Temporomandibular joint disorders

Temporomandibular
j oint disorders
Dr.Neha Sinha

TEMPOROMANDIBULAR JOINT
• Located anterior to the tragus of the ear
• Considered an articulation between the base of the skull and the condyle of the
mandible
• The articular surface is the squamous part of the temporal bone
• Consists of
– Articular Fossa (Glenoid Fossa) - Concave
– Articular Tubercle or (Eminence) - Convex
– Condyle of the mandible
– Articular Disc
– Joint capsule
– Ligaments

CLASSIFICATION OF TEMPORALMANDIBULAR
DISORDERS
1 . MASTICATORY MUSCLE DISORDERS
a) Protective muscle splinting
b) Muscle hyperactivity or spasm
c) Myositis (muscle inflammation)
2. DISK-INTERFERENCE DISORDERS (INTERNAL DERANGEMENTS)
a) In- coordination
b) Deformation of the articular disk
c) Partial anterior disk displacement
d) Anterior disk displacement with reduction
e) Anterior disk displacement without reduction
f) Anterior disk displacement with perforation
g) Posterior disk displacement

3. PROBLEMS THAT RESULT FROM EXTRINSIC TRAUMA
a)Tendonitis
b)Myositis
c) Traumatic arthritis
d)Dislocation
e)Fracture
f) Internal derangement
4. DEGENERATIVE JOINT DISEASE
a)Arthrosis (noninflammatory phase)
b)Osteoarthritis (inflammatory phase)
c) Osteochondritis dissecans or avascular necrosis

5. INFLAMMATORY JOINT DISORDERS
a) Synovitis and capsulitis
b) Retrodiskitis
c) Inflammatory arthritis
Rheumatoid arthritis
Infectious arthritis
Metabolic arthritis
6. CHRONIC MANDIBULAR HYPOMOBILITY
a) Ankylosis (fibrous or osseous)
b) Fibrosis of articular capsule
c) Contracture of elevator muscles (myostatic or myofibrotic)
d) Internal disk derangement (closed-lock)

7. Growth Disorders of the Joint
a) Developmental disorders
b) Acquired disorders
c) Neoplastic disorders
8. Postsurgical Problems

ARTHRITIS OF THE TEMPOROMANDIBULAR
JOINT
(Inflammation of articular surfaces of joint)
• Degenerative Joint Disease (Osteoarthritis)
Degenerative joint disease (DJD), also referred to as
osteoarthrosis, osteoarthritis, and degenerative
arthritis, is primarily a disorder of articular cartilage
and subchondral bone, with secondary inflammation
of the synovial membrane.
• It is a localized joint disease without systemic
manifestations.

Osteroarthritis/Osteoarthrosis
• When the bony changes are active the
condition is called as osteoarthritis.
• As remodeling occurs the condition can
become stable ,yet the bony morphology
remain unaltered.This condition is referred to
as osteoarthrosis.
(Management of tmj disorders and occlusion.Jeffrey Okeson.)

Osteoarthritis
• The process begins in loaded articular
cartilage, which thins and clefts (fibrillation)
and then breaks away during joint activity.
This leads to sclerosis of underlying bone,
subcondylar cysts, and osteophyte formation.
(Ref:Int Dent J 1990;40:339)

Causes of osteoarthritis
• It is essentially a response of the joint to chronic
microtrauma or pressure. The microtrauma may be
in the form of continuous abrasion of the articular
surfaces as in natural wear associated with age or as
increased loading forces possibly related to chronic
parafunctional activity.
• The fibrous tissue covering in patients with
degenerative disease is preserved.
• Ref:J Dent Res 1990;69:1512–18.

Types of DJD
(Textbook of Oral Medicine :Greenberg and Glick)
• Degenerative joint disease may be categorized as
primary or secondary
• Primary degenerative joint disease is of unknown
origin, but genetic factors play an important role.
• It is often asymptomatic and is most commonly seen
in patients above the age of 50 years.
• Secondary degenerative joint disease results from a
known underlying cause, such as trauma, congenital
dysplasia, or metabolic disease.

Clinical features
• DJD of the TMJ begins early and has been observed
in over 20% of joints in individuals over the age of 20
years.
• Many patients with mild to moderate DJD of the TMJ
have no symptoms although arthritic changes are
observed on radiographs.
• The presence of pain in patients with DJD is
associated with inflammation and joint effusions.

Clinical features
• Patients with symptomatic DJD of the TMJ
experience
1: unilateral pain directly over the condyle,
2: limitation of mandibular opening,
3:crepitus, and
4:a feeling of stiffness after a period of inactivity.
5: Lateral palpation of the condyle increases the pain

Radiographic features
• Narrow joint space when patient is in maximal
intercuspation position
• Flattening and subchondral sclerosis
• Loss of cortex or erosions of the articulating
surfaces of the condyle or temporal
component are characteristic of disease
(Ref:Oral Radiology:White and Pharoah)

DJD
• A: Physiologic joint with normally functioning
articular surfaces
• B: Progressive adaptation are expressed as
thickenings of the fibrocartilage that cannot
be seen on the radiograph
• C: Overloading leads to flattening of the
fibrocartilage

• D: Cartilage matrix is resorbed and the
condyle becomes flatter
• E: Bone contours are flattened even more
• F: If sufficient adaptation occurs the
fibrocartilage will compensate for the osseous
changes

• G: Formation of a lip at the anterior border
• H: Breaking off of free bodies within the joint
• I: Formation of subchondral cysts.

