Tmj and Tmd diagnosis / management /

1. Temporomandibular
disorders
 Cairo university
 Faculty of oral & dental medicine
 Oral pathology department
 MSc. Orthodontics students
 Shady Mohammed Akram Ahmed metwally
 Mohammed Saied Mahmoud Hassan
 Mohamed Zidan Mohamed Salem
 Asmaa Ahmed Abo el Naga

2. Temporomandibular joint
Disorders
Diagnosis
management

3. Temporomandibular joint (TMJ)
 Function :
connects the mandible or the lower jaw to the skull and regulates the movement of
the jaw . The important functions of the TMJ are mastication and speech
 Type :
It is a bi-condylar joint in which the condyles, located at the two ends of the
mandible, function at the same time.
 The TMJ is one of the most complex as well as most used joint in a human body.

4. TMJ Function
 The most important functions of the TMJ are mastication and speech.
 Strong muscles control the movement of the jaw and the TMJ. The temporalis muscle
which attaches to the temporal bone elevates the mandible.
 The masseter muscle closes the mouth and is the main muscle used in mastication.
 Movement is guided by the shape of the bones, muscles, ligaments, and occlusion of the
teeth.
 The TMJ undergoes hinge and gliding motion. The TMJ movements are very complex as
the joint has three degrees of freedom, with each of the degrees of freedom associated
with a separate axis of rotation.
 Rotation and anterior translation are the two primary movements.
 Posterior translation and mediolateral translation are the other two possible movements
of TMj

5. Classic TMD Symptoms
Frequent headaches / upon waking & late in
afternoon
Abnormal / painful jaw movements
Ear pain
Pain orbitally / circumorbitally
Cheek pain
Mandibular pain

6. Tmj Ligaments

7. Ligaments

8. Extracapsular ligaments

9. Muscles Related

12. Movements of Tmj & Related musculature
Depression Kinematics
 First 25 mm of opening that occurs primarily as a rotational motion (roll‐gliding) of the condyle
in the inferior joint space.
 Once the collateral ligaments tauten, the opening continues as primarily a translator
gliding motion in the upper joint space until 35 mm is reached and the posterior and collateral l
igaments are taut.
 Opening greater than 35 mm results from further translation with over rotation
and further stretching applied to the posterior and collateral The lateral pterygoid, inferior hea
d, provides a protracting force on the condyles and discs
 the geniohyoid and digastric muscles
produce a depressing and retracting force on the chin
 the mylohyoid muscle pulls downward on the body of the mandible
to combine to produce the rotatory and translator
movements of the jaw that occur with mandibular depression

13. A : Opening of the Mouth
B : Closing of the Mouth

14. Lateral excursion kinematics
 Lateral excursion occurs when the condyle and disc of the contralateral
side are pulled forward, downward, and medially along the articular eminence.
 The condyle on the ipsilateral
side performs minimal rotation around a vertical axis and a slight lateral shift
 These motions take place primarily in the upper joint space.
 Lateral excursion is created by contraction of the lateral pterygoid
muscles on the contralateral
side of the direction of the motion combined with the ipsilateral side temporalis
muscle contracting to hold the rest position of the condyle
to prevent the mandible from deviating anteriorly.

15. Active Lateral excursion

16. Protrusion kinematics
 Protusionof the mandible is created with symmetrical anterior translation of both condyle/
disc complexes on the articular eminence
 The motion occurs at the superior joint space.
 Protrusion is created by contraction of the inferior head of the lateral pterygoid
and holding action of the masseter and medial pterygoid muscles. The lateral pterygoid
pulls the condyle and disc forward and down along the articular
eminence while the elevator and depressor muscles maintain the mandibular position.
 Retrusion
is the return to rest position from the protrusion position and is created by the contractio
n of the middle and posterior fibers of both temporalis
muscles while the depressors and elevators maintain a slight opening of the mouth.

