Internal disc derangement/dental courses

INTERNAL DISKINTERNAL DISK
DERANGEMENTDERANGEMENT
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.comwww.indiandentalacademy.com

INTRODUCTIONINTRODUCTION

T.M.J is a synovial ginglyoarthrodial jointT.M.J is a synovial ginglyoarthrodial joint
Ginglymus – a hinge (rotation)Ginglymus – a hinge (rotation)
Arthrodial – sliding movementArthrodial – sliding movement
The sliding function (upper articular unit) yieldsThe sliding function (upper articular unit) yields
maximum mobility while at the same timemaximum mobility while at the same time
bringing the jaw to brink of dislocationbringing the jaw to brink of dislocation
The rotation occurs within the lower articularThe rotation occurs within the lower articular
unitunit

Because the right and left joint are joined by theBecause the right and left joint are joined by the
mandible, the movement of one joint directly affectsmandible, the movement of one joint directly affects
the otherthe other
Because of human’s upright posture and the abilityBecause of human’s upright posture and the ability
to speak, stability of TMJ is sacrificed for mobilityto speak, stability of TMJ is sacrificed for mobility
An upright posture necessitates extreme condylarAn upright posture necessitates extreme condylar
translation to prevent jaw opening from interferingtranslation to prevent jaw opening from interfering
structures in the anterior part of the neck, where asstructures in the anterior part of the neck, where as
speech requires numerous movementsspeech requires numerous movements
TMJ mobility is aided by a loose joint capsuleTMJ mobility is aided by a loose joint capsule

NORMALNORMAL
ANATOMYANATOMY
OF TMJOF TMJ

TEMPOROMANDIBULAR JOINTTEMPOROMANDIBULAR JOINT
Located anterior to the tragus of the earLocated anterior to the tragus of the ear
Considered an articulation between the base ofConsidered an articulation between the base of
the skull and the condyle of the mandiblethe skull and the condyle of the mandible
The articular surface is the squamous part ofThe articular surface is the squamous part of
the temporal bonethe temporal bone
Consists ofConsists of
Articular Fossa (Glenoid Fossa) - ConcaveArticular Fossa (Glenoid Fossa) - Concave
Articular Tubercle or (Eminence) - ConvexArticular Tubercle or (Eminence) - Convex
Condyle of the mandibleCondyle of the mandible
Articular DiscArticular Disc
Joint capsuleJoint capsule
LigamentsLigaments www.indiandentalacademy.comwww.indiandentalacademy.com

ARTICULAR FOSSA / GLENOID FOSSAARTICULAR FOSSA / GLENOID FOSSA : It is a: It is a
concave bony structure in both anteroposteriorconcave bony structure in both anteroposterior
and mediolateral direction in which the condyleand mediolateral direction in which the condyle
rests when the month is closedrests when the month is closed
Mediolateral – 15.5 -26 mmMediolateral – 15.5 -26 mm
Anteroposterior -- 13 to 20 mmAnteroposterior -- 13 to 20 mm
ARTICULAR TUBERCLE / EMINENCEARTICULAR TUBERCLE / EMINENCE – Anterior– Anterior
part of the fossa is continuous with articularpart of the fossa is continuous with articular
eminence, a transverse bony ridge, that is theeminence, a transverse bony ridge, that is the
anterior root of the zygomatic arch, stronglyanterior root of the zygomatic arch, strongly
convex in anteroposterior direction and slightlyconvex in anteroposterior direction and slightly
concave in mediolateral directionconcave in mediolateral direction

CONDYLE :CONDYLE :
Convex on surfaces that bear forcesConvex on surfaces that bear forces
Widest mediolateraly and roundedWidest mediolateraly and rounded
anteroposteriorlyanteroposteriorly
mediolateraly : 15.5 – 26 mmmediolateraly : 15.5 – 26 mm
anteroposterior : 7.1 – 14 mmanteroposterior : 7.1 – 14 mm
If more than DIF (Deviation in form), moreIf more than DIF (Deviation in form), more
common in young adultscommon in young adults

ARTICULAR DISKARTICULAR DISK : composed of dense: composed of dense
fibroelastic connective tissues which is nonfibroelastic connective tissues which is non
innervated and non vascularized andinnervated and non vascularized and
accommodates compressive forcesaccommodates compressive forces
It encloses superior surface of condyle whenIt encloses superior surface of condyle when
jaws are closedjaws are closed
It fuses to the capsule and the lateral pterygoidIt fuses to the capsule and the lateral pterygoid
muscle anteriorly, joins the capsulemuscle anteriorly, joins the capsule
mediolaterally, and attaches to the loosemediolaterally, and attaches to the loose
vascular connective tissues posteriorlyvascular connective tissues posteriorly

The disk is divided intoThe disk is divided into
Anterior BandAnterior Band ::
has fibres interspread with fibres of lateral pterygoidhas fibres interspread with fibres of lateral pterygoid
musclesmuscles
Intermediate Zone :Intermediate Zone :
Thinnest part of the disk during jaw opening, it formsThinnest part of the disk during jaw opening, it forms thethe
articulating surface between the condyle and the fossaarticulating surface between the condyle and the fossa
Posterior BandPosterior Band ::
Thickest part and joins the posterior attachment which isThickest part and joins the posterior attachment which is
highly vascularized and innervated often called ashighly vascularized and innervated often called as
BILAMINAR ZONE / RETRODISKAL PADBILAMINAR ZONE / RETRODISKAL PAD
The condyle articulates with the disk to form a separateThe condyle articulates with the disk to form a separate
joint called asjoint called as DISK-CONDYLAR COMPLEXDISK-CONDYLAR COMPLEX, this complex, this complex
articulates with the temporal bone to form a sliding jointarticulates with the temporal bone to form a sliding joint

JOINT CAPSULE :JOINT CAPSULE : lined by synovial membranelined by synovial membrane
and envelopes the meniscus. It is attachedand envelopes the meniscus. It is attached
superiorly : to rim of articular fossa/eminencesuperiorly : to rim of articular fossa/eminence
inferiorly : neck of the condyleinferiorly : neck of the condyle
posteriorly : bilaminar zoneposteriorly : bilaminar zone
anteriorly : pterygoid attachmentanteriorly : pterygoid attachment
medially : it is thinmedially : it is thin
laterally : it is thickerlaterally : it is thicker

LIGAMENTS:LIGAMENTS: Lateral ligament orLateral ligament or
Temporomandibular ligament is a strong bandTemporomandibular ligament is a strong band
of fibrous tissue that passes obliquely from theof fibrous tissue that passes obliquely from the
root of zygoma down to the posterior margin ofroot of zygoma down to the posterior margin of
mandibular neckmandibular neck
 Deep fibres of this ligament blend with the jointDeep fibres of this ligament blend with the joint
capsulecapsule
 Ligament is relaxed in rest position and tightensLigament is relaxed in rest position and tightens
during retrusion and protrusion of the jawduring retrusion and protrusion of the jaw
 Provide a limit to the range of movement in anProvide a limit to the range of movement in an
antero-posterior directionantero-posterior directionwww.indiandentalacademy.comwww.indiandentalacademy.com

