Temporomandibular Joint Disorders (TMD)

Temporomandibular joint disorder
Mohammed Matooq Al-Ali

Outline:
• TMJ anatomy.
• Epidemiology.
• Assessment.
• Classification.
• Treatment .

Temporomandibular joint disorder
• Collective term embracing a number of clinical problems that involve
the masticatory muscles, the temporomandibular joints (TMJs) and
associated structures, or both.
Mirchael Glick. Burket’s oral Medicine, 12th edition

JEFFREY P. OKESON. MANAGEMENT OF TEMPOROMANDIBULAR DISORDERS AND OCCLUSION. 7th edition.
TMJ

The Condylar disc

The temporomandibular ligament
Prevent posterior and inferior
displacement of the condyle

Sphenomandibular & Stylomandibular ligaments
Bernard Liebgott. The anatomical basis of dentistry. 2d edition
Limits excessive protrusive
movements of the
mandible.

The collateral (discal) ligaments
MDL
DDL
Vascular supply and are innervated.
Responsible for the hinging
movement of the TM

Masseter muscle

Temporal muscle
Inferior temporal line
Coronoid Process

Medial pterygoid muscle

Lateral pterygoid muscles.

Actions of Muscle Of
Mastication

Joint Movements
Closing position
Hing Movement Translatory movement

Epidemiology of TMDs
• Young and middle-aged adults.
• Twice women > men.
• Meta-analysis showed a prevalence of 45%, 41%, and 30% for muscle
disorders, disc derangement disorders, and joint pain disorders,
respectively.
• In fact, recent data demonstrated that 76% and 71% of soft and hard
tissue diagnoses, respectively, remained stable after an 8-year follow
up.
• 3.6% to 7% of individuals with TMDs Only are estimated to require
treatment.
Orofacial Pain, Guidelines for Assessment, Diagnosis, and Management Edited by Reny de Leeuw, DDS, PhD, MPH and Gary D.
Klasser, DMD The American Academy of Orofacial Pain Orofacial

Etiology of TMDs
• Trauma
- Direct. - Indirect. - Microtrauma.
• Anatomical factors
Facial skeletal abnormalities, steeper eminence
• Occlusal relationships
Current evidence: low
• Pathophysiologic factors
• Systemic pathophysiologic conditions, female Hormone.
• Genetic factors
• Psychosocial factors

Assessment of TMJ
• History:
• C/C: pain
- Location
- Type and severity.
- Intermitted or continuous.
- Provoked factor.
- Previous examination and treatment.
• MH.
• DH.
• Shaffer, S. M., Brismée, J. M., Sizer, P. S., & Courtney, C. A. (2014). Temporomandibular disorders. Part 1: anatomy and
examination/diagnosis. The Journal of manual & manipulative therapy, 22(1), 2–12.

Assessment of TMJ
• Extraoral examination:
- Observation.
- Range of movement.
- Sounds.
- Palpation.
• Intraoral examination:
- Source of dental pain
- Wear, facets, mobility, sorness.
- Occlusion
- Premature contact
- Missing teath
• Shaffer, S. M., Brismée, J. M., Sizer, P. S., & Courtney, C. A. (2014). Temporomandibular disorders. Part 1: anatomy and
examination/diagnosis. The Journal of manual & manipulative therapy, 22(1), 2–12.
• JEFFREY P. OKESON. MANAGEMENT OF TEMPOROMANDIBULAR DISORDERS AND OCCLUSION. 7th edition.