17. Protrusion .
Retrusion .

18. Differentiating between TMD / CCD
Cervicocranial disorder
 CCD is “ an abbreviation “ for a complex disorder emanating from the upper
vertebra of the neck including the related pain and symptoms
 SYMPTOMS :
 Limited head movement specially ROTATION
 Trouble swallowing
 Forward head posture
 Upper back pain
 Sore/tender/weak neck
 Frequent snapping / popping of Neck with regular Head movement
 Cervical referral pain into Facial area
Where CCD Starts/hurts
C0 –Skull / forehead
C1– Atlas/ eye
C2-Axis / cheek
C3-Jaw

19. Convergence between cervical nerves &
trigeminal nerve & Greater occipital
 The trigeminal nucleus caudalis extends to C2 spinal segment and to lateral cervical
nucleus in the dorsolateral cervical area
 Symptoms in the trigeminal or cervical territories produce symptoms in either area
 Muscular spasms & strictures trigger onset of pain
 Circulatory disorders / Constriction / Dilation
 Neurologic aberrations . e.g. Headache / migraine
 Skeletal displacement

20. TMJ Anatomy :
Condyle
Articular eminence
Articular disc
 The movable round upper end of the lower jaw is called the condyle and the socket
is called the articular fossa . Between the condyle and the fossa is a disc made of
fibrocartilage that acts as a cushion to absorb stress and allows the condyle to move
easily when the mouth opens and closes. The features that differentiate and make
the TMJ a unique joint are its articular surfaces covered by fibrocartilage instead of
hyaline cartilage.
 The bony structure: consists of the articular fossa; the articular eminence, which is
an anterior protuberance continuous with the fossa; and the condylar process of
the mandible that rests within the fossa. The articular surfaces of the condyle and
the fossa are covered with cartilage.

21. Detailed Anatomy of TMJ

22. Intercapsular Structures
 Articular disc
3 bands
 Anterior ‐2 mm
 Middle ‐1 mm
 Posterior ‐3 mm
 Attachments
 Medial and lateral collateral ligaments
 Posterior Attachments / Bilaminar Zone
 Superior Laminae
 Inferior Laminae
 Retrodiscal pad
 Lateral Pterygoid

23. Articular disc
lamina
Retrodiscal pad

24. Articular Disc/
Meniscus
 A dense fibrocartilaginous disc is located between the bones in each TMJ. The disc
divides the joint cavity into two compartments (superior and inferior). The two
compartments of the joint are filled with synovial fluid which provides lubrication
and nutrition to the joint structures. The disc distributes the joint stresses over
broader area thereby reducing the chances of concentration of the contact stresses
at one point in the joint. The presence of the disc in the joint capsule prevents the
bone-on-bone contact and the possible higher wear of the condylar head and the
articular fossa. The bones are held together with ligaments. These ligaments
completely surround the TMJ forming the joint capsule.

25. Muscles / Joint coordination
 Increased forward head posture
 Tight posterior neck musculature will rotate the cranium backward leaving the
mouth open at rest
 Muscles of mastication overwork to maintain jaw closure

26. Forward head posture leads to
Pseudo -malocclusion
 Changing Rest position of Mandible
can change Head & Neck posture/
Daly
 Increased FHP places mandible in a
more retruded position / Darling
 Increased FHP changes trajectory of
the mandible / Goldstein
 Po / Porion : Upper most point on
bony external auditory meatus
 Or / Orbitale : Most inferior anterior
point on margin of orbit

27. Temporomandibular disorder (TMD)
is a generic term used for any problem
concerning the jaw joint.
 Injury to the jaw, temporomandibular joint, or
muscles of the head and neck can cause TMD
TMD is seen most commonly in people
between the ages of 20 and 40 years, and
occurs more often in women than in men

28. Why are females more
susceptible to TMD ?
 some researchers suggest that the female sex hormones may
have a role in the pathogenesis of the TMJ disorders. Sex
hormones are known to influence the differentiation, growth
and development, and metabolism of connective tissues.
 A study conducted by Abubaker et al. suggests that sex
hormones affect the extracellular matrix of the TMJ disc of
female and male rats.1

29. The most common TMJ
disorders
pain dysfunction syndrome
internal derangement
arthritis
traumas

30. Disc Displacement
 Coordinated movement of condyle and disc is essential to maintain the integrity of
the disc.
 Disc displacement is the most common TMJ arthropathy and is defined as an
abnormal relationship between the articular disc and condyle.
 As the disc is forced out of the correct position there is often bone on bone
contact which creates additional wear and tear on the joint, and often causes the
TMD to worsen.
 Disc displacement generates a popping sound when the disc is first forced out of
alignment as the mouth opens up and then again as the disc is forced back into
place as the mouth is closed. Clinically, this popping sound or clicking is regarded
as an initial symptom of the temporomandibular joint internal derangement / TMJ-
ID
 The anterior disc displacement has different degrees of severity

31. Wilkes staging classifications for the TMJ
related internal derangement / disc
displacement
stages were defined based on :
 1 . clinical findings
 2 . radiological findings
 3 . the anatomic pathology of the jaw.