ANATOMIC UNIQUENESS OFANATOMIC UNIQUENESS OF
THE TMJTHE TMJ
Unlike other synovial joint , the articular surfaces are coveredUnlike other synovial joint , the articular surfaces are covered
by fibrocartilage rather than hyaline cartilageby fibrocartilage rather than hyaline cartilage
A fibrous disk divides the articular cavity into an upper andA fibrous disk divides the articular cavity into an upper and
lower compartmentslower compartments
Both TMJ operate in tandem and perform simultaneous,Both TMJ operate in tandem and perform simultaneous,
coordinated movementscoordinated movements
The teeth affect some of movements of the TMJ as well asThe teeth affect some of movements of the TMJ as well as
condylar position in the mandibular fossa in the rest positioncondylar position in the mandibular fossa in the rest position
in the mandibular fossa in the rest position and at completein the mandibular fossa in the rest position and at complete
closure (maximal intercuspation)closure (maximal intercuspation)
A marked difference exists in the shape of two bonyA marked difference exists in the shape of two bony
components ; the convex condyle articulated with thecomponents ; the convex condyle articulated with the
concave fossa at closing and convex eminence at fullconcave fossa at closing and convex eminence at full
openingopening www.indiandentalacademy.comwww.indiandentalacademy.com

ARTHROKINEMATIC STEPSARTHROKINEMATIC STEPS
OF TMJOF TMJ
Diarthroidal jointDiarthroidal joint
Hinge (ginglymus, rotation) and glidingHinge (ginglymus, rotation) and gliding
(arthoroidal, translatory) movements(arthoroidal, translatory) movements
The hinge action relates to the disk-The hinge action relates to the disk-
Condyle complexCondyle complex
The gliding action relates to the disk—The gliding action relates to the disk—
temporal bonetemporal bone
Also, the joint is capable of bodily (side)Also, the joint is capable of bodily (side)
movementmovement www.indiandentalacademy.comwww.indiandentalacademy.com

Movement involving the joints hasMovement involving the joints has
been divided different phasesbeen divided different phases
• Occlusal or rest positionOcclusal or rest position
• Retruded opening phase or rotationRetruded opening phase or rotation
• Early protrusive opening phase orEarly protrusive opening phase or
functional openingfunctional opening
• Late protrusive opening phase orLate protrusive opening phase or
translationtranslation
• Early closing phaseEarly closing phase
• Retrusive closing phaseRetrusive closing phasewww.indiandentalacademy.comwww.indiandentalacademy.com

OCCLUSAL OR REST POSITIONOCCLUSAL OR REST POSITION
• The rest position is the first step and involves a static jaw
position with maximum intercuspation.
• In this, the joint is in loose pack
position, the connective tissue at rest
• The posterior band occupies the
deepest part of the mandible fossa
• The intermediate zone and the anterior band lies between
the condyle and posterior slope of the eminence

RETRUDED OPENING PHASE ORRETRUDED OPENING PHASE OR
ROTATIONROTATION
•The condyle rotates and moves 5 to 6 mm inferior to the
intermediate zone
•The condyle joint surface glides forward
and the medial pole of the condyle
moves anterosuperiorly and the
lateral pole moves posteroinferiorly
•The shape of inferior compartment
changes the most
•The upper lateral pterygoid relaxes and the lower lateral
pterygoid contracts
•The posterior connective tissues is in a functional state of
rest www.indiandentalacademy.comwww.indiandentalacademy.com

EARLY PROTRUSIVE OPENINGEARLY PROTRUSIVE OPENING
PHASE OR FUNCTIONAL OPENINGPHASE OR FUNCTIONAL OPENING
•The condyle moves inferiorly and anteriorly approximately 6
to 9 mm below the intermediate zone.
•The disk and the condyle
experience the short anterior
translatory glide
•The upper and lower head of lateral pterygoid contract to
guide the disk and the condyle shortly forward
•The posterior connective tissues is in a functional tightning

LATE PROTRUSIVE OPENINGLATE PROTRUSIVE OPENING
PHASEPHASE
OR TRANSLATIONOR TRANSLATION
• The condyle moves inferiorly and anteriorly beneath the
anterior band i.e there is full
opening more, space develops
in the superior compartment
• The upper and lower head of
Lateral pterygoid contract to guide the disk and the condyle fully
forward
•The posterior connective tissues tightenswww.indiandentalacademy.comwww.indiandentalacademy.com

EARLY CLOSING PHASEEARLY CLOSING PHASE
The condyle translates posteriorly, about 6 to
9 mm, to the intermediate zone
There is simultaneous reduction of space
posteriorly in the superior compartment

RETRUSIVE CLOSING PHASERETRUSIVE CLOSING PHASE
• The condyle rotates superiorly but remains inferior to the
posterior band
• This movement reduces the space
in the inferior compartment
• The upper head of the lateral
pterygoid contracts and
• The lower head of the lateral
pterygoid relaxes
• This tightens the mandibular attachment, and forces blood
from the posterior compartments
• The posterior connective tissues returns to the functional restwww.indiandentalacademy.comwww.indiandentalacademy.com

CLASSIFICATION OFCLASSIFICATION OF
TEMPORALMANDIBULARTEMPORALMANDIBULAR
DISORDERSDISORDERS

CLASSIFICATION OFCLASSIFICATION OF
TEMPORALMANDIBULAR DISORDERSTEMPORALMANDIBULAR DISORDERS
1 . MASTICATORY MUSCLE DISORDERS1 . MASTICATORY MUSCLE DISORDERS
a)a) Protective muscle splintingProtective muscle splinting
b)b) Muscle hyperactivity or spasmMuscle hyperactivity or spasm
c) Myositis (muscle inflammation)c) Myositis (muscle inflammation)
2.2. DISK-INTERFERENCE DISORDERS (INTERNALDISK-INTERFERENCE DISORDERS (INTERNAL
DERANGEMENTS)DERANGEMENTS)
a)a) IncoordinationIncoordination
b)b) Deformation of the articular diskDeformation of the articular disk
c)c) Partial anterior disk displacementPartial anterior disk displacement
d)d) Anterior disk displacement with reductionAnterior disk displacement with reduction
e)e) Anterior disk displacement without reductionAnterior disk displacement without reduction
f)f) Anterior disk displacement with perforationAnterior disk displacement with perforation
g)g) Posterior disk displacementPosterior disk displacementwww.indiandentalacademy.comwww.indiandentalacademy.com

