Temporomandibular joint disorders

TEMPOROMANDIBULAR
JOINT DISORDERS-
DIAGNOSIS AND
MANAGEMENT

CONTENTS
 INTRODUCTION
 CLASSIFICATION SYSTEM FOR DIAGNOSING TMJ
DISORDERS.
 MASTICATORY MUSCLE DISORDERS
 TEMPOROMANDIBULAR JOINT DISORDERS
 DERANGEMENTS OF DISC CONYLE COMPLEX
 STRUCTURAL INCOMPATIBILITY OF ARTICULAR SURFACES
 KEYS IN MAKING DIFFERENTIAL DIAGNOSIS
 CONCLUSION
 REFERENCES

INTRODUCTION
 Temporomandibular disorder (TMD) is any disorder that affects
or is affected by deformity, disease, misalignment, or
dysfunction of the temporomandibular articulation.
 “Depending on the practitioner and the diagnostic methodology,
the term TMD has been used to characterize a wide range of
conditions diversely presented as pain in the face or jaw joint
area, limited mouth opening, closed or open lock of the TMJ,
abnormal occlusal wear, clicking or popping sounds in the jaw
joints, and other complaints(National Institute of Health
Technology Assessment Conference on Management of TMD
(1996))

 To manage masticatory disorders effectively, one must
understand the numerous types of problems that can exist and
the variety of etiologies that cause them.
 Separating these disorders into common groups of symptoms
and etiologies is a process called diagnosis.
 The clinician must keep in mind that for each diagnosis there is
an appropriate treatment.
 No single treatment is appropriate for all temporomandibular
disorders (TMDs).
 Therefore making a proper diagnosis becomes an extremely
important part of managing the patient disorder.

MASTICATORY
PROBLEMS
MASTICATORY
MUSCLE
DISORDERS
INTRACAPSULAR
JOINT
DISORDERS
CONDITIONS
THAT MIMIC
TMDs

MASTICATORY MUSCLE DISORDERS
 Masticatory muscle disorders, which are analogous to other
regional or localized muscle disorders in the body, include
myofascial pain, myositis, myospasm, unclassified local
myalgia, myofibrotic contracture, and neoplasia

MASTICATORY MUSCLE DISORDERS
 Pain - chewing, swallowing, and speaking.
 Aggravated by manual palpation or functional manipulation of the
muscles.
 Restricted mandibular movement is common.
 Muscle pain is of extracapsular origin and may be primarily induced
by the inhibitory effects of deep pain input.
 The restriction is most often not related to any structural change in the
muscle itself.
 Sometimes accompanying these muscle symptoms is an acute
malocclusion.
 Typically, the patient will report that his or her bite has changed.

MASTICATORY
MUSCLE
DISORDERS
PROTECTIVE
CO-
CONTRACTION
LOCAL MUSCLE
SORENESS
MYOFASCIAL
PAIN
MYOSPASM
CENTRALLY
MEDIATED
MYALGIA
FIBROMYALGIA

PROTECTIVE CO-CONTRACTION
Central nervous system (CNS) response to injury or threat of
injury.
all muscles are maintained in a mildly contracted state known as tonus.

ETIOLOGY
Altered sensory or
proprioceptive
input.
Constant deep pain
input
Increased
emotional stress

HISTORY
 The key to identify protective co-contraction is that it
immediately follows an event,and therefore history is
important.
A recent
alteration
in local
structures
A recent
source of
constant
deep pain
A recent
increase
in
emotional
stress

CLINICAL CHARACTERISTICS
Structural
dysfunction.
Minimum/no
pain at rest.
Increased
pain with
function
A feeing of
muscle
weakness.

TREATMENT
DEFINITIVE
TREATMENT
SUPPORTIVE
THERAPY
 Normal CNS response-not
indicated to treat the muscle.
Treatment should be directed
towards the reason for
contraction.
 If co-contraction is the result of
deep pain, the pain must be
appropriately addressed
 Restrict use of mandible within
painless limits.
 Soft diet
 Short term pain medications
 Simple PSR Techniques

LOCAL MUSCLE SORENESS(NON
INFLAMMATORY MYALGIA)
 Local myalgia is a primary, noninflammatory, myogenous pain
disorder.
 It is often the first response of the muscle tissue to continued
protective co-contraction.
 Represents a change in the local environment of the muscle
tissues.

ETIOLOGY
Protracted
co-
contraction
Deep pain
input
Trauma
Increased
emotional
stress

HISTORY
 Pin began several hours/days following an event with
protective co-contraction.
 Pain began associated with tissue injury.
 Pain began secondary to another source of pain.
 There was a recent episode of increased emotional stress

 Structural dysfunction.
 Minimum pain at rest.
 Pain increased with function.
 Actual muscle weakness
 Local tenderness when involved muscles are palpated.

