The document presents a seminar on the temporomandibular joint (TMJ) and its significance in prosthodontics, covering aspects such as anatomy, growth, development, and disorders. It details the functional mechanics of the TMJ, including the classification of disorders and the role of occlusion in these conditions, as well as treatment options. The seminar also delves into the joint's biomechanics, innervation, blood supply, and the muscles involved in mandibular movement.

1. Seminar-
TMJ And Its Applied
Aspects In
Prosthodontics
Presented by
Dr Tanmay Popat
Ist Year PG
09-06-2019 1

2. CONTENTS:
● Introduction
● Evolution
● Growth & Development
● Age Changes
● Functional Anatomy
○ Bony Components
○ Soft Tissue Components
○ Muscles
● Innervations and Blood
Supply
● Biomechanics of TMJ
○ Functional Movements
○ Mechanism of Disc
Control
○ Border Movements
● Examination of TMJ
● Classification Of TMJ
Disorders
● Role of occlusion in TMJ
Disorders
● Mounting of Diagnostic
Casts
● Treatment of TMJ Disorders
● Conclusion
● References
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3. Introduction
 Temporomandibular joint is one of the most complex
joints in the body and a major component of
masticatory system which is responsible for chewing,
speaking and swallowing.
 TMJ co-ordinates with the other components of
Masticatory system in performing various masticatory
functions.
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4. • Synovial
• Ginglymoarthroidal
(Hinging+gliding)
• Bicondylar
• Compound joint (a non ossified
3rd bone - Articular disc)
• Craniomandibular articulation.
• Weight bearing joint – about
500N force.
4
Temporomandibular Joint
09-06-2019

5. Evolution
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6.  There are 3 stages that define the normal embryologic
development of the TMJ:
–Blastemic Stage
–Cavitation Stage
–Maturation Stage
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Growth and Development

7.  Acc to Baume, temporomandibular articulation
originate from two different blastema.
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Growth and Development
Condylar
blastema –
(primodium
of the
mandible)
condylar
cartilage
aponeurosis
of the external
pterygoid
muscle
the disc
the capsular
elements of
the lower
joint.
Temporal
Blastema
Articular
structures of
the upper level.

8. 09-06-2019 8
Bender et al. Oral Maxillofacial Surg Clin N Am 30 (2018) 1–9

9. Growth and Development – Joint Innervations
 4th fetal month – nerve fibers may be observed in the
articular capsule
 5th month – appear to reach the disc.
 6th month – widest distribution over the condyle & within
the disc.
 Nerve fibers in capsule innervate the synovial membrane
of the joint as well.
 Acc. to Kitamura;
- branches of Auriculotemporal N., masseter N., & the
posterior deep temporal N. Branches of Mandibular
portion of Trigeminal N.
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10.  The growth of face and cranium involves two basic
types of growth changes:
1)Displacement
2)Remodelling
 Both these process, together constitute the growth
mechanism of craniofacial skeleton.
 As mandibular moves forward and downward, it grows
upward and backward at the same time by an equal
amount
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Growth and Development

11. 09-06-2019 11
Growth and Development

12. 09-06-2019 12
Growth and Development – Age Changes
A – At Birth
B – At 6 Years
C – In an Adult

13. 1st Decade of Life:
 Due to decreased vascularization entire cartilage layer
becomes significantly thinner. This continues upto the
third year.
 By 2 ½ years the articular eminence increase from 2 to
4mm.
 This is due to resorption of the bone in the roof of the
mandibular fossa and bone deposition anterior and
posterior to the fossa leading to formation of ‘S’ shape
curve.
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14. 2nd Decade of Life
 Characterized by progressive slowing of growth process.
 By 13-15 years decreased thickness of cartilage layer.
 Presence of proliferative layer at least till age of 18 years.
 A cortical bone cap coalescing with subchondral trabecular
bone by 10-12 years of age. This increases in thickness upto
3rd decade of life.
 Bone cap is completed by 20 years of age although cartilage
and sparse cartilage cells remain.
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15. Adult TMJ
 Deep to the articular layer in the region where
subchondral growth cartilage was located a chondroid type
bone may be found which directly overlies the bone cap.
 This marks the end of active growth of the condyle.
 Up through the 5th decade mandibular fossa became more
deep and articular eminence becomes more prominent.
 As age progresses further there is flattening of the
articular fossa and decrease in prominence of the articular
eminence
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16. 09-06-2019 16

17. Functional Anatomy – Bony Components
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• Condylar Head
• Glenoid Fossa
• Articular
Eminence

18. CONDYLAR HEAD
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‘Rugby ball’ or ‘Date-
stone’ shape
•Composed of cancellous bone
covered by a thin layer of compact
bone
•During the period of growth a layer
of hyaline cartilage lies
underneath the fibrous covering of
the condyle.
•Hyaline cartilage of the condyle is
hence referred to as SECONDARY
CARTILAGE

