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TEMPOROMANDIBULAR DISORDERS AND ITS

MANAGEMENT

Temporomandibular disorders embrace a wide spectrum of

specific and non-specific disorders that produce symptoms of pain

and dysfunction of the muscles of mastication and

temporomandibular joints.

Temporomandibular Joint Dysfunction is applied in a more

restricted sense to smaller cluster of related, relatively non-specific

disorders of TMJ and muscles of mastication that have many

symptoms in common.

SIGNS AND SYMPTOMS OF TMJ DYSFUNCTION

SIGN: Objective clinical finding revealed during an eamination.

SYMPTOM: ! description or complaint by the patient.

The commonly occurring symptoms are"

#$ %ain.

&$ Joint sounds.

'$ (imitation of mandibular movements.

)$ *ar symptoms.

+$ ecurrent headache.

#



1) Pain:

Origin Muscles, TMJ, Dentition

Muscle:

- %ain felt in muscle is called myalgia.

- Two main factors of myogenic pain are"

Mechanical trauma, Muscle fatigue.

Mechanical tau!a:

- Macrotrauma arises from an eternal force such as

blow to the face.

- Microtrauma arises in the absence of eternal force and

is commonly associated with parafunction such as bruism.

Muscle "ati#ue:

- ustained static muscle contraction can cause localied

ischaemic and an alteration in muscle fibre membrane

permeability that results in local oedema.

- (ocalied tender areas of muscle which may be

associated with firm bands or /nots of muscles are /nown as

trigger points and is termed myofascial pain.

&



- Myogenic pain is a type of deep pain and if it becomes

constant can produce central ecitatory effects which may

present as referred pain, secondary hyperalgesia or even

autonomic effects.

Aticula $ain

- 0t can arise as a result of inflammation of articular and

periarticular tissues caused by overloading or trauma to those

tissues.

Dentiti%n:

- These are commonly associated with brea/down

created by heavy occlusal forces to the teeth and their

supportive structures.

a$ Mobility - Due to loss of bone support

- 1eavy occlusal forces.

- (oss of bone support is primarily due to periodontal

disease.

'



- 2hen heavy horiontal forces are applied to the bone,

the pressure side of the root shows signs of necrosis and

opposite side shows signs of vascular dilation and elongation

of periodontal l igament. This increases the width of

periodontal space on both sides of the tooth which is init ially

filled with granulation tissue which changes gradually to

collagenous and fibrous connective tissue. This increased

width caused increased mobility.

b) Tooth wear:

This is observed as shiny flat areas of the teeth that do not

match occlusal form of tooth. This area of wear is called wear

facet, the etiology stems almost entirely from parafunctional and

not-functional activities.

&' J%int S%un(s

There are two types of joint sounds"

a) Crepitus

)



This is a grating or scraping noise that occurs on jaw

movement which can be noticed by the patient and often can be

palpated by the clinician. 0t is said by the patient to feel li/e sand

paper rubbing together. 0t is caused by roughened, irregular

articular surfaces of the osteoarthritic joint.

b) Clickin

This is caused by uncoordinated movement of condylar head

and TMJ disc.

Causes %" TMJ clic)in# *+lien,e#- .//.'

D0s"uncti%n:

#. 3lic/ associated with deviation in form of condyle, dis/ and

temporal fossa.

&. 3lic/ associated with neuromuscular dysfunction.

'. *minence clic/.

). 3lic/ 4reciprocal$ with anterior disc displacement.

+. 3lic/ associated with hypermobility.

5. Teethered disc clic/.

+



Cause:

i. emodelling and morphologic changes of the

articular surfaces and disc perforations may provide

mechanical obstruction to condylar translation.

ii. 6ncoordinated movement may be due to

dysfunction of controlling muscles, the lateral

pterygoid or masseter muscles.

i ii . *minence clic/ occurs in association with a forced

joint opening with a protrusive opening arc. This

can occur unconsciously for eample with 3lass 00

occlusion or as a delibrate movement.

iv. The anterosuperior part of the mandibular condyle

is normally related to central fossa of the disc. The

disc in some cases however may become displaced.

!nterior displacement of the disc in the joint space

causes a clic/ to occur as the condylar head moves

across the posterior ridge of the disc. This ta/es

place both on opening and closing movements of

5



the mouth. ! double clic/ is thus produced and is

referred to as reciprocal clic/ing. This condition

may progress to closed cloc/ when head of condyle

becomes unable to pass across posterior ridge. This

will result in limitation of opening of mouth.

v. 1ypermobility clic/ occurs when the head of the

condyle clic/s over the anterior ridge of the disc

when the mouth is wide open.

vi . Teethered disc cl ic/. ! posterior disc at tachment

that has been damaged as a result of trauma may

prevent the translation of TMJ disc that should

occur on opening the mouth. eciprocal clic/ing

may occur as the head of the condyle passes over

the anterior band of the meniscus on opening and

closing the mouth.