3. PROBLEMS THAT RESULT FROM EXTRINSIC3. PROBLEMS THAT RESULT FROM EXTRINSIC
TRAUMATRAUMA
a)a) TendonitisTendonitis
b)b) MyositisMyositis
c)c) Traumatic arthritisTraumatic arthritis
d)d) DislocationDislocation
e)e) FractureFracture
f)f) Internal derangementInternal derangement
4.4. DEGENERATIVE JOINT DISEASEDEGENERATIVE JOINT DISEASE
a)a) Arthrosis (noninflammatory phase)Arthrosis (noninflammatory phase)
b)b) Osteoarthritis (inflammatory phase)Osteoarthritis (inflammatory phase)
c)c) Osteochondritis dissecans or avascular necrosisOsteochondritis dissecans or avascular necrosiswww.indiandentalacademy.comwww.indiandentalacademy.com

5.5. INFLAMMATORY JOINT DISORDERSINFLAMMATORY JOINT DISORDERS
a)a) Synovitis and capsulitisSynovitis and capsulitis
b)b) RetrodiskitisRetrodiskitis
c)c) Inflammatory arthritisInflammatory arthritis
Rheumatoid arthritisRheumatoid arthritis
Infectious arthritisInfectious arthritis
Metabolic arthritisMetabolic arthritis
6.6. CHRONIC MANDIBULAR HYPOMOBILITYCHRONIC MANDIBULAR HYPOMOBILITY
a)a) Ankylosis (fibrous or osseous)Ankylosis (fibrous or osseous)
b)b) Fibrosis of articular capsuleFibrosis of articular capsule
c)c) Contracture of elevator muscles (myostatic orContracture of elevator muscles (myostatic or
myofibrotic)myofibrotic)
d)d) Internal disk derangement (closed-lock)Internal disk derangement (closed-lock)

7.7. Growth Disorders of the JointGrowth Disorders of the Joint
a) Developmental disordersa) Developmental disorders
b) Acquired disordersb) Acquired disorders
c) Neoplastic disordersc) Neoplastic disorders
8. Postsurgical Problems8. Postsurgical Problems

INTERNALINTERNAL
DISKDISK
DERANGEMENDERANGEMEN
TTwww.indiandentalacademy.comwww.indiandentalacademy.com

DEFINITIONDEFINITION
INTERNAL DISK DERANGEMENT of TMJINTERNAL DISK DERANGEMENT of TMJ
is defined as an abnormal relationship ofis defined as an abnormal relationship of
the articular disk to the mandibularthe articular disk to the mandibular
condyle, fossa and articular eminencecondyle, fossa and articular eminence
It implies anatomical disturbance of theIt implies anatomical disturbance of the
disk-condyle relationship and constantdisk-condyle relationship and constant
changes in the mechanics of the joint,changes in the mechanics of the joint,
such as clicking, locking and thesuch as clicking, locking and the
presence or absence of associatedpresence or absence of associated
disorders and muscular disordersdisorders and muscular disorders

Internal disk derangement of TMJ is aInternal disk derangement of TMJ is a
diagnostic term, not a specific lesiondiagnostic term, not a specific lesion
It is a sub classification of TMJIt is a sub classification of TMJ
disorders & two general phases ofdisorders & two general phases of
this problem arethis problem are
The Incordination PhaseThe Incordination Phase
The Locking PhaseThe Locking Phase

THE INCOORDINATION PHASETHE INCOORDINATION PHASE
In the Incordination Phase the articular disc isIn the Incordination Phase the articular disc is
thought either to undergo momentary jammingthought either to undergo momentary jamming
against the articular eminence or to be displacedagainst the articular eminence or to be displaced
anteromedially but undergo a reducing openinganteromedially but undergo a reducing opening
This action restabilizes the disc to its normalThis action restabilizes the disc to its normal
relationship with condyle, fossa and the articularrelationship with condyle, fossa and the articular
eminenceeminence
This reduction producing an impact of theThis reduction producing an impact of the
condyle against the dense part of the disccondyle against the dense part of the disc
,resulting in a click,resulting in a click
During closure the disc returns to its abnormalDuring closure the disc returns to its abnormal
relationship, usually producing a less noticeablerelationship, usually producing a less noticeable
reciprocal click near the intercuspal positionreciprocal click near the intercuspal positionwww.indiandentalacademy.comwww.indiandentalacademy.com

THE LOCKING PHASETHE LOCKING PHASE
In the Locking Phase the articular disc isIn the Locking Phase the articular disc is
definitely anteromedially displaced but does notdefinitely anteromedially displaced but does not
undergo reduction during opening or protrusionundergo reduction during opening or protrusion
Because the disc cannot be reproduced to itsBecause the disc cannot be reproduced to its
normal relationship with condyle, fossa and thenormal relationship with condyle, fossa and the
articular eminence during mandibulararticular eminence during mandibular
movements, the jaw opening is acutelymovements, the jaw opening is acutely
restricted (CLOSED LOCK)restricted (CLOSED LOCK)
In this process, the softer neurovascular discIn this process, the softer neurovascular disc
attachment tissues are drawn into a potentiallyattachment tissues are drawn into a potentially
painful area of articular loadingpainful area of articular loadingwww.indiandentalacademy.comwww.indiandentalacademy.com

The Incoordination phase and the LockingThe Incoordination phase and the Locking
phase are usually not accompany by anyphase are usually not accompany by any
oblivious radiographic changesoblivious radiographic changes
The progression of this condition can, however,The progression of this condition can, however,
cause perforation of the disc and subsequentcause perforation of the disc and subsequent
osseous remodeling of the condyle andosseous remodeling of the condyle and
temporal fossa.temporal fossa.

ETIOLOGYETIOLOGY
LATERAL PTERYGOID MUSCLE SPASMLATERAL PTERYGOID MUSCLE SPASM
TRAUMATRAUMA
CHRONIC FUNCTIONAL OVERLOADCHRONIC FUNCTIONAL OVERLOAD
(CLENCHING)(CLENCHING)
DEGENERATIVE JOINT DISEASESDEGENERATIVE JOINT DISEASES
Trauma directly leads to clicking and lockingTrauma directly leads to clicking and locking
Lateral pterygoid muscle spasm and chronicLateral pterygoid muscle spasm and chronic
clenching first cause incordination which canclenching first cause incordination which can
progress sequentially to clicking and lockingprogress sequentially to clicking and lockingwww.indiandentalacademy.comwww.indiandentalacademy.com

Part of Myofacial Pain Dysfunction Syndrome, canPart of Myofacial Pain Dysfunction Syndrome, can
cause anterior disc displacement in same patientscause anterior disc displacement in same patients
because the superior head of the muscle fails tobecause the superior head of the muscle fails to
relax during opening movement & the disk is pulledrelax during opening movement & the disk is pulled
downward & forward with the condyle rather thandownward & forward with the condyle rather than
being allowed to rotate posteriorly.being allowed to rotate posteriorly.
This can initially produce a slight hesitation or aThis can initially produce a slight hesitation or a
catching sensation due to the improper disk condylecatching sensation due to the improper disk condyle
relationshiprelationship
Also produces an abnormal stretching of the retroAlso produces an abnormal stretching of the retro
discal ligament, that if it continues, allows the disk todiscal ligament, that if it continues, allows the disk to
move slightly anterior to condyle during closingmove slightly anterior to condyle during closing
movement and causes clicking on opening.movement and causes clicking on opening.
LATERAL PTERYGOID MUSCLE SPALATERAL PTERYGOID MUSCLE SPA