19. • Articulating surface is more convex anteroposteriorly & slightly
convex mediolaterally.
• 15-20mm mediolaterally
• 8-10mm anteroposteriorly
• The main load-bearing areas are on the lateral aspect
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20.  The medial pole extends farther beyond the condylar
neck than the lateral pole does and is positioned more
posteriorly so that the long axis of the condyle deviates
posteriorly and meets a similar axis drawn from the
opposite condyle at the anterior border of the foramen
magnum.
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21. Glenoid Fossa
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• Concavity within temporal bone
that houses mandibular condyle.
• Covered by hard layer of bone.
• Single layer of cortical bone
separates glenoid fossa from
middle cranial fossa.
• It is covered with thin fibrous
layer.
• Anterior wall- Articular
eminence
• Posterior wall- SquamoTympanic
plate

22.  Anterior to the Glenoid fossa
there is a convex bony
prominence i.e. - “Articular
Eminence/Articular Tubercle”.
 Composed of spongy bone
covered by a thin layer of
compact bone
 The degree of convexity i.e.,
the steepness dictates the
pathway of condyle when
mandible is positioned
anteriorly.
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Articular Eminence

23. Functional Anatomy – Soft Tissue Components
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• Articular Disc
• Synovial Membrane
• Ligaments
• Muscles

24.  Firm,fibrous coonective tissue,
biconcave with a thick periphery
and thin central part.
 In sagittal plane it can be divided
into 3 parts
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Articular Disc
ARTICULAR DISC LOCATION
Ant. band Under the articular
tubercle
Central thin zone b/w condyle & post.
part of articular
tubercle
Post. band Over the condyle

25. Articular Disc
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ANTERIOR ATTACHMENT
(CAPSULAR LIGAMENT)
ATTACHES ARTICULAR DISC TO TYPE OF FIBERS
1. Superior Attchment Ant. Margin of Articular Surface of
Temporal Bone
Collagen fibers
2. Inferior Attachment Ant. Margin of Articulating Surface of
Condyle
Collagen fibers
POSTERIOR ATTACHMENT
(RETRODISCAL TISSUE/
BILAMINAR ZONE)
ATTACHES ARTICULAR DISC TO TYPE OF FIBERS
1. Superior Retrodiscal lamina Tympanic plate Elastic fibers
2. Inferior Retrodiscal lamina Post. surface of articulating surface of
condyle
Collagen fibers

26. The remaining portion of the retrodiscal tissue is
attached to a large venous plexus called the A-V shunt
or the Vascular Knee
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27. Synovial
Membrane and
Fluid
 A specialized layer of endothelial cells surrounding the internal
surfaces of joint cavity.
 This layer along with the synovial fringe at the anterior border of
retrodiscal tissues produces synovial fluid which fills both the
superior & inferior joint cavities.
 2 main Purposes –
–Medium for providing metabolic requirements. Exchange
exists between vessels of capsule, synovial fluid and articular
tissues.
–Serves as a lubricant during function
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28. 09-06-2019 28
Boundary
Lubrication Weeping
Lubrication
Mechanism of Lubrication

29. The Ligaments
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Functional Ligaments
• The Capsular Ligament
• The Collateral (Discal)
Ligaments
• The temporomandibular
Ligament
Accessory Ligaments
• The Sphenomandibular
Ligament
• The Stylomandibular
Ligament

30. The Capsular Ligament or The Joint capsule
• Surrounds and encompasses the
entire TMJ.
• The Fibers
• Superiorly - temporal bone
along the borders of the
articular surfaces of the
mandibular fossa & articular
eminence.
• Inferiorly – neck of the condyle
• Resist any medial, lateral / inferior
forces that tend to separate /
dislocate the articular surfaces.
• Helps to retain synovial fluid &
provides proprioceptive feedback.
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31. The Collateral (Discal) Ligaments
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• Attaches the medial & lateral
borders of the articular disc to
the poles of the condyles.
• Divides the joint mediolaterally
into the superior & inferior
cavities.
• True ligaments - do not stretch &
restricts movement of the disc
away from condyle.
• Responsible for hinging
movement of TMJ.
• Strain on these ligaments
produces pain.

