2. Temporomandibular Joint
Disorders and Facial Pain
Dr. ABDUL WAHID
Associate Professor
FCPS (Pak), FFDRCSI-A final (Ireland).
Oral & Maxillofacial Surgery.
3. Learning Objectives
• Normal anatomy (Various Components and
nerve supply).
• Normal Movements (Mouth opening,
protrusive, Retrosive and lateral) .
• Clinical Examination of joint.
• Investigation of the joint.
4. • D/D of joint pain.
• Diagnosis of joint disorders. (Joint
pain/Tmpds, Ankylosis , Dislocation joint).
• Management of Joint Disorders (Reversible
and non reversible).
• Complication of Joint Surgery.
• Follow up Exercise.
7. Articulatory System
The articulatory system comprises of the following:
a. Temporomandibular joint (TMJ)
b. Masticatory and accessory muscles.
c. Occlusion of the teeth.
• The function is governed by sensory and motor
branches of the third division of the trigeminal
nerve (mandibular nerve) and
• Few fibers of the facial nerve.
8. temporomandibular Joint Capsule
• The capsule is a thin sleeve of fibrous tissue
investing the joint completely.
• It is a funnel shaped capsule, which blends
with the periosteum of the mandibular neck
and it envelops the meniscus.
13. • The meniscus or an intervening disk divides
the articular space into two compartments:
1. Lower or inferior compartment—
condylodiskal complex between the condyle
and the disk.
2. Upper (temporodiskal) or superior
compartment between the disk and the
temporal bone or glenoid fossa.
14. • The disk is a firm but flexible structure.
• Anterior band is moderately thick (about 2
mm), but narrow anteroposteriorly. The
thickest and widest is the posterior band (3
mm), whereas the intermediate band is the
thinnest (1 mm).
15. • The volume of the upper joint space is about
1.2 ml and of the lower joint space is about
0.9 ml.
16. The synovial tissue
• It is a connective tissue membrane, which
lines the joint cavities or spaces and secretes
synovial fluid for lubrication of the joint.
17. Function of the synovium
• It provide to the joint:
• lubrication
• nutrition,
• phagocytosis and
• immunological response
18. Blood Supply
• superficial temporal branch of the external
carotid artery.
• Nerve Supply:
• Three branches from the mandibular nerve send
terminals to the joint capsule.
• The largest is the auriculotemporal nerve
• Masseteric nerve.
• A branch from the posterior deep temporal
nerve.
19. Movements
• The mandible can be
• depressed,
• elevated,
• Protruded
• Retruded and
• Lateral excursions
20. • The movements of TMJ are manifold.
• It is ginglymus,diarthroidial type of joint,
• As it is capable of rotating around more than
one axis and is capable of hinge/rotatory
movement
21. Jaw opening (depression)
• It is dominated by digastric muscle
contraction, which depresses the body of the
mandible.
• This action is assisted by the suprahyoid,
sternohyoid and geniohyoid muscles.
• The lateral pterygoid muscle is believed to be
the ‘trigger’ for opening and contracts to pull
the condylar head downward and forward on
the articular eminence.
22. Jaw closure (elevation)
• Simultaneous contraction of the masseter,
medial pterygoid, and temporalis muscles.
24. Retrusion
• Posterior fibers of temporalis muscle, assisted
by middle and deep parts of the masseter,
digastric and geniohyoid muscles.
25. Lateral movements
• These are carried out by unilateral contracture
of medial and lateral pterygoid of each side
acting alternatively.
26. Joint Type
• The TMJ is thus classified as:
• Complex, multiaxial, synovial, bicondylar and
ginglymodiarthrodial type of joint. It is highly
specialized unique joint and has got many
distinctive characteristics:
27. • Articular surfaces of TMJ are not covered by a
hyaline cartilage, but by an avascular
fibrocartilage.
• The right and left articulations are connected
by the mandible, the movements are coupled.
• Mandible is stabilized by three functionally
linked articulations—the dentition and the
two TMJs.
