
6

7. Craniomandibular articulation-TMJ
• Complex joint in the body
Hinging movements - Ginglymoid joint
Gliding movements –Arthroidal joint
 Hence called as Ginglymoarthroidal joint
• TMJ is a complex diarthroidal sliding- ginglymoid synovial joint,
which attaches the mandible to petrous part of temporal bone of
the cranium.
7

8. COMPONENTS OF TMJ
Hard tissue components
1. Mandibular condyles
2. Glenoid fossa of the
temporal bone
3. Articlar eminence
Soft tissue components
1. Articular capsule
2. Articular disc
3. Ligaments
4. Muscles
8

9. HARD TISSUE COMPONENTS
Mandibular condyle:
• Are ovoid and strongly convex anterioposterioly
and mildly convex mediolaterally.
• Perpendicular to ascending ramus of the mandible.
• The anterior surface shows a shallow depression
called as Lateral pterygoid fovea to which lateral
pterygoid muscle is attached.
• Bony surface of condyle and articular part of the
temporal bone covered with dense fibrous
connective tissue. 9

10. Glenoid fossa of the Temporal bone:
• The articular surface of the temporal bone is
situated on the inferior surface of the
squamous part of the temporal bone.
• This area which articulate with the
mandibular condyle is called the Glenoid
Fossa.
• The floor of the fossa is formed by a thin
plate of bone.
• It is also covered by a fibrous layer similar
to the condyle.
10

11. Articular eminence:
• The articular eminence is convex
anterioposteriorly and concave in the
transverse direction.
• It is enclosed by the articular capsule
of the TMJ.
11

12. SOFT TISSUE COMPONENTS:
Articular capsule:
• Articular capsule is a thin sleeve of dense
cartilaginous tissue enclosing the joint cavity.
• The articular capsule consists of two layers:
a) An outer layer (stratum fibrosum) composed of
avascular, white fibrous tissue.
b) An inner layer (stratum synoviale) which is a
secreting layer usually known as the synovial
membrane. 12

13. • Synovial membrane:
• It is a thin and flexible layer lining the inner
surface of the joint capsule
• The articulating surfaces and the
articulating disc are not covered by the
membrane
The synovial membrane consists of two
layers:
• Cellular intimal layer
• Vascular subintimal layer
13

14. • Function of synovial membrane
 Lubricating the joint
 Repairing wear
14

15. Articular disc:
• It is oval, firm, thick plate of dense fibrous cartilage
located between the condyle and the articulating
surface of the temporal bone.
• Disc divides the joint cavity in to two compartments
ie superior and inferior.
• Function of disc: due its viscoelasticity it acts as
shock absorber, stress distributor and provide gliding
motion during opening and closing of the jaw.
• The articular disc is predominantly avascular ,blood
vessels are seen at the margins of the disc. 15

16. Articular ligaments:
TMJ is associated with four ligaments, One
major and three minor ligaments.
Temporomandibular ligament : is fan
shaped present on lateral aspect of the
articular capsule. Hence also called as
lateral ligament.
TM ligament helps in preventing
displacement in posterior and inferior
direction.
Displacement of TMJ happens only in the
anterior or forward direction.
Temporomandibular Ligament (Lateral View).
There are two distinct parts: the outer oblique
portion (OOP) and the inner horizontal portion
(IHP). The OOP limits normal rotational
opening movement; the IHP limits posterior
movement of the condyle and disc.
16

17.  Sphenomandibular ligament:
• This ligament is a flat thin band which is attached to the
spine of the sphenoid superiorly and to the ligula
inferiorly.
• The main function of this ligament is to limit the
distention of the mandible in an inferior direction.
 Stylomandibular ligament:
• This ligament extends from the apex of the styloid
process of the temporal bone to the posterior border of
the angle of the mandible.
• Function: along with sphenomandibular ligament limits
excessive opening of the mandible.
17