TREATMENT
 The primary goal is to decrease sensory input to the CNS. The
following steps include
Eliminate any ongoing altered sensory or proprioceptive input
Eliminate any ongoing source of deep pain input.
Provide patient education and information on self management
Occlusal therapy
Pharmacological therapy

MYOSPASMS
 Myospasm is an involuntary, CNS-induced tonic muscle
contraction.
 Not common.
Local
muscle
conditions
Systemic
conditions
Deep pain
input

Structural dysfunction.
Pain at rest
Increased pain with function
Local muscle tenderness
Muscle tightness

TREATMENT
• Myospams are best treated by reducing the pain and then
passively lengthening or stretching the involved muscles.
• When obvious causes are present,attempts should be made
to eliminate these factors to reduce recurrent myospams
DEFINITIVE TREATMENT
• Soft tisue mobilization-Deep massage and passive stretching.
• Physical therapies-Muscle conditioning exercises and
relaxation techniques.
• Pharmacological therapy-not indicated
SUPPORTIVE THERAPY

MYOFASCIAL PAIN
 Myofascial pain is a regional myogenous pain condition
characterized by local areas of firm, hypersensitive bands of
muscle tissue known as trigger points.
 described by Travell and Rinzler in 1952.
 Myofascial pain arises from hypersensitive areas in muscles
called trigger points.
 Felt as taut bands when palpated, which elicits pain.

ETIOLOGY
 Although myofascial pain is seen clinically as trigger points in the
skeletal muscles, this condition is certainly not derived solely from
the muscle tissue.
 There is good evidence that the CNS plays a significant role the
etiology of this pain condition
Protracted local myalgia
Constant deep pain
Increased emotional stress
Sleep disturbances
Local factors:
Systemic factors
Idiopathic trigger point mechanism

HISTORY
 The patient’s chief complaint will often be the
heterotopic pain and not the actual source of pain (the
trigger points).
 Therefore the patient will direct the clinician to the
location of the tension-type headache or protective
cocontraction, which is not the source.
 If the clinician is not careful he or she may direct
treatment to the secondary pains, which,of course, will
fail.
 The clinician must have the knowledge and diagnostic
skills necessary to identify the primary source of pain
so that proper treatment can be selected.

Structural dysfunction
Pain at rest:
Increased pain with
function
Presence of trigger
points

 Eliminate any source of ongoing deep pain input in an
appropriate manner according to the etiology.
 Reduce the local and systemic factors that contribute to
myofascial pain.
 If a sleep disorder is suspected, proper evaluation and
referral should be made.
 One of the most important considerations in the management
of myofascial pain is the treatment and elimination of the
trigger points.

Spray and Stretch
Pressure and Massage
Ultrasound and
Electrogalvanic Stimulation
Injection and Stretch

SUPPORTIVE THERAPY
 Physical therapy modalities-soft tissue mobilization and
muscle conditioning techniques.
 Pharmacologic therapy - muscle relaxant
 Daily stretching to full length can be beneficial in maintaining
them pain free.
 This is especially true in the neck and shoulder region.
Regular exercise should always be encouraged

CENTRALLY MEDIATED MYALGIA
 Centrally mediated myalgia is a chronic, regional, continuous
muscle pain disorder originating predominantly from CNS
effects that are felt peripheral in the muscle tissues.
 The condition has also been referred to as persistent orofacial
muscle pain.
 This disorder clinically presents with symptoms similar to an
inflammatory condition of the muscle tissue and therefore is
sometimes referred to as myositis.
 This condition, however, is not characterized by the classic
clinical signs associated of inflammation.
 Chronic centrally mediated myalgia results from a source of
nociception found in the muscle tissue that has its origin in the
CNS

ETIOLOGY
 The pain associated with centrally mediated myalgia has its
etiology more in the CNS than the muscle tissue itself.
 As the CNS becomes exposed to prolonged nociceptive
input, brainstem pathways can functionally change.
 This can result in an antidromic effect on afferent peripheral
neurons.

HISTORY
 The patient reports a constant, primary, myogenous pain
condition usually associated with a prolonged history of
muscle complaints (months and even years).

 Structural dysfunction
 Pain at rest.
 The pain is increased with function.
 Generalized feeling of muscle tightness.
 Significant pain on muscle palpation.
 As chronic centrally mediated myalgia becomes protracted,
the lack of use of the muscle due to pain may induce muscle
atrophy and/or myostatic or myofibrotic contracture.

 The clinician needs to initially recognize the condition of chronic
centrally mediated myalgia since the outcome of therapy will not be as
immediate as with treating local myalgia.
 Neurogenic inflammation of muscle tissue, and the chronic central
sensitization that has produced it, often takes time to resolve.

 Restrict mandibular use to within painless limits.
 Avoid exercise and/or injections.
 Disengage the teeth-Voluntary or involuntary
 Anti inflammatory medication.
 Management of sleep
 Since the CNS is a major player in this type of pain condition
it is likely that the central neurons have become sensitized.

SUPPORTIVE TREATMENT
 Early in the treatment of chronic centrally mediated
myalgia, physical therapy modalities should be
used cautiously since any manipulation can
increase the pain
 isometric jaw exercise will be effective for
increasing the strength and use of the muscles
(Fig. 12.15). Passive stretching is also helpful in
regaining the original length of the elevators

FIBROMYALGIA
 Fibromyalgia is a chronic, global, musculoskeletal pain
disorder.
 Pain must be felt in three of the four quadrants of the body
and be present for at least three months.
 Fibromyalgia is not a masticatory pain disorder and therefore
needs to be recognized and referred to appropriate medical
personnel.

