3. Definition
• TMD is a collective term.
• function of the masticatory muscles and the jaw
joint.
• About 60-70 % of the population
• 25 % of these are aware of them
• only 5 % seeks treatment
(Dimitroulis et al. 1995).
6. Referred Pain
• Pain is felt outside the sensory distribution of
the primary source of pain
• Central convergence Multiple peripheral
nerves synapse on common central pathways
17. •If a dental source of the pain is not
found, no dental treatment should be
initiated
18. The most commoncauses of temporomandibulardisorders(TMDs)are muscular
disorders, which are commonly referredto as myofascialpainanddysfunction.
Thesemuscular disorders are generally managedwell with a varietyof reversible
nonsurgical treatment methods.
Othercauses of temporomandibular pain or dysfunction are articular in origin.
These causes includeinternal derangement and osteoarthritis, rheumatoidarthritis,
chronic recurrent dislocation, ankylosis,neoplasia, andinfection.
N.B: TMDs are eitherarticular or muscularor both.
26. Movements
• Rotational / hinge movement in first 20-25mm
of mouth opening
• Translational movement after that when the
mouth is excessively opened.
33. Action for each muscle :
Masseter
Elevation, protrusion
Temporalis
Elevation, retrusion
Medial pterygoid
Elevation, protrusion,lateral movement
Lateral pterygoid
– inferior belly Opening, protrusion,
– superior belly Active during clenching
34.
35.
36.
37. Definition
A collection of clinical problems affecting
the TMJs / muscles of mastication
A major cause of non-dental pain (both
acute and chronic)
A musculo-skeletal problem
Not just one disorder
Related disorders with common
symptoms
38. Etiology :
• Current Approach to Etiology of TMD
• Trauma
• Macrotrauma (direct/indirect)
• Microtrauma
• Anatomical Factors
• Skeletal/ Occlusal Relations
• Pathophysiological Factors
• Systemic/ Local Factors
• Psychosocial factors
• As many as 75 % of patients with TMJ
disorders have a
• significant psychological abnormality.
40. MOST COMMON TMDs
• Myofascial pain and dysfunction
• Internal derangement
• Osteoarthrosis & RA
• Dislocation
• Ankylosis
41. TMD Research Diagnostic Criteria
• GROUP I : Muscle disorders:
• Myofascial pain
• Myofascial pain with limited opening
• GROUP II : Disc Displacements :
• DD With reduction
• DD Without reduction with limited opening
• DD Without reduction without limited opening
• GROUP III : Arthralgia, Arthritis, Arthrosis:
• Arthralgia
• Osteoarthritis of the TMD
• Osteoarthrosis of the TMD
42. MYOFASCIAL PAIN AND DYSFUNCTION
• Refers to a group of poorly defined
muscle disorders (eg, fibromyalgia)
characterized by diffuse facial pain
and episodic limited jaw opening
• May result from parafunctional habits
and significant relationship to
psychophysiologic disorders such as
stress or depression
43. Myofascial pain:
• Cause
• Muscle stress or overload, emotional stress &
deep pain→trigger points
• Clinical features
• Trigger point → constant deep pain → central
excitatory effects referred pain
46. Diagnostic criteria :
• Regional dull, aching pain.
• Hyperirritable sites ( trigger points)
• Aggravated by movement
• >50% reduction of pain with vapocoolant
spray or l t LA
51. INTERNAL DERANGEMENT
• Abnormal relationship of the articular disc to
the mandibular condyle, fossa,and articular
eminence, interfering with the smooth action
of the joint (Dolwick 1983)
• Is a localized mechanical fault within the joint
• Synonymous with disc displacement
58. Group II: Disc Displacements
IIb-DD without
reduction with limited
opening:
• Key:
limited movement
with small passive
stretch
59. Group II: Disc Displacements
IIc-Disc displacement
without reduction
without limited
opening:
Key:
History of previously
limited opening but
imaging needed to
confirm DD
62. OSTEOARTHROSIS
• Is a non painful, localized degenerative joint disease that
mainly affects bone and articular cartilage.
• It is often idiopathic, but predisposing factors such as old
age, repetitive trauma (bruxism), abnormal joint
posturing, or multiple surgical procedures may be
involved. If painful,then referred to as osteoarthritis
65. Luxation and subluxation
Dislocation of the TMJ
– Luxation of the joint
– Subluxation
– Luxation ‘acute’, due to a sudden traumatic
injury resulting in the fracture of the condyle.
