TMJ disorders in dentistry

1. Temporomandibular
Joint Disorders
Arsalan Wahid Malik
ِ‫يم‬ ِ‫ح‬َّ‫ر‬‫ال‬ ِ‫من‬ْ‫ح‬َّ‫ر‬‫ال‬ ِ‫هللا‬ ِ‫م‬ْ‫س‬ِ‫ب‬

4. TMJ Disorders
(Causative Factors)
 Dysfunction Syndrome
 Pathological changes
 Internal derangement
 Aplasia, hypoplasia, hyperplasia
 Maxillofacial trauma
 Dislocation
 Ankylosis

5. Investigations
 History
Pain history
Joint sounds
Restriction of mouth
opening
Swelling
 Examination
 Imaging
Arthroscopy
 Management

6. Pain History
 Within the joint
 Muscles of mastication
 Periods of exacerbation and remission
 Muscular pain may cause headache

7. Joint Sounds
 Joint sounds (clicking) is a common finding
 Click represents sliding of one part of the joint over the
other
 In some cases it is audible and in some cases
stethoscope is required to detect that
 Reciprocal
 Crepitus (multiple sounds apart from clicking sounds)

8. Restriction of Mouth Opening
 Pain in opening or closing the mouth
 Locking refers to mandible being stuck in in an open position
 Dislocation refers to the displacement of the head of condyle
out of the glenoid fossa to a position anterior to articular
eminence

9. Swelling
 Swelling & pain in area of parotid gland
 Tenderness in maxillary area
 Differentiation between joint problem and parotid pathology

10. Trismus
 Inability to open the mouth
wide due to reflex muscle
spasm of masticatory
muscle
 Its usually a temporary
condition

11. TMJ Dislocation
 Displacement of the head of
condyle out of glenoid fossa to
a position anterior to the
articular eminence

12. Bruxism
 Tooth wear facets
 Crenated tongue
 Messeteric hypertrophy
 History of repeated fracture of
restoration
 Ridging of oral mucosa

13. Examination
 Degree of symmetry of
the mandible and face
 Path of opening and
closing
 Observe specific
landmarks of face
 IIO of 35-45 mm is normal
 Loud joint sounds

14. Examination
• Single finger must be placed
on each joint and mandible
is moved to check the
mandibular movements
• Abnormal tenderness can
be detected by light
pressure on joint
• Faint joint sounds must be
detected by stethoscope

15. Examination
• Muscular tenderness must
be detected by palpation
• Intraoral palpation of
masseter and temporalis
muscles must be performed
be asking the patient to
clench the mouth and then
checking the tenderness

16. TMJ Imaging

17. TMJ Imaging
 CT is useful for hard tissue details
 MRI is useful for hard as well as soft tissues
 Arthrography involves injection of radio-opaque dye in
joint and imaging it
 Indicated in chronic TMJ pain that is resistant to initial
treatment

18. Arthroscopy
 Its investigative or therapeutic
procedure
 Allows to visualize upper joint
space
 Lower joint space has limited
space so cannot be visualized.

19. TMPDS
 Most prevalent disorder of TMJ
 Mostly females (40-80 %)
 Associated with limitation of mouth , joint clicking or trauma
 History of nail or pencil biting
 May be associated with ortho treatment

20. Signs & Symptoms
 Pre auricular pain that may radiate to other sites.
 Tenderness of joint on palpation
 Limited mouth opening
 Tenderness of masticatory muscles
 Joint sounds
 headache

21. Etiological Factors
 Lack of posterior teeth
 Unilateral tooth loss
 Occlusal disharmony
 Skeletal jaw relationship
 Psychological stress & Anxiety

22. Management
 The management of TMPDS must be reversible and non
invasive
 Some patients need reassurance and some need occlusal
splints too
 Treatment can be divided into conservative as well as
specialist treatment

23. Initial (Conservative) management
 Reassurance
 Education
 Habit management
 Modification of function
 Anti inflammatory
 Analgesics
 Muscle relaxants
 Occlusal splints
 Physiotherapy

24. Specialist management
 Psychological intervention
 Occlusal adjustment
 Occlusal rehabilitation
 Anti depressants
 Interarticular steroids
 Manipulation under general
anesthesia
 Surgery

25. Internal derangement
 Common disorder due to
permanent displacement
of articular disc having
abnormal relationship to
both the glenoid fossa and
articular eminence.

26. Disc displacement with reduction
 Reproducible reciprocal clicking
 Disc displacement shown by imaging and absence of
degenerative bone disease
 Pain, deviation of jaw movement and no limitation in
mouth opening

27. Disc displacement without
reduction
 Persistent limitation of
mouth opening
 Disc displacement shown
by imaging and absence
of degenerative bone
disease
 May be pain and clicking

28. Rheumatoid Arthritis
 Common, multisystem, autoimmune inflammatory disease
 Major complaint of patient is limitation of mouth opening,
clicking, crepitus and pain.
 Joint tenderness and stiffness is also seen
 Ankylosis of the TMJ can occur
 Anterior open bite deformity

29. Treatment
 Mainstay of treatment is NSAIDs
 Some severe cases are treated by methotrexate and
azathioprine
 Surgery is indicated in cases of ankylosis

30. Osteoarthritis
 Metabolic defect of the articular cartilage
 Usually asymptomatic & chance finding on radiograph
 Females > 50 years
 Joint sounds and stiffness
 Pre-auricular pain

31. Radiographic findings
 Reduction in joint space and erosions of articulating
surfaces.
 Osteophytes may be seen in anterior edge of condyle

32. Trismus
 Inability to open the mouth due to muscle
spasm of the masticatory muscles
 Its usually a temporary rather than permanent
condition

33. Causes of trismus
Extra-articular
 Infection/ inflammation in
related structures
 Hematoma
 Trauma
 TMPDS
 Tetany
 Teanus
 Fibrosis
 Neoplasm
Intra-articular
 Infective arthriris
 Osteoarthrosis
 Rheumatoid arthriris
 Ankylosis of TMJ
 Dislocation

34. Questions???