1' Li!itati%n %" !an(i,ula !%2e!ent

a) Muscular restriction:

7



The restriction is caused by contraction in a group of muscles

and can be produced by forceful stretching of muscle or its

synergists or as a response to pain, either in the muscle or its

synergists, or around the joint. Difficulties in opening the mouth

after complicated tooth etractions and mandibular nerve bloc/s

might be caused by refle muscular inhibition or intramuscular

haemorrhage.

b) !isc "isplace#ent : close" lock:

!n anteriorly displaced disc may prevent the forward

translation of the mandibular condyle which results in limitation

of opening of the mouth, i.e. closed loc/. 3linical signs are

reduced opening capacity, mandibular deviation on opening and

tenderness to palpation of the affected TMJ. The early or acute

closed loc/ may result in interincisal opening of less than

'+mm.

c) $ia#entous %estrictions:

8



ometimes ligaments become stretched and thus

hypermobility results with possible se9uele i.e. dislocation of

the joint rather than restriction of movement. the

sphenomandibular ligament can sometimes be too short to

permit a normal mouth opening capacity.

") !islocation:

On wide opening of the mouth the head of the condyle

normally passes over the articular eminence occasionally a

patient may be unable to close the mouth because the condyle

cannot return into the fossa. The mouth will be wide open and a

feeling of panic is observed.

e) &ar sy#pto#s:

ubjective ear symptoms are commonly associated with TMJ

dysfunction. ymptoms include tinnitus, itching in the ear, a

bloc/ed feeling and vertigo. The symptoms are probably due to

functional disturbance of the *ustachian tube. The masseter

:



hyperfunction may lead to vibration and clones of tensor

tympani muscle which is also innervated by trigeminal nerve.

#;



') %ecurrent hea"ache

0 t fre9uently accompanies pain and tenderness in the

masticatory muscles. <ruism can produce temporal headache in

the absence of other subjective symptoms but the temporal

muscle is then usually tender to palpation and is often a

symptom of generalied tension related to an associated aniety

state.

AETIOLOGY

The aetiology of symptoms of TMJ dysfunction are generally

multifactorial. They have been described as being"

#. %redisposing.

&. %recipitating.

'. %erpetuating.

1( Pre"isposin 'actors:

=arious anatomical, physiological and biochemical factors

predispose an individual to TMJ dysfunction as may occur in

genetic or inherited disorders. 0n addition, neurological,

##



vascular, nutritional or metabolic disorders can affect the

musculos/eletal tissues and predispose an individual to TMJ

problems.

>Travell? pointed out that when muscles are subjected to

noious stimulation of various sorts 4mechanical, emotional,

infectious, metabolic or nutritional$ they develop spasm and

shorten. ! muscle in spasm will be unable to rela voluntarily

and it resists passive lengthening which results in poor

neuromuscular coordination.

( Precipitatin 'actors

a. tress @ %sychological factors"

3hronic stress plays a crucial role in aetiology of symptoms

of TMJ dysfunction. The pathogenesis of stress related symptoms

in TMJ dysfunction is believed to be related to increased autonomic

activity causing increased facial muscle activity. 1arris et al, #::'

postulated that emotional st ress could stimulate the release of

neuropeptides which could induce painful capsulitis or synovitis.

#&



tress is also associated with habitual tooth clenching and bruism

which produces TMJ dysfunction. =arious necrotic conditions such

as aniety neurosis, minor stress disorders and post traumatic stress

syndrome are also associated with increased muscular activity and

may be important aetiologic factors in TMJ dysfunction.

b. <ruism"

0t is defined as purposeless rhythmical habitual tooth

clinching or grinding movements which may occur either while

awa/e or during sleep.

Aeti%l%#0

i) Psychic stress:

0nvestigations have confirmed that stressful daytime

situations such as domestic 9uarrels, violent cinema films etc.

evo/e an immediate increase in muscular activity and such stressful

situations are found to be correlated with high levels of tooth

grinding at night.

#'



ii) Occlusal inter'erence:

%remature occlusal contacts on closure of the mandible in the

retruded contact position and balancing side interferences have

been found to be relatively more fre9uent in bruism.

iii) Other 'actors:

- Magnesium deficiency and other dietary factors may

elicit muscular hyperactivity.

- Muscular hyperactivity is a side effect of amphetamine

for weight reduction and levodopa in %ar/insonAs

disease.

Dia#n%sis:

- Occlusal sounds during sleep.

- Bunctional tooth surface wear.

- %er iodontal changes.

- Masticatory muscle fatigue C pain specially on wa/ing.

- Masticatory muscle tenderness.

- ecurrent head aches.

- Bractured fillings or split teeth.

#)



- oreness of oral mucosa below dentures.

- Tenderness upon percussion of teeth.

- Mucosal ridging of tongue and chee/.

E""ect %n !asticat%0 !uscles:

Masticatory muscle pain and fatigue.