32. The Temporomandibular Ligament
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Outer Oblique Portion - resists
excessive dropping of the condyle,
limiting the extent of mouth opening.
Inner Horizontal Portion – limits
posterior movement of the condyle &
disc, hence protects the retrodiscal
tissues from trauma.
– Also protects the lateral pterygoid
muscle from over-lengthening or
extension

33. 09-06-2019 33

34.  Remnant of Meckel’s cartilage
 Extends from the spine of the
sphenoid to the lingula of the
mandible
 May act as a pivot on the
mandible by maintaining the
same amount of tension
during both opening and
closing of the mouth.
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Sphenomandibular
Ligament

35.  Represents a thickened part of
deep cervical fascia which
separates the parotid &
submandibular salivary glands.
 Arises from the styloid process
and extends downward and
forward to the angle and
posterior border of the ramus of
the mandible.
 The stylomandibular ligament
limits excessive protrusive
movements of the mandible.
 Taut - when the mandible is
protruded & most relaxed - when
the mandible is opened.
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Stylomandibular Ligament

36. 09-06-2019 36

37. Muscles
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Primary or active muscles
These connect the mandible and
maxilla and are prime movers of
mandible.
Masseter
Temporali
s
Medial
Pterygoid
Lateral
Pterygoid
s
Accessory muscles
They play a small yet
important role in
mandibular movement.
Hyoid
muscles
Tongue
muscles
Cheek
muscles

38. Masseter
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• Origin – Zygomatic Arch
• Superficial portion (SP) -- Runs downward and slightly backward to get
inserted in the posterior part of the lateral surface of the mandible.
• Deep portion (DP) -- Runs in a predominantly vertical direction to get inserted
in upper part of the ramus and some area on the coronoid process
• Action – Elevates the mandible and brings teeth into contact
SP -- Aids in protruding the mandible.
DP -- Pulls the mandible into its retruded position in relation to the
maxilla.

39. 09-06-2019
Temporalis
39
• Origin – Temporal Fossa
• Insertion -- on the coronoid process and the anterior border of the ascending
ramus.
• Anterior Portion (AP) – Fibers directed almost vertically.
• Middle Portion (MP) – Fibers run obliquely forward.
• Posterior portion (PP) – Fibers directed almost horizontally
• Action – AP contracts the mandible is raised vertically.
• MP contracts it will elevate and retrude the mandible.
• PP fibres are relatively weak and they pull the condyle back into CR.

40. 09-06-2019
L. Pterygoid
40
• SLP – originates at the infratemporal surface of the greater sphenoid wing, - Runs
horizontally, backward, and outward – Inserts on the articular capsule, the disc, and
the neck of the condyle
• ILP – originates at the outer surface of the lateral pterygoid plate – Runs backward,
upward, and outward – Inserts primarily on the neck of the condyle
• Action – SLP It becomes active only in conjugation with elevator muscles especially
when the teeth are held together and power stroke (i.e. closure against resistance).
• ILP - When both right and left ILP contract simultaneously, the condyles are pulled
down the articular eminence. Unilateral contraction – mediotrusive movement of
that condyle and lateral movement of the mandible to the opposite side. Along with
the mandibular depressors,it helps depress the mandible.

41. 09-06-2019 41

42. 09-06-2019
M. Pterygoid
42
• Origin – From the pterygoid fossa.
• Extends – Downward, backward and outwards
• Inserts – Along the medial surface of the mandibular angle.
• Action - Along with the masseter, it helps elevate the mandible. It also
helps protrude the mandible.
• Unilateral contraction brings about a mediotrusive movement of the
mandible.

43. 09-06-2019 43
Hyoid muscles:- Suprahyoid and
infrahyoid group of muscles.
Suprahyoid muscles include
anterior belly of digastric, mylohyoid,
geniohyoid and hyoglossus. Main
action is to depress the mandible.
Infrahyoid muscles include the
sternohyoid, omohyoid,
sternothyroid and thyrohyoid. Main
action is stabilizing the hyoid bone
so that the suprahyoid muscles can
depress the mandible during opening
of mouth.

44. 09-06-2019 44

45. 09-06-2019 45
TEMPORALIS MASSETER
MEDIAL PTERYGOID
PROTRACTION
LATERAL PTERYGOID
DIGASTRIC
GENIOHYOID
RETRACTION
MYLOHYOID
DEPRESSION
ELEVATION

46. Innervations And Blood Supply
Innervations
 The trigeminal nerve – provides both motor &
sensory innervation to the muscles that control it.
 Afferent innervation – branches of the mandibular
nerve.
 Also by auriculotemporal nerve as it leaves the
mandibular nerve behind the joint & ascends
laterally & superior to wrap around the posterior
region of the joint.
 Additional nerves – temporal & masseteric .
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47. Innervations And Blood Supply
Blood Supply
The blood supply to TMJ is majorly superficial, there is no
blood supply inside the capsule.
 Posteriorly: Superficial temporal artery
 Anteriorly: middle meningeal artery
 Inferiorly: internal maxillary artery
Other arteries are: deep auricular, anterior tympanic and
ascending pharyngeal artery.
Condyle receives its supply through the marrow spaces by
inferior alveolar artery and feeder vesels that enter
directly into condylar head from larger vessels.
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48. Biomechanics of TMJ
09-06-2019 48
• Functional Movements
of TMJ
• Disc Control
• Mandibular Movements