ETIOLOGY
 The etiology of fibromyalgia has not been well documented.
 Presently, a reasonable explanation of the etiology of
fibromyalgia focuses on the manner by which the CNS
processes ascending neural input from the musculoskeletal
structures.
 Perhaps future investigations will reveal that fibromyalgia has
its origin in the brainstem with a poorly functioning
descending inhibitory system

HISTORY
 Patients experiencing fibromyalgia report chronic and
widespread musculoskeletal pain in all four quadrants of the
body that has been present for 3 months or longer.
 The pain must be present both above and below the waist
and on the right and left.
 The patient complains of arthralgic pain with no evidence of
any articular disorder.
 Sleep disturbances are a common finding along with a
sedentary physical condition and clinical depression.

 Structural dysfunction.
 There is widespread myogenous pain at rest, fluctuating over
time.
 The pain is increased with function of the involved muscles.
 Patients experiencing fibromyalgia report a general feeling of
muscle weakness. They also commonly report generalized
chronic fatigue.
 Patients with fibromyalgia generally lack physical
conditioning

 Since knowledge of fibromyalgia is limited, treatment should
be conservative and directed toward the etiologic and
perpetuating factors.
 The following general treatments should be considered:
 When other masticatory muscle disorders also exist, therapy should be directed
toward these disorders.
NSAIDs seem to be of some benefit with fibromyalgic symptoms and should be
administered in the same manner as with chronic centrally mediated myalgia.
If a sleep disturbance is identified it should be addressed

Although tender points and trigger points are thought to be
different, some evidence exists to suggest that treatment such
as gentle physical therapy and even trigger injections may be
helpful for some fibromyalgia patients
Therapies orientated toward reducing the upregulated autonomic
nervous system
Regular exercise program
Since depression has common comorbidity with fibromyalgia the
clinician must be aware and evaluate for this mental disorder.
When it is identified the patient needs to be appropriately managed

SUPPORTIVE THERAPY
 Physical therapy modalities and manual techniques.
 Techniques such as moist heat, gentle massage, passive
stretching, and relaxation training can be the most help.
 Also, muscle conditioning can be an important part of
treatment.
 A mild and well-controlled general exercise program such as
walking or light swimming can be very helpful in lessening
the muscle pain associated with fibromyalgia

TEMPOROMANDIBULAR DISORDERS
 TMJ disorders are a broad category of temporomandibular disorders
(TMDs) that arise from capsular and intracapsular structures

DEARANGEMENTS IN DISC-
CONDYLE COMPLEX
Disc
displacements/disc
displacements with
intermittent locking
Disc
displacements
without reduction.

DISC DISPLACEMENTS/DISC
DISPLACEMENTS WITH INTERMITTENT
LOCKING
 Represent early stages of disc derangement disorders .
 The clinical signs and symptoms relate to alterations or
derangements in the condyle-disc complex.

ETIOLOGY
 Elongation of the capsular and discal ligaments
coupled with thinning of the articular disc.
 Orthopedic instability plus joint loading seem to
combine as etiologic factors in some disc
derangement disorders
 Another concept that must be appreciated is that
perhaps the disorder actually begins at the
cellular level and then progresses to the gross
changes seen clinically
MACROTRAUMA MICROTRAUMA BRUXISM CLASS II DIV II

HISTORY
 When macrotrauma is the etiology the patient will often relate
an event that precipitated the disorder, such as a motor
vehicle accident or blow to the face.
 Taking a thorough history from the patient may frequently
reveal the more subtle findings of clenching and/or bruxism.
 The patient will also report the presence of joint sounds and
may even report a catching sensation during mouth opening.
 The presence of pain associated with this dysfunction is
important.

CLINICAL FEATURES
 relatively normal range of movement with restriction only
associated with the pain.
 Discal movement can be felt by palpation of the joints during
opening and closing.
 Deviations in the opening pathway are common.

ANTERIOR REPOISTIONING SPLINT
 Early 1970s, Farrar
 Provides an occlusal relationship that requires the mandible
to be maintained in a forward position.
 The position selected for the appliance is one that positions
the mandible in a slight protruded position in an attempt to
reestablish the more normal condyle-disc relationship.
 This is usually achieved clinically by monitoring the clicking
joint.
 The least amount of anterior positioning of the mandible that
will eliminate the joint sound is selected.

