This document discusses the diagnosis of occlusal parafunction and temporomandibular joint (TMJ) disorders. It defines occlusal parafunction as non-functional contact of the teeth that may include teeth clenching, grinding, or tapping. Bruxism is a type of parafunctional activity involving teeth grinding. TMJ disorders involve pain and dysfunction in the jaw joint and muscles controlling jaw movement. Various diagnostic methods and classifications of TMJ disorders are described, including myofascial pain, myospasm, disc displacement with and without reduction, and subluxation.

1. DIAGNOSIS OF OCCLUSAL PARAFUNCTION
AND TMJ DISORDERS

2. CONTENTS
 INTRODUCTION
 OCCLUSAL PARAFUNCTION
 BRUXISM
 TMJ DISORDERS
 TMD CLASSIFICATION
 REFERENCE

3. OCCLUSAL PARAFUNCTION
Parafunctional habits refers to lip biting , nail biting , check biting and teeth
clenching
In dentistry occlusal parafunction mostly focus on teeth grinding or bruxism
CATEGORIES OF PARAFUNCTIONAL ACTIVITY
 Tpye1( no parafunction)- no evidence of wear, mobility , tooth migration ,
muscle soreness , fracture , cracks , craze lines or abfractive lesions
 Type2(moderate)- slight evidence of all lesions is seen
 Type3( destructive)- excessive evidence of a lesion is seen

4. TRIAD OF OCCLUSAL PARAFUNCTION
 Parafunction
 Sleep disorders
 Occlusion
 Pathology
 Adaptive capacity
 Homeostasis

5.  Tooth wear
 Tooth sensitivity or pain
 Abfractions
 Tooth mobility
 Indentations of lateral border of tongue
 Ridging of buccal mucosa
 Maxillary and mandibular exostoses
 Jaw pain or stiffness
 Parotid-masseter syndrome
 Radiographic changes of the condylar region
 Hypertrophy of muscles (masseter and temporalis)
 Headaches
 Neck pain
 Back pain
SIGNS AND SYMPTOMS OF OCCLUSAL PARAFUNCTION

6. BRUXISM
 RAMFJORD (1966) - defined bruxism as a habitual grinding of teeth where
individual is not chewing or swallowing
 RUBINA (1986 ) -defined it as a non functional contact of teeth which may
include clenching , gnashing , grinding , tapping of teeth
 VANDERAS(1995)- defined bruxism as non functional movement of mandible
with or without an audible sound occurring during day or night

7. TYPES
 DAY TIME / DIURNAL BRUXISM
conscious or subconscious grinding of teeth usually during the day . It can occur along
with parafunctional habits such as chewing pencils , nails cheeks , lips
 NOCTURNAL BRUXISM
It is the subconscious grinding of teeth characterized by rhythmic pattern of EMG
activity
ETIOLOGY
 psychological and emotional stresses eg: anxiety, anger, frustration
 Occlusal interference or discrepancy
 Pericoronitis and periodontal pain is said to trigger bruxism in some individuals

8. CLINICAL FEATURES
 Occlusal trauma-resulting in mobility
 Tooth structure- results in occlusal wear, sensitivity , atypical shiny wear facet
with sharp edges , pulpal exposure , fracture in crown restoration
 Muscular tenderness – lateral pterygoid , masseter on palpation , fatigue on
walking , hypertrophy of masseter
 TMJ disturbances –crepitation , clicking , restriction of mandible movement ,
deviation of chin , pain
 Headache- muscular contraction type
 Other signs and symptoms – sound(grinding and tapping) , small ulceration on
buccal mucosa opposite to molar teeth , soft tissue trauma

9. SYMPTOMS
 Anxiety, stress and tension
 Depression
 Earache
 Eating disorders
 Headache
 Hot , cold or sweet sensitivity in the teeth
 Insomnia
 Sore or painful jaw
MANIFESTATION
The signs and symptoms of bruxism depends on
 Frequency of bruxing
 Intensity
 Age of patient associated with duration of habit

10. DIAGNOSIS
 There may be definite of bruxism but in an unaware patient a number of signs
help in its detection
 Advanced attrition
 Increased tooth mobility patterns
 Presence of widened PDL space in radiograph
 Hypertonicity of muscle of mastication , EMG examination
 TMJ discomfort

11. TEMPOROMANDIBULAR JOINT DISORDERS
Temporomandibular joint and muscle disorders commonly called TMJ disorders are
a group of conditions that cause pain and dysfunction in the jaw joint and the
muscle that control jaw movement
This disorder is characterized by
 Facial pain in the region of TMJ and for muscle of mastication
 Limitations or deviations in the mandibular range of motion
 TMJ sounds during jaw movement and function

