a seminar on tempromandibular joint disorders ,diagnosis and treatment ,specially for orthodontists

1. DR Mohammed basheer k
Yenepoya dental college , Mangalore
Subtitle

2. CONTENTS
Introduction
Functional anatomy
Etiology and classification of TMD
Signs and symptoms of TMD
History and examination of TMD
Diagnosis of TMD
Treatment of functional disturbances of the masticatory system
Conclusion

3. Introduction
• Functional disturbances of the masticatory system is called the
temporomandibular disorders or TMD.
• It was suggested by Bell in 1982
• Adopted by the American Dental Association in 1983

4. Why study TMJ as an orthodontist ?
• The TMJ influences the function, esthetics, & structural harmony of the teeth,
dentition, face

5. • NOTHING IS MORE FUNDAMENTAL TO TREATING PATEINTS THAN KNOWING THE
ANATOMY - JEFFERY P. OKESON
1972 a graduate of Kentucky college of
dentistry

6. • The masticatory system or the somatognathic system consists of the skull bones,
mandible, hyoid, clavicle, sternum; the masticatory muscles,& ligaments; the
dentoalveolar complex; the vascular, neural & lymphatics and the TMJ
• The masticatory system is responsible for CHEWING, DEGLUTATION,
SPEECH,

7. The Masticatory System
Dentition and supportive structures
Skeletal components
TMJ
Muscles of mastication

8. • The area where the mandible articulate with the cranium , the TMJ
• The tmj is formed by the mandibular condyle fitting into the mandibular fossa of
the temporal bone seprated by the articular disc
• Also known as ginglymoarthodidal joint
• Also classified a compound joint

9. Mandibular
fossa
Articular
eminence
Mandibular fossa
Lateral view Inferior view

10. Articular disc , fossa and condyle ( lateral view)
Post border Intermediate zone
Anterior border
In a normal joint
the articular
surface of the
condyle in
located on the IZ
of the disc

11. Articular disc ,fossa and condyle (anterior view)
Lateral
pole
Medial
pole

12. Retrodiscal
tissue
SLP
ILP

15. Innvervation and vascularization of TMJ
• Auricotemporal nerve ,deep temporal and masseteric nerves
• Superfical temporal artery , middle meningeal artery

16. ligaments
The collateral ligaments
The capsular ligaments
The tempromandibular ligaments
Sphenomandibular ligament
Stylomandibular ligament
Articular disc
Collateral –lateral disc ligament and
medial disc ligament
Main function is to restrict movement
of the disc from the condyle
Capsular
ligament
Superior joint
cavity
Lateral disc
ligament
Inferior joint
cavity
Capsular
ligament

17. CAPSULAR LIGAMENT( LATERAL VIEW ) TEMPROMANDIBULAR LIGAMENT( LATERAL VIEW)
ENCOMPASS THE JOINT ,THUS RETAINING THE
SYNOVIAL FLUID
OUTER
OBLIQ
UE
PORTI
ON
INNER HORIZONTAL PORTION
• OOP LIMITS NORMAL ROTATIONAL MOVEMENT
• IHP LIMITS POSTERIOR MOVEMENT

18. EFFECT OF TM LIGAMENT

19. Stylomandibular ligament –limits excessive protrusive
movements of the mandible
Sphenomandibular ligament- does not have any significant
limiting effects on mandibular movement

20. Muscles of mastication
MASSETER
TEMPORALIS
MEDIAL PTERYGOID
LATERAL PTERYGOID

21. ACCESSORY MUSCLES
• DIGASTRIC MUSCLES
• INFRAHYOID MUSCLES
• SUPRAHYOID MUSCLES

22. DP
SP
MASSETER
FUNCTION -ELEVATION OF THE MANDIBLE, CONSISTS OF 2 HEADS SUPERFICAL PART
AND A DEEP PART , POWERFUL MUSCLE HELPS IN CHEWING

23. TEMPORALIS
• WHEN THE MUSCLE CONTRACT –IT ELEVATES THE MANDIBLE AND BRINGS
THE TEETH INTO CONTACT
• WHEN THE ANTERIOR PORTION CONTRACTS –RAISES MANDIBLE
VERTICALLY
• WHEN THE MIDDLE PORTION CONTRACTS-ELEVATE AND RETRUDE
MANDIBLE