18.  Capsular Ligament:
• the entire TMJ is surrounded and
encompassed by the capsular ligament.
• The capsular ligament acts to resist any
medial, lateral, or inferior forces that tend to
separate or dislocate the articular surfaces.
• Significant function to encompass the
thus
Retains the synovial fluid
Capsular Ligament (Lateral View).It
extends anterior to include the articular
eminence and encompass the entire
articular surface of the joint.
18
joint

19. • Collateral (discal) ligament
• The collateral ligaments attach the medial and lateral borders of
the articular disc to the poles of the condyle.
• They are commonly called the discal ligaments
• There are two Medial discal ligament
lateral discal ligament
lateral
19

20. MUSCLES OF THE JOINT
The muscle associated with the TMJ is the Lateral
pterygoid muscle.
• Function : it pull the coronoid process of the
mandible anteriorly, forcing the condylar process
out of the mandible fossa along the articular
eminence to protrude mandible. The upper head
influences the position of the articular disc
during movement of the TMJ.
20

21. INNERVATION OF TMJ
• The innervations of the TMJ involves four type of receptors:
1. Ruffin’s corpuscles function as static mechanoreceptors
which position the mandible
2. Pacinian’s corpuscles are mechanoreceptors which helps
in the perception of movement & firm pressure
(not light touch).
3. Golgi tendon protect the muscle from excessive or
damaging tension.
4. The nociceptors (along with the proprioceptors) primarily
function to monitor the condition, position, and movement
of the tissues in the masticatory system.
21

22. • These receptors are innervated by the
Auriculotemporal nerve which leaves the
mandibular nerve behind the joint and
ascends laterally and superiorly to wrap
around the posterior region of the joint.
• Additional innervations by Deep temporal
and Massetric nerve.
22

23. BLOOD SUPPLY TO TMJ
• The main source of blood supply of
TMJ is provided by the Superficial
temporal artery and maxillary artery
which are branches of the External
carotid artery
• Other branches of the external carotid
artery- The Deep auricular artery,
Anterior tympanic artery and
Ascending pharyngeal artery also
contribute to the arterial blood supply
to the joint.
23

24. • In brief the muscles of mastication helps in biomechanics/movements of
mandible:
Movement Muscle
Elevation (closing) Temporalis,
Masseter
Medial pterygoid
Depression ( opening) Lateral pterygoid
Superior infrahyoid
Protrusion (forward) Lateral pterygoid
Masseter
Medial pterygoid
Retrusion (backward) Temporalis
Masseter
Lateral movement Temporalis (same side)
Pterygoid (of Opposite side)
Masseter
24

25. CLASSIFICATION OF TMJ DISORDERS
25

26. •Pseudotumors
(synovial
chondromatosis)
•Benign
(chondroma,
osteotoma)
•Malignant
(primary,
metastatic)
•Synovitis
•Capsulitis
•Rheumatoid arthritis
•Juvenile rheumatoid arthritis
•Ankylosing spondylitis
•Psoriatic arthritis
•Reactive arthritis (bacterial, viral,
fungal)
PETERSON’S CLASSIFICATION
ARTICULAR
DISORDERS
Inflammatory
arthropathies
•Primary osteoarthrosis (no
clear predisposind factor)
•Secondary osteoarthrosis
(trauma,previous
surgery,avasular necrosis)
•Mechanical derangements
•Bone and cartilage
disorders with
articular manifestations
•
•Non-neoplastic:developmental
(hyperplasia, hypoplasia,
dysplasia)
•Non-neoplastic: acquired(ie,
condylolysis)
Growth Disorder
Noninflammatory
arthropathies
Neoplasm
Diffuse connective tissue
disorders
Miscellaneous articular
disorders
26

27. •Muscle spasm (strain)
•Myofascial pain and
dysfunction (MPD)
•Fibromyalgia
•Myotonic dystrophies
•Myositis ossificans
progressiva
NON-ARTICULAR
DISORDERS
Muscle disorders
Growth disorders
27