Lateral tomogram with DJD showing
erosion and flattening

Ely cyst
• Not true cyst
• These are area of degeneration that contain
fibrous tissue ,granulation tissue and osteoid
• They appear as small ,round radiolucent areas
with irregular margins surrounded by varying
area of increased density visible deep to the
articulating surfaces

Osteophyte
• Bony proliferation occurs at the periphery of
the articulating surface,increasing the
articulating surface area
• This new bone is called as osteophyte
• Appears on anteriosuperior aspect of condyle
and lateral aspect of the temporal bone
• Osteophyte may break off and lie free within
the joint space(joint mice)

Differential diagnosis
• More erosive appearance resembles RA
• More proliferative appearance resembles
osteoma or osteochondroma

• These changes may be seen best on
tomograms or CT scans
• The presence of joint effusion is most
accurately detected in T2- weighted MRI
images.

Treatment
• Degenerative joint disease of the TMJ can usually be
managed by conservative treatment.
• Significant improvement is noted in many patients
after 9 months, and a “burning out” of many cases
occurs after 1 year.
• It seems prudent to manage a patient with
conservative treatment for 6 months to 1 year
before considering surgery unless severe pain or
dysfunction persists after an adequate trial of
nonsurgical therapy.

Conservative treatment
• Conservative therapy includes
1: nonsteroidal anti-inflammatory medications;
2:heat;
3:soft diet;
4:rest; and
5: occlusal splints that allow free movement of the
mandible.

Conservative treatment
• It also may be necessary to concomitantly treat
myofascial pain or meniscal defects.
• Intra-articular steroids can be used during acute
episodes, but there is concern that repeated
injections may cause degenerative bony changes.
• Preliminary reports suggest that the anti-
inflammatory effects of doxycycline therapy may be
helpful in reducing pain associated with TMJ DJD.

Surgical treatment
• When TMJ pain or significant loss of function persists
and when distinct radiographic evidence of
degenerative joint changes exists, surgery is
indicated.
• An arthroplasty, which limits surgery to the removal
of osteophytes and erosive areas, is commonly
performed.
• Artificial TMJs have been developed to treat patients
with advanced degenerative changes of the TMJ.
Ref:Int Dent J 1990;40:347.

Rheumatoid arthritis
• The percentage of rheumatoid arthritis (RA)
patients with TMJ involvement ranges from 40
to 80%, depending on the group studied and
the imaging technique used.
• REF:J Rheumatol 1989;16:298.

• The disease process starts as a vasculitis of the
synovial membrane. It progresses to chronic
inflammation marked by an intense round cell
infiltrate and subsequent formation of
granulation tissue. The cellular infiltrate
spreads from the articular surfaces eventually
to cause an erosion of the underlying bone.

CLINICAL MANIFESTATIONS
• The TMJs are usually bilaterally involved in RA.
• The most common symptoms include
1: limitation of mandibular opening and joint pain.
2: Pain is usually associated with the early acute phases of the
disease but is not a common complaint in later stages.
3: morning stiffness,
4: joint sounds, and tenderness and swelling over the joint
area.
The symptoms are usually transient in nature, and only a small
percentage of patients with RA of the TMJs will experience
permanent clinically significant disability.
Ref:Cranio. 1998 Jul;16(3):162-7.

• The most consistent clinical findings include pain on
palpation of the joints and limitation of opening.
• Crepitus also may be evident.
• Micrognathia and an anterior open bite are
commonly seen in patients with juvenile RA.
• Larheim attributes the micrognathia to a
combination of direct injury to the condylar head
and altered orofacial muscular activity.
• Ankylosis of the TMJ related to RA is rare.

From the literature
• RA disease activity is associated with
hyposalivation and TMJ dysfunction.
(Ref:Oral Dis. 2005 Jan;11(1):27-34.)

Radiographic changes
(Sharpened pencil/mouth piece of the flute)
• Radiographic changes in the TMJ associated with RA
may include a
1: narrow joint space,
2: destructive lesions of the condyle, and
3: limited condylar movement.
4: little evidence of marginal proliferation or other
reparative activity in RA in contrast to the
radiographic changes often observed in DJD.
High-resolution CT of RA patients’ TMJs will show
erosions of the condyle and glenoid fossae that
cannot be seen by conventional radiography.

TREATMENT
• Involvement of the TMJ by RA is usually
treated by anti-inflammatory drugs in
conjunction with the therapy for other
affected joints.
• The patient should be placed on a soft diet
during acute exacerbation of the disease
process, but intermaxillary fixation is to be
avoided because of the risk of fibrous
ankylosis.

Treatment
• Use of a flat plane occlusal appliance may be helpful,
particularly if parafunctional habits are exacerbating
the symptoms.
• An exercise program to increase mandibular
movement should be instituted as soon as possible
after the acute symptoms subside.
• When patients have severe symptoms, the use of
intra-articular steroids should be considered.
Prostheses appear to decrease symptoms in fully or
partially edentulous patients.

SURGICAL TREATMENT
• Surgical treatment of the joints including
placement of prosthetic joints, is indicated in
patients who have severe functional
impairment or intractable pain not
successfully managed by other means.