SUPPORTIVE THERAPY
 The patient needs to be encouraged to decrease loading of the joint
whenever possible.
 Softer foods, slower chewing, and smaller bites should be promoted.
 The patient should be told, when possible, not to allow the joint to click.
If inflammation is suspected, an NSAID should be prescribed.
 Moist heat or ice can be used if the patient finds either helpful.
 Active exercises are not usually helpful since they cause joint
movements that often increase pain.
 Passive jaw movements may be helpful and on occasion distractive
manipulation by a physical therapist may assist in healing.
 Even though this is an intracapsular disorder, physical self-regulation
(PSR) techniques should assist the patient’s recovery

Partial time use of anterior repositioning
splints in the management of tmj pain and
dysfunction: a one-year controlled study
Conti PC, Miranda JE, Conti AC, Pegoraro LF, Araújo CD. J. Appl. Oral Sci.
2005 Dec;13(4):345-50.
This study aimed at evaluating the effectiveness of partial
use of anterior repositioning appliances in the
management of TMJ pain and dysfunction when
compared to stabilization splints and a control group in a
one-year follow-up.

Methodology
 The sample was initially constituted of 60 patients, with
complaints of TMJ pain presented to treatment at the
Orofacial Pain Clinic at Bauru Dental School, University of
São Paulo,
INCLUSION CRITERIA
1.presence of TMJ disc
displacement with reduction and
chief complaint of pain in the joint
followed by positive TMJ tenderness
to manual palpation, accompanied
or not by muscle symptoms.
2.The presence of at least a clicking
joint during opening, eliminated
on opening in protrusion
EXCLUSION CRITERIA
1.Systemic diseases (i.e.
rheumatoid arthritis,
osteoarthritis, etc.),
2.History of recent
trauma or previous TMJ
surgery.

GROUPS
GROUP 1
STABILIZING
SPLINTS
GROUP 2
REPOSITIONING
SPLINTS
GROUP 3
NO TREATMENT

Conclusion
 Authors concluded that partial and controlled use of
repositioning splints might be very useful in the initial
management of TMJ pain and dysfunction.
 Long-term evaluation, however, showed that most
symptoms (pain and joint noises) seem to subside
regardless of the group studied, which warns about the
need of irreversible treatments after the initial
improvement.

DISC DISPLACEMENT WITHOUT
REDUCTION
 Disc displacement without reduction is a clinical condition in
which the disc is totally displaced (dislocated) most
frequently anteromedially to the condyle and does not return
to normal position with condylar movement
Etiology
 Macrotrauma and microtrauma are the most common causes
of disc displacement without reduction.

HISTORY
 Patients most often report the exact onset of this disorder. A
sudden change in range of mandibular movement occurs that
is very apparent to the patient.
 The history may reveal a gradual increase in intracapsular
symptoms (clicking and catching) prior to the dislocation.
 Most often, joint sounds are no longer present immediately
following the disc displacement without reduction.

 Examination reveals limited mandibular opening (25 to 30
mm) with some slight defection to the ipsilateral side during
maximum opening.
 There is normal eccentric movement to the ipsilateral side
and restricted eccentric movement to the contralateral side.

 Anterior positioning appliance is contraindicated for this
patient-only aggravate the condition by forcing the disc even
more forward.
 When the condition of disc displacement without reduction is
acute, the initial therapy should include an attempt to reduce
or recapture the disc by manual manipulation

 When an acute disc displacement without reduction has been
reduced, it is advisable to have the patient wear the anterior
positioning appliance continuously for several days before
beginning only nighttime use.
 The rationale for this is that the displaced disc may have
become distorted during the displacement, which may allow it
to redisplace more easily.
 Maintaining the anterior positioning appliance in place
constantly for a few days may help the disc reassume its
more normal shape

 If the disc is not successfully reduced, a second and possibly
a third attempt can be attempted.
 Failure to reduce the disc may indicate a dysfunctional
superior retrodiscal lamina or a general loss of disc
morphology.
 Once these tissues have changed, the disc displacement is
most often permanent.

Permanently displaced
STABILIZATION
SPLINT
SUPPORTIVE
THERAPY
SURGICAL
APPORACH

SUPPORTIVE THERAPY
 Educating the patient about the condition.
 Gentle, controlled jaw exercise may be helpful in regaining
mouth opening, but care should be taken to not be too
aggressive, which may lead to more tissue injury.
 The patient should also be told to decrease hard biting, no
chewing gum, and generally avoid anything that aggravates the
condition.
 If pain is present, heat or ice may be used. NSAIDs are
indicated for pain and inflammation.
 Joint distraction and phonophoresis over the joint area may be
helpful.
 Providing the patient with the basic aspects of PSR can also be
important in the recovery phase

 Long-term treatment of disk-interference disorders of the
temporomandibular joint with anterior repositioning
occlusal splints
Okeson JP. J Prosthet Dent. 1988 Nov 1;60(5):611-6.
 This study subjectively and objectively evaluated the effects of
AR splint therapy in patients with disc interference disorders,
followed by a gradual elimination of the splint without permanent
alteration of the occlusal condition.

Methods and results
 Forty patients with three different types of symptomatic disk-interference disorders were
treated with anterior repositioning splint therapy for 8 weeks.
 At the end of that period 80% of the patients were free of joint sound and pain.
 Each patient’s splint was then gradually modified until the patient’s original occlusal
condition was reestablished.
 Each patient was then allowed to function in that position.
 The patients were reevaluated an average of 2 years later.
 Seventy-five percent of the patients had no joint pain and 66% had a return of joint
sounds.
 Sixty-six percent of the patients did not find the need to seek additional treatment for
jaw pain and dysfunction.

