The document discusses internal derangement of the temporomandibular joint (TMJ) and its management. It defines internal derangement as an abnormal positional relationship between the articular disc and mandibular condyle. The broad etiologic categories resulting in internal derangement are macrotrauma, microtrauma, and systemic arthropathy. Management options include non-surgical, minimally invasive, and surgical treatments. Non-surgical options involve splint therapy, medications, and physical therapy. Minimally invasive options include arthrocentesis, arthroscopy, and injections. Surgical options involve procedures to reposition or replace the disc such as discectomy, disc repair/replacement, and condyl

1. INTERNAL DERANGEMENT
OF TMJ AND
IT’S MANAGEMENT
CHANDINI RAVIKUMAR
( PG II )

2. 1. Definition
2. Functional Anatomy of TMJ
3. Biomechanics of TMJ
4. Etiology
5. Pathogenesis
6. Classification
7. Clinical features
8. Diagnosis
9. Investigations
10. Management
CONTENTS

3. DEFINITION
The term ‘temporomandibular joint (TMJ) internal derangement’ refers to clinical
criteria classifying TMJ disorders but is generally used to denote an abnormal
positional relationship of the articular disk to the mandibular condyle and the articular
eminence
(Journal of Oral Rehabilitation 2003 30; 537–543 R. EMSHOFFS.R & A.
RUDISCH)

4. BONY COMPONENTS SOFT TISSUE COMPONENTS
 Condylar head
 Glenoid fossa
 Articular eminence
 Articular disc
 Synovial membrane
 Ligaments
 Muscles
FUNCTIONAL ANATOMY OF TMJ
REFERENCE : OKESON 8TH EDITION

5. FUNCTIONAL ANATOMY OF TMJ

6. • During full opening  condyle rotates along
with anterior translation towards the most
inferior portion of articular eminence
• During function  Biconcave disc remains
interpostional between the condyle and the
fossa with condyle remaining against the thin
intermediate zone during all phases of opening
and closing
• Normal TMJ position : 12 ‘o’ clock ( where
posterior band with be at 12 and intermediate
zone at 1)
BIOMECHANICS OF TMJ

7. [I] The broad etiologic categories resulting in internal derangement are:
• Macrotrauma—major impact to jaw, e.g., sports injury, assault
• Microtrauma—parafunctional habits (clenching and bruxism)
• Systemic arthropathy—rheumatoid, SLE, psoriatic arthritis, HLA B27, infective, etc.
[II] An alternative framework regarding etiology is:
• A normal joint subjected to overload (trauma or parafunction)
• An abnormal joint subjected to normal load (rheumatoid, SLE or psoriatic arthritis, osteochondroma,
chondromatosis)
ETIOLOGY
REFERENCE : Oral and Maxillofacial Surgery for the
Clinician

8. PATHOGENESIS
PROLONGED OVERLOADING OF JOINT
CHRONIC MACRO AND MICRO TRAUMA TO
THE JOINT
OVER STRETCHING OR LAXITY OF THE
RETRODISCAL TISSUES
HYPERACTIVITY OF LATERAL PTERYGOID
MUSCLE
MALRELATIONSHIP / IN COORDINATION OF
CONDYLE-DISC MOVEMENT
INTERNAL DERANGEMENT OF TMJ
Oral Maxillofacial Surg Clin N Am 28 (2016) 313–333

9. 1. Direct mechanical trauma
Mechanical overloading  generation of free radicals 
intercellular damage with reduction in reparative
capacity
2. Hypoxia – reperfusion injury
Increased intracapsular hydrostatic pressure (bruxism or
clenching)  hypoxia  joint pressure reduced  free
radicals are formed  intracellular damage
3. Neurogenic inflammation
Compression or stretching of the nerve  pro
inflammatory neuropeptides released  degeneration of
structures
Crit Rev Oral Biol Med 6(3):248-277(1995)