E""ect %n teeth:

!n early sign is the presence of shiny facets on the functional

surfaces of teeth or restorations. Burther <ruism leads to greater

attrition of enamel, which occasionally fla/es off. 3upping of

eposed dentine occurs and in ecessive tooth wear pulpal eposure

may ta/e place.

E""ect %n $ei%(%ntal tissues:

%rotective reaction by periodontal tissues to compensate for

heavy occlusal forces results in hypertrophy of periodontal tissues.

Thic/ening of alveolar bone, eostosis formation, increased

trabeculation of alveolar process, a thic/ened periodontal

membrane consisting of heavy collagenous fibres and increased

periodontal fibre attachment to the cementum are observed.

#+



c. Oral 1abits @parafunction

! common finding in patients with TMJ dysfunction is that

they unconsciously perform purposeless jaw movements which

results in increased physical load on the masticatory muscles. The

habits involved are nailbiting, chee/ biting, pencil biting, chewing

gum and occupational conditions li/e biting thread in tetile

factories.

d. Trauma

- Trauma, such as blow to the jaw may lead to

inflammation and tissue damage perpetuating factors

li/e bruism may delay healing.

- Microtrauma may be caused by repetitive strain type

injuries that also might damage the TMJ or muscles of

mastication.

- ome patients who have suffered cervical

hyperetension C hyperfleion 4whiplash$ injury may

complain of the onset symptoms of TMJ dysfunction.

#5



- ymptoms of dysfunction are particularly common

after unilateral subcondylar fracture with significant

fracture displacement.

e. Occlusal abnormalities"

i) Occlusal deficiencies:

- ! common finding is that TMJ dysfunct ion occurs

when there is loss of molar support, which forces the

patient to chew on the anterior teeth rather than to use

them purely for incision which results in conse9uent

ris/ of overuse and pain.

- 6nilateral loss of natural teeth will result in unilateral

mastication. This will re9uire increased action by

ipsilateral lateral pterygoid and contralateral masseter

muscle.

ii) Interferences:

- 0ntroduction of an occlusal interference e .g. by an

inade9uately contoured restoration may lead to TMJ

dysfunction.

#7



- Bollowing etraction of teeth, drifting and til ting of

remaining teeth in the arch can ta/e place.

- Occlusal interferences can be created which cause

deviation of the lower jaw into an eccentric position

leading to tension and pain in the musculature.

iii) Vertical dimension

!lteration of occlusal vertical dimension may produce

symptoms of dysfunction.

Over closure for long periods and sudden increase in vertical

dimension may also be a etiological factor in TMJ dysfunction.

iv) Incisor relationship:

0ncreased overjet C overbite and open bite may also be

initiating factors in production of symptoms of TMJ dysfunction.

13 Pe$etuatin# "act%s

They may be related to any combination of predisposing or

precipitating factors. %sychoimmunological changes may also

act as perpetuating factor.

#8



CLASSIFICATION

!merican !cademy of Orofacial %ainE @ McFeil

#$ !rticular

a$ Developmental

Deviation of form.

b$ Disc displacement

2ith reduction.

2ithout reduction.

c$ 1ypermobility.

d$ Dislocation.

e$ 0nflammatory

ynovitis.

3apsulitis.

f$ !rthritides

Osteoarthrosis.

Osteoarthritis.

%olyarthritides.

g$ !n/ylosisBibrous C bony

&$ Fon-!rticular

a$ Masticatory muscle disorders.

Myofascial pain.

Myositis.

#:



pasm.

%rotective splinting.

3ontracture.

Feoplasia.

ARTICULAR

a) !e*elop#ental:

The embryonic development of TMJ is fre9uently disturbed,

leading to many /inds of abnormalities. 3ommon growth

disturbances of the bones are agenesis 4no growth$, hypoplasia

4insufficient growth$, hyperplasia 4 too much growth$ or

neoplasia 4uncontrolled, destructive growth$.

Eti%l%#0

Trauma affecting condylar head

Genetic determination

Disease of adjacent structures, such as middle ear.

- 0t is not completely understood.

- Trauma may be a contribut ing factor especia lly in

young joint, can lead to hypoplasia of the condyle

resulting in asymmetric shift or growth pattern. This

&;



ultimately causes an asymmetric shift of the mandible

with an associated malocclusion.

- Trauma can cause hyperplastic reaction resulting in

overgrowth of bone commonly seen at the site of old

fracture.

- ome hypoplastic and hyperplastic activities relate to

inherent growth act ivi ties and hormonal body

imbalances 4e.g. acromegaly$.

4ist%0:

The clinical symptoms reported by patient are directly related

to structural changes present. ince these disorders usually produce

slow changes pain is not present and patients commonly alter

function to accommodate the changes.

Clinical chaacteistics:

- 3linical asymmetry.

- %ain is secondary to structural changes.

&#



De"initi2e teat!ent:

0t must be tailored specifically to the patientAs condition.

Generally t reatment is provided to restore function while

minimiing any trauma to associated structures.

