This document discusses the assessment and management of temporomandibular disorders (TMD). It begins with an introduction stating that TMD are common and multifactorial. It then discusses the various specialists that may be involved in treatment. The document covers the functional anatomy of the TMJ and associated muscles and nerves. It describes common causes of TMD like occlusal disharmony, trauma, and parafunctional habits. Imaging options for assessment are outlined. Specific TMD conditions discussed in detail include disc disorders, osteoarthritis, and myofascial pain dysfunction syndrome. Treatment involves a multidisciplinary approach including education, self-care, physiotherapy, appliances, medications, and behavioral therapies.

2. Introduction
• Routine practice TMD are common
• TMD are multi-factorial, avoid tunnel
vision
• TMJ, masticatory muscles and teeth
should not be considered in isolation.

3. • Dental treatment for 18 months
• General practitioner
• ENT consultant
• Neurologist
• Clinical psychologist
• Psychiatrist
• Restorative dentist
• General dental practitioner

4. • Three third molars removed
• Two apicoectomies done
• Four root canal treatments
• Symptoms unchanged
• TMJ clinic
• Minor occlusal correction

6. Functional Anatomy
• Ginglymodiathrodial joint
• Boney components enclosed and
connected by fibrous capsule
• Capsule lined with synovium
• Joint cavity filled with synovial fluid
• Fluid decreases friction

7. Articular Disc
• Space between condyle and mandiular fossa
is occupied by collagenous fibrous tissue
• Disc is attached to the lateral and medial
poles of the condyle by ligaments
• Thick in the centre and thin on both the ends.
• Avascular and little sensory nervous
penetration
• Divides joint to U/L compartments

10. • Retrodiscal tissue
• Temporomandibular ligament
• Capsular ligament

12. Muscles of mastication
• Massater
• Medial pteygoid
• Lateral pterygoid
• Temporalis
• Accessory muscles

16. • Vascular
– External carotid artery
• Nerve supply
– Trgeminal nerve
– Cranial nerve VII, IX, X, XI

18. 2

19. • Etiology
• Epidemiology
• Classification

20. Etiology
• Occlusal disharmony
• Psychological distress

21. • Parafunctional habits
• Emotional distress
• Acute trauma from blows or impacts
• Trauma from hyperextensions
• Instability of maxillo-mandibular reln
• Laxity of joint
• Rheumatic disorders (comorbidity)
• Poor general health

22. Epidemiology
• Age 20 – 40 Yrs
• Predominantly women
• 65 – 85% of the population
• 12% prolonged pain
• 5 – 7% need treatment.

23. Classification
• Cranial bones
– Congenital and developmental
– Fracture
– Neoplasia
Muscles
– Myofascial pain
– Myositis

24. • Temporomandibular joint
– Disc displacement
– Dislocation
– Inflammation
– Arthritis
– Neoplasia
– Ankylosis

25. Assessment
• History
• Physical examination
• Imaging

26. History
• Apart from routine history,
dental, medical and drug history
• PAIN is most important feature
• Pain diary could be maintained

27. Physical examination
• Mandibular movements
– Opening
– Lateral
– Protrusive
– Deviation
• Tenderness in muscles of
mastication

28. Imaging
• Plain film radiographs
• Arthrography
• Tomography
• Computed tomography
• Magnetic resonance imaging

37. Intracapsular Disorders

38. • Articular disc disorders
– With or without symptoms
• Arthritis
– With or without symptoms

39. Articular disc displacement
• Abnormal relationship of disc with its
surrounding structures
• Due to stretching or tearing of
attachment to condyle
and glenoid fossa

40. • Abnormal joint sounds
• Limitation in mandibular range of
motion
• Pain during mandibular movement
• Majority of cases of ADD occur
without significant pain or joint
dysfunction.
Contd…

41. Etiology
• Direct trauma to the joint
• Chronic low-grade microtrauma
• Craniofacial morphology

42. • Anterior disk displacement with
reduction (clicking joint)
• Anterior disk displacement without
reduction (closed lock).

43. • ADD with reduction
– Common, need no treatment but for pain
• ADD without reduction
– After trauma or nocturnal bruxism

44. Management
• Resolve with time
• Conservative treatment
• Techniques to reduce discomfort
• Disc will remain displaced

45. Osteoarthritis
• Disorder of articular cartilage and
subchondral bone
• Secondary inflammation of the synovial
membrane.
• Response of the joint to chronic
microtrauma or pressure.

46. CLINICAL MANIFESTATIONS
• Over the age of 20 years.
• Incidence increases wiath age
• Unilateral pain directly over the condyle
• Limitation of mandibular opening
• Crepitus
• Feeling of stiffness after a period of
inactivity

47. Radiographic findings
• Narrowing of the joint space
• Irregular joint space
• Flattening of the articular surfaces
• Osteophytic formation
• Anterior lipping of the condyle

48. Management
• NSAID
• Hot moist fomentation
• Soft diet
• Rest
• Occlusal splints

49. Myofascial Pain
Dysfunction Syndrome

50. Etiology
• Masticatory muscle spasm
• Improper restoration
• Grinding or Clenching
– Psycho-physiologic theory

51. Leads to…
• Pain
• Limitation of motion
• Minor shift in the jaw rest position
• When spasm is relieved patient
develops occlusal imbalance
• Degenerative arthritis & muscle
contracture
• Amplification of original spasm

52. Clinical symptoms
• Pain
• Muscle tenderness
• Clicking or popping noise
• Limitation of jaw motion

53. Negative findings
• Absence of changes in the joint
– Clinical
– Roentgenographic
• Lack of tenderness in joint

54. Diagnostic Imaging
Is of value in selected conditions but not as a
part of a standard assessment , should be
considered only when clinical presentation
suggests a progressive pathologic condition
like osteodegenerative disease, fractures or
tumors of bone.
Tomograms for evaluation of bony structures
MRI for evaluation of soft tissue

55. Imaging Options
• Radiographs
– OPG
– Extra oral views
• Arthrography
• CT
• MRI
• Bone scan
• 3 D reconstruction from CT, MRI

56. Radiographs
Transorbital
View

57. Transpharyngeal View

58. OPG

59. OPG

60. Degenerative osteoarthritis
TMJ Tomogram
Normal TMJ Tomogram
Degenerative osteoarthritis with
osteophyte TMJ Tomogram

63. MRI

64. Treatment
• Education & Information
• Self-care & Habit reversal
• Physiotherapy
• Intraoral appliances
• Pharmacotherapy
• Behavioural therapy & Relaxation
technique
• Trigger point therapy