24. MEDIAL PTERYGOID
ELEVATES THE MANDIBLE AND ALSO HELPS IN PROTRUDING THE MANDIBLE

25. LATERAL PTERYGOID
SUPERIOR
LP
INFERIOR
LP
WHEN THE
INFERIOR LP
CONTRACTS –
THE MANDIBLE
IS PROTRUDED
SUPERIOR LP –IS
ACTIVE DURING
POWER STROKE

26. DIGASTRIC MUSCLE
Function =depression of the mandible

27. Etiology of TMDs

28. The five etiologic factors that have gained significant research support
occlusal condition
trauma
emotional stress
deep pain input
parafunctional activity
Tmd and orthodontics :a clinical guide for the orthodontists

29. occlusal condition
• Even today this relationship is continuously debated, with proponents remaining
on both sides of the discussion.
• appears to be two ways the occlusal relationship of the teeth may be associated
with TMD symptoms.
• an acute change in the occlusal condition ( example ill fitting crown)
• Orthopedic Instability Coupled with Loading
• When the teeth are loaded by activities such as heavy biting, chewing, or
bruxism, the joints need to be in a stable position. When this does not exist,
continued loading can result in changes in the joint structures

31. Orthopedic
instablity

32. Trauma
• Trauma seems to be more related to intracapsular disorders than muscle
disorders
• Microtrauma & macrotrauma.

33. Emotional Stress
• individuals placed under acute emotional stress show slight increase in EMG
activities of their masseter muscles
Deep pain input
• Deep pain input refers to any source of neural impulses that originate in the deep
structures and lead to a pain experience
• TMD is secondary to another pain disorder and will continue until the primary source
of pain is resolved

34. • For many years dentists have focused on bruxism and clenching as a significant
etiologic factor associated with TMDs
• Diurnal activity
• Nocturnal activity

35. Classification of Temporomandibular Disorders
• Most temporomandibular disorders fall into one of two broad categories: muscle
pain disorders or intracapsular disorders
Masticatory muscle
disorders
Temporomandibular
Joint Disorders
•Local Muscle
Soreness
•Myofascial Pain
•Internal
Derangements
•Osteoarthritis

36. • Disc dislocation with reduction /without reduction
• Subluxation
• Open lock ( spontaneous dislocation)
• Synovitis
• Retrodiscitis
• Arthritides
• Chronic mandibular hypomobility

37. Masticatory muscle disorders
Local Muscle Soreness
• condition that is
characterized by changes in
the local environment of the
muscle tissues
• algogenic substances
bradykinin, substance P,
histamine that produce pain
• The most likely causes of
local muscle soreness are
overuse of the muscle or
trauma
• Clinically , they present with
pain on palpation and
function
Myofascial Pain
• Pain condition characterized by local areas of firm,
hypersensitive bands of muscle tissue known
as “trigger points.”

39. Temporomandibular Joint Disorders
Internal Derangements
• Internal derangements represent a group
of functional disorders that arise from
abnormalities in the anatomy and/or
positional relationships of the TM joint
structures
Etiology
• any condition or event that leads to
elongation of the discal ligaments or
thinning of the disc can cause these
derangements of the condyle-disc
complex disorders
•Microtrauma & macrotrauma.

40. Click
Click
Functional
displacement of
the disc with
displacement

41. ( b ) partial displacement of the disc,
( c ) complete displacement of the disc,
( d) impingement of
retrodiscal tissues,
( e ) retrodiscitis and tissue breakdown,
( f) osteoarthritis

42. Osteoarthritis
• most common tissues affected are the retrodiscal tissues and the articular
surfaces of the condyle and articular eminence.
• most common type of TMJ arthritis is osteoarthritis (sometimes called
degenerative joint disease)
• Other common causes of TMJ arthritis are traumatic arthritis, infectious arthritis,
psoriatic arthritis, and hyperuricemia (gout).

43. take home messages
TMD signs and symptoms are common in the general population, but only a small percentage
of those require treatment.
Orthodontists need to be aware how their treatments can affect
masticatory function.
There are five recognized etiologic factors associated with TMD.
Muscle pain is the most common painful TMD encountered in the
orthodontic practice
Most TMD symptoms can be managed by conservative approaches.
Treatment goals for all orthodontists should include developing or
maintaining orthopedic stability in the masticatory system

44. “ YOU CAN NEVER DIAGNOSE SOMETHING YOU HAVE NOT HEARD ABOUT “
JPO

45. Signs and Symptoms of TMDS
The clinical signs and symptoms of masticatory dysfunction can
be grouped into according to the structures that are affected
The muscles
The TM joint
The dentiton