AuriculoTherapy
• AuriculoTherapy operates on the same principle as
acupuncture - modern approaches such as electro-
stimulation, infra-red light, light source, etc., are
used as an alternative to needles.
• These stimuli are applied to sensitive points on the
ear which allow the body to release and heal by
unlocking the energy flow to the corresponding area
in the body. It also reduces stress levels, balances the
meridians and associated systems.

Juvenile rheumatoid arthritis
(Still’s Disease)
• Chronic inflammatory disease that appears
before the age of 16 years
• Characterised by chronic ,intermittent
synovial inflammation that results in synovial
hypertrophy ,joint effusion and swollen
painful joints.
• Gradually the cartilage and bone are
destroyed

Clinical features
• Pain and tenderness in the affected joints
• Unilateral onset
• Severe TMJ invovlement may cause restricted
mandibular growth
• Bird face appearance

• Osteopenia (Decreased density) initial finding
• Similar findings like RA with addition of
impaired mandibular growth
• Erosions may extend to mandibular fossa and
articular eminence may be destroyed
• Condyle positioned anteriosuperiorly in the
mandibular fossa
• Hypomobility at maximal opening

• Deepening of anteogonial notch
• Diminished height of the ramus
• Dorsal bending of the ramus and condylar
neck
• Obtuse angle between the mandibular body
and ascending ramus
Ref:Oral Radiology: White and Pharoah

Sagittal tomogram with juvenile chronic
arthritis

• Patients undergoing corticosteroid TMJ
injections whom we have seen in follow up,
noted clinical improvement.
Ref: Pediatric Rheumatology Online Journal June 2003

Psoriatic Arthritis
• Psoriatic arthritis (PA) is an erosive polyarthritis
occurring in patients with a negative rheumatoid
factor who have psoriatic skin lesions.
• The skin lesions precede the joint involvement by
several years. PA affects 5 to 7% of patients with
psoriasis. Investigators suspect that the cutaneous
and joint manifestations of the disease may be
traced to the same immunologic abnormality.
• PA commonly involves the fingers and spine. Pitting
of the nails is observed in 85% of patients. TMJ
involvement
Ref:Oral Surg 1990;70:555.

Psoriatic arthritis
• TMJ involvement is more common than
previously believed.

• The symptoms of PA of the TMJ are similar to
those noted in RA, except that the signs and
symptoms are likely to be unilateral.
• Limitation of mandibular movement,
deviation to the side of the pain, and
tenderness directly over the joint may be
observed on examination.
REF:Oral Surg 1991;71:770.

Radiographic changes
• Radiographic findings show erosion of the
condyle and glenoid fossae rather than
proliferation. Coronal CT is particularly useful
in showing TMJ changes of PA.
REF:Br J OralMaxillofac Surg 1987;25:61

TREATMENT
• The management of PA is similar to the treatment of
RA, with an emphasis on physical therapy and
NSAIDS that control both pain and inflammation in
many cases
• Antimalarial drugs should not be used because they
may cause severe skin reactions in patients with
psoriasis.
• Immunosuppressive drugs, particularly
methotrexate, are used for patients with severe
disease that does not respond to conservative
treatment.

Treatment
• Only when there is intractable TMJ pain or
disabling limitation of mandibular movement
is surgery indicated.
• Arthroplasty or condylectomy with placement
of costochondral grafts has been performed
successfully.
• Surgery may be complicated by psoriasis
forming in the surgical scar (Koebner effect).

Psoriatic arthritis
• A particularly interesting local trigger for psoriasis is
minor skin injury such as scratches or burns . Other
rashes, such as sunburn and contact dermatitis, may
act as a trigger for this response . Psoriasis may
develop in such areas a few days after the insult,
especially in patients with unstable or increasing
psoriasis at the time. The Koebner phenomenon also
occurs in several other skin disorders .

Septic Arthritis
• Septic arthritis of the TMJ most commonly occurs in
patients with previously existing joint disease such as
rheumatoid arthritis, or underlying medical disorders
(particularly diabetes).
• Patients receiving immunosuppressive drugs or
longterm corticosteroids also have an increased
incidence of septic arthritis. The infection of the TMJ
may result from bloodborne bacterial infection or by
extension of infection from adjacent sites such as the
middle ear, maxillary molars, and parotid gland.
• Br J Oral Maxillofac Surg 1987;25:61

Organisms responsible
• Gonococci are the primary bloodborne agents
causing septic arthritis in a previously normal
TMJ while Staphylococcus aureus is the most
common organism involved in previously
arthritic joints.
Ref: International Journal of Oral and Maxillofacial Surgery
Volume 22, Issue 5, October 1993, Pages 292-297

CLINICAL SYMPTOMS
• Symptoms of septic arthritis of the TMJ
include
1:trismus,
2:deviation of the mandible to the affected side,
3:severe pain on movement, and
4:an inability to occlude the teeth, owing to the
presence of inflammation in the joint space.

Examination
• Examination reveals redness and swelling in the
region of the involved joint. In some cases, the
swelling may be fluctuant and extend beyond the
region of the joint.
• Large tender cervical lymph nodes are frequently
observed on the side of the infection; this helps to
distinguish septic arthritis from more common types
of TMJ disorders.
• Diagnosis is made by detection of bacteria on Grams
stain and culture of aspirated joint fluid.