10. WILKES CLASSIFICATION
STAGES
STAGE I Early Painless clicking , anterior disc displacement with reduction
STAGE II Early intermediate Clicking with intermittent pain and locking, anterior disc displacement with reduction
STAGE III Intermediate Pain, joint tenderness, frequent and prolonged locking, restricted motion, anterior
disc displacement with or without reduction, no degenerative changes
STAGE IV Intermediate-late Chronic pain, restricted motion, no clicking, anterior disc displacement without
reduction, degenerative bony changes, adhesions
STAGE V Late Variable pain, painful/reduced function, crepitus, anterior disc displacement without
reduction , advanced degenerative bony changes, gross disc deformity and /or
perforation, advanced adhesions
CLASSIFICATIONS

11. AAOP TAXONOMIC CLASSIFICATION FOR TMDs
1. JOINT PAIN
2. JOINT DISORDERS
3. JOINT DISEASES
4. FRACTURES
5. CONGENITAL / DEVELOPMENTAL DISORDERS
Arthralgia
Arthritis
Disc disorders
Hypomobility disorders other than disc
disorders
Hypermobility disorders
Degenerative joint disease
Systemic arthritides
Condylsis/idiopathic condylar resorption
Osteochondritis dissecans
Neoplasm
Synovial chondromatosis
Osteonecrosis
DC : TMD
AXIS I : PHYSICAL DIAGNOSIS
1. Disc displacement with
reduction
2. Disc displacement with
reduction and intermittent
locking
3. Disc displacement without
reduction and limited opening
4. Disc displacement without
reduction without limited
opening
AXIS II : PSYCHOSOCIAL
STATUS
REFERENC
Oral Maxillofacial Surg Clin N Am 28 (2016) 313–333

12. CLINICAL
FEATURES
• Clinically internal derangements can be categorized into four phases :
Phase I (In-coordination phase) :
• Earliest indication
• No joint click or pain.
• However when asked to open or close the mouth, patient usually complaints of a catching sensation
Phase II (Anterior disc displacement with reduction):
• The articular disc slips anteromedially to the head of condyle
• Mouth opening is accompanied by a clicking or popping sound
• The percussive sound is produced as the condyle passes over the posterior band and returns to a normal
relationship with the disk
• In some patients a second clicking sound is heard during mouth closure, this is referred to as a reciprocal click
and it occurs on the posterior band of the disc as it slips forward of the condyle during closing

13. Phase III (Anterior disc displacement without reduction):
• Here, the disk is located even further forward
• The condyle is unable to pass over the posterior band on attempted opening
Phase IV (Disc adhesion to the articular eminence):
• This is the terminal stage in which due to continuous stretching, there is perforation followed by adhesion of
the disc to the articular eminence.
• Pain, crepitus and muscle tenderness becomes a predominant feature
• Associated invariably with limitation of mouth opening.
REFERENCE Internal derangement of temporomandibular joint etiology,
pathophysiology, diagnosis and management: A review of literature Dr.
Dhananjay Rathod
International Journal of Applied Research 2016; 2(7): 643-649

14. DIAGNOSIS
The diagnosis depends
upon
TAKING PROPER HISTORY: Location , Radiation, Severity, Timing , Duration and
frequency of episodes ,exacerbating factors ,relieving factors, associated symptoms
CLINICAL EXAMINATION: Intraoral and extraoral inspection and
palpation with muscle and joint examination
SEROLOGY : Rheumatoid factor, HLA- B 27, ANA , ACCP
RADIOGRAPHIC EVALUATION : Conventional X-rays , CT, MRI
DIAGNOSTIC LA BLOCK : Auriculotemporal nerve block
REFERENCE : Oral and Maxillofacial Surgery for the
Clinician

15.  Synovial fluid in TMJ provides joint lubrication and
stress distribution, provides nutrients and removing
waste products of collagen and proteoglycan catabolism.
 Intra-articular pathologic conditions are associated with
qualitative and quantitative changes in multiple synovial
fluid biomarkers.
 The biomarkers identified in any given patient may enable
a specific diagnosis to be made, including internal
derangement, synovitis, chondromalacia, and
autoimmune arthritis.
 Biomarkers may be used to monitor disease progression
and response to treatment
Oral Maxillofacial Surg Clin N Am - (2018)

