Contains in detail treatment options for different TMDs from a dentist and prosthodontist's perspective.

1. TMJ and its applied
Anatomy (Part III)
Prepared by: Vishal Trivedi
Guided by : Dr. Mrugnayani Patel

2. Contents
 1) Treatment of Masticatory Muscle Disorder
 2) Treatment of Temporomandibular Joint Disorders
 3) Treatment of Chronic Mandibular Hypomobility and Growth Disorder
 4) Occlusal Appliance therapy

3. Treatment of Masticatory Muscle
Disorder
 Protective Co-Contraction (Muscle Splinting)
 Local Myalgia (Noninflammatory Myalgia)
 Myospasms (Tonic Contraction Myalgia)
 Myofascial Pain (Trigger Point Myalgia)
 Centrally Mediated Myalgia (Chronic Myositis)

4. Protective Co-Contraction
(Muscle Splinting)
 Protective co-contraction is the initial response of a muscle to altered sensory or
proprioceptive input or injury. This response has been called Protective muscle
splinting.
 In the presence of altered sensory input or pain, antagonistic muscle groups seem
to activate during movement in an attempt to protect the injured part. Therefore,
pain felt in the masticatory system can produce protective co-contraction of
masticatory muscles.
 Protective co-contraction is not a pathologic condition but a normal physiologic
response of the musculoskeletal system.

5. Etiology
 Altered sensory or proprioceptive input.
 Constant deep pain input
 Increased emotional stress.
 Protective co-contraction only remains a few hours or days. If it is not resolved,
local myalgia is likely to follow.

7. Clinical Characteristics
 Structural dysfunction: Decreased range of motion, but the patient can achieve a
relatively normal range when requested to do so.
 Minimal pain at rest.
 Increased pain on function.
 The patient reports a feeling of muscle weakness.

8. Treatment
 Protective co-contraction is a
normal CNS response and
therefore there is no
indication to treat the muscle
condition itself.
 Treatment should instead be
directed toward the reason for
the co-contraction.
 When co-contraction results
from trauma, definitive
treatment is not indicated
since the etiologic factor is no
longer present.

9. Treatment
 When co-contraction results from a poorly fitting restoration, altering the
restoration is advised.
 If an increase in emotional stress is the etiology then appropriate stress
management.
 Short-term pain medication NSAIDs may be indicated

11. LOCAL MYALGIA
(NONINFLAMMATORY MYALGIA)
 It is noninflammatory, myogenous pain disorder. It is often the first response of the
muscle tissue to continued protective co-contraction.
 Local myalgia represents a change in the local environment of the muscle tissues.
It represents the initial response to overuse of muscle.

12. Etiology
 Protracted protective co-contraction secondary to a recent alteration in local
structures.
 A continued source of constant deep pain
 Local tissue trauma.
 Increased levels of emotional stress.

13. Clinical Characteristics
 Structural dysfunction: There is marked decrease in the range of mandibular
movement.
 There is minimum pain at rest and increased with function.
 Actual muscle weakness present.
 There is local tenderness when the involved muscles are palpated

14. TREATMENT
 The primary goal in treating local myalgia is to decrease sensory input (such as
pain)
 Achieved by-
 1. Eliminate any ongoing altered sensory input.
 2. Eliminate any ongoing source of deep pain input.
 3. Provide patient education and information on self-management
i.e. Advise the patient to restrict mandibular use to within painless limits.

15. TREATMENT
 If due to bruxism -fabricate an occlusal
appliance for nighttime use while for
daytime educate patient to control it.
 If the above therapies fail to resolve
the pain condition, the clinician may
consider the use of a mild analgesic.
 Such as aspirin, acetaminophen, or an
NSAID (i.e., ibuprofen), can be helpful.

16. MYOSPASMS
(TONIC CONTRACTION MYALGIA)
 Myospasm is an involuntary CNS-induced tonic muscle contraction often
associated with local metabolic conditions within the muscle tissues.
 Etiology :-
 Continued deep pain input.
 Overuse
 Idiopathic myospasm mechanisms

17. CLINICAL CHARACTERISTICS
 The patient reports a sudden onset of restricted jaw movement usually
accompanied by muscle rigidity.
 Structural dysfunction: There is marked restriction in range of mandibular
movement.
 Acute malocclusion is common.
 There is pain at rest and pain is increased with function.
 The affected muscle is firm and painful to palpation.