33. Radiographic Evaluation
• Radiographs of the TMJ are helpful in the
diagnosis of:
• intra-articular,
• osseous, and
• soft tissue pathologic conditions.
35. Anatomy over view of the joint
• A young patient has limited mouth opening
and deviated mandible to the lift side and
flatness of mandible on the opposite side. The
vital signs are normal and the radiograph
shows elongated condyle and ramus on the
right side.
36. ???????????
• What are the normal range of movements
• What are muscles involve in the movement of
mandible.
• Name different types of ligaments.
• What types of joint it is?
• Name types of joint spaces.
• What structure secretes synovial fluid.
• Name muscles which elevate and depress
mandible.
37. • Which nerve supply the joint.
• Which artery supply the joint.
• What are the different zones of meniscus of
the joint.
• What is the difference between TM joint and
other joint of the body.
38. CLASSIFICATION OF TMJ DISORDERS
• MYOFASCIAL PAIN
• DISK DISPLACEMENT DISORDERS
– Anterior Disk Displacement with Reduction
– Anterior Disk Displacement Without Reduction
• CHRONIC RECURRENT DISLOCATION
38
42. Myofascial Pain
• Masticatory pain and limited function for
which patients seek dental consultation and
treatment.
• Pain and dysfunction is muscular, with
masticatory muscles developing tenderness
and pain as a result of abnormal muscular
function or hyperactivity.
43. • The muscular pain is frequently, but not
always, associated with daytime clenching or
nocturnal bruxism.
44. causes
• Bruxism resulting from stress and anxiety.
• Occlusion being a modifying or aggravating
factor.
• Internal joint problems such as disk
displacement disorders or
• Degenerative joint disease.
45. Clinical features
• Diffuse, poorly localized, preauricular pain.
• Muscles of mastication such as the
1. Temporalis and
2. Medial pterygoid muscles.
• Nocturnal bruxism.
• Pain is frequently more severe in the morning.
46. • Decreased jaw opening with pain during
functions such as chewing.
• Headaches, bi-temporal in location.
• Pain is often more severe during periods of
tension and anxiety.
47. Clinical Examination
• Diffuse tenderness of the masticatory
muscles.
• TMJs are frequently non tender to palpation.
• In isolated MPD, joint noises are usually not
present.
• Range of mandibular movement in patients
with MPD may be decreased.
• Deviation of the mandible toward the affected
side.
49. Articular
• Amount of oral opening and lateral excursions.
• Extent of movement.
• Range of motion
• Active Range of motion.
• Passive Range of motion.
50. Muscular
• Location of muscle pathology.
• Location of trigger point.
• Evaluation of temperature changes.
• Location of swelling.
• Identification of anatomic land marks.
55. Radiographical Examination
• TMJs are usually normal.
• Degenerative changes.
1. altered surface contours,
2. erosion, or
3. osteophytes.
56. Diagnostic injection
• Muscle trigger point injection.
• When muscle injection is given , use of
vasoconstrictor is contraindicated.
• Auriculotemporal nerve block for true TMJ
pain.
57. Aims Treatment
• Reducing pain and discomfort,
• Decreasing inflammation in muscles and
joints, and
• Improving jaw function.
58. Treatment
• Reassurance and explanation to patients
• Jaw rest and soft diet.
• Analgesics/anti-inflammatory drugs
• Occlusal splints to interfere with parafunction
may offer some help
• Physiotherapy
• Muscle relaxants.
59. • In the case of anterior disk displacement
without reduction.
• Gradual progression of increased opening and
decreased discomfort without extensive
treatment.
• Result of physiologic and anatomic adaptation
of tissue within the joint.
60. Patient Education
• Patients must be aware of the pathologic
condition producing their pain and
dysfunction.
• A confident explanation should attempt to
assure the patient that muscular pain usually
improves with minimal treatment.
61. • Myofascial pain often results from
parafunctional habits or muscular
hyperactivity resulting from stress and anxiety.
• Patients awareness will control their activity
result in reduce discomfort and improve
function.
• Biofeedback devices provide information to
patients to help them control their muscular
activity.
62. • Stress control such as
• physical exercise reducing exposure to
stressful situations, and
• Psychological counseling.