16. INVESTIGATIONS
1. Transcranial view – Good visualization of both the condyle and the fossa
2. Transorbital and Reverse Towne’s projection – Depicts the entire mediolateral dimension of the articular
eminence, condyle and condylar neck.
3. Tomography – Assessing the osseous changes in condyle and eminence
4. Arthrography – Includes injecting a contrast material into the joint prior to radiography. It helps in evaluating the
morphology and position of the disc. However it is not commonly practiced due to the risk of infection, allergy and
potential damage to the disk or capsule
5. Computerized Tomography - Assessing the bony pathologic changes in the joint
6. Magnetic Resonance Imaging –For evaluating the soft tissue of the Temporomandibular joint
7. Temporomandibular joint arthroscopy – It permits direct visualization of the interior of joint with the help of a
small telescope. This technique is utilized for diagnostic and therapeutic modalities
REFERENCE Internal derangement of temporomandibular joint
etiology, pathophysiology, diagnosis and management: A review of
literature Dr. Dhananjay Rathod
International Journal of Applied Research 2016

17. MANAGEMENT
REFERENCE : Oral and Maxillofacial Surgery for the Clinician
Decrease joint overload
Decrease pain
Reduce inflammation
Improvement in the range of motion
Restore function
Causative factors to be identified
TREATMENT
GOALS

18. MANAGEMENT
NON
SURGICAL
MINIMALLY
INVASIVE
SURGICAL

19. NON-SURGICAL TREATMENT
AOMSI, Oral and Maxillofacial Surgery for the Clinician, 2021

20. I. ARTHROCENTESIS
1987- Murakami used a single needle pumping technique to
create a hydraulic distention of the upper joint space.
Nitzan and Dolwick subsequently modified the technique
and used two needles.
Indications
• Ant disc displacement without reduction
• Disc adhesion
• Reducible disc displacement with painful clicking and
popping
Arthrocentesis reduces pain by eliminating inflammatory cells
from the joint space and increases the mandibular mobility by
removing intra-articular adhesions, thus recovering disc and
fossa space which reduces the mechanical obstruction caused
by anterior disc displacement.
MINIMALLY INVASIVE PROCEDURES
Annals of Maxillofacial Surgery, 2019

21. • Provides lysis and lavage of the upper joint space using an
inflow needle, an outflow needle, and at least 300 ml
Lactated Ringer’s irrigation solution.
• Several authors have since reported success rates of
arthrocentesis in the management of internal derangement
ranging from 70 to 95%

22. II. ARTHROSCOPY
• Minimally invasive surgery
• Ohnishi in 1975
• The technique involves insertion of an arthroscope into the upper joint space and performance
of a diagnostic sweep with lysis and lavage.
Levels of TMJ arthroscopy (McCain’s terminology) Level I Arthroscopy sequence

23. 7 points of interest in TMJ
Arthroscopic examination
1. Medial synovial drape
2. Pterygoid shadow
3. Retrodiscal synovium
4. Posterior slope of articular
eminence and glenoid
fossa
5. Articular disc
6. Intermediate zone
7. Anterior recess

25. INTRA-ARTICULAR INJECTIONS
• Local anaesthetic
• Glucocorticoids
• Sodium hyaluronate
• Platelet rich plasma (PRP)
• Dextrose prolotherapy
• Autologous conditioned serum (ACS)
Int. J. Environ. Res. Public Health, 2020

26. PROLOTHERAPY
• Prolotherapy is a regeneration or
proliferation injection therapy, which
aims to rehabilitate the joint structures,
such as ligament or tendon, by
inducing cell proliferation
• Prolotherapy was found to be superior
to splints in reducing pain, and in
improving mouth opening and
clicking.
• Prolotherapy provides long-term relief
of symptoms, so it should be
considered in patients with internal
derangement of TMJ before any
surgical intervention.

