Introduction

• Routine practice TMD are common

• TMD are multi-factorial, avoid tunnel

vision

• TMJ, masticatory muscles and teeth

should not be considered in isolation.

• Dental treatment for 18 months

• General practitioner

• ENT consultant

• Neurologist

• Clinical psychologist

• Psychiatrist

• Restorative dentist

• General dental practitioner

• Three third molars removed

• Two apicoectomies done

• Four root canal treatments

• Symptoms unchanged

• TMJ clinic

• Minor occlusal correction

Functional Anatomy

• Ginglymodiathrodial joint

• Boney components enclosed and connected by fibrous capsule

• Capsule lined with synovium

• Joint cavity filled with synovial fluid

• Fluid decreases friction

Articular Disc

• Space between condyle and mandiular fossa

is occupied by collagenous fibrous tissue

• Disc is attached to the lateral and medial

poles of the condyle by ligaments

• Thick in the centre and thin on both the ends.

• Avascular and little sensory nervous

penetration

• Divides joint to U/L compartments

• Retrodiscal tissue

• Temporomandibular ligament

• Capsular ligament

Muscles of mastication

• Massater

• Medial pteygoid

• Lateral pterygoid

• Temporalis

• Accessory muscles

• Vascular– External carotid artery

• Nerve supply– Trgeminal nerve– Cranial nerve VII, IX, X, XI

2

• Etiology

• Epidemiology

• Classification

Etiology

• Occlusal disharmony

• Psychological distress

• Parafunctional habits

• Emotional distress

• Acute trauma from blows or impacts

• Trauma from hyperextensions

• Instability of maxillo-mandibular reln

• Laxity of joint

• Rheumatic disorders (comorbidity)

• Poor general health

Epidemiology

• Age 20 – 40 Yrs

• Predominantly women

• 65 – 85% of the population

• 12% prolonged pain

• 5 – 7% need treatment.

Classification

• Cranial bones– Congenital and developmental– Fracture– Neoplasia

Muscles– Myofascial pain– Myositis

• Temporomandibular joint– Disc displacement– Dislocation– Inflammation– Arthritis– Neoplasia– Ankylosis

Assessment

• History

• Physical examination

• Imaging

History

• Apart from routine history, dental, medical and drug history

• PAIN is most important feature

• Pain diary could be maintained

Physical examination

• Mandibular movements– Opening– Lateral– Protrusive– Deviation

• Tenderness in muscles of mastication

Imaging

• Plain film radiographs

• Arthrography

• Tomography

• Computed tomography

• Magnetic resonance imaging

Intracapsular Disorders

• Articular disc disorders– With or without symptoms

• Arthritis– With or without symptoms

Articular disc displacement

• Abnormal relationship of disc with its surrounding structures

• Due to stretching or tearing of attachment to condyle and glenoid fossa

• Abnormal joint sounds

• Limitation in mandibular range of motion

• Pain during mandibular movement

• Majority of cases of ADD occur without significant pain or joint dysfunction.

Contd…

Etiology

• Direct trauma to the joint

• Chronic low-grade microtrauma

• Craniofacial morphology

• Anterior disk displacement with

reduction (clicking joint)

• Anterior disk displacement without

reduction (closed lock).

• ADD with reduction– Common, need no treatment but for pain

• ADD without reduction– After trauma or nocturnal bruxism

Management

• Resolve with time

• Conservative treatment

• Techniques to reduce discomfort

• Disc will remain displaced

Osteoarthritis

• Disorder of articular cartilage and subchondral bone

• Secondary inflammation of the synovial membrane.

• Response of the joint to chronic microtrauma or pressure.

CLINICAL MANIFESTATIONS

• Over the age of 20 years.

• Incidence increases wiath age

• Unilateral pain directly over the condyle

• Limitation of mandibular opening

• Crepitus

• Feeling of stiffness after a period of inactivity

Radiographic findings

• Narrowing of the joint space

• Irregular joint space

• Flattening of the articular surfaces

• Osteophytic formation

• Anterior lipping of the condyle

Management

• NSAID

• Hot moist fomentation

• Soft diet

• Rest

• Occlusal splints

Myofascial Pain Dysfunction Syndrome

Etiology

• Masticatory muscle spasm

• Improper restoration

• Grinding or Clenching

– Psycho-physiologic theory

Leads to…

• Pain

• Limitation of motion

• Minor shift in the jaw rest position

• When spasm is relieved patient develops occlusal imbalance

• Degenerative arthritis & muscle contracture

• Amplification of original spasm

Clinical symptoms

• Pain

• Muscle tenderness

• Clicking or popping noise

• Limitation of jaw motion

Negative findings

• Absence of changes in the joint– Clinical– Roentgenographic

• Lack of tenderness in joint

Diagnostic Imaging

Is of value in selected conditions but not as a

part of a standard assessment , should be

considered only when clinical presentation

suggests a progressive pathologic condition

like osteodegenerative disease, fractures or

tumors of bone.

Tomograms for evaluation of bony structures

MRI for evaluation of soft tissue

Imaging Options

• Radiographs– OPG– Extra oral views

• Arthrography

• CT

• MRI

• Bone scan

• 3 D reconstruction from CT, MRI

Radiographs

Transorbital View

Transpharyngeal View

OPG

OPG

Degenerative osteoarthritis TMJ Tomogram

Normal TMJ Tomogram

Degenerative osteoarthritis with osteophyte TMJ Tomogram

MRI

Treatment

• Education & Information

• Self-care & Habit reversal

• Physiotherapy

• Intraoral appliances

• Pharmacotherapy

• Behavioural therapy & Relaxation technique

• Trigger point therapy