63. • Modification of diet combined with home
exercise routines are also an important part of
the patient’s educational process.
• Aggravating factors, including
• chewing of gum, fingernails and ice cessation
or limitation of these activities should be
encouraged.
72. Stabilization Appliance
• Stabilizes temporomandibular joints
• Redistribution of forces
• Relaxation of masticatory muscle
• Hard acrylic
• Maxillary arch
• Wear 24 h (except during meals).
73.
74.
75. Repositioning Appliance
• In therapy it attempts to recapture the
anterior displaced disk
• Need for possible occlusal equilibration and
constant adjustment
76.
77.
78. uses
1. Temporary disengage the teeth
2. Create a balanced joint-teeth stabilization of
the mandible.
3. To reduces muscles spasm, contractures and
hyperactivity.
4. To improve and restore vertical dimension
5. To serve as safety or protective appliance
82. Case 1
• Final year MBBS female student come to dental
OPD during exam preparation complaining of
limited mouth opening and diffused pain in the
prearicular region for the last 3 days. o/e the
occlusion has no wear facets and slight deviation
of the mandible on affected side and tenderness
in the muscles of mastication. The radiograph
shows no remarkable finding of the TM joint.
• What is your diagnosis
• How will you manage this case.
83. Case 2
• Middle age male come to OPD with diffuse
pain on both preauricular region with limited
mouth opening without deviation of mouth
for the last one month. o/e the patient has
missing posterior teeth on both side. The
muscles of mastication are tender. o/r missing
lower molar teeth both side.
• What is your diagnosis and treatment.
85. Definition
• It is the disruption of the internal aspects of
the TMJ, in which an abnormal relationship
exists between the disk and the condyle, fossa
and articular eminence.
86. INTERNAL DERANGEMENTS
(Disk displacement disorders)
• Definition:
Abnormal relationship between the disc, condyle,
and the mandibular fossa.
• Types:
1. Anterior disc displacement with reduction
2. Anterior disc displacement without reduction
86
89. Wilkes Staging Classification for Internal
Derangement of the Temporomandibular Joint
1. Early Stage
2. Early/Intermediate Stage
3. Intermediate Stage
4. Intermediate/Late Stage
5. Late Stage
90. Early Stage
a. Clinical: no significant mechanical symptoms,
other than soft, reciprocal clicking; no pain or
limitation of motion
b. Radiologic: slight forward displacement;
good anatomic contour of the disk; normal
computed tomography (CT) scan
c. Surgical: Normal anatomic form; slight
anterior displacement; passive incoordination
(clicking)
91. Early/Intermediate Stage
a. Clinical: first few episodes of pain, occasional
joint tenderness and related temporal headaches,
beginning major mechanical problems, increase
in intensity of clicking
b. Radiologic: slight forward displacement, slight
thickening of the posterior edge or beginning
anatomical deformity of disk, and normal CT scan
c. Surgical: anterior displacement, early anatomical
deformity (mild thickening of posterior edge of
disk), and well-defined central articulating area
92. Intermediate Stage
a. Clinical: multiple episodes of pain, joint tenderness,
temporal headaches, major mechanical symptoms—
intermittent catching or locking and sustained locking,
restriction of motion and pain with function
b. Radiologic: anterior displacement with significant
deformity of the disk (moderate to marked thickening
of posterior edge) and normal CT scan
c. Surgical: marked disk deformity with displacement,
variable adhesions and no hard-tissue changes
93. Intermediate/Late Stage
a. Clinical: chronic pain with variable and episodic
acute pain, headaches, variable restriction of
motion, and undulating course
b. Radiologic: increase in severity over intermediate
stage, abnormal CT scan, and early to moderate
degenerative remodeling hard-tissue changes
c. Surgical: increase in severity over intermediate
stage, hard-tissue degenerative remodeling
changes of both bearing surfaces, osteophytes,
multiple adhesions, and no perforation of disk or
attachments
94. Late Stage
a. Clinical: characterized by crepitus, grinding symptoms,
variable and episodic pain, chronic restriction of
motion, and difficulty with function
b. Radiologic: anterior displacement, perforation with
simultaneous filling of upper and lower joint space,
filling defects, gross anatomic deformity of disk and
hard tissue, abnormal CT scan as described, and
degenerative arthritic Changes
c. Surgical: gross degenerative changes of disk and hard
tissues, perforation of posterior attachments, erosions
of bearing surfaces, and multiple adhesions
95. 1. Anterior disc displacement with reduction
• In closed mouth position , the disc is positioned anterior and
medial to the condyle (abnormal relationship).
