Temporomandibular Disorders and their Management

1. TMJ DISORDERS
Dr. Hadi Munib
Oral and Maxillofacial Surgery Resident

2. OUTLINE
• Evaluation
• Classification
• Reversible Treatment
• Occlusion Modification
• Surgical Management
• Distraction Osteogenesis
• References

3. EVALUATION
• The most common causes of temporomandibular disorders (TMDs) are
muscular disorders - myofascial pain.
• Temporomandibular pain or dysfunction originate primarily within the
temporomandibular joint (TMJ).
• Internal derangement, osteoarthritis, rheumatoid arthritis, chronic
recurrent dislocation, Ankylosis, neoplasia, and infection.

4. HISTORY
• Muscular pain is usually described as “dull” and “achy”.
• Acute joint pain may be “sharp” or “shooting.”
• Pain that occurs primarily in the morning may indicate a systemic arthritis
such as rheumatoid arthritis or myofascial pain resulting from nocturnal
bruxism.
• If pain only occurs toward the end of the day, osteoarthritis may be
explored as a potential cause.

5. EXAMINATION
• The muscles should be palpated for the presence of tenderness,
fasciculation, spasm, or trigger points.
• The most common forms of joint noises are clicking (a distinct
sound) and crepitus (i.e., scraping or grating sounds).
• Maximum Opening = 45 mm Vertical and 10 mm Horizontal
• Wear Facets

8. RADIOGRAPHIC EVALUATION
• Panoramic radiography.
• Both TMJs on the same film.
• Bony anatomy of the articulating surfaces of the mandibular condyle and
glenoid fossa.

9. RADIOGRAPHIC EVALUATION
• Tomograms.
• Radiographic sectioning of the joint at different levels providing individual
views.
• Elimination of bony superimposition and overlap, relatively a clear picture
of the bony anatomy of the joint.

10. RADIOGRAPHIC EVALUATION
• Temporomandibular Joint Arthrography.
• Indirect Visualization of the intra-articular disk.
• Injection of contrast material into the inferior or superior spaces of a
joint, after which the joint is radiographed.
• Position and morphology of the articular disk, presence of perforations
and adhesions of the disk or its attachments.

11. DISC DISPLACEMENT WITHOUT REDUCTION

12. RADIOGRAPHIC EVALUATION
• Computed tomography.
• Variety of hard and soft tissue pathologic conditions in the joint.
• Most accurate radiographic assessment of the bony components of the
joint.

13. RADIOGRAPHIC EVALUATION
• Cone Beam Computed Tomography.
• Three-Dimensional reconstructions of the mandibular condyle and
articular eminence.
• Much less Radiation dose
• No Diagnostics of soft tissue

14. RADIOGRAPHIC EVALUATION
• Magnetic resonance imaging.
• Excellent images of intra-articular soft tissue.
• Does not use ionizing radiation is a significant advantage.

15. RADIOGRAPHIC EVALUATION
• Nuclear imaging.
• Intravenous injection of technetium-99 - γ-emitting isotope concentrated
in areas of active bone metabolism.
• Approximately 3 hours after injection of the isotope, images are obtained
using a gamma camera.

17. PSYCHOLOGICAL EVALUATION
• The comorbidity of psychiatric illness and temporomandibular dysfunction
can be as high as 10% to 20% of patients seeking treatment.
• A third of these patients is suffering from depression on initial presentation.
• More than two thirds have had a severe depressive episode in their history

18. CLASSIFICATION
• Myofascial Pain
• Internal Derangement
• Degenerative Joint Disease
• Systemic Arthritic Conditions
• Dislocations
• Ankylosis
• Infections
• Neoplasia

19. MYOFASCIAL PAIN
• Masticatory muscles developing tenderness and pain as a result of
abnormal muscular function or hyperactivity.
• Usually associated with daytime clenching or nocturnal bruxism.
• Complaint of diffuse, poorly localized, pre-auricular pain that may
involve muscles of mastication such as the temporalis and medial
pterygoid muscles as well as Bi-temporal headaches
• Examination reveals diffuse tenderness of the masticatory muscles.
• Isolated MPD, joint noises are usually not present.

20. INTERNAL DERANGEMENTS
• In normal circumstances, the condyle functions in a hinge and a
sliding fashion.
• During full opening, the condyle also translates forward to a position
near the most inferior portion of the articular eminence.
• During function, the biconcave disk remains inter-positioned
between the condyle and the fossa.

22. ANTERIOR DISC DISPLACEMENT WITH REDUCTION
• The disk is positioned anterior and medial to the condyle in the closed
position.
• During opening, the condyle moves over the posterior band of the disk and
eventually returns to the normal condyle-and-disk relationship.
• During closing, the condyle then slips posteriorly and rests on the retro-
diskal tissue.
• Maximal opening can be normal or slightly limited.
• The click occurring during the opening movement.