32. Early vs. Late Stages of TMD
 The early stage included slight displacement with clicking, and no pain or dysfunction.
 The last stage included degenerative changes to the disc with possible perforation, flattening of
bones, pain, and restricted motion
 In an early stage, there is a simple disc displacement in the closed mouth position, usually
anteriorly, due to ? weakness of the discal ligaments
 If the displaced disc returns to its normal position when the mouth is opened, accompanied by a
popping sound, it is referred to as disc displacement with reduction
 If the displaced disc does not return to the normal position and acts as an obstacle during
attempted mouth opening, the joint appears as locked. This is referred to as disc displacement
without reduction.
 Almost 70% of TMD patients have disc displacement. According to Tanaka , stress distributions in
the TMJ with a normal disc position are substantially different from those with anterior disc
displacement. It is suggested that the disc displacement induces the change of stress distribution
in the disc and the increase of frictional coefficients between articular surfaces, resulting in the
secondary tissue damage. The internal derangement frequently precedes the onset of TMJ
osteoarthritis

34. Wilkes’ staging classification / 5 stages
 Early
 Early intermediate
 Intermediate
 Late intermediate
 Last stage

35. Stages/findings Early stage Early intermediate Intermediate Late intermediate Late
Clinical findings opening
reciprocal clicking
no pain or
limitation of
motion
One or more
episodes of pain;
beginning major
mechanical
problems
consisting of mid-
to-late opening
loud clicking;
transient catching,
and locking
Multiple episodes
of pain; major
mechanical
symptoms
consisting of
locking
(intermittent or
fully closed);
restriction of
motion; difficulty
with function
Slight increase in
severity over
intermediate
stage
Characterized by
crepitus; variable
and episodic pain
chronic restriction
of motion and
difficulty with
function
Radiographic
findings
Slight forward
displacement;
good anatomic
contour of the
disc; negative
tomograms
: Slight forward
displacement;
beginning disc
deformity of
slight thickening
of posterior edge;
negative
tomograms
Anterior disc
displacement with
significant
deformity or
prolapse of disc
(increase
thickening of
posterior edge);
: increase in
severity over
intermediate
stage; positive
tomograms
showing early-to-
moderate
degenerative
: Disc or
attachment
perforation; filling
defects; gross
anatomic
deformity of disc
and hard tissues;
positive

36. Management & TTT Options
Self care
Splints
Surgery
Arthrocentesis
Arthroscopy
Disectomy
Joint replacement

37. Other treatment modalities
 Modalities
- Ultra sound / Iontophoresis / Moist Heat
 Postural Education
 Therapeutic exercise
 Neuromuscular Re-education
 Manipulation
- Cervical/thoracic spine
- TMJ
In a study by Majwer and Swid
er,
32 cases of
posttraumatic TMD benefited
with decreased pain from the
application of ?
dexamethasone
(n = 8) or
Xylocane
(n = 24)
through iontophoresis/ joint
wash

38. Condylar Remodeling
Rest Position
Gently rest device betw
een teeth between incis
ors.
Maintain normal airway
for breathing

39. Theory of Condylar Remodeling
 Contralateral lateral deviation will gap and
glide the condyle anteriorly on the eminence
while the disc remains positioned correctly.
 Biting in this position creates a co
‐contraction of the musculature acting on th
e disc and facilitates stabilization of :
 Posterior Temporalis
 Deep Masseter
 Superior Lateral Pterygoid
 The return to midline while maintaining the
contraction creates a coupling force.
 Approximates the natural condylar‐disc‐emin
ence relationships with motion.
 Theory suggests the biconcave disc can refor
m to the approximated condyle and eminenc
e

40. Condylar Rehabilitation /
Therapeutic exercises
 Rest device gently between front teeth
 Phase I ‐Roll device away from affected side.
 Phase II ‐After roll, gently bite down as if to make an impression on the device.
 Phase III ‐After bite, maintain force onto device and return to midline
 Do all exercises six times three times per day. T.D.S x 6

41. Physical Therapy and its importance
Discussion
 Patients with temporomandibular disorder who are treated wi
th a rehabilitation program including physical therapy interve
ntions + exercise
 demonstrate clinically , improvements in disability and ov
erall perceived change in a relatively short period of time.