12. ETIOLOGY
 Multifactorial origin - caused by altered anatomic relations and derangements
of TMJ associated with loss of occlusal vertical dimensions
 Loss of posterior tooth support
 Malocclusion
 Trauma
 Bad bite- clenching , biting
 Hormonal imbalance
 Genetic

13. CLINICAL SIGNS AND SYMPTOMS OF TMJ DISORDERS
Can be grouped according to the structure affected
1. Muscles
2. TMJs
3. Dentition

14. FUNCTIONAL DISORDERS OF MUSCLE
Two major symptoms
 Pain
 Dysfunction
PAIN
 Pain felt in the muscle is called myalgia
 Often associated with fatigue and tightness
 Myogenous pain is a type of deep pain if it becomes constant produce central
exditatory effects
 Another very common symptoms of masticatory muscle is headache

15. DYSFUNCTION
 When muscle tissues have been compromised by overuse , any
contraction or stretching it increases the pain hence decrease the
range of mandibular movement
 Acute malocclusion can occur due to change in occlusal condition
caused by disorder

16. FUNCTIONAL DISORDERS OF TMJ
Two major symptoms are pain and dysfunction
PAIN
 Pain in any joint structure including the TMJ is called arthralgia in
which discal ligaments , capsular ligaments and retrodiscal tissues
are compressed / elongated

17. DYSFUNCTION
 It presents as a disruption of the normal condyle disc movement with the
production of joint sounds
 The joint sound ma be a single event of short duration known as click
 If it is large referred to as pop
 Crepitation is a multiple , rough , gravel like sound described as grating and
complicated
 Dysfunction of TMJ may also present as catching sensation when the patient
opens the mouth
 Sometimes the jaw usually lock

18. FUNCTIONAL DISORDERS OF DENTITION
MOBILITY
 Mobility can result from two factors
 Loss of bony support( periodontal disease) and usually heavy occlusal forces
(traumatic occlusion)
PULPITIS
 Heavy occlusal force
 Cracked tooth
 Referred muscle pain

19. OTHER SIGNS AND SYMPTOMS OF TMJ DISORDERS
 Headache
 Ear pain
 Ear stiffness
 Tinnitus (ear ringing)
 vertigo

20. DIAGNOSTIC AIDS
RADIOGRAPHY
 Panoramic
 Lateral , transcranial
 Trans pharyngeal
 Trans orbital
 Conventional tomography
 Computed tomography
 Arthrography
 MRI
 Electromyography
 Analgesic blocking
 Mounted casts

21. 1. Mandibular restriction
 Restriction of mandibular opening is found in both joint and muscle disorder
 Check for endfeel
Disc dislocation – hard end feel occurs at 25-30mm
Muscle disorder- soft end feel occurs anywhere during opening
 In Disc dislocation without reduction (intracapsular restriction)- a contralateral
eccentric movement will be limited but an ipsilateral movement will be normal
 Muscle disorders – a normal range of eccentric movements exists
DIFFERENTIAL DIAGNOSIS

22. 2 . Mandibular interference
 If deviation occurs during opening and jaw returns to midline before 30-
35mm – disc derangement disorder
 If speed of opening alters the location of the deviation it is likely to be
discal movement(disc displacement with reduction)
 If speed of opening does not alter the interincisal distance of deviation and
if location of the deviation is the same for opening and closing-structural
incompatibility
 Deflection of the mandibular opening pathway results when one condyle
does not translate – intracapsular problem such as disc dislocation without
reduction , adhesion problem or myospasm

23. 3 . Acute malocclusion
 If the inferior lateral pterygoid is in spasm and shortens , the condyle will be brought
slightly forward in the fossa on the involved side this will result in a disocclusion of the
ipsilateral posterior teeth and heavy contact on the contralateral canines
 If the spasms are in the elevator muscles the patient is likely to report feeling that the
teeth suddenly doesnt fit right yet clinicaly it may be difficult to visualize any change
 Disk displacement – increase in the discal space – loss of ipsilateral posterior tooth
contact
 Disc dislocation- collapse of the discal space – heavy posterior contact on the ipsilateral
side

24. 4 . Loading of joint
 Positioning the condyles in stable position - if loading causes pain refers to
intracapsular problem
 If no pain - healthy joint
5 . Diagnostic anesthetic blockade
3 types muscle injection
Diagnostic – to determine source of pain
Theraputic- myofascial trigger point pain

25. 1 . Nerve block injection
Diagnostic purpose - site or source pain
Dental blocks
Auriculotemporal nerve blocks - rules out intracapsular disorders
2. Intracapsular injections- indicated for therapeutic purpose
3. Infraorbital nerve block- relieve neuropathic pain in case of trauma