 Conservative Therapy in Patients With Anterior Disc
Displacement Without Reduction Using 2 Common
Splints: A Randomized Clinical Trial
Schmitter, M., Zahran, M., Duc, J.-M. P., Henschel, V., & Rammelsberg, P.
(2005). Journal of Oral and Maxillofacial Surgery, 63(9), 1295–1303.
AIM- A comparative evaluation of different types of splint therapy for anterior
disc displacement without reduction (ADDWR) of the temporomandibular joint.

Patients and Methods
 Seventy-four patients agreed to participate (65 females and 9 males).
 All patients were examined using a clinical temporomandibular joint
disorder examination protocol, including muscle palpation, mandibular
range-of-motion measurement, and joint sound detection.
 Additionally, the patients marked their pain (during chewing, mandibular
movements, and rest position) and limitation levels on a visual analog
scale. Bilateral magnetic resonance images were acquired, confirming
ADDWR in at least one joint.
 After clinical examination and imaging, randomized splint therapy was
provided: 38 patients received a centric splint, while 36 received a
distraction splint.
 After 1, 3, and 6 months of therapy, outcome was evaluated

Results
 The improvements in mouth opening were significant in both
groups. The improvements in pain on chewing, pain during
other functions, pain at rest, functional limitation on chewing,
and other functions were also comparable in both groups.
However, the logistic regression test suggested that patients
using centric splints were treated more successfully than the
others

Conclusion
 Centric splints seem to be more effective than distraction
splints. Therefore, before the surgical treatment of ADDWR,
centric splints should be used instead of distraction splints.

TEMPOROMANDIBULAR JOINT
DISORDERS-DIAGNOSIS AND
MANAGEMENT
BY,
PAAVANA
III MDS

ETIOLOGY HISTORY CLINICAL
CHARACTERI
STICS
TREATMENT
PLAN
PROTECTIVE
CO-
CONTRACTION
FIRST
RESPONSE
TO MUSCLE
ALTERATION
(CNS
RESPONSE)
IMMEDIATELY
FOLLOWNG A
EVENT
• Structural
dysfunction.
• Minimum pain at
rest.
• Pain increased with
function.
• Muscle weakness
• Resolves once the
causative agent is
removed.
• Supportive therapy
is needed.
LOCAL MUSCLE
SORENESS
TISSUE
RESPONSE
AFTER
PROTECTIVE
CO-
CONTRACTI
ON
FEW HOURS
TO FEW DAYS
• Structural
dysfunction.
• Minimum pain at rest.
• Pain increased with
function.
• Actual muscle
weakness
• Local tenderness
when involved
muscles are
palpated.
• Appropriate
supportive therapy
• Stabilization splint
• If postive –factors
identified should be
resolved.
• If negative-
reevaluate etiology

CHARACTERI
STICS
TREATMENT
PLAN
MYOSPASMS INVOLUNTARY
CNS INDUCED
MUSCLE
CONTRACTIO
N
SUDDEN ONSET OF
PAIN,TIGHTNESS AND
OFTEN CHANGE IN
JAW POSITION
• Structural
dysfunction.
• Pain at rest
• Increased pain with
function
• Local muscle
tenderness
• Muscle tightness
Reduce pain by ice or
deep massage followed
by rest to the underlying
muscle.address local
and systemic factors
MYOFASCIAL
PAIN
REGIONAL
MYOGENOUS
PAIN
CONDITION
CHARACTERIS
ED BY
TRIGGER
MISLEADING
HISTORY IS
OFTEN GIVEN.
• Structural
dysfunction
• Pain at rest:
• Increased pain with
function
• Presence of trigger
points
One of the most
important
considerations in the
management of
myofascial pain is the
treatment and
elimination of the trigger
points.

CHARACTERI
STICS
PLAN
CENTRAL
MEDIATED
MYALGIA
CHRONIC
CONTINUNOU
S MUSCLE
PAIN
• DURATION-
TAKES TIME TO
DEVELOP.
• CONSTANCY
OF PAIN
• Structural dysfunction
• Pain at rest.
• The pain is
increased with
function.
• Generalized feeling
of muscle tightness.
• Significant pain on
muscle palpation.
• muscle atrophy
and/or myostatic or
myofibrotic
contracture.
Definitive
treatment plan
Supportive
treatment plan
FIBROMYALGI
A
HPA AXIS WIDESPREAD
MUSCULOSKELETAL
PAIN IN ALL FOUR
QUADRANTS OF THE
BODY THAT HAS
BEEN PRESENT FOR
3 MONTHS OR
LONGER.
• Structural dysfunction.
• There is widespread
myogenous pain at rest,
fluctuating over time.
• The pain is increased
with function of the
involved muscles.
• General feeling of
muscle weakness.
Generalized chronic
fatigue.
• Lack physical
conditioning
Since knowledge of
fibromyalgia is limited,
treatment should be
conservative and
directed toward the
etiologic and
perpetuating factors