49. The TMJ is a compound joint – can be divided into two
distinct systems:-
 One joint system - the tissues that surround the inferior
synovial cavity(the condyle and the articular disc). The disc
and its attachment to the condyle is called the condyle-disc
complex, this joint system is responsible for rotational
movement in the TMJ.
 Second system – the condyle – disc complex functioning
against the surface of the mandibular fossa. Translation
occurs between the superior surface of the articular disc
and the mandibular fossa. Thus the articular disc functions
as a nonossified bone contributing to both joint systems.
Hence justifying TMJ as a true compound joint.
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50. 09-06-2019 50

51. Mechanism of Disc Control
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52. Mandibular Movements
 Acc. to Okeson – 2 types of Movements
–Rotational/hinge
 Occurs mainly between the disc and condyle in the
lower joint compartment.
–Translational/sliding
 Occurs mainly between the articular eminence and
disc (and mandible) in the upper compartment.
 Based on Plane of border movements:
–horizontal, vertical (frontal) & sagittal plane
movements
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53. 09-06-2019 53
Rotation around
horizontal axis
Rotation around
sagittal axis
Rotation around Vertical axis Translation

54. 09-06-2019 54

55.  By combining the mandibular border movements in the three
planes a three dimensional envelope of motion can be produced
that represents the maximum range of movement of the
mandible. Although it has a characteristic shape it varies from
person to person.
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56. Eccentric Mandibular Movements
 Any movement of the mandible from centric occlusal
position that results in tooth contact is called as
eccentric movement.
 Types of eccentric movements:
– Protrusive movements.
– Retrusive movements.
– Laterotrusive movements
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57. Protrusive Movements
 Consists mainly of condylar translations.
 Sagittal Protrusive condylar path: 5-55o and mean is 30o
 Sagittal protrusive incisal path: range 50-70o
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58. Lateral Movements
 Sagittal lateral condylar path:
–When lateral movement is
executed, the working condyle
rotates and moves outward
while other, non-working
condyle translates forward,
medially downward orbiting
around the rotating working
condyle.
–This orbiting condylar path of
working condyle is called as
BENNETT MOVEMENT
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59. Examination of TMJ
 Clinical examination of TMJ:
–Inspection of TMJ
–Auscultation of TMJ
–Palpation of TMJ & Musculature associated with mandibular
movements
–Functional analysis of mandibular movements
 Radiographic examination of TMJ
–Transcranial & Transpharyngeal projections
–Panaromic projection -Transorbital projection
–Submentovertex projection -Computed tomography(CT)
–Arthrography -Magnetic resonance imaging(MRI)
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60. Inspection Of TMJ
 Area surrounding TMJ is inspected for any signs of
inflammation.
 Any gross asymmetry.
 Any Swelling/Growth
 Depression
 Discharge
 Colour change of skin over TMJ
 Surface of the overlying skin in the preauricular area.
 Mouth opening – Normal/Resricted
 Deviation/Deflection
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61. Ausculatation
 Sounds made by the TMJ can be examined with a
stethoscope. Also the timing of clicking during opening
and closure can be noted .
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62. Crepitations
 A grating or scalping noise that occurs on jaw
movements . Sound like when sand paper is rubbed
against a surface.
 Crepitation is very uncommon in asymptomatic joint
and may be an early sign of degenerative joint
disease.
 Crepitus is caused by roughened, irregular anterior
surface.
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63. Clicking
CLICK- single sound of short
duration
POP- loud click
Occurs due to the uncoordinated
movement of condylar head and
T.M.J disc.
 Joint clicking is differentiated as:
Initial
Intermediate
Terminal
Reciprocal
09-06-2019 63

64.  Initial clicking : It is a sign of retruded condyle
 Intermediate clicking : Is a sign of unevenness of the
condylar surfaces and articular disc
 Terminal clicking : is an effect of the condyle being moved
too far anteriorly in relation to the disc on maximum jaw
opening.
 Reciprocal clicking : is an expression of incordination
between displacement of the condyle & the disc.
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65. Palpation of TMJ
• Lateral
• Posterior
• Also the synchrony of the
left & right condyles during
movement can be checked.
09-06-2019 65
Palpation of TMJ &
Muscles

66. Muscles
 Digital palpation
–Temporalis
–Masseter
–Sternocleidomastoid
 Functional palpation
–Lateral pterygoid
–Medial pterygoid
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GRADING OF PAIN
0- no pain
1- uncomfortable
2- definite pain
3- evasive action

67. Temporalis
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68. Masseter
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Sternocleidomastoid