Sequelae
• Serious sequelae include
1:osteomyelitis of the temporal bone,
2: brain abscess, and
3: ankylosis.
4: Facial asymmetry may accompany septic
arthritis of the TMJ, especially in children.

• The primary sources of these infections were the
middle ear, teeth, and the hematologic spread of
gonorrhea.
• Evaluation of patients with suspected septic arthritis
must include a review of signs and symptoms of
gonorrhea, such as purulent urethral discharge or
dysuria.
• The affected TMJ should be aspirated and the fluid
obtained tested by Grams stain and specially
cultured for Neisseria gonorrhoeae.

TREATMENT
• Treatment of septic arthritis of the TMJ
consists of surgical drainage, joint irrigation,
and 4 to 6 weeks of antibiotics.

Gout and Pseudogout
• Gouty arthritis is caused by long-term
elevation of serum urate levels, which results
in the deposition of crystals in a joint,
triggering an acute inflammatory response.
• Acute pain in a single joint (monoarticular
arthritis) is the characteristic clinical
manifestation of gouty arthritis.

Gouty arthritis
• Gouty arthritis of the TMJ appears to be very rare
although crystal deposition may be apparent in
tissues adjacent to the joint. An attack of gouty
arthritis is most accurately diagnosed by examination
of aspirated synovial fluid from the involved joint by
polarized light microscopy. The detection of
monosodium urate crystals confirms the diagnosis of
gout.
• An acute attack of gout may be successfully treated
with colchicine, NSAIDS, or the intra-articular
injection of corticosteroids.

Pseudogout
• The deposition of other crystals, such as calcium
pyrophosphate dihydrate (CPPD) or calcium hydroxyapatite, may
cause a syndrome that resembles gout and that has been
referred to as pseudogout.
• This disorder most frequently effects elderly individuals, and
involvement of the TMJ has been reported in cases documented
by the demonstration of characteristic CPPD crystals in synovial
fluid.
• Pseudogout of the TMJ has been successfully treated with
colchicine or arthrocentesis.
Ref:Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998,85:349.

Internal derangement
• Classification of the disc displacement based on direction of disc
1: Anterior
2: Anteromedial
3: Medial rotatory
4: Lateral rotatory
5: Anterolateral
6: Medial
7: Lateral
8:Posterior
9: Normal disc position in sagittal oblique closed mouth position on
MRI
(Ref: Triple “O”:1995 :79)

Functional classification of disc
displacement
• Grade 0 : Normally placed disc
• Grade I : Ant Displacement of morphologically
normal disc ,with reduction on mouth opening
• Grade II : Ant Displacement without reduction on
mouth opening ,disc is morphologically normal
• Grade III : Anteriorly displaced ,non reducing on
mouth opening ,morphologically abnormal disc.

According to clinical course
• Acute reducible : Normal morphology and size
of disc
• Subacute: Irreducible disc with deformity seen
• Chronic: Irreducible disc with fibrosis
,calcification and perforation with DJD

Clinical features
• The most common symptoms of internal
derangement are
1: Pain
2: Muscular tenderness
3: Clicking / Popping sensation within the joint
4: Headache
5: Earache
6: Limited ability to open the jaw

Wilkes signs and symptoms
• Pain in the joint area with variable radiation to
the ear ,temporal and cervical areas
• Tenderness in the joint area and associated
musculature
• Temporal headache
• Change in occlusion in acute cases with a
static mandibular shift to the opposite side
and inability to approximate the posterior
teeth

Wilkes signs and symptoms
• Restriction of motion both vertical and lateral
• Clicking ,reciprocal clicking
• Closed locks ,associated with intermediate
stage cases
• Fine and coarse crepitus

Clinical stages in internal derangement
• Stage I: Disc displacement with reduction
• Stage II: Disc displacement with reduction and
intermittent locking
• Stage III: Disc displacement without reduction
(Closed lock)
• Stage IV: Disc displacement without reduction and
with perforation of the disc or posterior attachment
tissue (DJD)
(Ref: J Can Dent Association 2000)

Disc displacement with reduction
• This stage is characterized by reciprocal clicking as a
result of anterior disc displacement with reduction
• Later opening click occurs in advanced stage
• Normal mouth opening
• Deviation of mandible to the involved side until a
pop or click occurs
• After the click the patient is able to open the mouth
fully with a midline position of the mandible

Disc displacement with reduction and
intermittent locking
• Similar signs and symptoms of previous stage
plus,
1: Episode of limited mouth opening
2: Filling obstruction when opening is attempted
3: Obstruction appears spontaneously or the
patient may be able to manipulate the
mandible beyond interference

Closed lock
• Clicking sound disappears but limited opening
persists
• Opening less than 30 mm
• TMJ pain
• Preauricular tenderness and deviation of
mandible to the affected side and does not
return to the midline

Degenerative joint disease
• With continued mandibular function ,the
stretched posterior attachment slowly loses
its elasticity and patient begins to regain some
of its lost range of motion.
• Thinning and perforation of disc occurs

Etiology of Internal Derangement
• Trauma
• Occlusal disharmony
• Osteoarthritis
• Stress

