Tmj iii /orthodontic courses by Indian dental academy

Diagnosis anDDiagnosis anD
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INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
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Contents-IIIContents-III
Treatment of TMJ disorders
Treatment of Chronic Mandibular hypomobility
Treatment of growth disorders
Treatment sequencing

Treatment of TMJ disorders:Treatment of TMJ disorders:
 Management of capsular and intracapsular TMDs.
They are categorized as:
 Derangement Of The Condyle-disc Complex
 Structural incompatibility of the articular surfaces
 Inflammatory disorders.

Disc displacement and discDisc displacement and disc
dislocation with reduction:dislocation with reduction:
 It represents an early stage of disc derangement disorders
Cause:
 Elongation of the capsular and discal ligament, coupled with thinning of the
articular disc.
 These changes commonly result from microtrauma (bruxism) or macrotrauma
( revealed through history).
 Class II Division 2 malocclusion.
History:
 Macrotrauma
 Microtrauma- bruxism.
Clinical characteristics:
 Relatively normal range of movement with restriction only associated with pain.
 Deviation in the opening pathways are common.

Definitive Therapy:
 Anterior positioning appliance.
Supportive therapy:
 Aimed to decrease loading of the joint whenever possible.
 Softer foods, slower chewing and smaller bites should be
promoted.
 NSAIDs
 Moist heat
 Passive jaw movements may be helpful and distractive
manipulation by a physical therapist may assist in healing.

Disc dislocation without reduction:Disc dislocation without reduction:
 It is a clinical condition in which the disc is dislocated,
most frequently anteromedially, from the condyle and does
not return to normal position with the condylar movement.
Cause:
 Macrotrauma and microtrauma.
History:
 Reveal a gradual increase in intracapsular symptoms( i.e.
clicking , catching) before the dislocation.
 Most often the joint sound s are no longer present
immediately after the disc dislocation.

 Examination reveals limited mandibular opening(25-
30mm) with normal eccentric movement to the ipsilateral
side and restricted eccentric movement to the contralateral
side.
Definitive Therapy:
 Acute-> 1 week - the initial therapy should attempt to
reduce or recapture the disc by manual manipulation.
 Long history- success begins to decrease rapidly.
 Stabilization appliance to pts with permanent disc
dislocation.

Supportive therapy:
 Patient education
 Pts are encouraged not to open the mouth too widely
especially immediately after the dislocation .
 Pts told to decrease hard biting, gum chewing and
other activities that aggravate the condition. If pain is
present, heat or ice may be used.
 NSAIDs are indicated for pain and inflammation
 Joint distraction and phonopheresis over the joint area
may be helpful.

Surgical considerations:Surgical considerations:
 Surgery should be considered only when conservative non-surgical
therapy fails to adequately resolve the symptoms and progression of the
disorders.
Arthrocentesis-
 In this procedure two needles are placed into the joint and sterile saline
solution is passed through to lavage the joint.
 The lavage is thought to eliminate much of the algogenic substances and
secondary inflammatory mediators that produce the pain.
 The long term effects of arthocentesis are positive , maintaining the
patient in a relatively pain free state. It is certainly the most conservative “
surgical procedure” that can be offered and therefore has an important
role in managing intracapsular disorders.

 In cases of disc dislocation without reduction, a single needle
can be introduced to the joint and fluid can be forced into the
space in an attempt to free the articular surfaces.
 The technique is called “ pumping the joint” and may
improve the success of manual manipulation for closed lock.
 Arthocentesis has even proven to be helpful for short-term
relief of rheumatoid arthritis systems.

 Another relatively conservative approach for treating these
intracapsular disorders is arthroscopy.
 With this technique an arthroscope is placed into the superior joint
space and the intracapsular structures are visualized on a monitor.
 Joint adhesions can be identified and eliminated, and the joint can be
significantly mobilized.
 This procedure appears to be quite successful in reducing symptoms
and improving range of movement.
 The arthroscopy does not correct the disc position, instead, success is
more likely achieved by improving disc mobility.
 When indicated the joint may need to be opened for reparative
procedures. Open-joint surgery is generally called arthrotomy.