TRAUMATRAUMA
Most common cause of derangementsMost common cause of derangements
Mild trauma - can cause merely some damage toMild trauma - can cause merely some damage to
the articular surfaces and produce increasedthe articular surfaces and produce increased
friction during mandibular function in-friction during mandibular function in-
coordination phasecoordination phase
If severe enough - such frictional change canIf severe enough - such frictional change can
limit the ability of disk to pivot posteriorly duringlimit the ability of disk to pivot posteriorly during
opening movement & subsequently lead toopening movement & subsequently lead to
stretching of the retrodiskal ligament, andstretching of the retrodiskal ligament, and
anterior disk displacement and clickinganterior disk displacement and clicking..www.indiandentalacademy.comwww.indiandentalacademy.com

If left untreated, the constant impingement of condyleIf left untreated, the constant impingement of condyle
against posterior band of disk ultimately causeagainst posterior band of disk ultimately cause
sufficient looseness of retrodiskal ligament to result insufficient looseness of retrodiskal ligament to result in
permanent displacement.permanent displacement.
More severe trauma can result directly in stretching ofMore severe trauma can result directly in stretching of
retrodiskal ligament with anterior disk displacementretrodiskal ligament with anterior disk displacement
and clicking. This can be encountered in patientsand clicking. This can be encountered in patients
whose mouth opened abruptly and widely duringwhose mouth opened abruptly and widely during
whiplash injury.whiplash injury.
This condition can remain static or it eventually lead toThis condition can remain static or it eventually lead to
locking.locking. www.indiandentalacademy.comwww.indiandentalacademy.com

CHRONIC FUNCTIONALCHRONIC FUNCTIONAL
OVERLOAD (CLENCHING)OVERLOAD (CLENCHING)
Patients with MPDS who are prone to chronicPatients with MPDS who are prone to chronic
clenching are also candidates to develop discclenching are also candidates to develop disc
derangements. This is due toderangements. This is due to
Constant isometric loading and unloading of theConstant isometric loading and unloading of the
joint can lead to degenerative changesjoint can lead to degenerative changes
It squeezes the synovial fluid out of articularIt squeezes the synovial fluid out of articular
surface and reduces the effectiveness of weepingsurface and reduces the effectiveness of weeping
lubrication, o there is catchinglubrication, o there is catchingwww.indiandentalacademy.comwww.indiandentalacademy.com

DEGENERATIVE JOINTDEGENERATIVE JOINT
DISEASESDISEASES
May be a primary factor in the development of internalMay be a primary factor in the development of internal
derangement or may occur secondary to the development ofderangement or may occur secondary to the development of
internal disk derangement , from other causesinternal disk derangement , from other causes
In the first instance , the changes in the character of theIn the first instance , the changes in the character of the
articulating surface results in an inability of the parts slidearticulating surface results in an inability of the parts slide
smoothly over each other, this gradually lead to the a forwardsmoothly over each other, this gradually lead to the a forward
displacement of the disc , which normally rotates posteriorlydisplacement of the disc , which normally rotates posteriorly
during mouth openingduring mouth opening
In second instance, the displaced disk results in the alteredIn second instance, the displaced disk results in the altered
relationship between articulating components of the jointrelationship between articulating components of the joint
which leads to the degenerative changes in these structurewhich leads to the degenerative changes in these structurewww.indiandentalacademy.comwww.indiandentalacademy.com

CLINICAL FEATURESCLINICAL FEATURES
CLICKINGCLICKING
PAIN AND TENDERNESSPAIN AND TENDERNESS ::
- may or may not be present- may or may not be present
- can be measured by- can be measured by
1.1. Lateral PalpationLateral Palpation
2.2. Intra-auricular PalpationIntra-auricular Palpation

LATERAL PALPATIONLATERAL PALPATION INTRA-AURICULAR PALPATIONINTRA-AURICULAR PALPATION

DEVIATION :DEVIATION :
- may or may not be present , towards affected side- may or may not be present , towards affected side
- when viewed from the front, it may be- when viewed from the front, it may be
1.1. In a diagonal straight line from start to end; there may beIn a diagonal straight line from start to end; there may be
adhesion within the jointadhesion within the joint
2.2. Vertical until almost maximum range of individual’s rangeVertical until almost maximum range of individual’s range
of opening is achieved, when a marked lateral movementsof opening is achieved, when a marked lateral movements
becomes apparent; may be due to anterior diskbecomes apparent; may be due to anterior disk
displacement without reductiondisplacement without reduction
3.3. Vertical and lateral movements in the middle of theVertical and lateral movements in the middle of the
opening which then returns to the same vertical plane;opening which then returns to the same vertical plane;
may be due to anterior disk displacement with reductionmay be due to anterior disk displacement with reduction

DIAGRAMATIC REPRESENTATION
1
2
3

LIMITED MOUTH OPENING :LIMITED MOUTH OPENING :
Lower limit (female) : 35 mmLower limit (female) : 35 mm
Lower limit (male) : 40 mmLower limit (male) : 40 mm
Range of lateral movements should also beRange of lateral movements should also be
measured ,this is done in the midline tomeasured ,this is done in the midline to
midline ; mandible is moved to the firstmidline ; mandible is moved to the first
side than to other sideside than to other side
Normal range : 8 mm on either sideNormal range : 8 mm on either side

LockingLocking
Difficulty In ChewingDifficulty In Chewing
TirednessTiredness
Achy sensations about headAchy sensations about head
HeadacheHeadache
Clenching may be presentClenching may be present
Masticatory muscle dysfunctionMasticatory muscle dysfunction

WILKE’S STAGING OF INTERNAL DISKWILKE’S STAGING OF INTERNAL DISK
DERANGEMENTDERANGEMENT
STAGESTAGE CHARACTERISTICSCHARACTERISTICS IMAGINGIMAGING
I.I. EarlyEarly Painless clickingPainless clicking
No restricted motionNo restricted motion
Slightly forward diskSlightly forward disk
Normal osseous contoursNormal osseous contours
II.II.EarlyEarly
IntermediateIntermediate
Painless clickingPainless clicking
Intermittent lockingIntermittent locking
HeadachesHeadaches
Slightly forward diskSlightly forward disk
Early disk deformityEarly disk deformity
III .III .IntermediateIntermediate Frequent painFrequent pain
Joint tenderness,Joint tenderness,
Headaches, lockingHeadaches, locking
Restricted motionRestricted motion
Painful chewingPainful chewing
Anterior disk displacementAnterior disk displacement
Moderate to marked diskModerate to marked disk
thickeningthickening
IVIV.Intermediate.Intermediate
latelate
Chronic pain, headacheChronic pain, headache
Restricted motionRestricted motion
Anterior disk displacementAnterior disk displacement
Marked disk thickeningMarked disk thickening
Abnormal bone contoursAbnormal bone contours
V.V. LateLate Variable pain, joint crepitusVariable pain, joint crepitus
painpain
Anterior disk displacement withAnterior disk displacement with
disk perforation and grossdisk perforation and gross
deformitydeformity
Degenerative osseous changesDegenerative osseous changeswww.indiandentalacademy.comwww.indiandentalacademy.com