Trauma
• Most common causative factor
• May Be macrotrauma such as blow to the jaw,
or microtrauma as associated with chronic
muscle hyperactivity and orthopedic
instability

Macrotrauma
• Sudden force to the joint that can result in
structural alterations like elongation of the
discal ligament
• Direct trauma: Blow to the chin when the
teeth are in open mouth or closed mouth
position
• Close mouth trauma are less injurious to
condyle disc complex

Direct trauma
• Intubation procedures
• Third molar surgeries
• Long dental appointments
• Yawning

Indirect trauma
• Injuries that may occur to TMJ secondary to a
sudden force
• Cervical flexion extension injury (Whiplash
injury)

Microtrauma
• Small force that is reportedly applied to the
joint structures over a long period of time
• Parafunctional activities like bruxism

Occlusal factors
• Class II Div II malocclusion
• Loss of molar support
• Loss of vertical dimension
• Occlusal prematurity

Degenerative joint disesase
• Osteoarthritis particularly in patients with non
reducing disc displacement
• Larheim stated that disc displacement can be
seen in chronic rheumatoid arthritis and
juvenile rheumatoid arthritis

Orthodontic treatment
• May lead to disc derangement disorders

Stress
• Stress
• Anxiety
• Depression
The psychophysiological hypothesis postulates
that psychological distress causes an increase
in muscular tension and sets dysfunctional
oral habits under way ,giving rise to symptoms
of TMD.

Predisposing factors
• Steepness of articular eminence
1: Degree of steepness of posterior slope of articular
eminence influences condyle disc function
2: Flat eminence minimum amount of posterior
rotation of disc on the condyle during opening
Hence patients with steep eminences are likely to
demonstrate greater condyle disc movement during
function

Morphology of condyle and fossa
• Flat or gable like condyles that articulate
against inverted V-shaped temporal
components seem to have increased
incidence of disc derangement disorders and
degenerative disease

Joint
• Quality of ligaments vary from person to
person
• As a result some joints will show slightly more
freedom or laxity than others

Attachment of superior lateral pterygoid
muscle
• Attachment of muscle is greater to neck of the
condyle and less to the disc ,muscle function
will have correspondingly less influence on
disc position.

Posterior disc displacement
• Classified into three categories
1 : Thin flat disc
2: Grossly posterior displaced disc
3: Perforated disc with portion of the disc
displaced posteriorly

Posterior disc displacement
• Loss of disc contour anteriorly predisposes to
posterior displacement of the articular disc.
• Disc occupies abnormal position relative to
the condyle in the resting closed joint position
• As the condyle moves forward the elastic
traction of the superior retrodiscal lamina
displaces the disc posterioly.

Total anterior disc displacement

Imaging of disc
• Arthrography
• MRI

ARTHROGRAPHY
• Assess the position and function of disc in
patients with pain and dysfunction suggesting
internal derangement
• Perforation of disc or retrodiscal attachments
can be identified as contrast injected into the
inferior compartment passes freely into the
superior compartment of the joint

ARTHROGRAPHY
• Can be used in patient with disc displacement
with reduction to determine the mandibular
position that re-establishes a normal condyle
disc relationship
• May relieve patient symptoms

Short comings
• Invasive procedure
• Difficulty in technique
• Little information about the osseous
component
• Chances of allergic reaction
• Radiation exposure to the patient
• It is time consuming procedure

MRI
• Meniscus in abnormal TMJ have low signal
intensity compared with the moderately low
signal intensity of normal mensicus
• Displacement of the meniscus is well
demarcated
• Coronal and axial images provide an
additional view about the location of the
meniscal displacement

MRI
• Meniscal displacement with reduction is
clearly demostrated on MRI with jaw in both
closed and open position.
(Ref: Radiology 1986;158:183-189)

Definitive treatment for disc dislocation
with reduction
• Definitive treatment for a disc displacement is
to reestablish a normal condyle disc
relationship
• Farrar introduced the anterior positioning
appliance
• This appliance provides an occlusal
relationship that requires the mandible to be
maintained in a forward position

Anterior positioning appliance

• In early short term studies ,this appliance has
been found to be more effective in reducing
the intracapsular symptoms than the more
traditional stabilization appliance.
• As the condyle return to the fossa it moves
posteriorly on the adaptive retrodiscal tissues.

• If these tissues have adequately adapted
,loading can occur without pain .
• The condyle now functions on the newly
adapted retrodiscal tissues,although the disc
is still anteriorly displaced.
• Initially this appliance was worn 24 hours for
3- 6 months,but this lead to posterior open
bite

• The patient should be encouraged to wear the
appliance only at night time to protect the
retrodiscal tissue from heavy loading
• During the day,the patient should not wear
the appliance so that the mandible returns to
the normal position
• If symptoms do persist,patient should be
asked to wear the appliance during day time
for few weeks

• Once the patient is symptoms free,the use of
appliance should be gradually reduced
• If symptoms reappear,appliance should be
reinstituted and more time given for tissue
adaptation
• When repeated attempts fail to eliminate the
symptoms orthopedic instability should be
suspected

• When this occurs the anterior positioning
appliance should be converted to a
stabilization appliance that allows the condyle
to move to most stable position and occlusal
condition is assessed.