28. ETIOLOGIC FACTORS FOR
TEMPOROMANDIBULAR
DISORDERS
1. OCCLUSAL CONDITIONS
2. TRAUMA
3. EMOTIONAL STRESS
4. Deep Pain Input
5. Parafunctional Activity
28

29. TRAUMA
• Trauma can be divided into two general types: macrotrauma and
microtrauma.
• Macrotrauma is considered any sudden force that can result in structural
alterations, such as a direct blow to the face.
• Microtrauma refers to any small force that is repeatedly applied to the
structures over a long period of time. Activities such as bruxism or
clenching can produce microtrauma to the tissues that are being loaded
(i.e., teeth, joints, or muscles)
29

30. EMOTIONAL STRESS
• The emotional centers of the brain have an influence on muscle function.
• Stress affects the body by activating the hypothalamus-pituitary-adrenal
axis (HPA axis)
• The HPA axis, through complex neural pathways, increases the activity of
the gamma efferents, which cause the intrafusal fibers of the muscle
spindles to contract.
• This so sensitizes the spindle that any slight stretching of the muscle will
cause a reflex contraction. The overall effect is an increase in tonicity of
the muscle 30

31. DEEP PAIN INPUT
• Deep pain input can centrally excite the brainstem producing a muscle
response known as protective co-contraction.
• This represents a normal healthy manner in which the body responds to
injury or threat of injury.
• Therefore it is reasonable to find a patient who is suffering with pain, such
as toothache (i.e., necrotic pulp), to have limited mouth opening.
• This represents the body’s response to protect the injured part by limiting
its use.
31

32. 32

33. 33

34. 34

35. 35
TREATMENT OF
FUNCTIONAL
DISTURBANCES OF
THE MASTICATORY
SYSTEM

36. 1. General Considerations In The Treatment Of
Temporomandibular Disorders
36
3. Treatment of Temporomandibular Joint Disorders
2. Treatment of Masticatory Muscle Disorders
4. Treatment of Chronic Mandibular Hypomobility
and Growth Disorders
5. Occlusal Appliance Therapy

37. • Definitive Treatment
• Definitive therapy is aimed directly toward the elimination or
alteration of the etiologic factors that are responsible for the
disorder.
• For example, definitive treatment for an anterior displacement of
the articular disc will reestablish the proper condyle-disc
relationship.
37
1. General Considerations In The Treatment Of
Temporomandibular Disorders

38. • Supportive Therapy
• Supportive therapy is directed toward altering the patient’s
symptoms and often has no effect on the etiology of the
disorder.
• A simple example is giving a patient aspirin for a headache
that is caused by hunger. The patient may feel relief from the
headache, but there is no change in the etiologic factor
(hunger) that created the symptom.
• Supportive therapy is directed toward the reduction of pain and
dysfunction.
38

39. • The two general types of supportive therapies are
Pharmacologic Therapy
 Physical Therapy
1. Pharmacologic Therapy
• The most common classes of pharmacologic agents used for the
management of TMD are analgesics, antiinflammatories, muscle
relaxants, anxiolytics, antidepressants, anticonvulsives,
injectables, and topicals.
39

40. 2. Physical Therapy
• Physical therapy represents a group of supportive activities
that is usually instituted in conjunction with definitive treatment.
• Most physical therapy fits into one of two general categories:
modalities and manual techniques
40

41. 41
a)THERMOTHERAPY
(moist heat)
b)COOLANT THERAPY,
(ice pack and Fluoromethane spray)
c)IONTOPHORESIS TREATMENT d)ULTRASOUND THERAPY
e)TRANSCUTANEOUS
ELECTRICAL NERVE
STIMULATION (TENS)
Physical Therapy Modalities- types:
f)ELECTROGALVANIC
STIMULATION THERAPY,
g)LASER.
h) PHONOPHORESIS,

42. • Manual Techniques
Manual techniques are the “hands-on” therapies provided by the
physical therapist for the reduction of pain and dysfunction.
• Manual techniques are divided into three categories:
soft tissue mobilization,
 joint mobilization, and
muscle conditioning.
42