DIAGNOSISDIAGNOSIS
HISTORYHISTORY
EXAMINATIONEXAMINATION
RADIOGRAPHIC STUDIESRADIOGRAPHIC STUDIES
SPECIAL DIAGNOSTIC STUDIESSPECIAL DIAGNOSTIC STUDIES

PLAIN FILMPLAIN FILM
Initial screening for gross osseous abnormalities canInitial screening for gross osseous abnormalities can
be performed with standard TRANSCRANIAL,be performed with standard TRANSCRANIAL,
TRANSPHARYNGEAL and PANOROMIC (CURVEDTRANSPHARYNGEAL and PANOROMIC (CURVED
TOMOGRAPH) conventional x - raysTOMOGRAPH) conventional x - rays
ADVANTAGES :ADVANTAGES :
InexpensiveInexpensive
Easy to obtainEasy to obtain
AvailableAvailable
DISADVANTAGES :DISADVANTAGES :
Diagnostic value limited to gross osseous changesDiagnostic value limited to gross osseous changes
in the lateral part of the jointin the lateral part of the joint
Some anatomic structures are distorted whileSome anatomic structures are distorted while
others are elongatedothers are elongated

TRANSCRANIALTRANSCRANIAL
RADIOGRAPHRADIOGRAPH

TOMOGRAPHYTOMOGRAPHY
LINEAR TOMOGRAPHYLINEAR TOMOGRAPHY
PLEURIDIRECTIONAL TOMOGRAPHYPLEURIDIRECTIONAL TOMOGRAPHY
Accurate for osseous changes and condylar positionAccurate for osseous changes and condylar position
Thin-section complex motion tomographyThin-section complex motion tomography
no longer available in many institutionsno longer available in many institutions
Risk of false-negative diagnosis because noRisk of false-negative diagnosis because no
information about structures outside theinformation about structures outside the
selected tomographic sections obtainedselected tomographic sections obtained

ARTHROGRAPHYARTHROGRAPHY
The technique involves injection of a waterThe technique involves injection of a water
soluble, iodinated contrast material into thesoluble, iodinated contrast material into the
inferior compartments under fluoroscopyinferior compartments under fluoroscopy
A videotaped arthrofluoroscopic study couldA videotaped arthrofluoroscopic study could
clearly show the various stages of diskclearly show the various stages of disk
displacement with or without reductiondisplacement with or without reduction
It is the only imaging technique that shows theIt is the only imaging technique that shows the
perforation in the disc in “real time” becauseperforation in the disc in “real time” because
the operator can see the dye can escape fromthe operator can see the dye can escape from
inferior compartment to the superiorinferior compartment to the superior
compartment of TMJcompartment of TMJ

ARTHROGRAPHYARTHROGRAPHY
Accurate for anteroposterior position ofAccurate for anteroposterior position of
disc, perforation, and joint functiondisc, perforation, and joint function
Equipment for arthrography readily availableEquipment for arthrography readily available
Inaccurate for medial and lateral disc displacementsInaccurate for medial and lateral disc displacements
Dependent on examiner skillDependent on examiner skill
Patient discomfort & InvasivenessPatient discomfort & Invasiveness
Pain (intraoperative and post operative)Pain (intraoperative and post operative)
Risk of infectionRisk of infection
Potential damage to disk, capsule, and fibrocartilagePotential damage to disk, capsule, and fibrocartilage
Allergy to the contrast material (or local anesthetics)Allergy to the contrast material (or local anesthetics)

COMPUTED TOMOGRAPHYCOMPUTED TOMOGRAPHY
Currently the best method for assessing boneCurrently the best method for assessing bone
pathologic conditions.pathologic conditions.
Axial and Coronal views are excellent forAxial and Coronal views are excellent for
assessing normal and abnormal osseousassessing normal and abnormal osseous
anatomyanatomy
Disk displacement is frequently inferred fromDisk displacement is frequently inferred from
the degenerative changes can be seen on CTthe degenerative changes can be seen on CT
scanningscanning

COMPUTEDCOMPUTED
TOMOGRAPHYTOMOGRAPHY
Accurate for osseous changesAccurate for osseous changes
Patient comfortPatient comfort
Good for assessment of ankylosis and traumaGood for assessment of ankylosis and trauma
Inadequate soft tissue differentiationInadequate soft tissue differentiation
Difficulty in positioning patients for direct sagittal CTDifficulty in positioning patients for direct sagittal CT

MAGNETIC RESONANCE IMAGINGMAGNETIC RESONANCE IMAGING
MR Images can be obtained in the sagittal, axialMR Images can be obtained in the sagittal, axial
and coronal planesand coronal planes
Slice thickness may varies between 3 mm to 10Slice thickness may varies between 3 mm to 10
mmmm
MRI exams are accurate, non-invasive andMRI exams are accurate, non-invasive and
reproduciblereproducible

MAGNETIC RESONANCE IMAGINGMAGNETIC RESONANCE IMAGING
ADVANTAGESADVANTAGES ::
High soft tissue resolutionHigh soft tissue resolution
Multiplanar imaging capabilityMultiplanar imaging capability
Accurate for both soft and hard tissue structuresAccurate for both soft and hard tissue structures
Imaging technique can be standardized toImaging technique can be standardized to
avoid operator differencesavoid operator differences
High costHigh cost
Different image quality with different scanners and coilsDifferent image quality with different scanners and coils

NUCLEAR IMAGINGNUCLEAR IMAGING
Radionuclide imaging of the temporomandibular joint canRadionuclide imaging of the temporomandibular joint can
provide information about the dynamics of boneprovide information about the dynamics of bone
metabolism in a variety of pathologic statesmetabolism in a variety of pathologic states
A scintillation camera can be used for both dynamic andA scintillation camera can be used for both dynamic and
static imaging in which a gamma detector quantifiesstatic imaging in which a gamma detector quantifies
gamma rays emissions from injected isotopes such asgamma rays emissions from injected isotopes such as
Technetium 99Technetium 99
These Technetium labeled phosphate complexes areThese Technetium labeled phosphate complexes are
given to the patients intravenouslygiven to the patients intravenously
The uptake of radiopharmaceutical depends on the bloodThe uptake of radiopharmaceutical depends on the blood
flow of TMJ structuresflow of TMJ structures
Higher activity is seen at sites of growth, inflammation,Higher activity is seen at sites of growth, inflammation,
bone remodeling and osteoblastic activitybone remodeling and osteoblastic activitywww.indiandentalacademy.comwww.indiandentalacademy.com