TEMPOROMANDIBULAR DISORDERS
 DEARANGEMENTS OF CONDYLE-DISC COMPLEX
BREAKDOWN OF NORMAL
ROTATIONAL FUNCTION OF
DISC ON THE CONDYLE
ORTHOPEDIC
INSTABILTY
MACROTRAUMA
MICROTRAUMA
DEARANGEMENTS
OF CONDYLE-DISC
COMPLEX

CHARACTERI
STICS
TREATMENT
PLAN
DISC
DISPLACEMEN
T WITH
REDUCTION
• MICROTRAUMA
• MICROTRAUMA
• Taking a thorough history
from the patient may
frequently reveal the more
subtle findings of clenching
and/or bruxism.
• The patient will also report
the presence of joint sounds
and may even report a
catching sensation during
mouth opening.
• The presence of pain
associated with this
dysfunction is important
• relatively normal range of
movement with restriction
only associated with the
pain.
• Discal movement can be
felt by palpation of the
joints during opening and
closing.
• Deviations in the opening
pathway are common
ANTERIOR
REPOSITIONIN
G SPLINT
DISC
DISPLACEMEN
T WITHOUT
REDUCTION
• MICROTRAUMA
• MICROTRAUMA
• Patients most often report the
exact onset of this disorder. A
sudden change in range of
mandibular movement occurs
that is very apparent to the
patient.
• The history may reveal a
gradual increase in
intracapsular symptoms
(clicking and catching) prior to
the dislocation.
• Most often, joint sounds are no
longer present immediately
following the disc displacement
without reduction.
limited mandibular opening (25
to 30 mm) with some slight
defection to the ipsilateral side
during maximum opening.
There is normal eccentric
movement to the ipsilateral side
and restricted eccentric
movement to the contralateral
side.
MANUAL
REDUCTION
FOLLOWED BY
ANTERIOR
REPOSITIONING
SPLINT

STRUCTURAL INCOMPATIBILITY
OF THE ARTICULAR SURFACES
 Structural incompatibility of the articular surfaces can originate
from any problem that disrupts normal joint functioning.
 Alterations in the bony surfaces (e.g., a spicule) or in the
articular disc (a perforation) that impedes normal function
 These disorders are characterized by deviating movement
patterns that are repeatable and difficult to avoid.
Trauma
Pathologic
process
Excessive
mouth opening
Excessive static
interarticular
pressure.

STRUCTURAL
INCOMPATIBILITY
DEVIATION ADHESION SUBLUXATION LUXATION

DEVIATION IN FORM
 Changes in the smooth articular surface of the joint and disc.
 These changes produce an alteration in the normal pathway
of condylar movement.
Etiology
 Trauma. The trauma may have been a sudden blow or the
subtle trauma associated with microtrauma.
 Certainly, loading of bony structures causes alterations in
form.

HISTORY
 Patients often report a long history related to these disorders.
 Many of these disorders are not painful and therefore may go
relatively unnoticed by the patient.

 Patient with a deviation in the form of the condyle, fossa, or
the disc will commonly show a repeated alteration in the
pathway of the opening and closing movements.
 When a click or deviation in opening is noted, it will always
occur at the same position of opening and closing.
 Deviations in form may or may not be painful.

 Altered structure to normal form- surgical procedure.
 In the case of bony incompatibility, the structures are
smoothed and rounded (arthroplasty).
 If the disc is perforated or misshaped, attempts are made to
repair it (discoplasty). Since surgery is a relatively aggressive
procedure, it should be considered only when pain and
dysfunction are unmanageable.
 Most deviations in form can be managed by supportive
therapies.

SUPPORTIVE THERAPY
 Patient education.
 Stabilization appliance.
 Analgesics

ADHERENCES
 Adherences represent a temporary sticking of the articular
surfaces during normal joint movements.
 Adhesions are more permanent and are caused by a fibrosis
attachment of the articular surfaces.
 Adherences and adhesions may occur between the disc and
condyle or the disc and fossa

ETIOLOGY
 Prolonged static loading of the joint structures.
 If the adherence is maintained, the more permanent
condition of adhesion may develop.
 Adhesions may also develop secondary to hemarthrosis
caused by macrotrauma or surgery.

HISTORY
 Usually the patient will report a prolonged period of time when the jaw
was statically loaded (such as clenching during sleep).
 This period is followed by a sensation of limited mouth opening.
 As the patient tries to open, a single click is felt and normal range of
movement is immediately returned.
 The click or catching sensation does not return during opening and
closing unless the joint is again statically loaded for a prolonged time.
 These patients typically report that in the morning the jaw appears “stiff”
until they pop it once and normal movement is restored.
 Patients with adhesions will often report a restriction in the opening
range of movement.
 The degree of restriction is related to the location of the adhesion.
 Adhesions present clinically like adherences but movement does not
typically free the restriction.