18. TREATMENT
 Two treatments are suggested for acute myospasms.
 The first is directed immediately toward reducing the spasm itself while the other
addresses the etiology.
 1. Pain Reduction- can be achieved by manual massage, vapocoolant spray, ice,
or even an injection of local anesthetic (2% lidocaine without a vasoconstrictor is
recommended.)
 2. Etiology reduction When the myospasms are secondary to fatigue and overuse,
patient is advised to rest the muscle.
 Idiopathic - may represent an oromandibular dystonia

20. MYOFASCIAL PAIN
(TRIGGER POINT MYALGIA)
 Myofascial pain is a regional myogenous pain condition characterized by local area
of firm, hypersensitive bands of muscle tissue known as trigger points.

21. Etiology
 1. Continued source of deep pain input.
 2. Increased levels of emotional stress.
 3. The presence of sleep disturbances.
 4. Local factors that influence muscle activity such as habits, posture, muscle
strains, or even chilling.
 5. Systemic factors such as nutritional inadequacies, poor physical conditioning,
fatigue, and viral infections.
 6. Idiopathic trigger point mechanism.

22. Clinical Characteristics
 Structural dysfunction: There may be a slight decrease in the velocity and range of
mandibular movement depending upon the location and intensity of the trigger
points. This mild structural dysfunction is secondary to the inhibitory effects of pain
(protective co-contraction).
 Heterotopic pain is felt even at rest.
 There may be increased pain with function.
 There are tight muscle bands with trigger points which, when provoked, increase
the heterotopic pain

23. TREATMENT
 Eliminate any source of ongoing deep pain.
 If a sleep disorder is suspected, Often, low dosages
of a tricyclic antidepressant, such as 10 to 20 mg of
amitriptyline before bedtime, can be helpful.
 Elimination of the trigger points, by painlessly
stretching the muscle containing the trigger points.
 Spray and Stretch, Pressure and Massage
 Ultrasound and Electrogalvanic Stimulation
 Injection and Stretch.

24. TREATMENT
 A medication such as cyclobenzaprine (Flexeril), 10 mg before sleep can often
reduce pain but the trigger points still need to be treated.
 Analgesics may also be helpful in interrupting the cyclic effect of pain.

26. CENTRALLY MEDIATED MYALGIA
(CHRONIC MYOSITIS)
 Centrally mediated myalgia is a chronic, continuous muscle pain disorder
originating predominantly from CNS effects that are felt peripherally in the muscle
tissues.

27. Etiology
 Chronic centrally mediated myalgia may be caused by the prolonged input
of muscle pain associated with local myalgia or myofascial pain.
 Chronic upregulation of the autonomic nervous system
 Chronic exposure to emotional stress
 Other sources of deep pain input.

28. CLINICAL CHARACTERISTICS
 Structural dysfunction : patients experiencing centrally mediated myalgia
present with a significant decrease in the velocity and range of mandibular
movement.
 There is significant pain at rest and pain is increased with function.
 There is a generalized feeling of muscle tightness.
 There is significant pain on muscle palpation.

29. TREATMENT
 Restrict mandibular use to within painless limits
 Avoid exercise and/or injections. Since the muscle tissue is neurogenically
inflamed, any use increases pain.
 The patient should rest the muscles as much as possible.
 Disengage the teeth by a stabilization appliance.
 Begin taking an anti inflammatory medication. If a sleep disorder is
suspected, Often, low dosages of a tricyclic antidepressant is advised at
bedtime.

30. TREATMENT
 This internal physiology is only
under the control of the patient, not
the clinician.
 That is why the patient needs to
understand this relationship and
work on changing behavior that will
downregulate the autonomic
nervous system.
 Physical self regulation plays
important role in its treatment

33. Treatment of Temporomandibular
Joint Disorders
 Disc displacement and disc displacement with intermittent locking
 Disc displacement without reduction
 Structural incompatibility : Deviation in form and Adhesions
 Subluxation and Luxation
 Capsulitis, Retrodiscitis, and Acute Trauma to the TMJ
 Osteoarthritis
 Infectious arthritis

34. Disc displacement and disc
displacement with intermittent locking
 Etiology :-
 Disc derangement disorders result from elongation of the capsular and discal
ligaments coupled with thinning of the articular disc.
 Clinical Characteristics :-
 The clinical examination reveals a relatively normal range of movement with
restriction only associated with the pain.
 Discal movement can be felt by palpation of the joints during opening and closing.
 Deviations in the opening pathway.

37. TREATMENT
 Anterior positioning appliance to reposition to condyle back on the disc.
 It was originally suggested that this appliance be worn 24 hours a day for
as long as 3 to 6 months.
 The patient needs to be encouraged to decrease loading of the joint
whenever possible. Softer foods, slower chewing and smaller bites should
be promoted.
 If inflammation is suspected, an NSAID should be prescribed. Moist heat
or ice can be used. Active exercises are not advised

40. DISC DISPLACEMENT WITHOUT
REDUCTION
 Disc displacement without reduction is a clinical condition in which the disc is
totally displaced (dislocated) and does not return to normal position with condylar
movement.
 Etiology :-
 Macrotrauma and microtrauma are the most common causes of disc displacement
without reduction.