43. 43
MASSAGE THERAPY
SOFT TISSUE MOBILIZATION. JOINT MOBILIZATION
JOINT DISTRACTION OF THE TMJ

44. 44
MUSCLE CONDITIONING
ASSISTED MUSCLE STRETCHING
PASSIVE MUSCLE STRETCHING.
RESISTANCE EXERCISES
A. The patient is instructed to open against gentle
resistance provided by the fingers. This will
promote relaxation in the elevator muscles,
thus allowing increased mandibular opening.
B. When eccentric movement is limited the
patient can be asked to move in the eccentric
position with gentle resistance from the fingers.
These exercises are repeated 10 times each
session, six sessions a day. If they elicit
pain,they are discontinued.
A B

45. Acupuncture-
• Stimulation of acupuncture points appears to
cause the release of endogenous opioids
(endorphins and enkephalins), which reduce
painful sensations by flooding the afferent
interneurons with subthreshold stimuli.
• These effectively block the transmission of
noxious impulses and thus reduce the
sensations of pain.
45
These needles are maintained in
place for approximately 30 minutes
during which they are twirled every
5 to 10 minutes.

46. • Protective Co-Contraction (Muscle Splinting)
• Local Myalgia (Noninflammatory Myalgia)
• Myospasms (Tonic Contraction Myalgia)
• Myofascial Pain (Trigger Point Myalgia)
• Centrally Mediated Myalgia (Chronic Myositis)
46
2. Treatment of Masticatory Muscle Disorders

47. PROTECTIVE CO-CONTRACTION
(MUSCLE SPLINTING)
• Protective co-contraction is the initial response of a muscle to
altered sensory or proprioceptive input or injury. This response
has been called protective muscle splinting .
• In the presence of altered sensory input or pain, antagonistic
muscle groups seem to activate during movement in an
attempt to protect the injured part. Therefore, pain felt in the
masticatory system can produce protective co-contraction of
masticatory muscles.
47

48. • protective co-contraction is not a pathologic condition but a normal
physiologic response of the musculoskeletal system.
Etiology
1. Altered sensory or proprioceptive input.
2. The presence of constant deep pain input.
3. Increased emotional stress.
• Protective co-contraction only remains a few hours or days. If it is not
resolved, local myalgia is likely to follow.
48
P. Co-Contraction

49. Clinical Characteristics
1. Structural dysfunction: Decreased range of
movement.
2. There is very minimal pain at rest.
3. There is increased pain to function.
4. The patient reports a feeling of muscle
weakness.
49
This patient bites his cheek
causing acute tissue injury
and pain. This pain led to
protective co-contraction.
P. Co-Contraction

50. TREATMENT
• Protective co-contraction is a normal CNS response and
therefore there is no indication to treat the muscle condition
itself. Treatment should instead be directed toward the reason
for the co-contraction.
• When co-contraction results from trauma, definitive treatment is
not indicated since the etiologic factor is no longer present.
• When co-contraction results from a poorly fitting restoration,
altering the restoration is advised.
• If an increase in emotional stress is the etiology then
appropriate stress management.
• Short-term pain medication NSAIDs may be indicated
50
P. Co-Contraction

51. TO BE CONTINUED……..
51

52. 52

53. LOCAL MYALGIA
(NONINFLAMMATORY MYALGIA)
• It is noninflammatory, myogenous pain disorder. It is often the
first response of the muscle tissue to continued protective co-
contraction.
• Local myalgia represents a change in the local environment of
the muscle tissues. It represents the initial response to overuse
of muscle.
53

54. LOCAL MYALGIA (NON-INF. MYALGIA)
Etiology
1. Protracted protective co-contraction secondary to a recent
alteration in local structures.
2. A continued source of constant deep pain
3. Local tissue trauma.
4. Increased levels of emotional stress.
54