 When the disc is displaced or dislocated the most conservative surgical
procedure is a discal repair or placation.
 During placation a portion of the retrodiscal tissue and inferior lamina
is removed; then the disc is retracted posteriorly and secured with
sutures.
 Difficulty arises if the disc has been damaged and can no longer be
maintained for use in the joint; then the choice becomes removal or
replacement of the disc.
 Removal of the disc is called discectomy (sometimes called as
meniscectomy).
 Another choice is to remove the disc and replace it with a substitute-
silastic, proplast-teflon, dermal temporal fascial flaps and auricular
cartilage grafts have also been used.

Structural incompatibility of theStructural incompatibility of the
articular surfaces:articular surfaces:
There are four categories of structural
incompatibility:
Deviation in form
Adhesions
Subluxation
Spontaneous dislocation.

Deviation in form:Deviation in form:
 Deviation in form includes a group of disorders that is created by
changes in the smooth articular surface of the joint and disc. These
changes produce an alteration in the normal pathway of condylar
movement.

 Cause:
 trauma- sudden blow
 microtrauma.

 History:
 Pt often reports of long history realated to these disorders. Many of
these disorders are not painful and therefore may go unnoticed by the
pt.

Clinical characteristics:Clinical characteristics:
 Pt with a deviation in the condyle, fossa or disc will commonly show a
repeated alteration in the pathway of the opening and closing movements.
 When a click or deviation in opening is noted, it will always occur at the
same position of opening and closing. Deviation in form may or may not
be painful.
DT:
 Surgery- in case of bony incompatibility the structures are smoothened
and rounded. If the disc is perforated or misshapen, attempts are made tp
repair it (i.e. discoplasty)
 Most deviations can be managed by supportive therapies.

Supportive therapy:Supportive therapy:
 Patient education
 Pt made to learn a manner of opening and chewing
that avoids or minimizes the dysfunction.
 When bruxism is the cause- stabilization
appliance to decrease the muscle hyperactivity.
 If associated with pain, analgesics may be
necessary to prevent the development of
secondary central excitatory effects.

Adherence and adhesions.Adherence and adhesions.
 Adherences represent a temporary sticking of the articular surfaces
during normal joint movements. Adhesions are more permanent and
are caused by a fibrosis attachment of the articular surfaces.
 Adherences and adhesions may occur between the disc and condyle or
the disc and fossa.

 Cause:
 Adherences are commonly a result of prolonged static loading of the
joint structures.
 If adherence is maintained, the nore permanent condition of adhesion
may develop. Adhesions may also develop secondary to hemarthrosis
caused by macrotrauma or surgery.

 History:
 Long period whenthe jaw was statically loaded (e.g.
clenching during sleep) follwed by a sensation of limited
mouth opening.
 As the patient tries to open, a single click is felt and
normal range of movement is immediately returned.
 The click or catching sensation does not return during
opening and closing unless the joint is again statically
loaded for a prolonged time.
 These patients typically report that in the morning the jaw
appears “stiff”, until they pop it once and normal
movements is restored.

Clinical characteristicsClinical characteristics
 Adherence produce temporary restriction in mouth opening until the click
occurs, whereas adhesions produce a more permanent limitation in the mouth
opening.
 If the adhesion affects only one joint, the opening movement will deflect to
the ipsilateral side. When adhesions are permanent, the dysfunction can be
great. Adhesions in the inferior joint cavity cause a sudden jerky movement
during opening.
 Those in the superior joint cavity restrict movement to rotation and thus limit
the patient to 25 or 30 mm of opening. During mouth opening, adhesions
between disc and fossa will tend to force the condyle across the anterior
border of the disc.
 Posterior disc dislocation is far less common than anterior dislocation and is
more likely to be closely related to adhesions between the disc and the fossa.
 With a posterior dislocation, the patient opens normally but has difficulty
getting the teeth back into occlusion.
 Pain may or may not be present. If pain is a symptom, it is normally
associated with attempts to increase opening that elongate ligaments.