42. Goals of Physical Therapy
 Restore Natural Motion of TMJ and Cervical Spine
 Improve Postural Awareness
 Improve Function (eating, talking, etc.)
 Decrease Pain and Headaches
 Teach Patients How to Prevent Future Occurrences of Head a
nd Facial Pain

43. Self care
 Physical therapy is often used by TMD patients to keep the synovial joint lubricated,
and to maintain full range of the jaw motion. One such exercise for the jaw is to :
 open the mouth to a comfortable fully-open position and then to apply slight
additional pressure to open the mouth fully.
 Another exercise includes stretching the jaw muscles by making various facial
expressions.
 Avoiding extreme jaw movements, taking medications, applying moist heat or cold
packs, eating soft foods are other ways that may keep the disorder from worsening

44. Splints

45. Splints
 plastic mouthpieces that fit over the upper and lower teeth .
 They prevent the upper and lower teeth from coming together, lessening the effects of
clenching or grinding the teeth.
 correct the bite
 Dental splints are often used as a short-term treatment positioning the teeth in their most
correct and least traumatic position. during orthodontic management, before orthodontic
therapy, or if the TMJ disorders occur during dentofacial orthopedic procedures.
 Bruxism is believed to cause the TMJ dysfunction due to tooth attrition and subsequent
malocclusion; myofascial strain, fatigue or fibrosis of masticatory muscles; and capsulitis
and adhesions within the TMJ joint space.
 Splints are used to help control bruxism, a TMD risk factor in some cases. Splints are
effective in reducing the intensity of pain for patients with pain in jaw and masticatory
muscles by compensating for or correcting perceived bite defects of the sufferer.

46. Surgery
 Surgery can play an important role in the management of TMDs. As
different surgical approaches for treating the same condition are often
recommended in the literature, it is essential to understand which
approach can be more beneficial when surgery is needed.
 Conditions that are always treated surgically involve problems of
overdevelopment or underdevelopment of the mandible resulting from
alterations of condylar growth
 Mandibular ankylosis
 Benign and malignant tumors of the TMJ.
 The surgical treatments such as arthrocentesis, arthroscopy, discectomy,
and joint replacement are discussed below

47. Surgical treatments
arthrocentesis,
arthroscopy,
discectomy, and
 joint replacement

48. Arthrocentesis
A first needle injects fluid
to wash out joint
Second needle
attached
to syringe
Removes excess fluids

49. Arthrocentesis
 Arthrocentesis is the simplest form of surgical intervention
into the TMJ performed under general anesthesia for
sudden-onset , closed lockcases (restricted jaw opening) in
patients with no significant prior history of TMJ problems.
 Arthrocentesis is not only the least invasive of all surgical
procedures but also carries a very low risk. It involves
inserting needles inside the affected joint and washing out
the joint with sterile fluids
 Occasionally, the procedure may involve inserting a blunt
instrument inside the joint to dislodge a stuck disc

50. Arthroscopy
 Arthroscopy is a surgery performed to put the articular disc back into place. During this surgery a
small incision is made in front of the patient’s ear to insert a small, thin instrument that contains a
lens and light. This instrument is connected to a video screen, allowing the surgeon to examine
the TMJ and surrounding area. Depending on the cause of the TMD,
 the surgeon may remove inflamed tissue or realign the disc or condyle.However, if the ligament
and retrodiscal tissue was previously stretched beyond its elastic range, then just popping the
disc back into place is only a temporary fix as the joint still would not work as well as usual.
Therefore, an anchor—Mitek mini anchor—and artificial ligaments have been used for several
years to stabilize the articular disc to the posterior aspect of the condyle .When disc repositioning
and stabilization are indicated, the Mitek mini anchor system offers significant advantages over
other disc repositioning methods, The Mitek mini anchor has been analyzed in various studies to
assess its performance. A 2-year follow-up
 study showed a success rate of 90% in reference to incisal opening, jaw and occlusal stability, and
significant reduction in presurgical pain level.110 Fields and Wolford27 have demonstrated
osseointegration of the Mitek anchor in human condyles. The Mitek anchors are reported to
remain intact and biocompatible for as long as 59 months.27 Mehra and Wolford62 reported
that, in 105 patients (188 discs) treated with Mitek mini anchors, the radiographic evaluation for
the follow-up over 14–84 months demonstrated no significant condylar resorption or positional
changes of the anchors. They also reported a statistically significant reduction in TMJ pain, facial
pain, headaches, the TMJ noises and disability; and improvement in jaw function and diet. The
Mitek mini anchor also provides an effective method for prevention of condylar dislocation while
permitting some controlled translation

51. Discectomy
 Discectomy is a surgical treatment, which is often performed on individuals with
severe TMD, to remove the damaged and very often dislocating articular disc
without going to a more extreme treatment such as a joint prosthetic. However,
removal of the painful pathologic disc causes the TMJ reduced absorbency and
increased loading during articulation.
 Although materials such as tendon allografts are advocated for the use of disc
replacement, there are no ideal inter-positional materials that can protect articular
cartilage from degenerative changes following discectomy.