Factors affecting the appliance
• Acuteness of the injury:
Treatment rendered immediately after the
injury is more likely to succeed than if it is
delayed until the injury is old

Factors affecting the appliance
• Extend of the injury:
Small injuries will repair more successfully than the
extensive ones
• Age and health of the patient:
The TMJ structures are slow to repair
Young patients respond more quickly to treatment
Patients with medical disorders are not good
condidates for repair

Supportive therapy
• Soft diet
• Slow chewing
• Smaller bites
• NSAID in case of inflammation
• Heat or ice application
• Active exercises are not helpful as it increases
the pain
• Passive jaw movements may be helpful

Treatment for disc dislocation without
reduction
• Anterior positioning appliance is
contraindicated as it aggravates the condition
by forcing the disc even more forward
• As a general rule when patient reports a
history of being locked for 1 week or less
manipulation is usually very successful

Technique for manual manipulation
• Superior head of lateral pterygoid must be
relaxed.
• If it remains active because of pain or
dysfunction it may need to be injected with LA
before reducing
• Second the disc space must be increased so
that disc can be repositioned on the condyle.

• The patient needs to be encouraged to relax
and avoid forcefully closing the mouth
• The condyle must be in the maximum forward
translatory position.
• The only structure that can actively reduce an
anterior dislocation of the disc is the superior
retrodiscal lamina;if this tissue is to be
effective ,the condyle must be in the forward
most position

• The first attempt to reduce the disc should
begin by having the patient attempt to reduce
the dislocation without assistance
• The patient is asked to move the mandible to
the contralateral side of the dislocation as far
as possible
• If this is not successful than manual
manipulation is begun

(Management of tmj disorders and occlusion.Jeffrey
Okeson.)
• Maximum mouth
opening is seen

• The clinician right thumb is
placed intraorally over the
paitent’s left mandibular
second molar and the
mandible is grasped.
• With the left hand stabilizing
the cranium gentle but firm
force is applied downward on
the molar and upward on the
chin to distract the joint

• Once the joint is distracted the
mandible is brought forward
and to the right enabling the
condyle to move into the area
of dislocated disc.
• When this position is achieved
constant distractive force is
applied for 30-40 seconds while
the patient relaxes

• After the distraction the
thumb is removed and
that patient is asked to
close on the anterior
teeth maintaining the
jaw in a slightly
protrusive position.

• When the patient has
rested a moment the
patient is asked to open
the mouth ,if the disc is
reduced maximal
opening occurs

Supportive treatment
• Avoid excessive opening
• Soft diet ,Slow chewing
• Smaller bites
• NSAID in case of inflammation
• Heat or ice application

Surgical treatment
• A definitive treatment for derangements
• It is considered once the conservative
treatment fails

Arthrocentesis
• Two needles are placed into the joint and
sterile saline is passed through to lavage the
joint
• Lavage is thought to eliminate the algogenic
substances and secondary inflammatory
mediators which causes pain.
• Long term effects is positive

Arthrocentesis
• In case of disc dislocation without reduction a
single needle can be introduced to the joint
and fluid can be forced into the space in an
attempt to free the articular surfaces.
• This technique is called “Pumping the joint”
• It improves the success of manual
manipulation for a closed lock

Arthroscopy
• An arthroscope is placed into the superior
joint space and the intracapsular structures
are visualized on the monitor
• Joint adhesions can be identified and
eliminated and joint can be significantly
mobilized
• It does not correct the disc position instead
success is more likely achieved by improving
the mobility

Arthrotomy
• Open joint surgery is called as arthrotomy
• When a disc is displaced or dislocated the
most conservative surgical procedure is a
discal repair or plication
• During plication a portion of retrodiscal tissue
and inferior lamina is removed and disc is
retracted posteriorly and secured with sutures

Disectomy
• Removal of disc causes bone to bone contact
and causes osteoarthritic changes
• Silastic has been placed in place of the disc
• Proplast Teflon discal implants have been
used but it leads to inflammatory reaction.
• Dermal temporal fascial flaps and auricular
cartilage grafts have also been used

Complications of surgery
• Scarring restricts mandibular movements
• Post surgical adhesions
• Facial nerve damage

FRACTURES
• Fractures of the condylar head and neck often
result from a
blow to the chin .
• The patient with a condylar fracture usually
presents with pain and edema over the joint
area and limitation and deviation of the
mandible to the injured side on opening.
• Bilateral condylar fractures may result in an
anterior open bite.

Fracture of condyle
• The diagnosis of a condylar fracture is
confirmed by radiographic examination.
• Intracapsular nondisplaced fractures of the
condylar head are usually not treated
surgically.
• Early mobilization of the mandible is
emphasized to prevent bony or fibrous
ankylosis.

Classification of condylar neck fractures
(Spiessl and Schroll)

Classification
• Type I: Virtual fracture of neck but without
displacement
• Type II: Lower neck fracture with displacement
• Type III: Fracture high on the neck with
anterior,posterior,medial or lateral displacement
• Type IV: Lower neck fracture with separation
• Type V: High neck fracture with displacement
• Type VI: Fracture of head of the condyle within the
capsule
Ref:Colour atlas of Tmj and Orofacial pain: Wolf

Developmental disorders of TMJ
• Common growth disturbances of the bones
include
1: Agenesis
2: Hypoplasia
3: Hyperplasia
4: Neoplasia

Congenital and Developmental bone
disorders
• Agenesis of condyle

Hyperplasia of condyle
• True condylar hyperplasia usually occurs after
puberty and is completed by 18 to 25 years of age.
• Limitation of opening,deviation of the mandible to
the side of the enlargedcondyle, and facial
asymmetry may be observed.
• Pain is occasionally associated with the hyperplastic
condyle on opening.