DT:
 Diurnal clenching is best managed by patient awareness
and PSR techniques.
 Stabilization appliance- bruxism / clenching is suspected.
When adhesions are present breaking the adhesion is the
fibrous attachment is the only definitive treatment.-
arthroscopic surgery.
Supportive therapy:
 Passive stretching
 Ultrasound
 Distraction of the joint

SubluxationSubluxation
 Also called as hypomobility is a clinical
description of the condyle as it moves anterior to
the crest of the articular eminence. It is not
pathologic condition but reflects a variation in
anatomic form of the fossa.
 Cause:
 A steep short posterior slope of the aricular
eminence followed by a longer flat anterior slope
seem to display a greater tendency towards
subluxation.

 History:
 Pt reports of a locking sensation whenever the
mouth is opened too widely. The pt can return the
mouth to the closed position but often reports
alittle difficulty doing this.
 Clinical characteristics:
 During the final stage of maximal mouth opening
the condyle can be seen to suddenly jump forward
with a “thud” sensation. This is not reported as a
subtle clicking sensation.

DT:
 Surgical alteration of the joint itself- eminectomy which reduces the
steepness of the articular eminence and thus decreases the amount of
posterior rotation of the disc on the condyle during full translation.
Supportive therapy:
 Pt education – restriction of mouth opening.
 Occasionally an intraoral device can be given to restrict the movement.
Wearing the device develops a myostatic contracture of the elevator
muscles, thus limiting opening to the point of subluxation. The device
is worn continuously for 2 months and removed, allowing the
contracture to limit opening.

Spontaneous dislocation:Spontaneous dislocation:
 Commonly referred as “open lock”.
 Cause:
 It occurs after wide open mouth procedure. This condition refers to a
spontaneous dislocation of both the condyle and the disc.
History;
 The pt arrives at the office with the mouth in an open position and is
unable to close it.
 Pt remains in a wide open mouth condition. Pain is commonly present
secondary to the pt’s attempt to close the mouth.

DT:
 Is directed towards increasing the disc space, which allows the superior retrodiscal
lamina to retract the disc. When attempts are being made to reduce the dislocation, the pt
must open widely as if yawning-which activates the mandibular depressors and inhibit
the elevators. At the same time, slight posterior pressure applied to the chin will
sometimes reduce a spontaneous dislocation.
 If this is not successful, the clinician’s thumbs are place don the mandibular molars and a
downward pressure is exerted as the patient yawns. This will usually provide enough
space to recapture normal disc position.
 If spontaneous dislocation becomes chronic or recurrent- surgery- eminectomy.
 A new conservative approach is the injection of botulinum toxin (botox) to the muscle
involved (inferior lateral pterygoid, bilaterally) with dislocating the condyle. If
symptoms return repeated injections should be considered.
Supportive therapy:
 Prevention
 Pt is taught the reduction technique.

Inflammatory disorders of the TMJInflammatory disorders of the TMJ
Synovitis and capsulitis:
 These should be discussed together because they cannot be differentiated on a simle
clinical basis. They can only be differentiated from each other by visualizing the tissues
through arthroscopy or arthotomy.
Cause:
 Trauma
 Spreading of infection from an adjacent structure.
 The majority of inflammatory conditions in the joint are secondary to macrotrauma or
microtrauma to the tissues within the joint.this represents sterile inflammation, and
antibiotics are not indicated.
History:
 History of trauma- macrotrauma- e.g.blow to the chin.
 Trauma is most likely to cause injury to the capsular ligament when the teeth are
separated.

 Any movement that tends to elongate the capsular ligament will accentuate the pain.
 Pain is reported directly in front of the ear, and the lateral aspect of the condyle is
usually tender to palpation.
DT:
 The condition is self-limiting.
 When recurrence of trauma is likely, prevention by athelitic appliance should be given.
Supportive therapy:
 Restrict all mandibular movements within painless limits.
 A soft diet, slow movement and small bites are necessary.
 Mild analgesics
 Thermotherapy
 Ultrasound
 Corticosteroid injections

RetrodiscitisRetrodiscitis
 An inflammatory condition of the retrodiscal tissues is referred to as
retrodiscitis. This is relatively common intracapsular disorder.
Cause:
 Trauma.
 1. intrinsic- anterior displacement or dislocation of the disc is present-
disc becomes more anteriorly positioned.
 2. extrinsic- sudden movement of the condyle into the retrodiscal
tissue.
 Trauma-inflammation-swelling-condyle to move forward- acute
malocclusion
 Malocclusion- inability to occlude on the ipsilateral side and if force is
applied increased pain is elicited.
 Trauma- hemarthrosis- ankylosis/adhesions or both.