55. 1. Structural dysfunction: There is marked decrease in the range
of mandibular movement.
2. There is minimum pain at rest and increased with function.
4. Actual muscle weakness present.
5. There is local tenderness when the involved muscles are
palpated
55
Clinical Characteristics
LOCAL MYALGIA (NON-INF. MYALGIA)

56. • The primary goal in treating local myalgia is to decrease sensory
input (such as pain)
• Achieved by-
1. Eliminate any ongoing altered sensory input.
2. Eliminate any ongoing source of deep pain input.
3. Provide patient education and information on self-management
i.e Advise the patient to restrict mandibular use to within painless
limits.
56
TREATMENT LOCAL MYALGIA (NON-INF. MYALGIA)

57. • If due to bruxism -fabricate an occlusal appliance
for nighttime use while for daytime educate
patient to control it.
• If the above therapies fail to resolve the pain
condition, the clinician may consider the use of a
mild analgesic.
• such as aspirin, acetaminophen, or an NSAID
(i.e., ibuprofen), can be helpful.
57
LOCAL MYALGIA (NON-INF. MYALGIA)

58. MYOSPASMS
(TONIC CONTRACTION MYALGIA)
• Myospasm is an involuntary CNS-induced tonic muscle
contraction often associated with local metabolic conditions
within the muscle tissues.
Etiology
1. Continued deep pain input.
2. overuse
3. Idiopathic myospasm mechanisms
58

59. CLINICAL CHARACTERISTICS
• The patient reports a sudden onset of restricted jaw movement
usually accompanied by muscle rigidity.
• Structural dysfunction: There is marked restriction in range of
mandibular movement.
• Acute malocclusion is common.
• There is pain at rest and pain is increased with function.
• The affected muscle is firm and painful to palpation.
59

60. • Two treatments are suggested for acute myospasms.
• The first is directed immediately toward reducing the spasm
itself while the other addresses the etiology.
1. Pain Reduction- can be achieved by manual massage,
vapocoolant spray, ice, or even an injection of local
anesthetic (2% lidocaine without a vasoconstrictor is
recommended.)
2. Etiology reduction When the myospasms are secondary to
fatigue and overuse, patient is advised to rest the muscle.
• Idiopathic - may represent an oromandibular dystonia
60
TREATMENT

61. MYOFASCIAL PAIN
(TRIGGER POINT MYALGIA)
• Myofascial pain is a regional myogenous
pain condition characterized by local areas
of firm, hypersensitive bands of muscle
tissue known as trigger points.
61

62. Etiology-
1. Continued source of deep pain input.
2. Increased levels of emotional stress.
3. The presence of sleep disturbances.
4. Local factors that influence muscle activity such as habits,
posture, muscle strains, or even chilling.
5. Systemic factors such as nutritional inadequacies, poor
physical conditioning, fatigue, and viral infections.
6. Idiopathic trigger point mechanism. 62
Myofascial Pain

63. 63
TREATMENT
Myofascial Pain
1. Eliminate any source of ongoing deep pain.
2. If a sleep disorder is suspected, Often, low dosages
of a tricyclic antidepressant,such as 10 to 20 mg of
amitriptyline before bedtime, can be helpful.
3. elimination of the trigger points, by painlessly
stretching the muscle containing the trigger points.
• Spray and Stretch, Pressure and Massage,
Ultrasound and Electrogalvanic Stimulation,
Injection and Stretch.

64. • A medication such as cyclobenzaprine (Flexeril), 10 mg before
sleep can often reduce pain but the trigger points still need to
be treated.
• Muscle relaxants help convert an active trigger point into a
latent or dormant trigger point but may not necessarily
eliminate it.
• Analgesics may also be helpful in interrupting the cyclic effect
of pain.
64
TREATMENT

65. CENTRALLY MEDIATED MYALGIA
(CHRONIC MYOSITIS)
• Centrally mediated myalgia is a
chronic, continuous muscle pain
disorder originating predominantly
from CNS effects that are felt
peripherally in the muscle tissues.
65
The illustration depicts how central
activation of the hypothalamus, the
limbic structures and the cortex can
combine to produce an antidromic effect
to the muscle tissues.