 Temporary restriction in mouth opening until the click occurs,
while adhesions present with a more permanent limitation in
mouth opening.
 The degree of restriction is dependent on the location of the
adhesion.
 When adhesions are permanent, the dysfunction can be great.
 Adhesions in the inferior joint cavity cause a sudden jerky
movement during opening.
 Those in the superior joint cavity restrict movement to rotation,
and thus limit the patient to 25 or 30 mm of opening.
 During mouth opening, adhesions between disc and fossa will
tend to force the condyle across the anterior border of the disc.

 Patient awareness and PSR techniques
 Stabilization appliance
 Arthroscopic surgery

SUPPORTIVE THERAPY
 Patient education is the most appropriate treatment.
 Passive stretching, ultrasound, and distraction of the joint.
 Caution should be taken not to be too aggressive with the
stretching technique,

 Intra-articular adhesions of the temporomandibular joint:
Relation between arthroscopic findings and clinical
symptoms
Zhang S, Yang C, Cai X, Chen M, Haddad MS, Yun B, Chen Z. BMC
musculoskeletal disorders. 2009 Dec 1;10(1):70.
 The purpose of this study was to describe the incidence and
distribution of IA in patients with internal derangement (ID)
and to investigate the correlation between adhesions and the
clinical symptoms of patients with ID of TMJ with closed-lock.

Materials
 A retrospective analysis was conducted of 1822 TMJs with ID that were
refractory to nonsurgical treatments and underwent arthroscopic
surgery between May 2001 and June 2008.
 Clinical findings were assessed on the basis of mandibular range of
motion, patients' age and locking duration at the initial visit.
 1506 patients (1822 joints) with ID were divided into an adhesion group
(486 patients) and a non-adhesion group (1020 patients).
 The associations between the two groups with respect to interincisal
opening, clicking duration, locking duration and patients' age were
statistically analyzed using a t-test.

Conclusion
 The arthroscopic findings confirmed that the incidence ratio
of adhesion was high and occurred predominantly with older
patients with longer locking duration and less interincisal
opening. As the stage of ID increased, the adhesion grade
rose.

SUBLUXATION
 Subluxation/hypermobility is a clinical description of the
condyle as it moves anterior to the crest of the articular
eminence.
 It is not a pathologic condition but reflects a variation in
anatomic form of the fossa.

ETIOLOGY
 Patients who have a steep short posterior slope of the articular
eminence followed by a longer flat anterior slope seem to display a
greater tendency toward subluxation.
 Subluxation results when the disc is maximally rotated posteriorly on the
condyle before full translation of condyle-disc complex occurs
History
 The patient reports a locking sensation whenever they open too wide.
 The patient can return the mouth to the closed position but often reports
a little difficulty.

 During the final stage of maximal mouth opening, the condyle
can be seen to suddenly jump forward with a “thud”
sensation.
 This is not reported as a subtle clicking sensation.

 Surgical alteration of the joint itself accomplished by an
eminectomy.
 In most cases, however, a surgical procedure is far too
aggressive for the symptoms experienced by the patient.
 Therefore much effort should be directed at supportive
therapy in an attempt to eliminate the disorder or at least
reduce the symptoms to tolerable levels.

SUPPORTIVE THERAPY
 Patient education.
 Intra oral devices

LUXATION
 This condition is commonly referred to as an openlock since the patient’s
mouth is wide open and he or she cannot reduce it.
 It can occur following wide-open mouth procedures such as having a dental
appointment.
 With luxation, both the condyle and the disc are totally displaced in front of
the eminence and the patient cannot voluntary return them to their normal
positions

ETIOLOGY
 Luxation of the TMJ can occur in any patient if the condyle is
brought anterior to the crest of the eminence
 Although a luxation occurs secondary to a wide mouth
opening experience, it may also be caused by sudden
contraction of the inferior lateral pterygoid or infrahyoid
muscles

HISTORY
 The patient presents with the mouth in an open position and
the lack of ability to get it closed.
 The condition immediately followed a wide opening
movement such as a yawn or a dental procedure.
 Since the patient cannot close the mouth, he or she is often
quite distressed with the condition.
 Some patients may report a sudden and unprovoked open
lock that repeats itself several times a week or even daily.
 This presentation is significant for an oromandibular dystonia.

 The patient remains in a wide-open mouth condition.
 Pain is commonly present secondary to the patient’s
attempts to close the mouth

 Directed toward increasing the disc space, which allows the
superior retrodiscal lamina to retract the disc.