27. SURGICAL MANAGEMENT
1. Disc repositioning
2. Disc repair
3. Discectomy alone
4. Discectomy with autologous
graft replacement
5. Condylotomy

28. There are two main indications for disc-repositioning procedures:
1. Patients with painful anterior disc displacement with reduction that has not
responded to nonsurgical and minimally invasive procedures
2. Patients with anterior disc displacement without reduction with persistent pain
and limited mouth opening that has not responded to nonsurgical and
minimally invasive procedure.
I. DISC REPOSITIONING
Peterson’s principles of Oral and Maxillofacial Surgery, 3rd Edition.
 GOAL- to relocate the disk so that its posterior band can be returned to the
normal condyle-disk fossa relationship.

29.  In 1979 McCarty and Farrar first reported surgery to reposition the disc into its normal anatomic relationship
relative to the condyle and fossa.
 One must closely inspect the disc before proceeding with its repositioning.
 The disc should not be distorted or placed under tension during posterior repositioning.
 Intraoperatively, if the disc is amenable to repositioning, it is plicated posteriorly or posterolaterally to return the
anteromedially displaced disc to its more normal anatomic location.
Fonseca, Oral and Maxillofacial Surgery, 3rd Edition.

30. • 3 PROCEDURES:
1. Plication- Remodeled posterior attachment is folded on itself and
the lateral tissues are approximated

31. 2. Full thickness
excision-
Wedge-shaped
portion of the
posterior
attachment is
removed and
the
lateroposterior
tissues are
approximated

32. 3. Partial thickness excision-
Superior lamina of the
retrodiskal tissue and
posterior attachment are
removed, without violation
of the inferior joint space,
and the lateroposterior
tissues are approximated

38. II. DISC REPAIR
 When indicated, perforations of the disc can be managed by
reparative techniques.
 For smaller perforations, the disc can be undermined from the
surrounding soft tissue for a tension-free primary closure with a
non-resorbable suture.
 Larger perforations of a dislocated disc require a more
extensive repair, because the disc is unlikely to reduce after the
margins of the perforation are excised due to more dense
adhesion formation and scarring.
 If the disc cannot be adequately repaired, then the surgeon must
make the decision to replace the disc with either an autologous
or homologous graft, or perform a discectomy.

39. III. DISCECTOMY
 Discectomy should be considered in cases in which the disc is determined to be
unsalvageable due to deformation, perforation, calcification and/or severe
displacement.
 Partial and total discectomies have been described in the literature.
 The goal of surgery is to assist the patient to adapt to the pathology at hand by
removing the physical impediment to movement.

40. 1. Partial discectomy
• The partial diskectomy procedure is used to
correct partial reducing disk displacement.
• The goal of the procedure is to excise the
pathologic posterior attachment and that
portion of the displaced atrophic/resorbed
disk that represents an obstruction or is
presumed to be responsible for terminal
jolting.
• The portion of the disk that is properly
positioned, usually the medial aspect of the
disk, is left in place. This procedure was
recently re-described under the term disk
reshaping.

41. 2. Total discectomy
• Total diskectomy is the procedure in which the
remodeled posterior attachment and entire disk
are excised.
• It is the most extensively used and reported surgical
procedure.
• Total diskectomy has been used to treat the full
gamut of internal derangements, without
consideration for the degree of displacement of disk
morphology, with generally good to excellent
results.
• Diskectomy is indicated in those situations for
which disk repositioning is not feasible because of
disk atrophy, deformation, or severe degeneration.

42. IV. DISC REPLACEMENT
• Autogenous, homologous, and alloplastic replacements for the disk have been
used following diskectomy to prevent or reduce intra-articular adhesions, osseous
remodeling, and recurrent pain.
• In addition, the interpositional material was believed to decrease joint noises by
dissipating loading forces on the osseous surfaces.