41.  Clinical Characteristics
 A sudden change in range of mandibular movement occurs.
 Examination reveals limited mandibular opening with some slight
defection to the ipsilateral side.
 Treatment
 Fabricating an anterior positioning appliance is contraindicated for
this patient, as it will aggravate the condition by forcing the disc
even more forward
 Recapture the disc by manual manipulation.

42. TREATMENT
 Technique for Manual Manipulation.
 The clinician's right thumb is placed intraorally over the patient's left mandibular
second molar and the mandible is grasped. With the left hand stabilizing the
cranium, gentle but firm force is applied downward on the molar and upward on the
chin to distract the joint.

43. TREATMENT
Once the joint is distracted, the mandible is brought forward and to the right,
enabling the condyle to move into the area of the displaced disc. When this
position is achieved, constant distractive force is applied for 20 to 30 seconds
while the patient relaxes.

44. TREATMENT
After the distraction, the thumb is removed and the patient is asked to close on the
anterior teeth, maintaining the jaw in a slightly protrusive position. When the patient
has rested a moment, he or she is instructed to open maximally. If the disc has been
reduced, a normal range of movement (48 mm) will be possible.

45. TREATMENT
 Patients should be encouraged not to open too wide, especially
immediately following the disc displacement without reduction.
 The patient should also be told to decrease hard biting, no chewing gum.
 If pain is present, heat or ice may be used. NSAIDs are indicated for pain
and inflammation.
 Joint distraction and phonophoresis over the joint area may be helpful.

46. TREATMENT
 Surgical Considerations for Condyle-Disc Derangement Disorders
 Arthrocentesis- In this procedure, two needles are placed into the joint and
sterile saline solution is passed through lavaging the joint.
 Arthroscopy- With this technique, an arthroscope is placed into the superior
joint space and the intracapsular structures are visualized on a monitor.
(diagnostic)
 Arthrotomy- Open joint surgery.
 Discal Repair Or Plication- During a plication procedure, a portion of the
retrodiscal tissue and inferior lamina is normally removed and the disc is
retracted posteriorly and secured with sutures.

48. STRUCTURAL INCOMPATIBILITY
DEVIATION INFORM AND ADHESIONS
 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.
 The etiology of most deviations in form is trauma.
 Adherences/Adhesions
 Adherences represent a temporary sticking of the articular surfaces during normal
joint movements. Caused by a fibrosis attachment of the articular surfaces

50. SUBLUXATION AND LUXATION
 Subluxation
 Subluxation or hypermobility is a clinical description of the condyle as it moves
anterior to the crest of the articular eminence.
 It is not a pathologic condition but a variation in anatomic form of the fossa.
 Luxation
 This condition is commonly referred to as an openlock since the patient's mouth is
wide open and cannot reduce it. It can occur following wide-open mouth
procedures such as having a dental appointment.

53. Orthodontic
tubes
Intra-arch orthodontic
elastics

54. CAPSULITIS, RETRODISCITIS AND
ACUTE TRAUMA TO THE TMJ
 Capsulitis
 An inflammatory condition of the
capsular tissues
 Retrodiscitis
 An inflammatory condition of the
retrodiscal tissues.

56. OSTEOARTHRITIS
 Arthritis means inflammation of the articular surfaces of the joint.
 Osteoarthritis is one of most common arthritis affecting theTMJ.
 Etiology:-
 Overloading of the articular structures of the joint.

57. Radiological features

58. Radiological features
 Osteoarthritis can lead to significant loss of subarticular bone in the condyle. Once
this occurs, the condyles can collapse into the fossae causing a posterior rotational
movement of the mandible. This results in heavy posterior tooth contacts and an
anterior open bite.

61. Treatment of Chronic Mandibular
Hypomobility and Growth Disorders
 Chronic Mandibular Hypomobility
 The predominant feature of this disorder is the inability of the patient to
open the mouth to a normal range.
 Chronic mandibular hypomobility is rarely accompanied by painful
symptoms.
 Subdivided into three categories according to etiology:
 Ankylosis
 Muscle contracture
 Coronoid impedance.