Assessment of TMJ
• Radiographic examination:
- Position of the condyle.
- Width of joint space.
- Change in the shape and structure .
• OPG.
• CT.
• CBCT.
• MRI.
• Nuclear imaging.
Rakesh Pawar, Nitin Gulve , Amit Nehete , Shweta Dhope , Deepali Deore , Nangthombam, Chinglembi Examination of the
Temporomandibular Joint- A Review. Journal of Applied Dental and Medical Sciences. Volume 2 Issue 1 January - March 2016

MRI of TMJ
• STUART C. WHITE, MICHAEL J. PHAROAH, Oral Radiology P R I N C I P L E S a n d I N T E R P R E T A T I O N. 6th edition
• Bag AK, Gaddikeri S, Singhal A, et al. Imaging of the temporomandibular joint: An update. World J Radiol.
2014;6(8):567–582. doi:10.4329/wjr.v6.i8.567

Joint pain
• Arthralgia
• Jaw movement, function, or parafunction and replication of this pain with
provocation testing, either during mandibular movement or palpation of the
TMJs.
• History :
- In the past 30 days, pain in the jaw.
- Pain altered with jaw movement, function , or parafunction.
• Examination:
- Confirmation of the pain location.
- Familiar pain in the TMJ at least with on of the provocation test:
- Palpation of the lateral pole.
- Maximum opening.
• Schiffman , Ohrbach , etl.Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: Recommendations
of the International RDC/TMD Consortium Network* and Orofacial Pain. J Oral Facial Pain Headache. 2014 ; 28(1): 6–27.
• Orofacial Pain, Guidelines for Assessment, Diagnosis, and Management Edited by Reny de Leeuw, DDS, PhD, MPH and Gary D. Klasser, DMD The
American Academy of Orofacial Pain Orofacial

Joint pain
• Arthritis
• Clinical characteristics of inflammation or infection:
• History:
• Swelling, redness, and/or increased temperature in front of the ear.
• Dental occlusal changes (posterior open bite).
• Examination:
• Presence of edema, erythema, and/or increased temperature over the TMJs.
• Reduction in dental occlusal contacts noted between two consecutive measurements.

Joint disorders: Disc-condyle complex disorders
Disc displacement with reduction

• History:
- In the last 30 days, any noise(s) present with jaw movement or
function, or patient report of joint sounds during the examination.
• Examination:
- Both an opening and closing clicking, or Either an opening or
closing clicking, popping.

STUART C. WHITE, MICHAEL J. PHAROAH, Oral Radiology P R I N C I P L E S a n d I N T E R P R E T A T I O N. 6th edition

• Disc displacement with reduction with intermittent locking
• In the last 30 days
- Noises present with jaw movement or function.
- Report of intermittent locking with limited opening or evidence of
intermittent locking during clinical examination.
• Examination:
- Disc displacement with reduction as defined above.
• MRI

• Disc displacement without reduction with limited opening

Disc displacement without reduction with limited opening
• History:
- Jaw lock or catch so that it will not open all the way.
- Limitation in jaw opening severe enough to interfere with the
ability to eat.
• Examination:
- Maximum assisted opening (passive stretch) < 40 mm.

• Disc displacement without reduction with limited opening: MRI
Close position Open position

• Disc displacement without reduction without limited opening
• History :
- Same as defined for disc displacement without reduction with
limited opening.
• Examination:
- Maximum assisted opening > 40 mm.

Joint disorders: Other hypomobility disorders
Adhesions and adherence
• Fibrous adhesions within the TMJ are thought to occur mainly in the superior
compartment of the TMJ.
• History :
- No history of TMJ clicking (historically to differentiate from disc displacement
without reduction with limited opening).
- History of loss of jaw mobility.
• Examination :
- Limited range of motion on opening.
- Uncorrected deviation of the jaw to the affected side on opening if present
unilaterally.
- Marked limited laterotrusion.

TMJ fibrous ankyloses
History of progressive loss of jaw mobility
• Examination :
- Severe limited range of motion on opening.
- Uncorrected jaw deviation to the affected side.
- Marked limited laterotrusion to the contralateral side.
• CT or CBCT :
- Imaging findings of decreased ipsilateral condylar translation on opening.
- Imaging findings of a joint space between ipsilateral condyle and
eminence.

TMJ Bony ankylosis
• History :
- Progressive loss of jaw mobility.
• Examination :
- Absence of or severely limited jaw mobility with all movements.