69. Splenius Capitus
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Trapezius

70. 09-06-2019 70
Inferior Lateral Pterygoid:
Protruding mandible against
resistance
• STRECHES ONLY ON MAX
INTERCUSPATION
Superior Lateral Pterygoid:
Clenching against
powerful stroke
• STRECHES ONLY ON MAX
INTERCUSPATION

71. INTRACAPSULAR DISORDER OF TMJ :
 Can elicit pain with increase in interarticular pressure
and movement.
 Confusing with muscle pain origin.
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72. • But if clenching done on a separator – pressure doesn’t
increase.
To differentiate with inferior lateral Pterygoid muscle –
patientt is asked to protrude and bite on a separator.
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73. Functional Analysis of TMJ
 Maximum Jaw Opening
 The distance between the incisal edges of the upper and lower central
incisors.
–Normal maximum ≥ 40mm.
–Men: 38.7- 67.2 (mean 52.8mm)
–Women: 36.7 -60.4 ( mean 48.3)
–Child: 6 year mean- 44.8mm
10 year mean- 44 mm
–Lateral movement ≥ 8mm
–Protrusive movements ≥ 7mm
 In overbite cases, this amount is added to the obtained value whereas
in open bite it is subtracted.
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74. 09-06-2019 74
 DEVIATION :
Because of disc derrangement
in 1 or both joints
shift of jaw midline during
openeing that disappear with
opening
 DEFLECTION :
Restricted movement in 1 joint
Shift of midline to 1side and
become greator with opening
and doesn’t dissapear

75. Radiographic Evaluation of TMJ
 Transcranial:
–Sagittal view of the lateral
aspect of condyle and
temporal component
–Displaced condylar #
–Osseous changes on lateral
aspect
 Transpharyngeal/Infra-
cranial:
–Sagittalview of the medial
pole of condyle.
–Erosive changes of the
condyle
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76.  Panaromic:
–Commonly used routinely
(not for TMJ), odontogenic
diseases, asymmetries,
extensive erosions or #
 Transorbital:
–Ant. view of TMJ, entire
mediolateral dimension of
A.E, condylar head & neck.
 Submentovertex(Basal):
–Facial asymmetries,
condylar displacement,
rotation of the mandible in
horizontal plane assoc. with
trauma
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77.  Computed Tomography:
–Complete view of Osseous
components of TMJ joint.
–Presence/extent of ankylosis &
neoplasms.
 Arthrography:
–Invasive(as radio-opaque
contrasting agent is injected)
–Small disk perforations & joint
adhesions
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78.  MRI (Magnetic Resonance Imaging):
–Both the soft(discal) and hard(osseous) tissues can be
imaged.
–Non invasive, no radiation hazard
–Inflammation, joint effusions etc.
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79. Other Diagnostic Aids
 Mandibular tracking devices
 Sonography
 Vibration analysis
 Thermography
 Electromyography
 Mounted casts
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80. Six ways to verify that TMJ is healthy
 Is it difficult or painful to open the
mouth (e.g., yawning)?
 Does the jaw get stuck, locked, or go
out?
 Is it difficult or painful to chew, talk, or
use the jaws?
 Do the jaw joints make noises?
 Do the jaws often feel stiff, tight, or
tired? Is there pain in or about the
ears, temples, or cheeks?
 Are headaches, neck aches, or
toothaches frequent?
 Has there been a recent injury to the
head, neck, or jaw?
 Have there been any recent changes in
bite?
 Has there been previous treatment for
any unexplained facial pain or a jaw
joint problem?
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1. SCREENING HISTORY

81. 2. LOAD TEST
3. RANGE & PATH OF
MOVEMENT
4. DOPPLER ANALYSIS
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82. 09-06-2019 82
5. Radiographic
Imaging
6. Anterior
Deprogramming
Device

83. Classification of diseases of TMJ/Diagnostic Classification
(Acc. To Okeson)
I. Masticatory muscle disorders
– Protective co-contraction
– Local muscle soreness
– Myofascial pain
– Myospasm
– Centrally mediated myalgia
II. Temporomandibular joint (TMJ) disorders
A. Derangement of the condyle-disc complex
–1. Disc displacements
–2. Disc dislocation with reduction
–3. Disc dislocation without reduction
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84. B. Structural incompatibility of the
articular surfaces
1. Deviation in form
a. Disc
b. Condyle
c. Fossa
2. Adhesions
a. Disc to condyle
b. Disc to fossa
3. Subluxation (hypermobility)
4. Spontaneous dislocation
C. Inflammatory disorders of the TMJ
1. Synovitis/capsulitis
2. Retrodiscitis
3. Arthritides
a. Osteoarthritis
b. Osteoarthrosis
c. Polyarthritides
4. Inflammatory disorders of
associated structures
a. Temporal tendonitis
b. Stylomandibular ligament
inflammation
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85. III. Chronic mandibular
hypomobility
A. Ankylosis
1. Fibrous
2. Bony
B. Muscle contracture
1. Myostatic
2. Myofibrotic
C. Coronoid impedance
IV. Growth disorders
A. Congenital and developmental
bone disorders
1. Agenesis
2. Hypoplasia
3. Hyperplasia
4. Neoplasia
B. Congenital and developmental
muscle disorders
1. Hypotrophy
2. Hypertrophy
3. Neoplasia
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86. Diagnosis
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87. 09-06-2019 87
Joint Pain Muscle Pain
Initiating event present Initiating event absent
Symptoms are constant Symptoms are cyclic
25-30 mm
mouth opening
Hard end feel
8-10 mm
Mouth opening
Soft end feel
Contra lateral eccentric
movements limited
Normal range of
eccentric movements
Key
2. Mandibular
Restriction
1. History
7 Keys for Diagnosis