62. ANKYLOSIS
 Abnormal immobility of a joint.
 The two basic types of ankylosis are
differentiated the tissues that limit the
mobility: fibrous and bony.
 Fibrous ankylosis - most common and
can occur between the condyle and the
disc or the disc and the fossa.
 Bony ankylosis of TMJ - would occur
between the condyle and fossa and
therefore the disc is mostly absent from
the discal space prior to the ankylosis.

63.  Etiology - The most common etiology of ankylosis is hemarthrosis
(bleeding within the joint).
 Chronic inflammation aggravates the disorder leading to the development
of more fibrous tissue.
 Management-
 If function is inadequate or the restriction is intolerable, surgery is the only
definitive treatment available.

64. MUSCLE CONTRACTURE
 MYOSTATIC CONTRACTURE
 Myostatic contracture results when a muscle is kept from fully lengthening
(stretching) for a prolonged time.
 For example if the mandible is fractured and wired together with maxilla for 6 to 8
weeks the elevator muscle cannot fully lengthen.
 Management -The resting length of the muscles can be reestablished by two
types of exercise: passive stretching and resistant opening.
 Thermotherapy and Ultrasound are also helpful.

65. Myofibrotic Contracture
 Myofibrotic contracture occurs as a result of excessive tissue adhesions
within the muscle or its sheaths.
 These fibrosis tissue adhesions prevent the muscle fibers from sliding over
themselves disallowing full lengthening of the muscle.
 Etiology- Myositis or trauma to the muscle tissues.
 Management - surgical detachment of the muscles involved.

66. CORONOID IMPEDANCE
 If the pathway of coronoid process is impeded, it will not slide
smoothly and the mouth will not fully open.
 Etiology- Coronoid impedance is generally due to either elongation of
the process or the encroachment of fibrous tissue.
 Management-
 1. Surgery, that either shortens the coronoid process or eliminates
the tissue obstruction ( if function is severely impaired).
 2. Gentle passive stretching.

68. GROWTH DISORDERS
Congenital and Developmental Bone Disorders
 Common growth disturbances of the bones are agenesis (no
growth), hypoplasia (insufficient growth), hyperplasia (too
much growth), or neoplasia (uncontrolled, destructive growth).

69.  Condylar Hyperplasia
 Bone disease characterized by the
increased development of one
mandibular condyle
 Management - Condylectomy and
orthognathic surgery, Mandibular ramus
osteotomy
 Condylar Hypoplasia
 Known as underdevelopment of condyle
 Management - Orthognathic Surgery,
distraction osteogenesis, surgery with
costochondral bone graft

72. Occlusal Appliance Therapy
 An occlusal appliance is a removal device made of hard acrylic that fits
over the occlusal surfaces of the teeth in one arch.
 It is commonly referred to as an occlusal splint, bite guard, night guard,
interocclusal appliance, or even orthopedic device.
 Occlusal appliances provides an occlusal condition that allows the
condyles to assume their most orthopedically stable joint position.
 They are also used to protect the teeth and supportive structures from
abnormal forces that may create breakdown and tooth wear.

73. Appliance
therapy
Stabilization
Appliance
Anterior
repositioning
Appliance

74. Stabilization Appliance
 The treatment goal of the stabilization appliance is to eliminate any
orthopedic instability between the occlusal position and the joint position,
thus removing this instability as an etiologic factor in the TMD.

75. Stabilization Appliance
 Indications :
1. Bruxism
2. Redrodistics secondary to trauma
3. Local muscle soreness
4. Centrally mediated myalgia
5. Post surgical management of TMJ(Arthroscopy)
6. Increase in Vertical Occlusal Dimension

76. Stabilization Appliance
 Fabricating the appliance
 Locating the Musculoskeletally stable position
 Developing the occlusion
 Adjusting the centric relation contacts
 Adusting the eccentric guidance

83. Post Insertion Instructions
 Finger pressure is used to align and seat it initially. Once it has been
pushed onto the teeth, it may be stabilized with biting force.
 Removal is most easily accomplished by catching it near the first molar
area with the fingernails of the index fingers and pulling the distal ends
downward.
 Day time vs Night time..
 The appliance should be brushed immediately after being taken out of the
mouth (with water, a dentifrice, or perhaps baking soda) to prevent the
buildup of plaque and calculus.
 The patient is asked to return in 2 to 7 days for evaluation.

84. ANTERIOR POSITIONING
APPLIANCE
The anterior positioning appliance causes the mandible to
assume a more forward position, temporarily creating a more
favorable condyledisc relationship

89. Orthognathic Surgery
 Class 3 or Mandibular Excess

90. Orthognathic Surgery
 Class 2 or Maxillary excess

91. Genioplasty

92. Extra oral appliances

93. Extra oral appliances

94. THANK YOU