52. Artificial Joint Replacement
 Joint replacement is a surgical procedure in which the severely damaged part of the TMJ is
removed and replaced with a prosthetic device. While more conservative treatments are
preferred when possible, in severe cases or after multiple operations, the current end stage
treatment is joint replacement.
 If either a condyle or a fossa component of the TMJ is replaced, the surgery is called partial
joint replacement.
 In total joint replacement, condyle and fossa are both replaced .
 Joint replacement is performed in certain circumstances such as bony ankylosis, recurrent
fibrous ankylosis, severe degenerative joint disease, aseptic necrosis of the condyle,
advanced rheumatoid arthritis, two or more previous TMJ surgeries, absence of the TMJ
structure due to pathology, tumors involving the condyle and mandibular ramus area, loss
of the condyle from trauma or pathology.
 There are now long-term studies available in the literature that support the safety and
efficacy of joint replacement under appropriate circumstances. However, before a joint
replacement option is ever considered fora patient, all non-surgical, conservative treatment
options must be exhausted; and all conservative surgical methodologies should be
employed.

53. Tmj Replacement Prosthesis

54. Normal occlusion / Tmj relationship
Normal molar relationship along
Good intercuspation
Promotes
proper condylar head / disc /
mandibular Relationship
Stress Free

55. Traumatic occlusion & its pathological
effect on TMJ
Poor intercuspation / molar relationship
Pushes mandible Forward in occlusion / via
mandibular cusp slopes
Places forwardly directed stressed on disc
accompanied by jaw & facial pain

56. Patient Education & Instruction
 Limit parafunctional activities as Nail biting , gum chewing , clenching , Teeth grinding
 Tongue position : at Rest : The tip of the tongue should be at the ridge of the roof of
the mouth with the front one third of the tongue on the roof of the mouth
 Teeth position : the teeth should be 2-3 mm apart at rest
 Lips should be lightly contacting together / breathing through the nose
 When Yawning / keep tip of tongue up on roof of Mouth
 Avoid sleeping in prone position “ Lying Face downwards “
 Do not rest chin in hands
 Soft diet : avoid hard crunchy food
 Small bites of food
 Warm water rinses
 Postural & Tmj exercises 5-6 times a day

57. Temporo mandibular disorders
Capsulitis / Synovitis
Capsular Fibrosis
Hypermobility
Articular Disc Displacement
 With reduction &
Without reduction
Post ‐Surgical TMJ

58. Capsulitis / synovitis
 Tender to palpation at TMJ lateral condyle or posterior compartment
 Pain with biting on opposite side
 Pain with retrusive overpressure
 Pain with accessory motion testing

59. Masticatory Muscle Disorders
 joint sounds
Pain with palpation muscles of mastication
Inconsistent alterations in mandibular control
Parafunctional oral behaviors
Pain with biting on same side

60. Capsular Fibrosis
 Capsular pattern:
-Deviation toward limited side with opening and protrusion
-Limited contralateral lateral excursion
 Limited AROM mandibular dynamics
 Limited mobility with TMJ accessory motion tests
 No joint sounds
 History of trauma or surgery

61. Hypermobility
 End range click with deviation away from hypermobile side
 Symptomatic
 May lead to disc displacement condition
 Excessive AROM with opening >40 mm
 Joint sound at end range of opening
 Hypermobility with accessory motion testing

62. Post surgical TMJ
capsulitis/synovitis
Assess for underlying TMJ dysfunction

63. Osteoarthritis
TMJ crepitus as noted with
stethoscope
Pain with TMJ palpation
Radiographic evidence of osteoarthritis

64. Imaging techniques for Tmj
 2d :
 Panograph / transcranial / tomograms / arthrograms
 3d :
 CT / MRI T-1 / MRI T-2 / MRI GRADIENT
 Flair / fast t-2 / shows edema
 STIR : suppress fat content good for MS diagnosis

65. Your Prescription in TMD
1) vitamin d-3 , 2000 to 10,000 IU per day
2) Doxycycline ( 50 mg , bid for 3 months )
3) omega 3 – 2.6 mg/day
4) NSAIDS
5) Glucosamine ( 1500 mg/day )
6) TMJ Splint
7) Muscle relaxant

66. Tmj
diagnosis
chart