CT of TMJ Bony ankylosis
coronal
STUART C. WHITE, MICHAEL J. PHAROAH, Oral Radiology P R I N C I P L E S a n d I N T E R P R E T A T I O N. 6th edition

Hypermobility disorders : subluxation or luxation

• History :
- In the last 30 days, jaw locking or catching in a wide open mouth
position, even for a moment, so the patient could not close from the
wide open position.
- Report of inability to close from wide opening.
• A self-maneuver
• Specific mandibular maneuver by the clinician

• Examination :
• persistent presentations:
- Wide open mouth.
- Protruded jaw position.
- Lateral position to the contralateral side.
JEFFREY P. OKESON. MANAGEMENT OF
TEMPOROMANDIBULARDISORDERS AND OCCLUSION

DJD
• deterioration of articular tissue with concomitant osseous changes in the condyle
and articular eminence.
• History :
- In the past month, any joint noises present with jaw movement or function.
- Patient report of any noises during the examination.
• Examination :
- Crepitus detected with palpation during at least one of the following: maximum
unassisted opening, maximum assisted opening, right or left lateral
movements, or protrusive movements.

DJD: CT
Sadaksharam Jayachandran
Osteophytes in TMJ. 2016Kyung-Soo Nah. Condyle bony change
in TMD patient. 2012JEFFREY P. OKESON. MANAGEMENT OF TEMPOROMANDIBULAR
DISORDERS AND OCCLUSION. 7th edition.

Condylysis/idiopathic condylar resorption
• Idiopathic degenerative condition leading to the loss of condylar height and
a progressive anterior open bite.
• spontaneously, bilateral.
• adolescent and young adult females.
• History :
- Progressive dental occlusal changes.
• Examination :
- Anterior open bite.
- Evidence of progressive dental occlusal changes.
- RA test .

Osteochondritis dissecans
• Piece of cartilage and a small bone fragment break loose from the end of the bone and
result in loose osteochondral fragments within the joint.
• History :
- Arthralgia
- Joint noises with mandibular movement or swelling
• Examination:
- Crepitus.
- Maximum assisted opening plus vertical overlap < 40 mm
- Swelling around the affected joint.
• CT/CBCT :
• Loose osteochondral fragments within the joint.
• RA test

Systemic arthritides
• Clinical signs and symptoms of an ongoing chronic TMJ inflammation
are variable between patients and within a patient over time.
• History:
- Rheumatologic diagnosis of a systemic inflammatory joint disease.
- TMJ pain or noises present in the past month or TMJ pain that
worsens with the episodes and exacerbations of the systemic
inflammatory joint disease.

Systemic arthritides
• Examination :
• Rheumatologic diagnosis of a systemic joint disease.
• Arthritis signs and symptoms as defined previously or crepitus
detected with palpation during maximum unassisted and assisted
opening, lateral, and protrusive movements.
Imaging criteria:
• Similar to DJD

Neoplastic disorders
• Benign:
- Osteoma, osteochondroma, chondroma.
• Clinical manifestation:
- Condylar deformity.
- Mandibular deviation.
- Cross bite and rapid ipsilateral open bite.
Paul H. Known, Daniel M. Laskin. Clinician’s manual of oral and maxillofacial surgery , 3d edition

Neoplastic disorders
• Malignant:
- Osteosarcoma and chondrosarcoma.
- Neoplasia extending to the TMJ region.
• Clinical Manifestations:
- Pain and swelling.
- Rapid destruction.
- Limited mouth opening.
- Mandibular deviation.

Clinical case
• A 20-year-old female patient
• complaining of
- eating difficulty.
- facial asymmetry.
- pain in the left TMJ.
• History:
- slowly progressive facial asymmetry and tooth crowding for at least
4 years.
- No trauma.