47. Signs and symptoms of the muscles
Pain
Dysfucntion

48. masticatory muscle model

49. Perpetuating factors
• Certain conditions when present may prolong the muscle pain condition . It can
be divided into
• Local perpetuating factors
• Systemic perpetuating factors

50. Local perpetuating factors
• Protracted cause
• Recurrent cause
• Therapeutic management

51. Systemic perpetuating factors
• Continued emotional stress
• Sleep disturbances
• Learned behavior
• Secondary gain
• Depression

52. Signs and Symptoms of TM joint
Arthralgia
Clicking
sound
Crepitation

53. Signs and Symptoms of the dentiton
• Mobility
• Pulpitis
• Tooth wear

54. Other signs and symptoms
• Headache
• Tension type headache
• Neurovascular headache ( migrane )
• Sensation of fullness in the ear
• Ear stuffiness
• Tinnitus
• Vertigo

56. Screening history and examination
Do you have difficulty or pain when opening your mouth ,for instance ,when yawning ?
Does your jaws get “ stuck “ or “locked “ ?
Do you have difficulty / pain when chewing ,talking or using your jaws ?
Are you aware of the noises in the jaw joints ?
Do you regularly feel stiff ,tight or tired ?
Do you have pain in or about the ears .temples or cheeks ?
Do you have frequent headaches ,neck aches or toothaches ?
Have you had a recent injury to your head ,neck or jaw ?
Have you been aware of any recent changes in your bite ?
Have you been previously treated for any jaw problem ?

57. History taking
• Chief complaint of the patient
• Location of the pain
• Onset of the pain
• Characteristics of pain
• Aggravating and alleviating factors
• Effect of functional activities
• Effect of physical modalities

58. • Past consultations and treatments
• Medical history

59. Clinical examination
• Because of the complexity of head and neck pain disorders
• It is important certain non masticatory structures be at least grossly examined for
ruling our other disorders
• If abnormal findings are identified , an immediate referral to the appropriate
specialist is indicated

60. Checking the patients visual field (
optic nerve)
Checking the patients extra ocular muscles

61. Cotton tip applicators are used to compare light
touch discrimination between the right and left
maxillary branches of the trigeminal nerve
Motor function of the trigeminal nerve is tested by
evaluating the strength of the masseter muscle
contraction ,

62. Hear sensation The spinal accessory nerve function
(motor) to the sternocleidomastoid is
tested

63. CERVICAL EXAMINATION

64. MUSCLE PALPATION
Palpation of the tendon of the
temporalis – finger mover up the
ant border of the ramus until the
coronoid process

65. Palpation of the masseter muscles

66. FUNCTIONAL MANIPULATION of MUSCLE
Fuctional manipulation of the inferior lateral
pterygoid
Functional manipulation of superior
lateral pterygoid

67. Measuring mouth opening
Checking the “end feel “

68. Examination of the lateral movement of the mandible

69. Alterations in the opening pathway

70. TMJ examination

72. Dental Examination
• Mobiltiy
• Pulpitis
• Tooth wear
• Abfractions
• Occlusal examination

75. Guiding the mandible into centric relation

81. Additional diagnostic tests
• Opg
• CT
• CBCT
• MRI

82. DIAGNOSIS OF TEMPROMANDIBULARDISORDERS
“the most important thing you can for your patient is to make the
correct diagnosis .it is the foundation of success “
-JPO

83. diagnosing pain disorders
• The clinician should be able to differentiate between referred pain and primary
pain
• Analgesic blocking is good method to identify pain disorders
• Trigger point injections
• Nerve block injections
• Intracapsular injections

84. Trigger point injections

86. Intra capsular

87. Keys in making a differential diagnosis
• History
• Mandibular restriction
• Mandibular interference
• Acute malocclusion
• Loading of the joint
• Functional manipulation
• Diagnostic anesthetic blockade

88. Protocol for the management of TMD signs
and symptoms within an orthodontic practice

90. Management of TMD Signs and Symptoms in the Orthodontic Practice

91. General considerations
• Like all other dentists, orthodontists are likely to encounter some patients with
TMD signs and symptoms in their practices that require some form of
professional treatment.
• The two major clinical features of most temporomandibular disorders are pain
and dysfunction
• basic TMD treatment

92. Management
patient self-directed care
physical therapies
cognitive-behavioural therapies
biofeedback
pharmacologic agents,
oral occlusal appliances

93. Patient Self-Directed Care and Education
• well known that patients experiencing TMD related pain and dysfunction
frequently are anxious
• it is important for the orthodontist to reduce that anxiety by communication with
the patient