NUCLEAR IMAGINGNUCLEAR IMAGING
Highly sensitiveHighly sensitive
NonspecificNonspecific
Logistics in obtaining nuclear medicine imagesLogistics in obtaining nuclear medicine images

TREATMENTTREATMENT
MODALITIESMODALITIES

The correct management of InternalThe correct management of Internal
Disk Derangement is predicted byDisk Derangement is predicted by
two factorstwo factors
- Making a correct diagnosis- Making a correct diagnosis
- Understanding the natural cause- Understanding the natural cause
of the disorderof the disorder

EDUCATIONEDUCATION
PHYSICAL THERAPYPHYSICAL THERAPY
- To improve pain- To improve pain
- To improve function- To improve function
PHARMACOLOGICAL THERAPYPHARMACOLOGICAL THERAPY
OCCLUSAL THERAPYOCCLUSAL THERAPY
NON SURGICAL TREATMENT MODALITIES

EDUCATIONEDUCATION
It is very important that each patients should understandIt is very important that each patients should understand
the mechanism that is causing symptomsthe mechanism that is causing symptoms
Well informed patient play a significant role in therapyWell informed patient play a significant role in therapy
Patient should instructed toPatient should instructed to
- Decrease loading of joint as much as possible- Decrease loading of joint as much as possible
- Soft food diet- Soft food diet
- Slower chewing- Slower chewing
- Smaller bites- Smaller bites
- Not to allow joint to click- Not to allow joint to click
-Not to open his mouth forcefullyNot to open his mouth forcefully
Each clinician should have a model orEach clinician should have a model or
illustrations of TMJ in the officeillustrations of TMJ in the office
Patient should be told that condition is self limitingPatient should be told that condition is self limitingwww.indiandentalacademy.comwww.indiandentalacademy.com

PHYSICAL THERAPYPHYSICAL THERAPY
Manages symptoms associatedManages symptoms associated
with internal disk derangementwith internal disk derangement
Therapies are divided into towTherapies are divided into tow
typestypes
Those that reduces painThose that reduces pain
Those that improve functionThose that improve function

PHYSICAL THERAPY FORPHYSICAL THERAPY FOR
PAIN REDUCTIONPAIN REDUCTION
MOIST HEATMOIST HEAT
Thermotherapy utilizes heat as a primeThermotherapy utilizes heat as a prime
mechanism and is based on the premisemechanism and is based on the premise
that heat increases circulation to thethat heat increases circulation to the
applied areaapplied area
- Hot water bottle or hot moist towel and- Hot water bottle or hot moist towel and
Electric heating pad are applied forElectric heating pad are applied for

COOLANT THERAPYCOOLANT THERAPY
Ice should be applied directly to theIce should be applied directly to the
symptomatic joint / muscles and moved in asymptomatic joint / muscles and moved in a
circular motion without pressure to the tissues.circular motion without pressure to the tissues.
Continuous icing will result in mild aching andContinuous icing will result in mild aching and
numbness , when numbness begins , ice shouldnumbness , when numbness begins , ice should
be removedbe removed
It should not be left on the tissues for not longerIt should not be left on the tissues for not longer
that 5 – 7 minthat 5 – 7 min
After a period of warming, second application isAfter a period of warming, second application is
advisedadvised www.indiandentalacademy.comwww.indiandentalacademy.com

VAPOR SPRAYVAPOR SPRAY
Ethlychloride and Fluoromethane applied to desired area forEthlychloride and Fluoromethane applied to desired area for
5 seconds5 seconds
After tissue has been rewarmed, the procedure can beAfter tissue has been rewarmed, the procedure can be
repeatedrepeated
Care must be taken not to allow the spray to contact eyesCare must be taken not to allow the spray to contact eyes
, ears , nose or mouth, ears , nose or mouth
Reduction of pain is due to the stimulation of cutaneousReduction of pain is due to the stimulation of cutaneous
nerve fibres that in turn shut down the smaller pain fibresnerve fibres that in turn shut down the smaller pain fibres
(C fibres) as they do not penetrate tissue like ice(C fibres) as they do not penetrate tissue like ice
This type of pain reduction is likely to be of short durationThis type of pain reduction is likely to be of short duration

COLD LASER:COLD LASER:
For wound healing and pain reliefFor wound healing and pain relief
Not a routine physical therapy modalityNot a routine physical therapy modality
IONTOPHORESISIONTOPHORESIS ::
is a technique by which certain medications areis a technique by which certain medications are
locally introduction into the tissues.locally introduction into the tissues.
The medication are placed in a pad and pad isThe medication are placed in a pad and pad is
placed over the joint , then a low electricalplaced over the joint , then a low electrical
current is passed through the pad driving thecurrent is passed through the pad driving the
medications (like local anesthesia and anti-medications (like local anesthesia and anti-
inflammatories) into the tissues.inflammatories) into the tissues.

PHONOPHERESIS :PHONOPHERESIS :
If the medication is driven into theIf the medication is driven into the
tissues with ultrasound, the modality istissues with ultrasound, the modality is
known as Phonopheresisknown as Phonopheresis

PHYSICAL THERAPY TOPHYSICAL THERAPY TO
IMPROVE FUNCTIONIMPROVE FUNCTION
Pain in Internal Disk Derangement restricts thePain in Internal Disk Derangement restricts the
jaw movements which can lead to chronic hypojaw movements which can lead to chronic hypo
mobility and muscle atrophy. Therefore must bemobility and muscle atrophy. Therefore must be
instructedinstructed
- to gently open the mouth to resistance and- to gently open the mouth to resistance and
closeclose
- jaw should be moved eccentrically- jaw should be moved eccentrically
If the disk is displaced without reduction thenIf the disk is displaced without reduction then
passive distraction of the joint can increase thepassive distraction of the joint can increase the
mobilitymobility

INTERNAL DISK DERANGEMENTINTERNAL DISK DERANGEMENT
WITHOUT REDUCTIONWITHOUT REDUCTION
INITIAL THERAPYINITIAL THERAPY : Attempt to reduce or: Attempt to reduce or
recapture the disk displacement by manualrecapture the disk displacement by manual
manipulationmanipulation
This is successful in patients experiencing theThis is successful in patients experiencing the
first episode of locking as the tissue are healthyfirst episode of locking as the tissue are healthy
& morphological not changed& morphological not changed
In patients with longer history of dislocation,In patients with longer history of dislocation,
the success rate decreasesthe success rate decreases