Su$$%ti2e thea$0:

ince most bone growth disorders are not associated with

pain or dysfunction, supportive therapy is not indicated. 0f pain or

dysfunction arises, then treatment is rendered according to the

problem identified.

a) !e*iation o' 'or#:

Eti%l%#0: 0t is caused by actual changes in the shape of articular

surfaces i.e. either condyle, fossa and C or the disc. !lterations

in form of bony surface may be a flattening of the condyle or

fossa or even a bony protuberance on the condyle. 3hanges in

the form of the disc include both thinning of the borders and

perforations.

&&



4ist%0:

0t is usually a long term dysfunction that may not present as a

painful condition. Often the patient has learned a pattern of

mandibular movement 4altered muscle engrams$ that avoids the

deviation in form and therefore avoids painful symptoms.


Most deviations in form cause dysfunction at a particular

point of movement when a clic/ or deviation in opening is noted, it

will always occur at the same position of opening and closing. 0t

may C may not be painful.


The definitive approach is to return the altered structure to

normal form which is often accomplished by a surgical procedure.

0n case of bony incompatibility the structures are smoothened and

recorded. 0f the disc is perforated or misshaped, it is repaired

4discoplasty$. ince surgery is a relatively aggressive procedure it

should be considered only when pain and dysfunct ion are

&'



unmanageable. Most deviations in form can be managed by

supportive therapies.

Su$$%ti2e thea$0:

- The patient should be encouraged, when possible, to

learn a manner of opening and chewing that avoids or

minimies the dysfunction.

- 0n case of increased interarticular pressure associated

with bruismCmuscle relaation appliance is indicated

to decrease muscle hyperactivity.

- 0f pain is associated, analgesics may be necessary to

prevent development of secondary central ecretory

effects.

b) !isc !isplace#ent:

otational and sideways displacements of the dis/ are most

typical ly found with the mouth closed, rota tional disc

displacement is characteried by an anterior, and medial or

lateral position of the disc with respect to an ideal position

&)



between condyle and the eminence. The sideways displacement

consists of either a medial or lateral displacement.

Classi"icati%n

a( !isk "isplace#ent with re"uction:

The dis/ is displaced from its position between the condyle

and the eminence to an anterior and medial or lateral position, but

reduces on full opening, usually resulting in a noise.

b( !isk "isplace#ent without re"uction:

! condition in which the dis/ is displaced from normal

posi tion between the condyle and the fossa to an anterior and

medial or lateral position, associated with limited mandibular

opening.

c( !isk "isplace#ent without re"uction

without li#ite" openin:

! condition in which the dis/ is displaced from its position

between the condyle and the eminence to an anterior and medial or

lateral position, not associated with limited opening.

&+



"( !isk "isplace#ent with re"uction:

Eti%l%#0: 0t results from elongation of the capsular and discal

ligaments coupled with thinning of the articular disc which

commonly results from macroCmicrotrauma. The other causes are

orthopedic instability plus joint loading.

4ist%0:

2hen macrotrauma is the etiology the patient will often

relate an event that precipitated the disorder. The patient will also

report the presence of joint sounds and catching sensation during

mouth opening.


3linical eamination 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 are common.

&5




Definitive approach is to reestablish a normal condyle-disc

relationship. The treatment goal is to reduce intracapsular pain and

not to recapture the disc.

! muscle relaation appliance should be used whenever

possible because adverse long term effects are minimal. 2hen this

appliance is not effective, an anterior repositioning appliance

should be fabricated. The patient should be initially instructed to

wear the appliance always at night during sleep and during the day

when needed to reduce symptoms. This part time use will minimie

adverse occlusal changes. !s symptoms resolve the patient is

encouraged to decrease the use of the appliance. These adaptive

changes can ta/e 8 to #; wee/s or even longer. !fter elimination of

the appliance if symptoms return and orthopedic stability is

present, dental therapy to correct this condition is indicated.

&7



Su$$%ti2e thea$0:

The patient should be educated to the mechanics of the

disorder and the adaptive process that is essential for treatment.

ofter foods, slower chewing, smaller bites should be promoted. 0f

inflammation is suspected, F!0DAs should be prescribed moist

heat or ice can be used if the patient finds either helpful. %assive

jaw movements may be helpful and on occasion destructive

manipulation by a physical therapist may assist in healing.

Disc (isl%cati%n 5ith%ut e(ucti%n:

Eti%l%#0:

Macrotrauma and microtrauma are the most common cause.

4ist%0:

%atients most often report the eact onset of this disorder. !

sudden change in range of mandibular movement occurs that is very

apparent to the patient. The history may reveal a gradual increase in

intracapsular symptoms 4clic/ing and catching$ prior to the

dislocation.

&8




*amination reveals limited mandibular opening 4&+-';mm$

with normal eccentric movement to the ipsilateral side and

restricted eccentric movement to the contralateral side.