• During mouth opening, the Condyle moves into a normal
condyle and disk relationship.
• During closing, the disc again assumes abnormal relationship.
95
97. 2. Anterior disc displacement WITHOUT reduction
• Disc displacement cannot be reduced.
• Condyle is unable to translate to its full anterior extent:
– prevents maximal mouth opening
– deviation of the mandible to affected side
• NO clicking occurs
• MRI
97
98. REVERSIBLE TREATMENT
• Non surgical initial treatment is aimed at:
– Reducing pain and discomfort
– Decreasing inflammation in muscles and joints
– Improving jaw function
• Involves :
a. Patient education
b. Medication
c. Physical therapy
d. Splint therapy
98
OCCLUSAL SPLINT
99. Repositioning Appliance
• In therapy it attempts to recapture the
anterior displaced disk
• Need for possible occlusal equilibration and
constant adjustment
102. Case 1
• Final year MBBS female student come to dental OPD
during exam preparation complaining of diffused pain
in the prearicular region with tmjoint clicking on the
left side for the last 3 days. o/e the occlusion has no
wear facets and slight deviation of the mandible and
clicking of joint on affected side during opening and
closing of mouth and tenderness in medial pterygoid
muscle. The mouth opening is normal on full excurtion
of the mandible.The MRI shows slight change of
position of the disk in rest position of the TM joint.
• What is your diagnosis
• How will you manage this case.
103. Case 2
• Middle age male come to OPD with diffuse
pain on preauricular region with limited
mouth opening with deviation of mouth for
the last one month. o/e the patient has the
medial pterygoid muscle and TM joints are
tender and limited mouth opening in full
excurtion. o/r MRI shows change of disc
position .
• What is your diagnosis and treatment.
106. Dislocation and Subluxation
• During normal or unstrained opening of the
mouth, the condylar heads translate forward
to a position under the apices of the articular
eminences.
• If oral opening proceeds to its maximum
capacity, the condylar heads move to the
anterior slope of the articular eminences in
many normal individuals.
107. • Excursion of the condylar heads beyond these
limits may be viewed as abnormal and termed
as dislocation.
• The dislocation can be unilateral or bilateral.
• Types of dislocation:
1. Acute
2. Chronic recurrent (habitual) subluxation
3. Long-standing.
108. TMJ DISLOCATION
• NORMAL MOUTH OPENING: The condylar heads translate
forward to a position under the articular eminences.
• DISLOCATION: Excursion of the condylar heads beyond these
limits.
108
110. DISLOCATION
• Occurs when relocation of
condyle back to its normal
position in glenoid fossa doesn't
occurs voluntarily.
• It can occur as single acute event
or as chronic recurrent episodes.
110
111. Causes of Acute Dislocation
• Anterior acute dislocation
• The normal anatomic relationships within the
joint have been completely disrupted, with
the condyle fixed anterior to the articular
eminence.
a. Extrinsic forces or iatrogenic causes
b. Intrinsic or self-induced forces
112. CAUSES:
EXTRINSIC (IATROGENIC) CAUSES:
• Trauma:- blow on chin with mouth open.
• Excessive pressure on mandible,
during extraction.
INTRINSIC ( SELF-INDUCED) CAUSES:
• Wide opening of mouth:- eating, excessive
yawning, vomiting, singing or laughing loudly
• Hysterical fits.
PREDISPOSING FACTORS:
• Laxity of ligaments, capsule.
• Malocclusion.