66. Etiology
• Chronic centrally mediated myalgia may be caused by the
prolonged input of muscle pain associated with local myalgia or
myofascial pain.
• Chronic upregulation of the autonomic nervous system
• Chronic exposure to emotional stress
• Other sources of deep pain input.
66

67. CLINICAL CHARACTERISTICS
1. Structural dysfunction
2. There is significant pain at rest and pain is increased with
function.
4. There is a generalized feeling of muscle tightness.
5. There is significant pain on muscle palpation.
67

68. • Restrict mandibular use to within painless limits
• Avoid exercise and/or injections. Since the muscle tissue is
neurogenically inflamed, any use increases pain.
• The patient should rest the muscles as much as possible.
• Disengage the teeth by a stabilization appliance.
• Begin taking an antiinflammatory medication.
• If a sleep disorder is suspected, Often, low dosages of a tricyclic
antidepressant is advised at bedtime.
68
TREATMENT

69. • This internal physiology is only under the
control of the patient, not the clinician. That is
why the patient needs to understand this
relationship and work on changing behavior
that will downregulate the autonomic nervous
system.
• Physical self regulation plays important role
in its treatment
69
TREATMENT
Application of moist heat or
cold can be helpful for
chronic centrally mediated
myalgia

70. • Disc displacement and disc displacement with intermittent
locking
• Disc displacement without reduction
• Structural incompatibility Deviation in form and Adhesions
• Subluxation and Luxation
• Capsulitis, Retrodiscitis, and Acute Trauma to the TMJ
• Osteoarthritis
• Infectious arthritis 70
3.Treatment of Temporomandibular Joint Disorders
Inflammatory
disorders

71. Etiology
• Disc derangement disorders result from elongation of the capsular
and discal ligaments coupled with thinning of the articular disc.
Clinical Characteristics
• The clinical examination reveals a relatively normal range of
movement with restriction only associated with the pain.
• Discal movement can be felt by palpation of the joints during
opening and closing.
• Deviations in the opening pathway .
71
Disc displacement and disc displacement with
intermittent locking

72. • Anterior positioning appliance to reposition to
condyle back on the disc.
• It was originally suggested that this appliance be
worn 24 hours a day for as long as 3 to 6 months.
• The patient needs to be encouraged to decrease
loading of the joint whenever possible. Softer
foods, slower chewing,and smaller bites should be
promoted.
72
TREATMENT

73. • If inflammation is suspected, an NSAID should be prescribed.
• Moist heat or ice can be used.
• Active exercises are not advised.
73

74. SO YOU ALL MIGHT BE WONDERING
HOW DOES THIS WORKS ??
74

75. 75
In the resting closed joint
position the disc is anteriorly
displaced from the condyle
A C
B
Maxillary occlusal
appliance is placed which
creates an occlusal
condition that requires the
mandible to shift slightly
forward.
Note that when the
appliance is in place & the
teeth are occluding, the
condyle is repositioned on
disc in normal condyle-disc
relationship.
Anterior Positioning Appliance

76. 76
An anteriorly displaced disc
with the condyle articulating on
the retrodiscal tissues
producing pain.
APA is placed in mouth to
bring the condyle forward,off
of the retrodiscal tissues onto
the disc. This relationship
reduces the loading of the
retrodiscal tissues, which
decreases the pain.
Once the tissues have
adapted, the appliance is
removed. Condyle now
functions on the adaptive
fibrotic tissues resulting in
a painless functioning joint,
but because the disc is still
displaced, clicking may still
be present.
A C
B

77. DISC DISPLACEMENT WITHOUT REDUCTION
• Disc displacement without reduction is a clinical condition in
which the disc is totally displaced (dislocated) and does not
return to normal position with condylar movement.
Etiology
• Macrotrauma and microtrauma are the most common causes of
disc displacement without reduction.
77

78. • A sudden change in range of mandibular movement occurs.
• Examination reveals limited mandibular opening with some slight
defection to the ipsilateral side.
Treatment
• Fabricating an anterior positioning appliance is contraindicated for
this patient, as it will aggravate the condition by forcing the disc
even more forward.
• Recapture the disc by manual manipulation.
78
Clinical Characteristics

79. 79
TREATMENT
• Technique for Manual Manipulation.
The clinician’s right thumb is placed intraorally over the
patient’s left mandibular second molar and the mandible is
grasped. With the left hand stabilizing the cranium, gentle but
firm force is applied downward on the molar and upward on the
chin to distract the joint.