43. DISC REPLACEMENT OPTIONS
AOMSI, Oral and Maxillofacial Surgery for the Clinician, 2021

44. 1. TEMPORALIS MYOFASCIAL
FLAPS
Uses
1. Interpositional
graft in the TMJ to
avoid ankylosis
2. Reconstruction of
a joint with
significant
degenerative
remodeling.
3. Replacement
material after
discectomy
Advantages
1. Vascularized flap; maintains a viable blood supply.
2. Versatile; harvested in variable thicknesses to allow
for reconstruction of defects of variable sizes
3. In unilateral cases of ID where the disc is
unrepairable, it can avoid a posterior open bite on the
non-operated side
Disadvantages
1. Flap necrosis
2. Fibrosis or
adhesion
formation within
the joint space

45. 2. AURICULAR CARTILAGE
GRAFTS
 USES
1. Interpositional material after
discectomy
2. Occasionally in ankylosis
treatment
 ADVANTAGES
1. Do not induce foreign body reactions
2. Resists occlusal loading forces
 DISADVANTAGES
1. Requires 2nd donor site
2. Graft may become
prematurely displaced

46. 3. DERMAL GRAFTS

47. INTERPOSITIONAL MATERIAL LIMITATION
Sialastic, Proplast/ Teflon Foreign body reactions
Ear cartilage Fragmentation and Ankylosis
Fat Fragmentation and poor handling
Full-thickness skin Epidermoid cyst formation
Fascia and dermis Insufficient bulk and difficult to anchor
Allogenic grafts Potential cross-infection and
unpredictable Resorption
Temporalis muscle Fibrosis and trismus
Dermis-fat graft Visible scar in donor site
LIMITATIONS OF INTERPOSITIONAL MATERIALS USED TO
REPLACE ARTICULAR DISC FOLLOWING DISCECTOMY

48. V. CONDYLOTOMY
 Campbell described the first condylotomy, a closed procedure performed with a Gigli saw.
 Nickerson modified the procedure in 1983 by changing the osteotomy to that resembling an IVRO.
 Purpose: To increase joint space by allowing the mandibular condyle to move inferiorly with respect to both the
articular disc and eminence.
 Goal: To establish a normal condyle/disc relationship, particularly for Wilkes I, II, and III (early) internal
derangements.
 Indications: Patients with intra-articular pain or locking in association with internal derangement, and recurrent
temporomandibular joint dislocation.
 Advantages: Extra-articular approach that avoids entry into the temporomandibular joint, short duration of the
procedure, and the ability to complete the surgery in an ambulatory setting.
 Disadvantages: Inability to address additional sources of intra-articular pain and locking, such as synovitis, fibrous
adhesions, pseudowalls, osteoarthritis, chondromalacia, and synovial chondromatosis. Furthermore, patients
require arch-bars and a period of elastic maxillomandibular fixation lasting 10 days to 6 weeks.

49. V. CONDYLOTOMY

50. ARTHROPLASTY
• Several authors have advocated combining a disc repositioning procedure with an arthroplasty of the
condyle or the articular eminence.
• Arthroplasty reduces the amount of posterolateral repositioning required and therefore permits
repositioning of an atrophic disk
• The current trend, however, is to avoid removal of any normal articular bone since the postoperative
healing phase already involves some loss of bone substance, which may be additive and result in occlusal
disturbance.
• A 2 to 4 mm condylar-eminence arthroplasty can be performed with rotary or hand instruments.
• In some cases an arthroplasty of the eminence is essentially a lateral tuberculectomy for access and
decompression of the anterior recess of the superior joint space.

53. REFERENCE
S
1. Internal Derangements of the Temporomandibular Joint : Oral Maxillofacial Surg Clin N Am 20 (2008)
159–168
2. Internal Derangement of the Temporomandibular Joint New Perspectives on an Old Problem : Oral
Maxillofacial Surg Clin N Am 28 (2016) 313–333
3. Management of TMJ disorders and occlusion : Jeffrey okeson , 8th edition
4. Oral and Maxillofacial Surgery for the Clinician
5. Internal Derangements of the Temporomandibular Joint Pathological Variations Clyde H. Wilkes
6. Guidelines for Diagnosis and Management of Disorders Involving the Temporomandibular Joint and
Related Musculoskeletal Structures : American Society of Temporomandibular Joint Surgeons
7. Pathogenesis of degenerative joint disease in the human temporomandibular joint : Christine L Haskin

54. THANK YOU