88. 3. Mandibular Interference
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Deviation. The opening pathway is
altered but returns to a normal midline
relationship at maximal opening.
Deflection of the opening path is commonly
associated with a disc dislocation without
reduction or a unilateral muscle restriction.
4. Acute Malocclusion

89. 09-06-2019 89
5. Loading The Joint
6. Functional
Manipulation
7. Diagnostic
Anaesthetic Blockade

90. Key points for Diagnosis
 Single/double click at different levels of mouth opening – disc
displacement
 Single/double click at different levels of mouth opening with
mandibular deflection - disc dislocation with reduction
 No click; mandibular deviation; closed lock (opening – 25 to 30
mm) - disc dislocation without reduction.
 A single click after a prolonged static loading – adherence
 Click at the same level of mouth opening & closing - adhesion
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91. Key points for Diagnosis
• Sudden thrust near to maximum opening with pre – auricular
depression – subluxation
• Inability to close the mouth (open lock) – spontaneous dislocation
• Pain in inflammatory disorders are dull & continuous accentuated
by function.
• Synovitis, capsulitis & retrodiscitis have same clinical presentation
& additional diagnostic aids are required to differentiate between
them .
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92.  Frequent postural alterations in
patients with different types of
temporomandibular disorders. Irene A
et. al.
Objective: To describe postural
alterations according to the type of
temporomandibular disorder (TMD).
Conclusion: TMD patients present
postural changes, mainly forward head
posture, pelvic tilt and high shoulder,
with special involvement related to
muscle and combined diagnosis.
09-06-2019 92
Rev. Salud Pública. 20 (3): 384-389, 2018

93. Role of Occlusion in TMDs
 Normal function + event > physiological tolerance TMD
symptoms.
 Events can be:
–Local: improperly occluding crown, Post-injection trauma after
L.A, trauma from wide mouth opening, etc
–Systemic: emotional stress
 Physiologic tolerance: influenced by
–Local factors: occlusal instability associated with dev., genetic
or iatrogenic causes
–Systemic factors: acute or chronic diseases, gender diet
effectiveness of pain modulation systems etc.
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94. 09-06-2019 94
Occlusal interferences
Occlusal disharmony
Functional malocclusion
Stresses within
Stomatognathic sys.
Ability of the tissues to
resist
Func. Disturbance &/or
F.disorder
Occlusal Dysfunction
TMDs
overcome

95. Determinants of Occlusion
 The anatomy of the TMJ has effect on the mandibular
movements and tooth morphology.
 The paths of the condyles within the glenoid fossae, and
the locations of the rotational centers determine the
occlusal morphology of teeth.
 These have an effect on the allowable cusp height, fossa
depth along with the acceptable ridge and groove
directions.
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96. 09-06-2019 96

97. Mounting Of Diagnostic Casts
• When there is Acute inflammation,
muscle spasm, pain & heavy infusion of
fluids in joint tissues etc, programming
the condyles into CR is not possible.
• Treatment of the acute symptoms of
the TMJ dysfunction should be carried
out.
• If the mouth opening permits
diagnostic impressions, effort should be
made to make bite record in CR for
constructing the interocclusal palliative
acrylic splint.
• Once the TMD symptoms are resolved,
diagnostic cast mounting should be
done.
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98.  Pantographic recording: is a
record of the degrees of 3-D
pathways of the border
movements of condyles in their
respective fossa during
function.
 INDICATIONS:
–Procedures like full mouth
reconstruction & occlusal
correction by selective
grinding which requires
precision.
–When a patient is suspected
of a large amount of Bennett
Immediate side shift during
Lateral excursions
9809-06-2019