History:
 History of trauma-ectrinsic trauma
 Instrinsic trauma- history off gradual onset of pain, report
the progressive onset of the condition(clicking,catching).
 Constant preauricular painthat is accentuated with jaw
movement.
 Clenching of the teeth increases the pain.
 Loss of posterior occlusal contact on the ipsilateral side.

DT:When extrinsic trauma is the cause;
 Since the cause of trauma no longer present no definitive
treatment.
ST: to establishe optimal conditions for healing is genrally
the most effective treatment.
 Analgesics.
 Restrict the movemnts within the painless limits
 Soft diet.
 Ultrasound
 Thermography
 Whenacute malocclusion exits clenching can further
aggravate the inflamed retrodiscal tissue and hence a
stabilization appliance should be given for ocllusal
stability.

DT: When intrinsic trauma is the cause:
 Directed towards eliminating the traumatic cause
 An anterior positioning appliance is used to reposition the
condyle off the retrodiscal tissues and onto the disc.
Supportive therapy:
 Soft diet.
 Ultrasound.
 Thermography.

Arthritis:Arthritis:
 Means inflammation of the articular surfaces of the joint:
 Osteoarthritis, osteoarthrosis,
 Polyarthritides.
Osteoarthritis:
 Most common arthrosis affecting the TMJ.
 Also referred to as degenerative joint disease.
Cause:
 Overloading of the structures.
 Not a true inflammatory response, rather is is a non-inflammatory condition in
which the articular surfaces and their underlying bone deteriorate.
 When the precise cause is unknown – it is thought to be because of
mechanical overloading, painful, bony changes are active- called as primary
osteoarthritis.
 When the precise cause can be identified the condition is referred to as
secondary osteoarthritis.e.g disc dislocation without reduction.www.indiandentalacademy.com

History:
 Unilateral joint pain that is aggravated by mandibular movements. The
pain is often constant but often worsens in late afternoon or evening.
 Limited mandibular opening, joint pain, a soft end feel is common
unless the osteoarthritis is associated with an anteriorly dislocatd
condyle. Crepitations, TMJ radiographs- structural changes in the
subarticular bone of the condyle or fossa- flattening, osteophytes,
erosions.

DT:
 Decrease the joint loading
 Anterior positioning appliance therapy- may not be always
helpful.
 If hyperactivity is suspected then-stabilization appliance.
 PSR techniques.
Supportive therapy:
 Osteoarthritis is a self-limiting disorder
 First stage-clicking and catching-pain may or may not be
present
 Second stage- restriction of movement-locking and pain.
 Third stage-pain decreases but joint sounds are present-
followed by a phase in which a return to normal range of
painless movement with reduction of joint sounds is seen.

 Pt education
 Fabrication of appliance
 Pain medication
 Anti-inflammatory agents
 Soft diet.
 Passive muscle exercises within painless limits
 Thermography

Osteoarthrosis:Osteoarthrosis:
 When the bony changes are active the condition is called osteoarthritis
. as the remodelling occurs the condition can become stable, yet the
bony morphology remins altered. This condition is referred to as
osteoarthrosis.
Cause;
 Joint overloading;
 If the functional demand exceeds adaptability- osteoarthritis begins.
History:
 Pt does not report symptoms
 Crepitation is common, pt reports not clinical symptoms.
DT:
 No therapy is indicated for this condition.