– Yawning / wide opening of mouth
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68. Luxation & Subluxation
• C/f:
– Sudden locking and immobilization of the jaws.
– Prolonged spasmodic contraction of the temporal,
internal pterygoid and masseter muscles.
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69. Luxation & Subluxation
• Treatment:
– Relaxation of the muscles and then guiding the head of the
condyle under the articular eminence into its normal
position by an inferior and posterior pressure of the
thumbs in the mandibular molar area.
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71. Ankylosis
–Fusion of head of the condyle temporal bone.
• Etiology:
–Idiopathic
–Traumatic injuries
–Infection
–Rheumatoid arthritis
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om
72. Ankylosis
• C/f:
–1st decade
–Before 10 years
–M = F
–Unilateral /Bilateral
–In ability to open the jaws
–Pain, tenderness and malocclusion
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73. TRAUMA
Extravasation of blood into the joint space
haemarthrosis
Calcificatiion and obliteration of the joint space
Intra-capsular ankylosis Extra-capsular ankylosis
PATHOPHYSIOLOGY
77. Ankylosis
Intra-articular ankylosis Extra-articular ankylosis
-Destruction of the meniscus
-Flattening of the mandibular
fossa thickening of the head
of the condyle
-narrowing of the joint space
-Fibrous adhesion
External fibrous / osseous
encapsulation.
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78. Ankylosis
• R/F:
–Abnormal / irregular shape of the head of the
condyle
• Treatment:
–Surgical osteotomy / removal of section of bone
below the condyle.
–Fibrous ankylosis can be treated by functional
methods.
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om
79.
80. Quiz
Diagnsis ???
• Constant diffuse unilateral pain
• Severe in the morning and worsens as day
progresses
• Radiates to cervical region, shoulders and back
• Limitation of jaw movement
• Deviation to the affected site
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81. Diagnostic questions
• Has the correct diagnosis been made?
• Is the diagnosis related principally to:
– muscle
– or TMJ
– or both?
• Any Predisposing, Precipitating or Prolonging
factors (e.g. life events, psychological conflicts, chronic pain
behaviour, parafunction, occlusal changes, trauma)?
82. The group is recognized by one or
more of three principal clinical
features:
• 1. Pain associated with the
temporomandibular joint (TMJ) and/or the
masticatory muscles
• 2. Noises associated with the TMJ
• 3. Limitation of jaw movement.
85. Noises
• The most common noise associated with the
TMJ is
• clicking (or snapping, cracking, bumping or
popping).
palpation or
auscultation.
86.
87.
88. Limitation of jaw movement
• A reasonable measure of the lower limit
• of interincisal opening for an adult with a class
1
• occlusion is 40 mm, measured between the
upper
• and lower incisal edges.
Hard end feelSoft end feel
91. History
• symptoms in order of severity
• detailed pain history
• previous treatment?
• history of clicking/locking?
• awareness of parafunction?
• other musculo-skeletal problems?
• other stress-related conditions?
103. Pharmacotherapy
• Analgesics
– eg. asprin, paracetamol
• NSAIDs
– e.g. ibuprofen
• Antidepressants
– e.g. amitriptyline
• Muscle relaxants/tranquilisers
– e.g. diazepam
104. Pharmacotherapy - injections
• Corticosteroid
– e.g. TMJ injection with methyl prednisolone
• Local anaesthetic
– e.g. trigger point injection with 0.5% procaine
105. Psychotherapy
• Mouth and jaws prime focus for symbolic
portrayal of psychological conflicts
• Beware of becoming DIY psychiatrist
• Suitable referral may be difficult.
106. Occlusal splints
The best of many designs are:
• Soft splint
– initial treatment (with counselling and exercises)
• Stabilisation splint
– muscle and joint pain
• Anterior (re)positioning splint
– joint pain, clicking, intermittent locking,
secondary muscle symptoms
107. Occlusal splints
• general functions:
– alter occlusal relationships
– redistribute occlusal forces
– reduce bruxism
– reduce tooth wear and mobiltiy
– treat masticatory pain and dysfunction
– alter structural relationships in TMJ
110. Anterior positioning splint
• decrease adverse joint loading
• alter condyle-disc relationship
• holds jaw forward with indentations
• guidance ramps
• wean off before 3m full time wear