24. ANTERIOR DISK DISPLACEMENT WITHOUT REDUCTION
• The disk displacement cannot be reduced, and thus the condyle is unable
to translate to its full anterior extent.
• Prevents maximal opening and causes deviation of the mandible to the
affected side.
• No clicking happens.
• The restricted mouth opening may be due to the adherence of the disk to
the fossa.
• Plain radiography or CT will produce similar findings as in anterior disk
displacement with reduction.
• MRI generally demonstrates anteromedial disk displacement in the
closed mouth position

26. DEGENERATIVE JOINT DISEASE
• Irregular, perforated, or severely damaged disks.
• Current concepts of DJD incorporate three possible mechanisms of injury:
(1) Direct mechanical trauma; Significant and obvious to Micro-trauma
(2) Hypoxia reperfusion injury
(3) Neurogenic inflammation.
• The diagnosis of DJD includes Wilkes stage IV and V internal derangements.
• Pain associated with clicking or crepitus located directly over the TMJ.
• Radiographic findings are variable but generally exhibit decreased joint space,
surface erosions, osteophytes, and flattening of the condylar head.

28. SYSTEMIC ARTHRITIC CONDITIONS
• The most common is Rheumatoid Arthritis - Inflammatory process results
in abnormal proliferation of synovial tissue in a so-called pannus
formation.
• Symptoms are rarely isolated to the TMJs and usually bilateral.
• May be earlier in age than DJD
• Radiographic findings initially show erosive changes in the anterior and
posterior aspects of the condylar heads.
• Small, pointed condyle in a large fossa.
• Anterior Open Bite and Premature Bite on Posterior teeth.

31. DISLOCATION
• Mandibular hypermobility.
• Subluxation; displacement of the condyle, self-reducing.
• May occur spontaneously after opening the mouth widely such as when
yawning, eating, or during a dental procedure.
• Dislocations should be reduced as soon as possible.
• Downward pressure on posterior teeth and upward pressure on the chin,
accompanied by posterior displacement of the mandible.
• If Muscular spasm is present, Anesthesia of the auricular temporal nerve or
sedation.
• After reduction the patient should be instructed to restrict mandibular opening
for 2 to 4 weeks.
• Moist heat and NSAIDs are also helpful in controlling pain and inflammation.

33. ANKYLOSIS
• Intracapsular Ankylosis
• Leads to reduced mandibular opening
• Fusion of the condyle, disk, and fossa complex.
• Macrotrauma, Previous surgeries or infections.
• Severe restriction of maximal opening, deviation to the affected side,
and decreased lateral excursions to the contralateral side.
• Fibrous Tissue vs. Bony Tissue
• Radiographs; irregular articular surfaces of the condyle and fossa.

34. EXTRACAPSULAR ANKYLOSIS
• Coronoid process and the temporalis muscle.
• Coronoid process enlargement, or hyperplasia, and trauma to the zygomatic arch
area.
• Initially have limitation of opening and deviation to the affected side.
• Complete restriction of opening is rare, lateral and protrusive movements can
usually be performed,
• Panoramic radiography generally demonstrates the elongation of a coronoid
process.
• A submental vertex radiograph or CBCT may be useful in demonstrating
impingement caused by a fractured zygomatic arch or zygomaticomaxillary
complex.

36. REVERSIBLE TREATMENT
• Patient Education
• Physical Therapy
• Medications:
• NSAIDs
• Stronger Analgesics
• Muscle Relaxants
• Antidepressants
• Botox

37. SPLINT THERAPY
• Reversible or Conservative
• Most splints can be classified into two distinct groups: (1) Auto-
repositioning splints and (2) anterior repositioning splints.

38. SURGICAL JOINT TREATMENT
• Indications
• Absolute Indications; Ankylosis
• Gap arthroplasty
• Interpositional arthroplasty
• Costochondral graft
• Prosthetic joint

39. HYPERMOBILITY
• Sclerosing agent
• Plication
• Daughtry procedure
• Eminectomy

40. ARTHROSCOPY
• Small cannula into the superior joint space, followed by insertion of an
arthroscope to allow direct visualization of all aspects of the glenoid
fossa, superior joint space, and superior aspect of the disk.
• One cannula is used for visualization of the procedure with the
arthroscope, whereas instruments are placed through the other cannula
• Internal derangements, hypomobility as a result of fibrosis or adhesions,
DJD, and hypermobility.
• Advantage of less surgical morbidity and fewer and less severe
complications.

42. • Minimally invasive technique that involves placing ports (needles or small
cannulas) into the TMJ to lavage the joint and to break up fine adhesions.
• IV Sedation and Auricotemporal Nerve Blocks
• Lactated Ringer solution is injected to distend the joint space and release
fine adhesions that may be limiting disk mobility.
• Post-Operative Complaints are usually Mild pain
ARTHROCENTESIS

45. REFERENCES
• Chapter 31: Temporomandibular and Other Facial Pain Disorders

46. THANK YOU