Patient is asked to move the mandible as far asPatient is asked to move the mandible as far as
possible to the contralateral side, From thispossible to the contralateral side, From this
eccentric position mouth is opened maximallyeccentric position mouth is opened maximally
If this not successful at first, then patientIf this not successful at first, then patient
should attempt several timesshould attempt several times
If fails to reduce the displacement, thenIf fails to reduce the displacement, then
ASSISTANCE MANIPULATIONASSISTANCE MANIPULATION is neededis needed
The thumb is placed intra-orally on the 2The thumb is placed intra-orally on the 2ndnd
molarmolar
on the affected side and fingers placed on theon the affected side and fingers placed on the
inferior border of the mandible anterior to theinferior border of the mandible anterior to the
thumb positionthumb position www.indiandentalacademy.comwww.indiandentalacademy.com

Firm but controlled downward force is exertedFirm but controlled downward force is exerted
and at the same time upward force is placed byand at the same time upward force is placed by
the fingersthe fingers
Patient is asked to relax while 20 – 30 secondsPatient is asked to relax while 20 – 30 seconds
of constant distractive force is applied to theof constant distractive force is applied to the
jointjoint
Then the force is discontinuedThen the force is discontinued
Then an anterior repositioning appliance isThen an anterior repositioning appliance is
immediately placed to prevent any clenching onimmediately placed to prevent any clenching on
posterior diskposterior disk
General instructions are given to the patientGeneral instructions are given to the patient

PHARMACOLOGICAL THERAPYPHARMACOLOGICAL THERAPY
Can be an effective adjunct in managingCan be an effective adjunct in managing
symptoms associated with TMJ disorderssymptoms associated with TMJ disorders
Most common medicines are used in InternalMost common medicines are used in Internal
Disk Derangement areDisk Derangement are
ANALGESICSANALGESICS
ANTI - INFLAMMATORIESANTI - INFLAMMATORIES

ANALGESICS :ANALGESICS :
NSAIDS like Ibuprofen, Diclofenac Sodium,NSAIDS like Ibuprofen, Diclofenac Sodium,
Piroxicam, ketolorac Tromethamine,Piroxicam, ketolorac Tromethamine,
Indomethacine are usedIndomethacine are used
ANTI – INFLAMMATORIES :ANTI – INFLAMMATORIES :
- Can be administered orally or by injection- Can be administered orally or by injection
- Injecting an anti-inflammatory drugs such as- Injecting an anti-inflammatory drugs such as
hydrocortisone into the joint space may give reliefhydrocortisone into the joint space may give relief
of pain and restricted movementsof pain and restricted movements

If the joint is adapting (fibrosis of the retrodiskalIf the joint is adapting (fibrosis of the retrodiskal
tissues), then pain decreases and eventuallytissues), then pain decreases and eventually
range of mandibular movements increasesrange of mandibular movements increases
(more than 40 mm of inter incisal opening)(more than 40 mm of inter incisal opening)
If the joint is not adapting to the displaced disk,If the joint is not adapting to the displaced disk,
pain becomes significant symptom, thenpain becomes significant symptom, then
therapies may be considered (arthrocentosis,therapies may be considered (arthrocentosis,
arthroscopy or arthrotomy)arthroscopy or arthrotomy)
If on repeated attempts, it does not reduce thenIf on repeated attempts, it does not reduce then
surgery may be consideredsurgery may be consideredwww.indiandentalacademy.comwww.indiandentalacademy.com

OCCLUSAL THERAPYOCCLUSAL THERAPY
DISK DISPLACEMENT WITH REDUCTION :DISK DISPLACEMENT WITH REDUCTION :
ANTERIOR MANDIBULAR REPOSITIONING APPLIANCEANTERIOR MANDIBULAR REPOSITIONING APPLIANCE
- To be worn 24 hours a day for 3 – 6 months- To be worn 24 hours a day for 3 – 6 months
- To position condyle back on the disk- To position condyle back on the disk
DISADVANTAGEDISADVANTAGE
Patient may develop POSTERIOR OPEN BITE due toPatient may develop POSTERIOR OPEN BITE due to
the reversible, myostatic contracture of inferiorthe reversible, myostatic contracture of inferior
lateral pterygoid muscleslateral pterygoid muscles

MUSCLE RELAXATION APPLIANCE :MUSCLE RELAXATION APPLIANCE :
Appliance of choiceAppliance of choice since the risk of alteringsince the risk of altering thethe
occlusion is minimizedocclusion is minimized
- It should be noted that both appliances should- It should be noted that both appliances should
provide full arch coverage so as to avoid toothprovide full arch coverage so as to avoid tooth
eruptioneruption
- as soon as patient becomes symptom free, the- as soon as patient becomes symptom free, the
appliance should be gradually reducedappliance should be gradually reduced
- If the patient is suspected to have BRUXISM, a- If the patient is suspected to have BRUXISM, a
muscle relaxation or flat plane appliance ismuscle relaxation or flat plane appliance is

SURGICALSURGICAL
MODALITIESMODALITIES

Surgical treatment is doomed to be failure, ifSurgical treatment is doomed to be failure, if
muscular problems are eliminated beforemuscular problems are eliminated before
surgerysurgery

INDICATIONS FOR SURGERYINDICATIONS FOR SURGERY
PATIENTS WITH PAIN AND CLICKING WHOSEPATIENTS WITH PAIN AND CLICKING WHOSE
PAIN DOES NT RESPONDPAIN DOES NT RESPOND
SATISFACTORICALLY TO NON SURGICALSATISFACTORICALLY TO NON SURGICAL
THERAPY OVER A PERIOD OF 2 – 3 MONTHSTHERAPY OVER A PERIOD OF 2 – 3 MONTHS
CHRONIC CLOSED LOCK JAWCHRONIC CLOSED LOCK JAW
ARTICULAR DISC PERFORATIONSARTICULAR DISC PERFORATIONS

STAGE OF CONDITIONSTAGE OF CONDITION PROCEDUREPROCEDURE
DISK DISPLACEMENT WITH REDUCTIONDISK DISPLACEMENT WITH REDUCTION
MECHANICALMECHANICAL
INTERFERENCEINTERFERENCE
ARTHROTOMYARTHROTOMY
SMOOTH MOVEMENTSMOOTH MOVEMENT ARTHROTOMYARTHROTOMY
MODIFIED CONDYLECTOMYMODIFIED CONDYLECTOMY
DISK DISPLACEMENT WITHOUT REDUCTIONDISK DISPLACEMENT WITHOUT REDUCTION
ACUTEACUTE ARTHROCENTESIS, LAVAGE ANDARTHROCENTESIS, LAVAGE AND
MANIPULATION, ARTHROSCOPYMANIPULATION, ARTHROSCOPY
WITH LAVAGE, LYSISWITH LAVAGE, LYSIS
CHRONICCHRONIC ARTHROTOMY OR RTHROSCOPYARTHROTOMY OR RTHROSCOPY
WITH LAVAGE, LYSISWITH LAVAGE, LYSIS
DISK DISPLACEMENT WITH PERFORATIONDISK DISPLACEMENT WITH PERFORATION