80. • Once the joint is distracted, the mandible is brought forward and
to the right, enabling the condyle to move into the area of the
displaced disc. When this position is achieved, constant
distractive force is applied for 20 to 30 seconds while the patient
relaxes.
80
TREATMENT

81. • After the distraction, the thumb is removed and the patient is
asked to close on the anterior teeth, maintaining the jaw in a
slightly protrusive position.
• When the patient has rested a moment, he or she is instructed
to open maximally. If the disc has been reduced, a normal
range of movement (48 mm) will be possible.
81
TREATMENT

82. • Patients should be encouraged not to open too wide, especially
immediately following the disc displacement without reduction.
• The patient should also be told to decrease hard biting, no chewing
gum.
• If pain is present, heat or ice may be used. NSAIDs are indicated
for pain and inflammation.
• Joint distraction and phonophoresis over the joint area may be
helpful.
82
TREATMENT

83. • Surgical Considerations for Condyle-Disc Derangement Disorders
• Arthrocentesis- In this procedure, two needles are placed into the
joint and sterile saline solution is passed through lavaging the joint.
• Arthroscopy- With this technique, an arthroscope is placed into the
superior joint space and the intracapsular structures are visualized
on a monitor. (diagnostic)
• Arthrotomy- Open joint surgery
• Discal Repair Or Plication- During a plication procedure, a portion of
the retrodiscal tissue and inferior lamina is normally removed and
the disc is retracted posteriorly and secured with sutures
83
TREATMENT

84. STRUCTURAL INCOMPATIBILITY DEVIATION IN
FORM AND ADHESIONS
Deviation in Form-
• Includes a group of disorders that is created by changes in the
smooth articular surface of the joint and disc. These changes
produce an alteration in the normal pathway of condylar movement.
• The etiology of most deviations in form is trauma.
Adherences/Adhesions
• Adherences represent a temporary sticking of the articular surfaces
during normal joint movements. caused by a fibrosis attachment of
the articular surfaces. 84

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Deviation in Form
and Adhesions
TREATMENT

86. SUBLUXATION AND LUXATION
Subluxation
• Subluxation or hypermobility is a clinical description of the condyle as
it moves anterior to the crest of the articular eminence.
• It is not a pathologic condition but a variation in anatomic form of the
fossa.
Luxation
• This condition is commonly referred to as an openlock since the
patient’s mouth is wide open and cannot reduce it.
• It can occur following wide-open mouth procedures such as having a
dental appointment.
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87. 87
Subluxation
and Luxation
TREATMENT

88. CAPSULITIS, RETRODISCITIS, AND ACUTE
TRAUMA TO THE TMJ
Capsulitis-
• An inflammatory condition of the capsular
tissues
Retrodiscitis-
• An inflammatory condition of the retrodiscal
tissues.
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Retrodiscitis

89. 89
Capsulitis,
Retrodiscitis,
and Acute
Trauma to the
TMJ.
TREATMENT

90. OSTEOARTHRITIS
• Arthritis means inflammation of the articular surfaces of the
joint.
• Osteoarthritis is one of most common arthritis affecting the
TMJ.
Etiology
• overloading of the articular structures of the joint.
90

91. 91
Osteoarthritis
TREATMENT

92. A. Chronic Mandibular Hypomobility-
• The predominant feature of this disorder is the inability of the
patient to open the mouth to a normal range.
• Chronic mandibular hypomobility is rarely accompanied by
painful symptoms.
• subdivided into three categories according to etiology:
• ankylosis, muscle contracture, and coronoid impedance.
92
4. Treatment of Chronic Mandibular Hypomobility
and Growth Disorders