The initial therapy should include an attempt to reduce or

recapture the disc by manual manipulation. 0n patients with longer

history, success by manual manipulation decreases rapidly.

Techni6ue "% !anual !ani$ulati%n:

The lateral pterygoid muscle must be relaed. 0f it remains

active by pain or dysfunction it should be injected with local

anesthetic prior to any attempt to reduce the disc. Definitive

treatment begins by having the patient attempt to reduce the

dislocation without assistance. The patient is as/ed to move the

mandible to the contralateral side as far as possible. Brom this

eccentric position the mouth is opened maimally. 0f it fails,

assistance with manipulating is needed. The thumb is placed

&:



intraorally over the mandibular second molar on the affected side.

The fingers are placed on the inferior border of the mandible

anterior to thumb position. Birm but controlled downward force is

then eerted on the molar and at the same time upward force is

placed by the fingers. The opposi te hand helps stabil ie the cranium

above the joint that is being distracted. 2hile the joint is thus being

distracted, the condyle is brought downward and forward which

translates it out of the fossa. 0t may be helpful also to bring the

mandible to the contralateral side during the distraction procedure

since the dis/ is li/ely to be dislocated anteriorly and medially and

a contralateral movement will move the condyle onto it better. Once

the full range of laterotrusive ecursion has been reached, the

patients is as/ed to rela while &;-'; seconds of constant

destructive force is applied to the joint. The patient then lightly

closes to the incisal end to end position on the anterior teeth and

after relaing for few seconds open wide and returns to this anterior

posi tion. !n anterior repositioning appliance is immediately placed

to prevent any clenching on the posterior teeth which would li/ely

';



redislocate the disc. 0f the disc is not successfully reduced, a

second and possibly a third attempt will be needed.

Su$$%ti2e thea$0:

%atients should be encouraged not to open too wide

especially immediately following dislocation. The patient should

also be told to decrease hard biting, no chewing gum, and generally

avoid anything that aggravates the condition. 0f pain is present, heat

or ice may be used. F!0DAs are indicated for pain and

inflammation. Joint distraction and phonophereses around the joint

area can be helpful.

Su#ical c%nsi(eati%ns "% c%n(0le (isc (ean#e!ent

(is%(es3

urgery should be considered only when conservative therapy

fails to resolve ade9uately the symptoms and or progression of the

disorder.

'#



Ath%cetesis:

- Most conservative surgical procedures.

- Two needles are placed into the joint and sterile saline

solution is passed through lavaging the joint. The

lavage is thought to eliminate much of the algogenic

substances and brea/down by products that produce the

pain.

Pu!$in# the 7%int:

0n 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.

Ath%sc%$0:

!n arthroscopy is placed into the superior joint space and the

intercapsular structures are visualied on a monitor. This procedure

appears to be very successful in reducing symptoms and improving

movement. 0t helps in improving disc mobility.

'&



Ath%t%!0:

0t is a open joint surgery. ! variety of arthrotomy procedures

can be performed when disc is displaced or dislocated, the surgical

procedure of choice is plication during which a portion of the

retrodiscal tissue and inferior lamina is removed and the disc is

retracted posteriorly and secured with sutures.

Disect%!0:

2hen disc is damaged and can no longer be maintained for

use in the joint the disc is removed. 0t leaves a bone to bone

articulation which is li/ely to produce some osteoarthritic changes.

!nother choice is to remove the disc and replace it with a substitute

@ Discal implants which include medical si last ic, proplast-Teflon,

Dermal and auricular cartilage grafts.

Imaging of disk displacements can be done by:

- Transcranial radiography.

- Tomography.

- !rthrography.

- 3omputed tomography.

''



- Magnetic resonance imaging.

- !rthroscopy.

- 6ltrasonography.

c) +yper#obility:

1ypermobility does not necessarily represent a pathologic

condition. The term hypermobility implies there is radiographic or

clinical evidence that the mid ais of the mandibular condyle is

translating beyond the pea/ of the articular eminence.

0t is also preferred to as subluation. 3linical observations of

affected joints reveal that as the mouth opens to its fullest etent a

momentary pause occurs, followed by a sudden jump or leap to

maimally open position. The jump does not produce a clic/ing

sound but instead is accompanied by more of a thud. During

maimum opening the lateral poles of the condyles will jump

forward, causing a noticeable preauricular depression. ubluation

is more li/ely to occur in a TMJ whose articular eminence has a

short setup posterior shape followed by a longer flatter anterior

slope. During opening the steep eminence re9uires a significant

')



amount of discal rotation to occur before the condyle reaches the

crest. !s the condyle reaches the crest, the disc rotates on the

condyle to the posteriorly maimum degree allowed by the anterior

capsular ligament. 0n subluating joint maimum rotational

movement of the disc is reached before the maimum translation of

the condyle. Therefore as the mouth opens wider the last portion of

the translatory movement occurs with a bodily shift of the condyle

and disc as a unit. This is abnormal and it creates a 9uic/ forward

leap and thud of the condyle disc comple.