Hyperplasia of condyle
• Facial asymmetry often results from disturbances in
condylar growth because the condyle is considered
to be a site for compensatory growth and adaptive
remodeling.
• The facial deformities associated with condylar
hyperplasia involve the formation of a convex ramus
on the affected side and a concave shape on the
normal side.
• If the condylar hyperplasia is detected and surgically
corrected at an early stage, the facial deformities
may be prevented.

From the literature
• An increased uptake of Technetium 99 as
determined by gamma scintigraphy in patients
with condylar hyperplasia
Ref:International Journal of Oral and Maxillofacial Surgery
Volume 19, Issue 2, April 1990, Pages 65-71

Hypoplasia of condyle
• Deviation of the mandible to the affected side and
facial deformities also are associated with unilateral
agenesis and hypoplasia of the condyle.
• In cases of hypoplasia, there is a short wide ramus,
shortening of the body of the mandible, and
antegonial notching on the affected side, with
elongation of the mandibular body and flatness of
the face on the opposite side.

Condylar hypoplasia
• Early surgical intervention is again emphasized
to limit facial deformity.
• Rib grafts have been used to replace the
missing condyle to minimize the facial
asymmetry in agenesis.

Dislocation of condyle
• In dislocation of the mandible, the condyle is
positioned anterior to the articular eminence
and cannot return to its normal position
without assistance.
• This disorder contrasts with subluxation, in
which the condyle moves anterior to the
eminence during wide opening but is able to
return to the resting position without
manipulation.

• Dislocations of the mandible usually result from
muscular incoordination in wide opening during
eating or yawning and less commonly from trauma;
they may be unilateral or bilateral.
• The typical complaints of the patient with
dislocation are an inability to close the jaws and pain
related to muscle spasm.
• On clinical examination, a deep depression may be
observed in the pretragus region corresponding to
the condyle being positioned anterior to the
eminence.

• The condyle can usually be repositioned without the
use of muscle relaxants or general anesthetics.
• If muscle spasms are severe and reduction is difficult,
the use of intravenous diazepam (approximately 10
mg) can be beneficial.
• The practitioner who is repositioning the mandible
should stand in front of the seated patient and place
his or her thumbs lateral to the mandibular molars
on the buccal shelf of bone; the remaining fingers of
each hand should be placed under the chin.

• The condyle is repositioned by a downward
and backward movement. This is achieved by
simultaneously pressing down on the
posterior part of the mandible while raising
the chin.As the condyle reaches the height of
the eminence, it can usually be guided
posteriorly to its normal position.

• Postreduction recommendations consist of a
decrease in mandibular movement and the use of
aspirin or nonsteroidal anti-inflammatory
medications to lessen inflammation.
• The patient should be cautioned not to open wide
when eating or yawning because recurrence is
common, especially during the period initially after
repositioning.
• Long periods of immobilization are not advised due
to the risk of fibrous ankylosis.

• Chronic recurring dislocations have been
treated with surgical and nonsurgical
approaches.
• Injections of sclerosing solutions are not used
as often now because of difficulty in
controlling the extent of fibrosis and condylar
limitation.

• Various surgical procedures have been
advocated for treating recurrent dislocations
of the mandible; these include bone grafting
to the eminence, lateral pterygoid myotomy,
eminence reduction, eminence augmentation
with implants, shortening the temporalis
tendon by intraoral scarification, plication of
the joint capsule, and repositioning of the
zygomatic arch.

Spontaneous dislocation
• Also called as “open lock”
• It can occur after wide open mouth
procedures
• This condition refers to spontaneous
dislocation of both the condyle and the disc

Causes of dislocation
• When the mouth opens to its fullest extent,the
condyle is translated to its anterior limit.
• In this position the disc is rotated to its most
posterior extent on the condyle.
• If the condyle moves beyond this limit, the disc can
be forced through the disc space collapses.
• This same spontaneous dislocation can also occur if
the superior lateral pterygoid contracts during the
full limit of translation ,pulling the disc through the
anterior disc space.

• When a spontaneous dislocation occurs the
superior retrodiscal lamina cannot retract the
disc because of the collapsed anterior disc
space

• A direct punch or kick to the mandible
• Opening the mouth wide on yawning or
eating
• Excessive laxity of the capsule and its
ligaments, which allows excessive movement
• Intubation during general anaesthesia

History
• Patient comes with a open jaw
• Condition followed a wide opening movement
such as yawn,dental procedure.

Clinical characteristics
• Wide open mouth
• Pain is commonly present secondary to the
patient’s attempts to close the mouth.

Definitive treatment
• When attempts are being made to reduce the
dislocation the patient must open widely
• This will activate the mandibular depressors
and inhibit the elevators.
• At the same time slight posterior pressure
applied to the chin will sometimes reduce a
spontaneous dislocation.
• (Management of tmj disorders and occlusion.Jeffrey Okeson.)

• If this is not successful the clinician thumbs
are placed on the mandibular molars and
downward pressure is exerted as the patient
yawns.
• Clinicians thumb is covered with gauze.