ARTHROSCOPYARTHROSCOPY
TMJ Arthroscopy is performed under G.A.TMJ Arthroscopy is performed under G.A.
The cannula attached to the rigid arthroscope is insertedThe cannula attached to the rigid arthroscope is inserted
in the upper joint compartment and the arthroscope isin the upper joint compartment and the arthroscope is
connected to a television camera equipped with videoconnected to a television camera equipped with video
monitormonitor
The upper joint compartment is thoroughly examinedThe upper joint compartment is thoroughly examined
either directly through ocular or indirectly from theeither directly through ocular or indirectly from the
monitormonitor
The most common procedures performed by arthroscopyThe most common procedures performed by arthroscopy
are lysis and lavageare lysis and lavage
Improvement reported is 73 % to 93 %Improvement reported is 73 % to 93 %
SIGNIFICANCE :SIGNIFICANCE :
-- Has diagnostic & therapeutic valueHas diagnostic & therapeutic value
- Surgery can be performed at all stages of IDD- Surgery can be performed at all stages of IDD

ARTHROCENTESISARTHROCENTESIS
Arthrocentesis coupled with lavage andArthrocentesis coupled with lavage and
manipulation has been the procedure of choicemanipulation has been the procedure of choice
Joint is anesthetized by LA and the patient isJoint is anesthetized by LA and the patient is
under conscious sedation, 20-gauge needle isunder conscious sedation, 20-gauge needle is
placed in the upper compartment about 1 cm inplaced in the upper compartment about 1 cm in
front of the year, hydraulic pressure is createdfront of the year, hydraulic pressure is created
by injecting about 2ml of Ringer’s Lactateby injecting about 2ml of Ringer’s Lactate
SolutionSolution
The second 20-gauge is placed about 1cmThe second 20-gauge is placed about 1cm
anterior to the first needle and the joint isanterior to the first needle and the joint is
irrigated with 50-100ml of Ringer’s Lactateirrigated with 50-100ml of Ringer’s Lactate
SolutionSolution www.indiandentalacademy.comwww.indiandentalacademy.com

May be indicated for all stages of IDDMay be indicated for all stages of IDD
TWO PROCEDURETWO PROCEDURE
DISK REPOSITIONING :DISK REPOSITIONING :
HIGH CONDYLECTOMYHIGH CONDYLECTOMY
EMINOPLASTYEMINOPLASTY
SignificanceSignificance : Conservative joint surgery: Conservative joint surgery
Long term prognosis - ExcellentLong term prognosis - Excellent
DISEKTOMY :DISEKTOMY :
Removal of disc due to perforation,Removal of disc due to perforation,
fragmentation, loss of elasticity and persistentfragmentation, loss of elasticity and persistent
pain after disc repositioningpain after disc repositioning

REFERENCEREFERENCE
SS

1.1. MANAGEMENT OF TEMPOROMANDIBULARMANAGEMENT OF TEMPOROMANDIBULAR
JOINT DEGENERATIVE DISEASES –JOINT DEGENERATIVE DISEASES –
B. STREGENGE , L.G.M.DE BONTB. STREGENGE , L.G.M.DE BONT
22. THE TEMPOROMANDIBULAR JOINT AND. THE TEMPOROMANDIBULAR JOINT AND
RELATED OROFACIAL DISORDERS –RELATED OROFACIAL DISORDERS –
FRANCIS M BUSH, M. FRANKLIN DOLWICKFRANCIS M BUSH, M. FRANKLIN DOLWICK
3.3. THE TEMPOROMANDIBULAR JOINT – ATHE TEMPOROMANDIBULAR JOINT – A
BIOLOGICAL BASIS.BIOLOGICAL BASIS.
SARNAT , LASKINSARNAT , LASKIN
4.4. ORAL AND MAXILLOFACIAL SURGERYORAL AND MAXILLOFACIAL SURGERY
CLINICS OF NORTH AMERICA –CLINICS OF NORTH AMERICA –
FEBRUARY 1995FEBRUARY 1995www.indiandentalacademy.comwww.indiandentalacademy.com

5.5. ORAL AND MAXILLOFACIAL SURGERYORAL AND MAXILLOFACIAL SURGERY
CLINICS OF NORTH AMERICA – MAY 1994CLINICS OF NORTH AMERICA – MAY 1994
6.6. THE DENTAL CLINICS OF NORTH AMERICA –THE DENTAL CLINICS OF NORTH AMERICA –
JANUARY 1991JANUARY 1991
7.7. THE DENTAL CLINICS OF NORTH AMERICA –THE DENTAL CLINICS OF NORTH AMERICA –
JULY 1983JULY 1983
8.8. COLOR ATLAS - THECOLOR ATLAS - THE
TEMPOROMANDIBULAR JOINTTEMPOROMANDIBULAR JOINT
9.9. PERSEPECTIVES IN THE TEMPOROPERSEPECTIVES IN THE TEMPORO
-MANDIBULAR DISORDERS –-MANDIBULAR DISORDERS – GLENN TGLENN T
CLARK, WILLIAM K SOLBERGCLARK, WILLIAM K SOLBERG

10.10. MAGNETIC RESONANCEMAGNETIC RESONANCE OF THE TEMPOROOF THE TEMPORO
MANDIBULAR JOINT : CLINICALMANDIBULAR JOINT : CLINICAL
CONSIDERATIONS –CONSIDERATIONS –E. PALACIOS, G.E.E. PALACIOS, G.E.
VALVASSORI, M. SHANNONVALVASSORI, M. SHANNON
11.11. THE TEMPOROMANDIBULAR DISORDERSTHE TEMPOROMANDIBULAR DISORDERS
:DIAGNOSIS AND TREATMENT -:DIAGNOSIS AND TREATMENT - MARK HMARK H
FRIEDMAN, JOSEPH WEISBERG, P.T.FRIEDMAN, JOSEPH WEISBERG, P.T.
1212.. ARTHROSCOPIC ATLAS OF THE TMJARTHROSCOPIC ATLAS OF THE TMJ
DAVID I.B. , LESLIE B.HEFFEZDAVID I.B. , LESLIE B.HEFFEZ

13.13. THE CLINICAL APPROACH TO THETHE CLINICAL APPROACH TO THE
TEMPOROMANDIBULAR DISORDERSTEMPOROMANDIBULAR DISORDERS
BRITISH DENTAL JOURNAL JUNE 1994BRITISH DENTAL JOURNAL JUNE 1994
14.14. THE CLINICAL APPROACH TO THETHE CLINICAL APPROACH TO THE
BRITISH DENTAL JOURNAL JULY 1994BRITISH DENTAL JOURNAL JULY 1994
1515. THE CLINICAL APPROACH TO THE. THE CLINICAL APPROACH TO THE
BRITISH DENTAL JOURNAL AUGUST 1994BRITISH DENTAL JOURNAL AUGUST 1994www.indiandentalacademy.comwww.indiandentalacademy.com

DISEASE COMEDISEASE COME
THEIR OWNTHEIR OWN
ACCORD, BUTACCORD, BUT
CURES COMECURES COME
DIFFICULT ANDDIFFICULT AND
HARD

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