De"initi2e teat!ent

- urgical alteration of the joint.

E!inect%!0

0t reduces the steepness of the articular eminence and thus

reduces the amount of posterior rotation of the disc on the condyle

during full translation.

'+



Su$$%ti2e thea$0:

The patient must learn to restrict opening so as not to reach

the point of translation that initiates the interference. On occasion,

when the interference cannot be voluntarily resolved, an intraoral

device to restrict movement is employed. 2earing the device

develops a myostatic contracture of the elevator muscles, thus

limiting opening to the point of subluation. The device is worn for

& months and removed, allowing the contracture to limit the

opening.

DISLOCATION

Spontaneous "islocation:

This is commonly referred to as an open-loc/.

Eti%l%#0:

2hen the mouth opens to its fullest etent, the condyle is

translated to its anterior limit. 0n this position the disc is rotated to

its most posterior etent on the condyle. 0f the condyle moves

beyond this limit, the disc can be forced thorough the disc space

'5



and trapped in this anterior position as the disc space collapses as a

result of the condyle moving superiorly against the articular

eminence. This same spontaneous dislocation can also occur if the

superior lateral pterygoid contracts during the full l imit of

translation pulling the disc through the anterior disc space. 2hen a

spontaneous dislocation occurs the superior retrodiscal lamina

cannot retract the disc space. pontaneous reduction is further

aggravated when the elevator muscles contract, since this activity

increases the interarticular pressure and further decreases the disc

space. The reduction becomes even more unli/ely when the

superiorC inferior lateral pterygoid eperiences myopasms, which

pull the disc and condyle forward.

4ist%0:

The patient reports this condition immediately following a

wide opening movement such as a yawn or a dental procedure.

'7




The patient remains in a wide open mouth condition. %ain is

commonly present secondary to the patientAs attempts to close the

mouth.


Definitive treatment is directed toward increasing the disc

space, which allows the superior retrodiscal lamina to retract the

disc. 2hen attempts are being made to reduce the dislocation the

patient must open wide as if yawning. This will activate the

mandibular depressors and inhibit the elevators. !t the same time

slight posterior pressure applied to the chin will sometimes reduce

a spontaneous dislocation. 0f this is not successful, the thumb

placed on the mandibular molars and downward pressure is eerted

as the patient yawns. This will usually provide enough space to

recapture normal disc position.

'8



2hen spontaneous dislocation becomes chronic or recurrent,

definitive treatment may consist of surgical procedure directed

toward correcting the structures that contribute to the disorder.

Su$$%ti2e thea$0:

Most effective method is prevention. 2hen spontaneous

dislocation is recurrent the patient is taught the reduction. 3hronic

recurrent dislocations are treated by surgical procedure.

In"la!!at%0 (is%(es:

They are generally characteried by continuous joint area

pain, often accentuated by function. ince the pain is constant, it

can also result in secondary central ecilatory effects such as cyclic

muscle pain, hyperalgesia and referred pain.

The four categories are"

a$ ynovitis.

b$ 3apsulit is .

c$ etrodiscitis.

d$ !rthrritides.

':



e) Syno*itis an" capsulitis:

These both can be distinguished only by visualiing the

tissues through arthroscopy or arthrotomy.

Eti%l%#0:

Trauma Macro

Micro0nfection from adjacent structures.

4ist%0:

1istory of macrotrauma such as a blow to the chin. Trauma is

most li/ely to cause injury to the capsular ligament when teeth are

separated.


!ny movement that tends to elongate the capsular ligament

will accentuate the pain which is reported to be directly in front of

the ear and the lateral aspect of the condyle is usually tender to

palpation.

);




ince the etiology is self limiting there is no definitive

treatment indicated when recurrence of trauma is li/ely, efforts are

made to protect the joint from any further injury.

Su$$%ti2e thea$0:

- The pat ient is instructed to restrict a ll mandibular

movements within painless limits-soft diet, slow

movements and small bites are necessary.

- %atients with constant pain should receive mild

analgesics.

- Moist heat )-+ times a day for #;-#+ minutes.

- 6ltrasound therapy @ &-) times C wee/.

- ingle injection of corticosteriod to the capsular

tissues. epeated injections are contraindicated.

)#



b) %etro"iscitis

0t is a inflammatory condition of retrodiscal tissues. 0t is a

common intracapsular disorder.

Eti%l%#0

Trauma *trinsic

0ntrinsic

&,trinsic: 3reated by a sudden movement of the condyle into the

retrodiscal tissues. These tissues often respond to this type of

trauma with inflammation which leads to swelling and on occasion

trauma to the retrodiscal tissues cause intercapsular hemarthrosis.

Intrinsic trau#a: Occurs when an anterior functional displacement

or dislocation of the disc is present.

4ist%0

%atients eperiencing retrodiscitis caused by intrinsic trauma

will report a more subtle history with a gradual onset of the pain

problem. They are also li/ely to report the progressive onset of the

condition 4clic/ing cathing$.