• If dislocation still continues it is appropriate to
inject the lateral pterygoid with local
anesthetic without a vasocontrictor in an
attempt to eliminate the myospasms and
promote relaxation.

Chronic /Recurrent dislocation
• Surgical procedure like eminectomy
• Best approach has been to inject botulinum
toxin to the inferior lateral ptyergoid muscles
bilaterally.
• Patient should be recalled in 3 to 4 months

• Prevention is best supportive treatment
• Proper education to the patient
• Patient must learn to restrict opening so as
not to reach point of translation that initiates
the interference
• Patient should be taught reduction procedure.

Subluxation
• Also called as “hypermobility”
• Clinical description of the condyle as it moves
anterior to the crest of the articular eminence.
• Not a pathologic condition but reflects a
variation in anatomic form of the fossa

Causes of subluxation
• Result of anatomic form of the fossa
• Steep short posterior slope of the articular eminence
followed by longer flat anterior slope seem to have
greater tendency for subluxation.
• Disc is maximally rotated on the condyle before full
translation of condyle disc complex occurs.

History
• Locking sensation whenever the patient opens
mouth too widely
• Can close the mouth to closed position but
reports some 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 to be subtle clicking
sensation.

Treatment
• Ideal treatment, eminectomy which reduces
the steepness of the articular eminence and
thus decreases the amount of posterior
rotation of the disc on the condyle during full
translation.

• Proper education to the patient
• Patient must learn to restrict opening so as
not to reach point of translation that initiates
the interference.
• Wearing the device limits opening to the point
of subluxation. The device is worn for 2
months continously and removed.

Ankylosis
• Ankylosis means abnormal immobility of a
joint.
• Two types :
1: Fibrous
2: Bony

Bony Ankylosis
• It occurs between the condyle and
fossa,therefore the disc would have to have
been lost already from discal space
• They are rare
• Chronic and extensive disorder may cause
bony ankylosis

Cause
• Hemarthrosis secondary to macrotrauma
• Fibrous ankylosis represents a continued
progression of joint adhesions,that creates
significant limitation of joint movement.
• Chronic inflammation aggravates the disorder
leading to the development of more fibrous
tissue.

History
• Limited mouth opening
• Absence of pain
• Problem present for a long period of time

• Condyle can still rotate with some degree of
restriction on inferior surface of the disc
• The patient is usually able to open approx.25
mm interincisally
• Lateral movements are restricted
• Restricted movements to the unaffected side
• During mouth opening the opening pathway
deflects to the ipsilateral side

Treatment
• Compromised function warrants surgery
• Arthroscopic surgery is the least aggressive
surgical procedure
• Gap arthroplasty is one of the treatment
followed for ankylosis

• Generally not indicated
• If mandible is forced beyond its restriction
injury to the tissues can occur
• Analgesics and deep heat therapy can also be
used.

Tumors affecting TMJ
• Originating and involving TMJ are rare
• Tumors may be intrinsic or extrinsic
• Intrinsic tumors may develop in the condyle
,temporal bone or coronoid process
• Extrinsic tumors may affect the morphology
,structure or function of the joint without
invading the joint itself.

Benign tumors
• Most common includes
1: Osteomas
2: Osteochondromas
3: Langerhans Histocytosis
4: Osteoblastoma
• Ameloblastomas,OKC ,simple bone cysts may
involve the entire ramus and in rare cases the
condyle

Clinical features
• Slow growth
• Patient complaints of TMJ swelling
• Pain and decreased range of motion
• Facial asymmetry
• Malocclusion
• Deviation of the mandible to unaffected side

Tumors affecting coronoid process
• Painless
• Limitation of motion

• Condylar enlargement that often is irregular in
outline
• The trabecular pattern may be altered
resulting in regions of destruction seen as
radiolucencies or new abnormal bone
formation which may increase the
radioopacity of condyle with abnormal
trabeculae

• Unilateral condylar hyperplasia
• Osteomas and osteochondromas

Treatment
• Surgical excision of the tumor
• Occassionally excision of condylar head or
coronoid process.

Malignant tumors
• May be primary or metastatic
• Primary tumors include;
1: Chondrosarcoma
2: Osteogenic sarcoma
3: Synovial sarcoma
4: Fibrosarcoma of the joint capsule

Metastatic lesions
• Neoplasms originating in the :
1: Breast
2: Kidney
3: Lung
4: Colon
5: Prostate
6: Thyroid gland

Clinical features
• Asymptomatic
• Pain
• Limited mandibular opening
• Mandibular deviation
• Swelling

• Variable degree of bone destruction
• Ill defined irregular margins
• Lack tumor bone formation with exception of
OS

Radiological features
• Chondrosarcoma may appear as an indistinct
radiolucent destructive lesion of the condyle
with surrounding discrete soft tissue
calcifications that may simulate the
appearance of the articular loose bodies seen
in pseudogout.

Radiological features
• In case of metastatic tumors the appearance
is nonspecific condylar destruction and does
not indicate site of origin

• Differentiate it from DJD
• DJD causes peripheral bone destruction
whereas malignant tumor causes central bone
destruction
• Osteophyte formation seen with DJD

Temporomandibular joint disorders

Temporomandibular joint disorders

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