26. CLASSIFICATION FOR THE DIAGNOSIS OF TMJ
DISORDERS
MASTICATORY MUSCLE DISORDER
Myofacial pain
Myospasm
Fibromyalgia

27. MYOSPASM( TONIC CONTRACTON MYALGIA)
Myospasm is an involuntary CNS induced tonic muscle contraction and is
responsible for the source of myogenic pain
ETIOLOGY
 Muscle soreness
 Muscle fatigue
 Systemic conditions
 Deep pain input
 HISTORY
 Sudden onset of pain
 Tigtness
 Change in jaw position

28. CLINICAL CHARACTERISTICS
 Structural dysfunction
 Restriction in range of mandibular movement
 Acute malocclusion
 Pain at rest
 Increased pain with function
 Local muscle tenderness
 Muscle tigtness
Spasm of lat pterygoid muscle

29. MYOFACIAL PAIN
Characterized by local areas of firm , hypersensitive bands of muscle tissue known as trigger
points . No overall shortening of the muscle will occur only a selected group of motor units
contract
ETIOLOGY
 Protracted local muscle soreness
 Constant deep pain
 Increased emotional stress
 Sleep disturbance
 Local factors- habits , posture
 Systemic factors-poor physical conditioning , fatigue and viral infections
 Idiopathic pain

30. CLINICAL HARACTERISTICS
 Structural dysfunction
 Pain at rest (referred pain)
 Increased pain with function
 Presence of trigger points
HISTORY - with a chief complaint of heterotrophic pain and not the actual source
of pain

31. FIBROMYALGIA(FIBROSTITIS)
 Fibromyalgia is a chronic global musculoskeletal pain disorder . In
fibromyalgia there is a tenderness at 11 or 18 specific tender
points throughout the body
ETIOLOGY
 Acute myalgic disorder such as constant deep pain and increased
emotional stress may be significant
HISTORY
 Pain in numerous sites of the body
 Poor quality of sleep
 Depression

32. CLINICAL CHRACTERISTICS
 Structural dysfunction
 Pain at rest
 Increased pain with function
 Weakness and fatigue
 Presence of tender points
 Sedentary physical conditions

33. FUNCTIONAL DISORDERS OF THE
TEMPOROMANDIBULAR JOINTS
 Disc dislocation with reduction
 Disc dislocation without reduction
 Subluxation
 Spontaneous dislocation
 Adherence and adhesions

34. DISC DISLOCATION WITH
REDUCTION
If the inferior retrodiscal lamina and discal collateral ligaments become further elongated
and the posterior border of the disc becomes sufficiently thinned the disc can slip or be
forced completely through the discal space
Since the disc and condyle no longer articulate this condition is referred to as disc dislocation
If the patient can so manipulate the jaw as to reposition the condyle onto the posterior border
of disc it is said to be reduced
HISTORY
 Long clicking
 Recent catching
 Self reduction
 Pain may be present or absent

35. CLINICALLY
 Limited jaw opening
 Protruded position of mouth eliminate catching sensation
 Two clicks
 Opening click – occurs anywhere during the opening movement depending upon the
amount of disc displacement
anatomy of the disc and speed of movement
 closing click- occurs very near the intercuspal position when the influencing factor ,
superior lateral pterygoid muscle encourages the disc to once again be displaced

36. DISC DISLOCATION WITHOUT REDUCTION
 As the ligament becomes more elongated and the elasticity of the superior
retrodiscal lamina is lost recapturing of the disc becomes more difficult
 When the disc is not reduced the forward translation of the condyle merely forces
the disc in front of the condyle . The dislocation without reduction has also been
termed as closed lock

37. CLINICALLY
 25-30mm opening
 mandibular deflection to involved side
 hard end feel
 pain on loading the joints
HISTORY
 Biting on a hard object
 Person usually is aware of which joint is involved
 Locked jaw
 Pain either felt or not
 Clicking before the dislocation

38. ADHERENCES AND ADHESIONS
ETIOLOGY
 prolonged static loading of the joint structures
 Loss of effective lubrication
 Secondary to hemarthrosis or inflammation(adhesion)
HISTORY
 Clicking of joints after a period of static loading
 Morning stiffness of joints
 If permanent adhesion develops there will be a decrease in opening
 Pain may or may not be seen

39. CLINICAL CHARACTERISTICS
SUPERIOR JOINT SPACE ADHESION
 mandibular opening of only 25 to 30 mm
 no pain on loading the joints
CHRONIC FIXED DISC
 Normal opening movement with little or no restriction
 During closure the patient senses an inability to get the teeth back into occlusion
INFERIOR JOINT SPACE ADHESION
 Stiffness or catching on the way to maximal opening