Histopathology
Estevam Rubens Utumi; Irineu Gregnanin Pedron, Andréia Perrella, Camila Eduarda ZambonI, Marcelo Minharro Ceccheti. Marcelo Gusmão
Paraíso CavalcantiOsteochondroma of the temporomandibular joint: a case report>Braz. Dent. J. vol.21 no.3 Ribeirão Preto 2010

Estevam Rubens Utumi; Irineu Gregnanin Pedron, Andréia Perrella, Camila Eduarda ZambonI, Marcelo Minharro Ceccheti. Marcelo Gusmão
Paraíso CavalcantiOsteochondroma of the temporomandibular joint: a case report>Braz. Dent. J. vol.21 no.3 Ribeirão Preto 2010
Osteochondroma of the temporomandibular joint

Synovial chondromatosis
• formation of cartilaginous nodules that may be pedunculated and/or detached from the synovial
membrane, becoming loose bodies within the joint space. Calcification of the cartilage can occur.
• History :
- Report of preauricular swelling.
- Arthralgia
- Progressive limitation in mouth opening
- Presence of joint noises in the last month
• Examination :
- Preauricular swelling.
- Arthralgia.
- Maximum assisted opening (passive stretch) < 40 mm.
- Crepitus.
STUART C. J. PHAROAH, Oral Radiology P R I N C I P L E S
a n d I N T E R P R E T A T I O N. 6th edition

Aplasia
• unilateral absence of the condyle and incomplete development of the articular fossa and
eminence.
• History :
- Progressive development of mandibular asymmetry or micrognathia from birth or
early childhood.
- Development of malocclusion, which may include posterior open bite.
• Examination :
- Confirmation of mandibular asymmetry, with deviation of the chin to the affected side or
micrognathia.
- Inability to detect the condyle upon palpation during mandibular movements.
• Imaging :
- Severe hypoplasia of the fossa and eminence.
- Aplasia of the condyle.

Hypoplasia
• Incomplete development or underdevelopment of the cranial bones or the
mandible
• History :
- Progressive development of mandibular asymmetry or
micrognathia from birth or early childhood.
- Development of malocclusion, which may include posterior open
bite.
• Examination and Imaging :
- Hypoplasia of the fossa.
- Hypoplasia of the condyle.
- Shortened mandibular ramus height.

Hyperplasia
• Overdevelopment of the cranial bones or mandible.
• History :
- Positive for progressive development of mandibular or facial
asymmetry.
• Examination and imaging:
- Confirm this history.

Myalgia
• Pain of muscle origin is modified by jaw movement, function, or
parafunction, and replication of this pain is elicited with provocation
testing of the temporalis or masseter muscles, which are the muscles
involved with highest prevalence.
• Local myalgia: localization of the pain in the masticatory muscle
structure.
• Myofascial pain with spreading: pain spreading beyond the location
of the palpating fingers but within the boundary of the masticatory
muscle being examined.
• Myofascial pain with referral: pain beyond the boundary of the
masticatory muscles being palpated.

Myositis
• Pain of muscle origin with clinical characteristics of inflammation or
infection.
• Examination :
- Local myalgia.
- Presence of edema, erythema, and/or increased temperature over
the muscle.

Spasm
• This is a sudden, involuntary, reversible tonic contraction of a muscle.
Acute malocclusion may be present.
• History :
- Immediate onset of muscle pain modified by function and
parafunction as operationalized in myalgia.
- Immediate report of limited range of jaw motion.
• Examination :
- Myalgia.
- Limited range of jaw motion.
- Elevated electromyographic activity.

Masticatory muscle disorders
• Contracture :
- Is the shortening of a muscle due to fibrosis of tendons.
• Hypertrophy :
- Is enlargement of one or more masticatory muscles.
• Neoplasm:

Oral dyskinesia and dystonia
Orofacial dyskinesia
• Involves involuntary movements that may involve the face, lips,
tongue, and/or jaw.
• 20 % antipsychotic medication.
Oromandibular dystonia
• This involves excessive, involuntary, and sustained muscle
contractions that may involve the face, lips, tongue, and/or jaw.
• Disappears /sleep.

Treatment
• Patient education and self-management.
• Behavioral therapy.
• Pharmacotherapy.
• Physiotherapy.
• Orthopedic appliances.
• Occlusal therapy.
• Surgery.

Patient education and self-management
• Success depend on:
• Acceptance, motivation, cooperation, and compliance.
• Self management routine:
- Rest of the masticatory system.
- Habit awareness and modification.
- Home physiotherapy program.