93. ANKYLOSIS
93
• Abnormal immobility of a joint.
• The two basic types of ankylosis are differentiated by
the tissues that limit the mobility: fibrous and bony.
• Fibrous ankylosis - most common and can occur
between the condyle and the disc or the disc and the
fossa.
• Bony ankylosis of TMJ- would occur between the
condyle and fossa and therefore the disc is mostly
absent from the discal space prior to the ankylosis.

94. • Etiology- The most common etiology of ankylosis is
hemarthrosis (bleeding within the joint).
• Chronic inflammation aggravates the disorder leading to the
development of more fibrous tissue.
• Management-
• If function is inadequate or the restriction is intolerable, surgery
is the only definitive treatment available.
94

95. MUSCLE CONTRACTURE
• MYOSTATIC CONTRACTURE
• Myostatic contracture results when a muscle is kept from
fully lengthening (stretching) for a prolonged time.
• For example if the mandible is fractured and wired
together with maxilla for 6 to 8 weeks the elevator muscles
cannot fully lengthen.
• Management -The resting length of the muscles can be
reestablished by two types of exercise: passive stretching
and resistant opening.
• Thermotherapy and ultrasound are also helpful.
95

96. Myofibrotic Contracture-
• Myofibrotic contracture occurs as a result of excessivev tissue
adhesions within the muscle or its sheaths.
• These fibrosis tissue adhesions prevent the muscle fibers from
sliding over themselves disallowing full lengthening of the
muscle.
• Etiology-myositis or trauma to the muscle tissues.
• Management - surgical detachment of the muscles involved.
96

97. CORONOID IMPEDANCE
• If the pathway of coronoid process is impeded,
it will not slide smoothly and the mouth will not
fully open.
• Etiology- Coronoid impedance is generally due
to either elongation of the process or the
encroachment of fibrous tissue.
• Management- 1. surgery, that either shortens
the coronoid process or eliminates the tissue
obstruction ( if function is severely impaired).
2. Gentle passive stretching
97
very long coronoid process

98. B. GROWTH DISORDERS
• Common growth disturbances of the bones are agenesis (no
growth), hypoplasia (insufficient growth), hyperplasia (too
much growth), or neoplasia (uncontrolled, destructive growth).
98
Congenital and Developmental Bone Disorders

99. Condylar Hyperplasia-
• Bone disease characterized by the increased
development of one mandibular condyle
• Management -Condylectomy and orthognathic
surgery, Mandibular ramus osteotomy
Condylar Hypoplasia-
• Known as underdevelopment of condyle
• Management - orthognathic surgery, distraction
osteogenesis, surgery with costochondral bone graft
99
Hyperplasia
Hypoplasia

100. • An occlusal appliance is a removal device made of hard acrylic
that fits over the occlusal surfaces of the teeth in one arch.
• It is commonly referred to as an occlusal splint, bite guard, night
guard, interocclusal appliance, or even orthopedic device .
• Occlusal appliances provides an occlusal condition that allows
the condyles to assume their most orthopedically stable joint
position.
• They are also used to protect the teeth and supportive structures
from abnormal forces that may create breakdown and tooth
wear 100
5. Occlusal Appliance Therapy

101. • The two most commonly used are the
stabilization appliance (muscle relaxation
appliance) and the anterior positioning appliance
(orthopedic repositioning appliance).
• Other types are the anterior bite plane, the
posterior bite plane, the pivoting appliance, and
the soft or resilient appliance
101
stabilization appliance
anterior positioning appliance

102. REFERENCES:
• B D Chaurasia; Human Anatomy For Dental Students 3rd
Edition.
• Jeffrey P. Okeson, DMD 8th Edition
• Peterson’s Principles Of Oral And Maxillofacial Surgery 2nd
Edition.
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