Polyarthritides:Polyarthritides:
 It represents a group of arthritis conditions that are less
common and pesnt with similar findings as osteoarthritis.
Six categories:
 Traumatic arthritis
 Infectious arthritis
 Rheumatoid Arthritis
 Hyperuricemia
 Psoriatic arthritis
 Ankylosing spondylitis

Traumatic arthritis:Traumatic arthritis:
Cause:
trauma- lead to sudden loss of subarticular bone, which may lead to a change in the occlusal
condition- avascular necrosis.
DT:
 Not indicated. Preventionof future trauma- full mouth protector for sports.
ST:
 Rest.
 Restricted use of jaw
 Soft diet- small bites and slow chewing
 NSAID-reduce the inflammation
 Moist heat
 Ultrasound
 Stabilization appliance if bruxism is present or if pain increases when teeth are
occluded.

Infectious arthritis:Infectious arthritis:
 Bacterial infection
Cause:
 Trauma- puncture wound.
 A spreading infection from adjacent structures.
DT:
 Antibiotic medication
ST:
 Directed at maintaining or increasing the normal range of mandibular
movement to avoid post-infection fibrosis or adhesions.
 Passive exercises and ultrasound may be helpful.

Rheumatoid arthritis:Rheumatoid arthritis:
 Chronic systemic disorder of unknown cause: likely related to
autoimmune disorder with a strong genetic factor. 80% of Rheumatoid
pts are seropositive for rheumatoid factor.
 Produces a persistent inflammatory synovitis-destruction of the the
articular surfaces and subarticular bone.
DT:
 Cause is unknown- no definitive therapy.
 Supportive therapy:
 Directed towards pain reduction.
 Stabilization appliance sometimes is given- decrease the force on the
articular surfaces and thus decrease the pain- and when bruxism or
clenching is present..
 Arthrocentesis and arthroscopaic procedures may be helpful.

Hyperuricemia: (Gout)Hyperuricemia: (Gout)
 Is an arthritic condition in which an increase in the serum urate
concentration precipitates urate crystals (i.e monosodium urate
monohydrate) in certain joints.
 A genetic factor appears to be involved.
DT:
 Is directed towards lowering of the serum uric acid levels.
 Most effective method is by eliminating certain foods from the diet.
 No supportive therapy exists for gout.

Psoriatic arthritis:Psoriatic arthritis:
 Inflammatory condition.
 Pt gives history of psoriatic skin lesions which helps to establish the
diagnosis.
DT:
 Cause is known so no definitive t/t.
 Supportive treatment:
 NSAIDs
 Gentle physical therapy- to maintain joint mobility is important.
 Moist heat
 Ultrasound.

Ankylosing spondylitis:Ankylosing spondylitis:
 A chronic inflammatory disease of unknown cause primarily affects
the vertebral column. It is a painful condition with hypomobile joint
with no history of trauma and neck or back complaints.
DT:
 No definitive treatment.
Supportive treatment:
 Because this condition is a systemic disorder, a rheumatologist should
direct the major treatment.
 NSAIDs can be helpful.gentle physical therapy
 Moist heat and ultrasound.

Inflammatory disorders ofInflammatory disorders of
associated structures:associated structures:
Temporalis tendonitis:
 Chronic hyperactivity of this muscle may create tendonitis
 The condition is characterised by pain during function (e.g. chewing, yawning)
 Another complaint is retroorbital pain.
 Intraoral palapation of the attachment of the ligament to the coronoid process elicits
significant pain; local anesthetic blocking of this area eliminates the pain.
DT:
 Resting the muscle.
 Stabilization appliance may be used if clenching or bruxism is suspected.
 PSR.
Supportive therapy:
 Analgesics and anti-inflammatory medications
 Ultrasound
 Local anaesthetic injection or corticosteroid injection into the attachment of the tendon
followed by rest may help resolve the condition.

Stylomandibular ligamentStylomandibular ligament
inflammation:inflammation:
 The main symptom is pain at the angle of the mandible radiating upto the joint
ear. Protrusion of the mandible seems to aggravate the pain because this
movement longates the ligament. An injection of local anaesthetic to this
region will significantly reduce the pt’s complaint.
DT:
 Rest is an appropriate treatment.
 Instituing PSR technique can be helpful in resting the muscle.
Supportive therapy:
 Analgesics and anti-inflammatory medications
 Ultrasound
 Local anaesthetic injection or corticosteroid injection into the attachment of
the angle of the mandible may help resolve the condition.