)&



%atients eperiencing retrodiites caused by etrinsic trauma

will report the incidence in the history.


- 3onstant periauricular pain that is accentuated with

jaw movement.

- 3leansing the teeth, increases the pain.

- 0f the tissues swell a loss of posterior occlusal contact

can occur on the ipsilateral side.

De"initi2e teat!ent "%! e8tinsic tau!a:

ince etiologic factor of trauma is generally no longer

present there is no defini tive treatment. 2hen trauma is li/ely to

occur, care must be ta/en to protect the joint.

Su$$%ti2e thea$0 "% et%(iscites "%! e8tinsic tau!a:

0f no evidence of acute malocclusion is found, the patient is

given analgesics for pain and instructed to restrict movement to

within painless limits and begin a soft diet. To decrease the

)'



li/elihood of an/ylosis, movement is encouraged. 6ltrasound and

chemotherapy are often helpful in reducing pain. 0f pain persists, a

single intracapsular injection of corticosteroids may be used in

isolated cases of trauma, but repeated injections are

contraindicated. ! muscle relaation appliance should be fabricated

to stabilie the occlusal condition and eliminate further loading of

the retrodiscal tissues. On occasion when acute malocclusion

results from etrinsic trauma, intermaillary fiation may be

indicated to reestablish the proper occlusal conditions. 0f

intermaillary fiation is used, the mandible should be freed at

least twice a day for atleast #; minutes of movement.

De"initi2e teat!ent "% et%(iscites "%! intinsic tau!a:

Definitive treatment is directed towards eliminating

traumatic condition. !n anterior repositioning appliance is used to

reposition the condyle off the retrodiscal tissues and onto the disc.

))



Su$$%ti2e thea$0 "% et%(iscitis "%! intinsic tau!a:

upportive therapy begins with voluntary restricting use of

the mandible to within painless limits. !nalgesics are prescribed

when pain is not resolved with repositioning appliance.

Thermotherapy and ultrasound can be helpful in controlling

symptoms. ince the inflammatory condition is often chronic intra-

articular injection of corticosteroids is generally not indicated.

Athitis:

!rthritis means inflammation of the articular surfaces of the

joint . The different types are"

Osteoarthritis

Osteoarthrosis

%olyarthritides

Oste%athitis

- These are the most common arthritis. They are also

referred to as degenerative joint disease.

)+



Eti%l%#0

Overloading of the articular structures of the joint. This may

occur when joint surfaces are compromised by disc dislocation and

retrodiscites.

4ist%0:

eport of unilateral joint pain that is aggravated by

mandibular movement. The pain is usually constant but often

worsens in the late afternoon or evening.


- (imited mandibular opening is characteried because

of joint pain.

- ! soft end feel is common unless the osteoarthritis is

associated with an anteriorly displaced disc.

- 3repitation can be typically felt.

- (ateral palpation of the condyle increases the pain as

does manual loading of the joint. The patient may have

)5



symptoms for as long as 5 months before there is

enough demineraliation of bone to show up

radiographically.


- The mechanical loading should be decreased.

- The condyle-disc relationship, anterior repositioning

appliance therapy should be used. 2hen muscle

hyperactivity is suspected, a muscle relaation

appliance is indicated. !ny oral habits that create pain

in the joint must be identified and discouraged.

Su$$%ti2e thea$0

0t begins with an eplanation of the disease process to the

patient. !long with the fabrication of an appliance in a comfortable

mandibular position. %ain medication and anti-inflammatory agents

are prescribed to decrease the general inflammatory response. !

soft diet is instituted. Thermotherapy is usually helpful in reducing

symptoms.

)7



Oste%ath%sis:

Eti%l%#0

- Joint overloading.

4ist%0

ince osteoarthrosis represents a stable adaptive phase

symptoms are not reported by the patient.


Ostearthrosis is confirmed when structural changes in the

subarticular bone are seen on radiographs but no clinical symptoms

of pain are reported by the patient.

De"initi2e teat!ent

ince osteoarthrosis represents an adaptive process, no

therapy is indicated for the condition. The only treatment that may

be considered is if bony changes in the condyle have been

significant enough to alter the occlusal condition.

P%l0athiti(es:

The si categories are"

- Traumatic arthri tis .

)8



- 0nfectious arthri tis .

- heumatoid arthrit is.

- 1yperuricemia.

- %siorat ic arthri tis .

- !n/ylosing spondylitis.

Tau!atic athitis

2hen the condyle receives sudden macrotrauma a secondary

arthritic condition can develop. This traumatic arthritic condition

can lead to sudden loss of subarticular bone.


Definitive treatment is not indicated when future trauma is

epected, he should be protected 4e.g. a mouth protector for sports$.

Su$$%ti2e thea$0:

0t begins with rest, jaw use should be decreased and soft diet

is instituted.