99. Management of TMJ Disorders
 Definitive Therapy: directed towards controlling or eliminating
the cause of the disorder.
 Occlusal Factors
 Emotional Stress
 Trauma
 Deep Pain Input
 ParaFunctional Activities
 Supportive Therapy: alters the patient’s symptoms & no effect
on the cause of the disorder
 Pharmacological Therapy
 Physical Therapy
–Modalities
–Manuel Techniques
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100.  Definitive therapy considerations for Occlusal
Factors:
– any treatment that is directed toward altering the
mandibular position and/or occlusal contact pattern
of the teeth.
–Reversible Occlusal Therapy:
–Occlusal appliances
–Irreversible Occlusal Therapy:
–Selective grinding of the teeth.
–Restorative Procedures
–Orthodontic Treatment
–Surgical Procedures
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Definitive Therapy

101. Occlusal Splint/ Occlusal Device
Any removable artificial occlusal surface used for diagnosis
or therapy affecting the relationship of the mandible to the
maxillae. It may be used for occlusal stabilization, for
treatment of TMJ disorders, or to prevent wear of the
dentition
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102.  According to Okeson
–Muscle relaxation appliance/ stabilization appliance used to
reduce muscle activity
–Anterior repositioning appliances/ orthopedic repositioning
appliance
–Other types:
 Anterior bite plane
 Pivoting appliance
 Soft/ resilient appliance
 According to Dawson:
 Permissive splints/ muscle deprogrammer
 Directive splints/ non-permissive splints
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103. Permissive Splints
 ANTERIOR DEPROGRAMMING DEVICE:
–Simplest type of permissive splint.
–Used in diff. diagnosis of TMDs(Intracapsular Vs
Extracapsular, i.e., occlusal interferences)
–When correctly fabricated & used in non
intracapsular TMDs, patient gets comfortable
within min or hrours.
–Used for extended periods, may cause intrusion
of covered teeth and supraeruption of separated
teeth.
 UPPER or LOWER splint :- Decision made on
which splint is easy to wear and most
unobstructive to the mandibular movements
and esthetically pleasing.
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104.  Principles of Splint Design
–Allow uniform, equal-intensity
contacts of all teeth against a
smooth splint surface.
–Anterior guidance ramp angled
as shallow as possible for
horizontal freedom.
–Provide immediate disclusion
of all posterior teeth in all
excursive movements.
–Splint should fit the arch
comfortably and have good
stable retention.
 Worn until:
–All related pain is gone
–Joint structure is stable
–Bite structure is stable
 Stability is verified by:
–Elimination of painful
symptoms
–Verification of CR by load
testing
 Avg time : 2-4 weeks, worn
24hrs/day except : eating &
brushing
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105. Modified Anterior Deprogramming Devices
 Anterior midline point stop (AMPS)
 Nociceptive Trigeminal Inhibitor Tension Suppression
System (NTI-TSS)
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106. Directive Splints
 ANT. REPOSITIONING APPLIANCE:
–Goal of treatment is not to alter the mandibular position
permanently but only to change the position temporarily so as
to enhance adaptation of the retrodiscal tissues.
 Indications:
–To treat disc derangement disorders.
–Patients with joint sounds (e.g., a single or reciprocal click) can
sometimes be helped by this.
–Intermittent or chronic locking of the joint (e.g., retrodiscitis).
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107. Irreversible Occlusal THERAPY
Selective grinding/Occlusal equilibration
 It is a procedure by which the occlusal surfaces of the teeth are precisely
altered to improve the overall contact pattern.
 Indications:
–When occlusal appliance therapy eliminated TMD symptoms and the
cause revealed any occlusal contact interferences.
–When there is a definitive need of improved occlusal condition.
–Indicated in treatment of trauma from occlusion, for decreasing
mobility and fremitus.
 Contraindications
–Severe over closure.
–Sensitive, worn and adolescent teeth.
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108. GOALS OF SELECTIVE
GRINDING/OCCLUSAL ADJUSTMENT:
 The primary goal of any occlusal
adjustment is Occlusal stability, which
is achieved by:
–Elimination of Prematurity
–Elimination of Interferences
–Establishment of Centric Forces
Directed Axially
–Establishment of Optimal Occlusion
with out loss of VD and shapes of
cusps and fossae.
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109.  Restorative procedures:
–It mainly includes replacement of missing teeth and restoration of
caries.
 Orthodontic treatment:
–Correcting the malalignment of teeth, correcting the skeletal
relationships of the maxilla and mandible, i.e., Orthognathic
surgeries
 Surgical Procedures:
–Estimated-5% or less in all TMD Patients.
–Ankylosis, destroyed/perforated articular disc, bizarre remodelling of
osseous structures & patients requiring surgery prior to orthodontic
and/or restorative treatment.
–Includes: Arthrocentesis, Arthroplasty, Autotenous disc replacement,
Alloplastic hemi arthroplasty, Orthognathic surgeries, Discoplasty
etc.
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110.  Definitive therapy considerations for Emotional
Stress:
09-06-2019 110
Muscle
Hypertrophy
High levels of
anxiety
Apprehension
Frustration
Anger
Fear
– Types of Emotional
Stress therapy:
• Patient awareness
• Restrictive use
• Voluntary avoidance
• Relaxation therapy
• Others
– Self-hypnosis
– Meditation
– Yoga