 If the luxation is still not reduced, it is likely that the inferior
lateral pterygoid is in myospasm, preventing posterior
positioning of the condyle. When this occurs, it is appropriate
to inject the lateral pterygoid muscle with local anesthetic
without a vasoconstrictor in an attempt to eliminate the
myospasms and promote relaxation.
 If the elevators appear to be in myospasm, local anesthetic is
also helpful.
 Chronic or recurrent and it is determined that the anatomic
relationship of the condyle and fossae are etiologic
considerations-Surgical considerations.
 Luxation is produced by muscle contraction-Botulinum toxin

SUPPORTIVE THERAPY
 The most effective method of treating luxation is prevention.
 Prevention begins with the same supportive therapy
described for subluxation, since this is often the precursor of
the dislocation.
 When a luxation recurs, the patient is taught the reduction
technique.
 As with subluxation, some chronic recurrent luxation can be
definitively treated by a surgical procedure.
 However, surgery is considered only after supportive therapy
has failed to eliminate or reduce the problem to an
acceptable level

KEYS IN MAKING DIFFERENTIAL
DIAGNOSIS
 It is extremely important that they be differentiated since their treatments are quite
different.
 The clinician who cannot routinely separate them is likely to have relatively poor
success in managing TMDs.
History
Mandibular
restriction
Mandibular
interference,
Acute
malocclusion
Loading of
the joint
Functional
manipulation
Diagnostic
anesthetic
blockade

DIFFERENTIATING BETWEEN TMD AND
OCCLUSAL-MUSCLE DISORDERS

CONFIRMATORY TESTS
CLENCH TEST
ANTERIOR
DEPROGRAMMING
TEST

STABILIZATION SPLINT
 Full coverage splint.
 Upper splints/Michigan splints
 Lower arch/Tanner splints

CORRECTION OF MINOR OCCLUSAL
DISCREPANCIES
PRIMARY IMPRESSION
JAW RELATION
BITE REGISTRATION/OCCLUSAL
RECORD
FACEBOW TRANSFER AND
TRANSFERRING IT TO
SEMIADJUSTABLE ARTICULATOR

ANTERIOR REPOSITIONING SPLINTS

SUMMARY
FEATURES
TREATMENT
PLAN
DEVIATION Actual change
in the shape of
the articular
surface
A long history related to
these disorders.
Many of these disorders
are not painful and
therefore may go relatively
unnoticed by the patient.
• Repeated alteration in
the pathway of the
opening and closing
movements.
• When a click or
deviation in opening is
noted, it will always
occur at the same
position of opening
and closing.
• Patient
education
and
supportive
therapy
• Surgical-
Definitive
ADHERENCES
/ADHESION
Prolonged static
loading
Fibrous
changes
• The patient will report a
prolonged period of time
when the jaw was statically
loaded (such as clenching
during sleep).
• This period is followed by a
sensation of limited mouth
opening.
• As the patient tries to open,
a single click is felt and
normal range of movement is
immediately returned.
• Temporary restriction in
mouth opening until the
click occurs, while
adhesions present with a
more permanent limitation
in mouth opening.
• The degree of restriction is
dependent on the location
of the adhesion.
• Patient
education
• Stabilization
appliance
• Surgical

FEATURES
TREATMENT
PLAN
SUBLUXATION Anatomic variation in
which the articular
eminence has a
steep,short posterior
slope and longer
anterior slope
The patient reports a locking
sensation whenever they
open too wide.
The patient can return the
mouth to the closed position
but often reports a little
difficulty
• During the final stage
of maximal mouth
opening, the condyle
can be seen to
suddenly jump forward
with a “thud” sensation.
• This is not reported as
a subtle clicking
sensation.
• Surgical approach
• Patient education
• Intraoral devices
LUXATION Forced opening beyond
the normal restrictions
of the ligaments
if the condyle is brought
anterior to the crest of the
eminence
Although a luxation occurs
secondary to a wide mouth
opening experience, it may
also be caused by sudden
contraction of the inferior
lateral pterygoid or infrahyoid
muscles
• The patient remains in a
wide-open mouth
condition.
• Pain is commonly
present secondary to
the patient’s attempts to
close the mouth
• Manual reduction
• Surgical approach
• Muscle contraction-
Botulinum toxin

CONCLUSION
 Since most of the disorders present with similar signs and
symptoms,it is important that the clinician must be able to
differentiate in order to give a proper diagnosis as treatment
in each scenerio is different.

REFERENCES
 Management of Temporomandibular disorders and occlusion –Okeson,6th edition
 Management of Temporomandibular disorders and occlusion –Okeson,8th edition
 Okeson JP. Long-term treatment of disk-interference disorders of the
temporomandibular joint with anterior repositioning occlusal splints. J Prosthet Dent.
1988 Nov 1;60(5):611-6.
 Conti PC, Miranda JE, Conti AC, Pegoraro LF, Araújo CD. Partial time use of anterior
repositioning splints in the management of tmj pain and dysfunction: a one-year
controlled study J. Appl. Oral Sci. 2005 Dec;13(4):345-50.
 Schmitter, M., Zahran, M., Duc, J.-M. P., Henschel, V., & Rammelsberg, P. (2005).
Conservative Therapy in Patients With Anterior Disc Displacement Without Reduction
Using 2 Common Splints: A Randomized Clinical Trial. Journal of Oral and Maxillofacial
Surgery, 63(9), 1295–1303.
 Zhang S, Yang C, Cai X, Chen M, Haddad MS, Yun B, Chen Z. Intra-articular adhesions
of the temporomandibular joint: Relation between arthroscopic findings and clinical
symptoms. BMC musculoskeletal disorders. 2009 Dec 1;10(1):70.

Temporomandibular joint disorders

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