Fon steroidal antiinflamamtory medications are given to

reduce the inflammation. Moist heat is helpful. ! muscle relaation

appliance is indicated if there is increased pain to occlude the teeth

):



or if bruism is present. Dental therapy should not begin until

symptoms have been totally resolved.

In"ecti%us athitis:

The common cause is trauma such as a punctured wound. !

spreading infection from adjacent structures is also possible.

De"initi2e teat!ent

0nitiate appropriate antibiotic medication to eliminate the

invading organism.

Su$$%ti2e thea$0

!fter the infection has been controlled, supportive therapy

may be considered and should be directed at maintaining or

increasing the normal range of mandibular movement to avoid

post infection fibrosis or adhesions. %assive eercises and

ultrasound may be helpful.

+;



Rheu!at%i( athitis

This condition produces a persistent inflammatory synovites

that leads to the destruction of the articular surface and subarticular

bone.


There is no definitive treatment

Su$$%ti2e thea$0

0t is directed toward pain reduction. ometimes a muscle

relaation appliance can decrease forces on the articular surfaces

and thereby decrease pain.

40$euice!ia *#%ut'

0t is an arthritic condition in which an increase in serum urate

concentrations precipitates urate crystals in certain joints.

De"initi2e teat!ent

0t is directed towards lowering serum urate concentration.

The most effective method may be merely the elimination of certain

+#



foods from the diet. 1owever since this is a systemic problem, gout

is usually best managed on a medical basis by the patients

physic ian.

Su$$%ti2e thea$0

The patients physician will be treating the patient on a

medical basis.

Ps%iatic athitis

De"initi2e teat!ent

ince etiology is un/nown there is no definitive treatment

available.

Su$$%ti2e teat!ent

Often F!0D is helpful. Gentle physical therapy to maintain

joint mobility is important since hypermobility is often a

conse9uence of this disorder. On occasion moist heat and

ultrasound therapy may reduce symptoms and increase joint

mobility.

+&



An)0l%sin# s$%n(0litis

The clinician should be suspicious of an/ylosing spondylitis

when a patient reports with a painful, hypomobile joint, no history

of trauma, and nec/ or bac/ complaints.


Fo defini tive treatment is available.

Su$$%ti2e thea$0

Gentle physical therapy to improve joint mobili ty is

indicated, but care should be ta/en not to be too aggressive and

increase symptoms. On occasion moist heat and ultrasound therapy

may also be helpful.

An)0l%sis

0t means abnormal immobility of joint. 0t may be<ony

Bibrous

! fibrous an/ylosis is most common and can occur between

the condyle and the disc and the fossa.

+'



! bony an/ylosis of the TMJ would occur between the

condyle and fossa and therefore the disc would have to have been

lost already from the discal space.

Eti%l%#0:

3ommon etiology @ 1aemarthrosis secondary to

macrotrauma. Bibrous an/ylosis represents a continued progression

of joint adhesions that gradually create a significant limitation in

joint movement.

4ist%0

%atients report limited mouth opening without any pain. The

patient is aware that this condit ion has been present for a long time

and may not even feel that it poses a significant problem.

Clinical chaacteistics

The condyle can still rotate with some degree of restriction

on the inferior surface of the disc. Therefore the patient is usually

able to open approimately &+mm interincisally, lateral movements

are restricted. The clinical eamination discloses a normal range of

+)



lateral movement to the affected side. During mouth opening

pathway difficult to the ipsi lateral side. Fo condylar movement is

felt or visualied on a radiograph.

De"initi2e teat!ent

0f function is inade9uate or the restriction is intolerable,

surgery is the only definitive treatment available.

Su$$%ti2e thea$0

ince an/ylosis is normally asymptomatic generally no

supportive therapy is indicated. 1owever, if the mandible is forced

beyond its restriction, injury to the tissues can occur. 0f pain and

inflammation result, supportive therapy is called for and consists of

voluantarily restricting movement to either painless limits.

!n/ylosis along with deep heat therapy can also be used.

++



Re"eences:

#. Harb !. George " TMJ and masticatory muscle disorders,

*d. &.

&. Briction . James " !dvances in pain research. =ol. &.

'. O/enson %. Jeffrey " Management of temporomandibular

disorders and occlusion. *d. '.

). Trowell Janet" Temporomandibular joint pain referred from

muscles of the head and nec/. J %rosthet Dent #:5;I #;" 7)+-

75'.

+. <runo !. ebasteen " Feuromuscular disturbances causing

temporomandibular dysfunction and pain. J %rosthet Dent

#:7#I &5" '87-':7.

5. McFeill 3harles " Management of temporomandibular

disorders. J %rosthet Dent #::7I 77" +#;-&&.

7. O/enson %. Jeffrey " Fon surgical management of disc

interference disorders. Dent 3lin Forth !m '+" &:-)8.

8. =aughan 3ree, 1omer" Temporomandibular joint pain. J

%rosthet Dent #:+)I )" 5:+-7;8.

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