Biobehavioral therapy
• The success depends on:
• patient factors:
- Awareness of the putative behaviors.
- Motivation commitment to treatment.
- life stress.
• Clinical factors:
- Possible symptom-behavior relationships.
- Monitoring behavioral patterns and

Pharmacologic management
• widely used pharmacologic:
- Nonsteroidal anti-inflammatory drugs (NSAIDs).
- Corticosteroids.
- Low-dose antidepressants.
• Pharmacologic agents less:
- Gabapentinoids.
- Benzodiazepines.
- Muscle relaxants.

NSAIDs
• Most commonly prescribed for pain.
• Mild to moderate mild to moderate pain.
• Ibuprofen, naproxen, celecoxib.
• Side effect:
- Effect on the gastrointestinal (GI) tract.
- Lithium toxicity.
Aviv Ouanounou, Michael Goldberg, Daniel A. Haas. Pharmacotherapy in Temporomandibular Disorders: A
Review. J Can Dent Assoc 2017;83:h7

NSAIDs
• In a randomized, double-blind:
- Celecoxib (100 mg twice a day), naproxen (500 mg twice a day) and placebo for
6 weeks.
- Naproxen significantly reduced the symptoms of painful TMJ disc displacement.
Celecoxib was not significantly effective for TMD pain.(1)
• Comparing ibuprofen and piroxicam with placebo failed to demonstrate a
decrease in symptoms among patients with chronic myogenous pain.(2)
1- Ta LE, Dionne RA. Treatment of painful temporomandibular joints with a cyclooxygenase-2 inhibitor: a randomized placebo-controlled
comparison of celecoxib to naproxen. Pain. 2004;111(1-2):13-21
2- Aviv Ouanounou, Michael Goldberg, Daniel A. Haas. Pharmacotherapy in Temporomandibular Disorders: A Review. J Can Dent Assoc
2017;83:h7

Opioids
• Chronic moderate to severe pain.
• Codeine and oxycodone.
• Intra-articular morphine produced a significant increase in the pain
threshold in the diseased joint.
• Demonstrated no pain reduction.
• Side effects:
• Tolerance and respiratory depression.
Pharmacotherapy in Temporomandibular Disorders: A Review J Can Dent Assoc 2017;83:h7 July 24, 2017

Corticosteroids
• Moderate to severe TMD.
• Injected directly into the TMJ, taken orally or applied topically.
• Intra-articular corticosteroid diluted with a LA.
• Side effects:
- Acute adrenal crisis.
- Hypertension.
- Fibrous layer and bone resorption.

Muscle Relaxants
• Treatment of TMD and chronic orofacial pain.
• Cyclobenzaprine.
• In a randomized controlled trial cyclobenzaprine was superior to placebo or 0.5
mg clonazepam when added to self-care and education in the management of
TMD.
• Contraindication:
- Monoamine oxidase inhibitors.
- Hyperthyroidism and congestive heart failure.
• Cyclobenzaprine 10 mg at bedtime.
Herman CR, Schiffman EL, Look JO, Rindal DB. The effectiveness of adding pharmacologic treatment with clonazepam or
cyclobenzaprine to patient education and self-care for the treatment of jaw pain upon awakening: a randomized clinical trial. J Orofac
Pain. 2002;16(1):64-70.
Moldofsky H, Harris HW, Archambault WT, Kwong T, Lederman S. Effects of bedtime very low dos cyclobenzaprine on symptoms and
sleep physiology in patients with fibromyalgia syndrome: a double-blin randomized placebo-controlled study. J Rheumatol.
2011;38(12):2653-63

Antidepressants
• Tricyclic antidepressants appear to be most effective.
• Amitriptyline.
• Double-blind , amitriptyline (25 mg/day) is effective in reducing pain
and discomfort among patients with chronic TMJ pain.
• 25–50 mg/day of amitriptyline.
• Side effect:
• Dizziness, blurred vision, constipation and dry mouth.
• Monoamine oxidase inhibitors.