111.  Definitive therapy considerations for Trauma: Directed
towards elimination of para functional habit.
Two types of Trauma:
–Macrotrauma: Supportive therapy
–Microtrauma: E.g. Bruxisim - Orthopedic stability
 Definitive therapy considerations for Deep Pain Input:
–True source of pain must be located before definitive
treatment begins.
–If the source is not obvious, referral to another medical
specialist should be done.
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112.  Definitive therapy considerations for Parafunctional
Activity:
–Diurnal activity: Patient education & Cognitive
Awareness Strategies
–Nocturnal activity: Occlusal appliance therapy
–Measures to decrease the level of emotional stress
should be made.
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113. Supportive Therapy
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Physical
Therapy
modalities
Thermot
herapy
Coolant
therapy
Ultrasou
nd
therapy
Phonoph
oresis
Iontopho
rosis
EGS
TENS
Cold
laser

114. 09-06-2019 114
Pharmacolo
gic Therapy
Analgesics
Anti-
convulsant
s
Anti-
inflammat
ory agents
Topical
Anxiolytic
agents
Muscle
relaxants
Anti-
depressan
ts
Injectables

115. Conclusion
 A thorough knowledge of TMJ & its relationship with
surrounding structures is essential to fully comprehend normal
anatomy & physiology, adaptive processes, dysfunction &
pathology of the TMJ.
 Although numerous treatments have been advocated, none are
universally effective for all patients all the time.
 A good Prosthodontic treatment bears direct relation with TM
articulation since establishment of occlusion is one of the main
steps in complete denture, fixed partial & removal partial
dentures.
 Effective treatment begins with the thorough understanding of
the disorder & its etiology and an appreciation of the various
types of treatments is essential for effective management of the
symptoms.
09-06-2019 115

116. References
 Okeson, JP. Management of Temporomandibular Disorders and
Occlusion , 7th ed., (2003), Mosby.
 Zarb GA, Bolender CE. Prosthetic treatment for edentulous patients,
Complete dentures & Implant supported prosthesis. 13th ed.
 Dawson PE. Functional occlusion from TMJ to smile design.3rd ed.
 Charles McNeill. Science and practice of occlusion.
 Temporomandibular disorders-diagnosis treatment and management:
Weldon E. Bell (3rd ed)
 Neil S. Norton. Neter’s Head And Neck Anatomy For Dentistry. 2nd Ed.
Philadelphia. Elsevier Inc 2012.
 Irene A. Espinosa de Santillana, Ariana García-Juárez, Jaime Rebollo-
Vázquez y Ana K. Ustarán-Aquino. Frequent postural alterations in
patients with different types of temporomandibular disorders. Rev.
Salud Pública. 20 (3): 384-389, 2018.
09-06-2019 116

117. References
 Melissa E. Bender, Rosa B. Lipin, Steven L. Goudy. Development of the
Pediatric Temporomandibular Joint. Oral Maxillofacial Surg Clin N Am
30 (2018) 1–9.
 Mohl ND, Ohrbach RK, Crow HC, Gross AJ. Devices for the diagnosis &
treatment of temporomandibular disorders. Part III:
Thermography,ultrasound, and electric stimulation. J Prosthet Dent
1990; 63(1):472-5.
 Mohl ND, McCall WD, Lund JP, Plesh O. Devices for the diagnosis &
treatment of temporomandibular disorders. Part I: Introduction,
Scientific evidence, and jaw tracking. J Prosthet Dent 1990; 63(1):198-
201.
 Mohl ND, Lund JP, Widmer CG, McCall WD. Devices for the diagnosis &
treatment of temporomandibular disorders. Part II: Electromyography
and sonography. J Prosthet Dent 1990; 63(1):332-5.
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118. References
 David L. Stocum & W. Eugene Roberts. Part I: Development and
Physiology of the Temporomandibular Joint. # Springer
Science+Business Media, LLC, part of Springer Nature 2018.
 Dania Tamimi, Elnaz Jalali, David Hatcher. Temporomandibular Joint
Imaging. Radiol Clin N Am – 2017.
 Weiner S. Biomechanics of occlusion and the articulator. DCNA
1995:39(2):257-284.
 Okeson JP. Occlusion and functional disorders of the masticatory
system. DCNA 1995:39(2):285-301.
 Nowlin TP, Nowlin JH. Examination and occlusal analysis of the
masticatory system. DCNA 1995:39(2):379-402.
 World Wide Web.
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