Treatment of chronic mandibularTreatment of chronic mandibular
hypomobility and growth disorders:hypomobility and growth disorders:
 Chronic mandibular hypomobility is longterm
painless restriction of the mandible. Pain is
elicited only when force is used to attempt
opening beyond limitations. The condition can be
classified according to the cause:
 Ankylosis
 Muscle contracture
 Coronoid process impedance.

Ankylosis:Ankylosis:
 Sometimes the intracapsular surfaces of the joint develop
adhesions that prohibit normal movements. This is called
ankylosis. When ankylosis is present, the mandible cannot
translate from the fossa, resulting in a very restricted range
of movement. Ankylosis can result from fibrotic adhesions
in the joint or fibrotic changes in the capsular ligament. On
occasion a bony ankylosis can develop in which the
condyle actually joins with the fossa.
Cause:
 Macrotrauma
 TMJ surgery
 Previous infection

History:
 Previous injury or capsulitis
Clinical characteristics
 Movements restricted in all positions
 If the ankylosis is unilateral, midline pathway deflection
will be to that side during opening.
 Tmj radiographs will confirm this. The condyle will not
move significantly in protrusion or laterotrusion to the
contralateral side; therefore no significant difference is
apparent in these two films. Bony ankylosis can also be
confirmed with radiographs.

Definitive treatment:
 Surgery
 Arthroscopic surgery is least aggressive surgical
procedure; therefore it should be considered.
Supportive surgery:
 As it is normally asymptomatic generally no supportive
therapy is indicated.
 If pain and inflammation result, supportive therapy is
called for and consists of voluntarily restricting movement
to within painless limits. Nalgesics, along with deep heat
therapy can also be used.

Capsular fibrosis:Capsular fibrosis:
 Another cause of mandibular hypomobiltiy related fibrotic
changes is capsular fibrosis. The capsular ligament
surrounding the TMJ is partly responsible for limiting the
normal range of joint movement, if it becomes fibrotic the
movements of the condyle within the joint is also
restricted, creating a condition of chronic mandibular
hypomobility.
 It is usually a result of inflammation, which may be
secondary to inflammation of the adjacent tissues but is
more commonly caused by trauma.

 DT for capsular fibrosis is almost always contraindicated
 capsular fibrosis restricts only the outer range of mandibular
movements and is not a major functional problem for the patient.
 because the changes are fibrotic, therapy falls within the surgical
range.however because surgery can cause this disorder, a surgical
procedure to free the fibrous restriction must be carefully weighed.
Supportive therapy:
 It is usually asymptomatic and hence no supportive therapy is
indicated.

Muscle contracture:Muscle contracture:
 The clinical shortening of the resting length of a muscle without
interfering in its ability to contract further.
Myostatic Contracture: it results when a muscle is kept from fully
relaxing (i.e. stretching) for a prolonged time. The restriction may be
because the full relaxation causes pain in an associated structure.
 For example, if the mouth can open only 25mm without pain in the
TMJ, the elevator muscles will protectively restrict movement to
within this range .
History : the patient reports a long history of restricted jaw movement. It
may have begun secondary to pain condition that has now resolved.
Clinical characteristics: Myostatic contracture is characterized by painless
limitation of mouth opening.

 The original cause to be identified, and eliminated before effective
treatment of the contracture can result.
 Gradual lengthening of the involved muscles done over a period of
many weeks by
 1) passive stretching
 2) Resistant opening
Supportive therapy:
 When symptoms due occur, analgesics can be helpful and should
accompany a decrease in the intensity of exercise program.
 Thermotherapy and ultrasound are also helpful.

Myofibrotic contracture:Myofibrotic contracture:
Cause;
it occurs as a result of tissue adhesions within the muscle or its sheath. It
commonly follows as myositic condition or trauma to the muscle.
History:
the history for myofibrotic contracture reveals a previous muscle injury or a long
term restriction in the range of movement. There is no pain complaint.
Sometimes the patient will not even be aware of the limited range of opening
because it has been present for so long.
 It is characterized by painless limitation of mouth opening. Lateral condylar
movement is unaffected. Thus if the diagnosis is difficult, radiographs
showing limited condylar movement during opening but normal movement
during lateral excursions may help. There is no acute malocclusion.