Antidepressants
• Selective serotonin reuptake inhibitors.
• Excellent first-line medications ,refractory to splint therapy.
• Citalopram and paroxetine.
• Fewer side effect .
• Side effects:
• GI disturbances.

Anticonvulsants
• Gabapentin and pregabalin.
• Gabapentin significantly reduces TMD pain along with decreased
tenderness in the masticatory muscles (temporalis and masseter
muscles), compared with placebo.
• Side effects:
• Dizziness.
• Dry mouth, weight gain and inability to concentrate.
Kimos P, Biggs C, Mah J, Heo G, Rashig S, Thie NM, et al. Analgesic action of gabapentin on chronic pain in the masticatory muscles: a
randomized controlled trial. Pain. 2007;127(1-2):151-60.

Benzodiazepines
• Acute muscle spasm and sleep disorders.
• Superiority of these drugs to placebo in double-blind trials for the treatment of
TMD.
• Regardless of the positive outcome of some studies, the use of benzodiazepines
for TMD has been discouraged:
- Confusion, amnesia and impaired coordination.
- Tolerance to and physical dependence.
- Grapefruit juice , azole antifungals, erythromycin and the calcium channel
blockers.

Physical therapy
• Physical therapy helps to relieve musculoskeletal pain and to restore
normal function by :
- Altering sensory input.
- Increasing range of motion.
- Reducing inflammation; decreasing.
- Coordinating, and strengthening muscle activity.
- Promoting the repair and regeneration of tissues.

Physical therapy
• Posture training
• Prevention of untoward muscle activity of the head, neck, and
shoulder musculature, as well as the masticatory and tongue muscles.
• Exercise
- Repetitive exercises .
- Isotonic exercises.
- Isometric exercises.

Physical therapy
• Mobilization
- Indicated for improving decreased range of motion and pain.
- Muscle contracture.
- Disc displacement without reduction.
- Fibrous adhesions in the joint.

Physical agents or modalities
• Electrotherapy
• Applied clinically in an effort to aid in muscle relaxation, reduce
inflammation, and increase blood flow to tissues.
• Ultrasound
• It has been proposed that ultrasound may be used to produce deep
heat in the joints and treat joint contracture.
• Iontophoresis
• Enhance the transport of drug ions across a tissue barrier.
• Weak current.

• Anesthetic agents
• Has been shown to be useful for the management of myofascial pain
(alone /with muscle stretching or mobilization).
• Bupivacaine should not be used for muscle injections.
• In a recent RCT, the effect of TP injections infiltrating with either
saline or anesthetic showed no differences in pain intensity, headache
frequency, or intensity between the two intervention groups.

• Botulinum toxin
• In a recent review of the literature, it was concluded that there was
insufficient evidence to determine whether or not this medication is
effective.
• Acupuncture and Low-level laser therapy
• Further research is needed to support the use of low-level laser
therapy in TMD treatment.

Orthopedic appliance therapy
• Stabilization appliances.
• Partial-coverage appliances.
• Anterior positioning appliances.
• Orofacial Pain, Guidelines for Assessment, Diagnosis, and Management Edited by Reny de Leeuw, DDS, PhD, MPH and Gary D.
• Orofacial Pain, Guidelines for Assessment, Diagnosis, and Management Edited by Reny de Leeuw, DDS, PhD, MPH and Gary D.
Klasser, DMD The American Academy of Orofacial Pain Orofacial.

Surgical treatment
• Arthrocentesis.
• Arthroscopy.
• Arthroplasty.
• Discoplasty.
• Discectomy.
• Eminectomy.
• Condylectomy and joint reconstruction.

Conclusion
• TMD is a group of clinical problems that affect TMJ and associated
structure.
• Most of TMD problems are stable and asymptomatic.
• Pain is the main reason, why the patient seek for care.
• The most valuable aspect of assessment and diagnosis in TMDs is the
history.
• TMDs best managed with conservative reversible treatments.

Temporomandibular Joint Disorders (TMD)

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