40. SUBLUXATION(HYPERMOBILITY)
Sudden forward movement of the condyle beyond the crest of the articular eminence during
the latter phase of mouth opening
ETIOLOGY
 No pathologic conditions
 The TMJ whose articular eminence has a steep , short posterior slope followed by longer
anterior slope which is often more superior than the crest tends to subluxate
HISTORY - jaw goes out with a thud sound on wide opening
CLINICAL CHARACTERISTICS - observed by requesting the patient to open wide , the
condyle jumps forward leaving a small void or depression on the face behind the condyle
and is often repetable

41. SPONTANEOUS DISLOCATION(OPEN LOCK)
ETIOLOGY
 Represents a hyperextension of the TMJ resulting in a condition that fixes the joint in a open position preventing
any translation
HISTORY
 Associated with procedures requiring wide open mouth (dental appointment/extended yawning)
 Inability to close mouth
 Pain associated with dislocation
CLINICAL CHARATERISTICS
 Spontaneous dislocation is sudden and the patient is locked in the wide open mouth position
 Anterior teeth and usually separated with posterior teeth closed

42. INFLAMMATORY JOINT DISORDERS
(ARTHRALGIA)
Inflammatory disorders of the TMJ are characterized by continuous deep pain
accentuated by function , referred pain , excessive sensitivity to touch(allodynia)
and increased protective co contraction
The four categories are
 Synovitis
 Capsulitis
 Retrodiscitis
 Arthritis

43. SYNOVITIS AND CAPSULITIS
These both can be distinguished only by visualizing the tissues
through arthroscopy
ETIOLOGY
 Trauma-blow to the chin or slow impingement on these tissues by
an anterior displacement of the disc
 Infection from adjacent structures

44. HISTORY
 Trauma or abuse
 Continuous joint pain
CLINICAL FEATURES
 Pain on palpation which is reported to be directly in front of the ear
 Limited mouth opening with soft end feel
 If edema present then disocclusion of ipsilateral posterior teeth

45. RETRODISCITIS
It is an inflammatory condition of retrodiscal tissues
ETIOLOGY
 Trauma blow to the chin or progressive phases of disc displacement and dislocation
 The condyle gradually encroaches on the inferior retrodiscal lamina and retrodiscal tissues
which gradually insults these tissues leading to retrodiscitis

46. HISTORY
 Incidence of trauma to jaw or a progressive disc derangement disorder
 Clenching of teeth increases pain but clenching on ipsilateral side decreases pain
CLINICAL FEATURES
 Soft end feel
 Constant periauricular pain that is accentuated with jaw movement
 If the tissues swell a loss of posterior occlusal contact can occur on the ipsilateral
side and heavy contact on contralateral anterior teeth

47. ARTHRITIS
Arthritis means inflammation of the articular surfaces of the joint
OSTEOARTHRITIS
ETIOLOGY
 Bony articular surfaces of the condyle and fossa becomes altered
 Increased loading of a joint
 Surface becomes softened and the subarticular bone begins to resorb
 Loss of subchondral cortical layer, bone erosion
 Previous disc dislocation without reduction or perforation

48. CLINICAL CHARACTERISTICS
 Limited mandibular opening because of joint pain
 Soft end feel
 Crepitation typically felt
 Lateral palpation of the condyle increases the pain
 Osteoarthritis is often painful and jaw movement accentuates the symptoms
DIAGNOSIS - confirmed by TMJ radiographs(flattening , erosion , ostophytes)
History
 Report of unilateral joint pain that is aggravated by mandibular movement
 The pain is usually constant but often worsens in the late afternoon or evening

49. CHRONIC MANDIBULAR HYPOMOBILITY
ANKYLOSIS - Adhesion of intracapsular surfaces of joint
Types
 Fibrous/bony
 Unilateral/bilateral
ETIOLOGY
 HISTORY - previous history injury / capsulitis
 TRAUMA-macro trauma / secondary inflammation / haemarthrosis / bleeding / TMJ surgery
 INFECTION-otitis media / osteomyelitis of jaw / haematogenous
CLINICAL FEATURES
 Restricted movement. If ankylosis is unilateral - midline pathway deflection to affected side on opening

50. GROWTH DISORDERS
 ETIOLOGY- developmental issues that may be associated with trauma or genetic
factors
 HISTORY- clinical symptoms reported by the patient are directly related to the
associated structural changes . Pain is not common and the patient develops
functional changes that accommodate the altered growth
 CLINICAL CHARACTERISTICS
 Any alteration of function or the presence of pain is secondary to structural
changes
 Clinical asymmentry may be noticed that is associated with and indicative of a
growth or developmental interruption

51. REFERENCES
 Management of TMDS and occlusion – Jeffrey okeson 6th edition
 Comprehensive occlusal concept in clinical practice-Irwin
 Occlusion , function and parafunction -a rewiew system by steven
D bender