 The muscle tissue in this condition can relax but the muscle length
does not increase. It id therefore permanent.
 Some elongation of the muscle can be accomplished by continuous
elastic traction. This is done by linear growth of the muscle and is
slow and limited by the muscle tissue health and adaptibility
 In general, surgical detachment and reattachment of muscles is done.
Supportive therapy:
 Rarely associated with pain so no supportive therapy is indicated.

Coronoid impedance:Coronoid impedance:
 During opening the coronoid process passes anteroinferiorly between
the zygomatic process and the posterior lateral surface of the maxilla.
 If the coronoid is extremely long or if fibrosis has developed in this
area, its movement will be inhibited and chronic hypomobility of
mandible may result.
 Trauma to or infection in the area just anterior to the coronoid process
can lead to fibrotic adhesions or union of these tissues. Surgical in the
area can also cause coronoid impedance. In certain conditions it is
possible for the coronoid process to become elongated, which would
prevent its movement through this soft tissue area. These conditions
may allbe related to chronically dislocated disc.
Cause:
 Elongation of the coronoid process- disc dislocations
 Encroachment of fibrous tissue- trauma or infection

History: There is a painless restriction of opening that, in many cases, followed trauma to the
area or an infection. There may also have been a long-standing anterior disc dislocation.
 Clinical characteristics: limitation is evident in all movements, but especially in
protrusion. A straight midline opening path is commonly observed, unless one coronoid
process is freer than the other. If the problem is unilateral, opening will deflect the
mandible to the same side.
 DT for coronoid impedance is alteration of the tissue responsible.
 Sometimes ultrasound followed by gentle passive stretching helps mobilize the tissues
 A true DT is surgery, a surgical procedure can also create the very process that it trying
to eliminate (i.e. fibrosis) therefore it should be considered only if function is severely
impaired.
Supportive therapy:
 Because this is asymptomatic no supportive therapy.

Growth disordersGrowth disorders
Common growth disturbances of bones are-
 Agenesis (no growth)
 Hypoplasia (insufficient growth)
 Hyperplasia (too much growth)
 Neoplasia (uncontrolled, destructive growth)
Common growth disturbances of muscles are
 Hypotrophy (weakened muscle)
 Hypertrophy (increased size & strength of muscle)
 Neoplasia (uncontrolled, destructive growth)

Common growth disturbances ofCommon growth disturbances of
bones:bones:
Cause:
 Deficiency of or alteration in growth typically result from trauma and can induce major occlusions.
Neoplasia activities involving the TMJ is rare but, if left undiagnosed, can become aggressive.
History:
 Clinical symptoms present are directly related to the structural changes present.
 Clinical characteristics;
 Clinical asymmetry
 Any alteration of function or presence of pain is secondary to structural changes
 Radiographs of TMJ are important in identifying structural (bony) changes. Clinical asymmetry may
be noticed that is associated with and indicative of a growth or developmental interruption.
 It must be tailored specifically to the pt’s condition. Generally treatment is provided to restore
function, while minimizing any trauma to the associated structures. Neoplastic activity needs to be
aggressively investigated and treated.
 Not indidcated.

Congenital and developmentalCongenital and developmental
muscle disorders:muscle disorders:
 Common congenital and developmental disorders
can be divide into:
– hypotrophy
– hypertrophy
– Neoplasia
Cause
 Largely unknown, certain systemic disorders may
play an important role (E.G. multiple sclerosis)

 Hypertrophic changes may be secondary to increased use , such
as bruxism.
History:
 Hypotrophy- feeling of muscle weakness
 Hypertrophy- esthetic problems.
 Hypotrophy is often difficult to recognize.
 Hypertrophy can be observed as a large muscle mass.
 Definitive treatment:
 Treatment is provided to restore function, while minimizing any
trauma to the associated striuctures.
 When hypertrophy is present secondary to bruxism, am muscle
relaxant appliance should be offered. Neoplastic activity needs to
be aggressively investigated and treated.
 Not indicated

Thankyou !!!

Tmj iii /orthodontic courses by Indian dental academy

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