• Flattened articular eminence
• Diseases: Epilepsy , Ehlers-Danlos Syndrome
112
113. Clinical features
UNILATERAL ACUTE
DISLOCATION:
• Deviation of chin towards
contralateral side.
• Lateral cross & open bite on
contralateral side.
• Pre-auricular hollow on same
side.
• Difficulty in mastication &
speech.
113
114. Clinical features
BILATERAL ACUTE DISLOCATION:
• Pain
• Inability to close mouth
• Protruding chin
• Excessive salivation
• Difficulty in speech
• Gagging of molar teeth with anterior
open bite
• B/L Pre-auricular hollow
114
115. Management
• The major problem in reduction of dislocation
is overcoming the resistance of the severe
muscle spasm.
(i) reassuring the patient,
(ii) tranquilizer or sedative drugs,
(iii) pressure and massage to the area, and
(iv) manipulation
116. Manipulation procedure
• Remains the same irrespective of the type of
anesthesia used.
• Under local anesthesia the patient will be
seated in a dental chair, while under general
anesthesia the patient is made to lie on th
operation table in a supine position.
• First of all, the patient should be given
assurance about the procedure and asked to
relax completely in a dental chair.
117. • Normally, the dislocation is maintained by
muscle
• spasm secondary to painful stimuli arising
from the capsule.
• Few drops of local anesthetic solution may be
injected in the glenoid fossa which will
eliminate the pain factor and spontaneous
reduction may be brought about due to
elimination of a neural reflex.
118. Manipulation
1. Manipulation without any form of anesthesia.
2. Manipulation with local anesthesia.
3. Manipulation under general anesthesia /
sedation with muscle relaxants.
119.
120. Management
PALLIATIVE: Reassurance, tranquilizers or sedative drugs,
pressure & massage to the area.
MANIPULATION PROCEDURES:
• Manipulation without anesthesia
• Manipulation under L.A.
• Manipulation under G.A.
120
122. Management
• IMF WITH ELASTICS:- 3-4 weeks; gives rest to the joint.
• INJECTING SCLEROSING SOLUTION INTO THE JOINT
SPACE:- Sodium morrhuate; produces fibrosis in the capsule.
• SURGICAL PROCEDURES :- (Miller & Murphy-1976)
• 1. Capsule tightening procedures.
• 2. Creation of mechanical obstacle/block.
• 3. Direct restraint of the condyle.
• 4. Creation of new muscle balance.
• 5. Removal of mechanical obstacle.
122
123. 1. CAPSULE TIGHTENING PROCEDURES:-
• Capsulorrhapy – shortening of capsule by removing a section
& suturing it.
• Reinforcement of the capsule – turning down a strip of
temporal fascia & suturing to the capsule.
• Placement of vertical incision in the capsule- drawing it tightly
by overlapping the edges & suturing.
123
124. 2. CREATION OF MECHANICAL OBSTACLE/BLOCK.
Dautry
silastic block
124
125. 3. DIRECT RESTRAINT OF THE CONDYLE
• Temporalis facia: turned down & sutured to the lateral surface
of the capsule.
• 4. CREATION OF NEW MUSCLE BALANCE.
• Medial pterygoid myotomy
• Temporalis tendon is sutured in a tight horizontal manner.
125
126. 5. REMOVAL OF MECHANICAL OBSTACLE
• Menisectomy
• High condylectomy
• Eminectomy
126
128. Case 1
• A young patient come to OPD with open bite on
lift side having difficulty in close of mouth and in
swallowing for the last 2 hours. O/E patient
unable to close mouth in centric occlussion and
open bite and hollowness on preauricular region
on left side. The muscles of mastication are
tender. O/R lateral view show condylar head
anterior to articular eminence.
• What is your diagnosis?
• How you will manage this case.
129. Case 2
• An edentulous patient complaining of difficulty of
closing the mouth since 1 hour. O/E anterior open
bite and hollowness both side in preauricular
region with stiffness and tenderness of the
muscles of mastication. O/R OPG show both side
condylar head anterior to articular eminance.
• What is your diagnosis?
• What is the immediate and late treatment of this
patient.