94. Home Care Instructions
• Patients should limit or stop such activities as chewing gum, yawning, yelling,
singing, cheerleading, and so on.
• can support their mandible to limit opening when yawning
• keeping their head in a neutral position while sitting and using an orthopedic
pillow at night
• eat soft foods, avoid hard or chewy foods, avoid wide opening during meals
• hot showers, saunas, or steam baths are known to be helpful for dealing with all
types of musculoskeletal pain

95. Psychological Approaches to Treatment
• Cognitive behavioral therapy is a highly effective modality in facilitating stress
reduction and enhancing self management.
• This involves educating the patient about the mind-body connection
• Techniques and skills to reduce both their stress and their symptoms

96. oral occlusal appliances
• Oral appliances have been shown to be effective in some TMD patients
• The key to effective splint therapy is its short term use as well as night time
• No irreversible occlusal changes or alterations of TMJ relationships should
occur following splint wear

97. Defintive therapy considerations for occlusal factors
Reversible occlusal therapy
Irrevisble occlusal therapy

98. Relaxation procedures

99. Supportive therapy
Drugs
• Analgesics
• NSAIDs (ibuprofen ,naproxen a dosage of 600 -800 mg TID )
• Corticosteroids( hydrocortisone)
• Anxiolytic agents (valium ,diazepam 2.5mg- 5mg,clonazepam,alprazolam)
• Muscle relaxants (mephenesin)
• Anti depressants (amitriptyline)
• Local anesthetics

100. Physical therapy
• Thermotherapy
• Coolant therapy
• Ultrasound therapy
• Ionto phoresis
• Trans cutaneous electrical nerve stimulation

101. TENS
iontophoresis
Moist heat

102. Manual techniques
• Massage therapy
• Joint distraction of the TM joint
• Passive exercises
• Stretching exercises
• Resistance exercises
• Postural training

103. Avoid
unwanted
movements
Resistan
ce
exercises

104. Disc dislocation without reduction
• It is a clinical condition in
which the disc is dislocated ,
most frequently anteromedially
from the condyle and does not
return to normal position with
condylar movement
• Cause can be micro trauma and
macro trauma

105. Disc displacement and disc displacement
with reduction
• It results as a result from elongation of the capsular and discal ligaments coupled
with thinning of the articular disc

107. Subluxation
• Some times called hypermobility of the condyle , it moves anterior to the crest of
the articular eminence
• Definitive treatment of subluxation is surgical alteration of the joint

109. Surgical Management of Temporomandibular Joint Problems
Discoplasty and discoectomy

111. Arthrocentesis

112. Take home messages

113. Orthodontics and TMD : a evolution of controversy
• The modern history of TMD essentially starts in 1934. An otolaryngologist, Dr
James Costen, described a syndrome (Costen’s syndrome)
• The etiology was believed to be overclosure of the mandible due to loss of
dental vertical dimension
• It was disapproved by Dr harry Sicher
• During this same time period, Dr. Alan Brodie, Chair of the Orthodontic
Department at the University of Illinois (and student of Dr. Edward H. Angle),
wrote about the differential diagnosis of TM joint conditions in orthodontics

114. • “gnathologic-prosthodontic” view made its way into orthodontics, led by Dr.
Ronald H. Roth
• “gnathologic-prosthodontic” view made its way into orthodontics, led by Dr.
Ronald H. Roth temporomandibular joint (TMJ) disorders.

115. Acc to roth gnathologic goals were
• Attain a canine-protected (mutually protected) occlusion
• Analyze the discrepancy between a patient’s occlusion and centric relation
position after obtaining a particular centric bite registration (Power-Bite)
followed by the articulator mounting of the patient’s dental casts.
• Attain coincidence of a patients centric occlusion

116. • Of importance, the modern evidence-based view does not argue that occlusion
and condyle position have no relevance to the considerations of TMD.
• The gross evaluation of a patient’s occlusion is important in the diagnosis and
treatment of TMD
• There is no evidence that early orthodontic treatment of patients with
malocclusions will prevent the development of TMD in the future

117. References
• Management of tempromandibular disorders and occlusion -JEFFERY P
OKESON 6TH EDITION
• Management of tempromandibular disorders and occlusion -JEFFERY P
OKESON 7TH EDITION
• Contemporary orthodontics : PROFFIT 5th edition
• TMD AND ORTHODONTICS – a clinical guide for orthodontists – Charles S
Greene
• Orthodontics ,diagnosis and management of dentofacial deformities –OP
Kharbanda