9

THE TEMPOROMANDIBULAR JOINT

Michael B. Goldberg • Howard C. Tenenbaum •
Bruce V. Freeman • Adel G. Fam

Applied Anatomy of the joint, between the temporal bone and the articular
disk, acts as a sliding joint; it allows both disk and mandible
The temporomandibular joint (TMJ) is an articulation to glide anteriorly, posteriorly, and laterally (left or right)
between the mandibular condyle and both the mandibular along the slope of the articular eminence. The eminence is
(glenoid) fossa and the articular eminence (tubercle) of the the primary functional area of the temporal bone during
temporal bone (Figure 9‑1). The paired TMJs are classified mandibular movement. Normal opening and closing of the
as condylar joints, because the mandible articulates with mouth, a combination of rotation and translation move‑
the skull by means of two distinct articular surfaces, or con‑ ments, relies on function in both compartments of each
dyles. Unlike other synovial (diarthrodial) articulations, the joint. Further, it depends on a smooth sliding of the disk
articulating surfaces of the TMJ are covered by fibrocartilage down the slope of the eminence. During mouth opening,
in place of hyaline cartilage. An intraarticular fibrocartilagi- the condyles glide forward over the articular eminence with
nous disk (meniscus) divides the joint into a large superior the disk in between. Therefore, during mouth opening, the
and a smaller inferior compartment, each lined with syno‑ condyles rest on the articular eminences, and any sudden
vial membrane (see Figure 9‑1). The disk consists of a thin, movement, such as wide mouth opening that might occur
central portion; a thick, large, highly innervated and more during yawning, and some forms of trauma may displace
vascular posterior portion (posterior band); and a smaller one or both condyles anteriorly and even past the articular
anterior portion (anterior band). The disk is tightly bound eminence, a process that can lead to open lock of the man‑
to the medial and lateral poles of the mandibular condyle. It dible.
provides congruent contours, acts as a shock absorber during In the closed position, the mandible lies in the glenoid
mastication, and stabilizes the joint during mandibular move‑ fossa, in contact with the posterior band of the disk (see
ments. The stability of the TMJ depends on the osseous, con‑ Figure 9-1). In the resting position, the mouth is slightly
formation, muscles of mastication, capsule, ligaments, and open so that the teeth are not in contact. In centric occlu-
intraarticular disk. The capsule is thin and loose and allows sion occurs with maximal contact of the teeth, the position
a wide range of movements. It is attached to the condyle and assumed by the jaw when swallowing.
to the articular eminence, and it is reinforced on the lateral
aspect by the lateral temporomandibular ligament and on TEETH
the medial aspect by the sphenomandibular ligament.
In humans, there are 20 deciduous—primary or “baby”—
teeth, and 32 secondary, or permanent, teeth. Deciduous
MOVEMENTS
teeth are shed between the ages of 6 and 13 years. To identify
Mastication, swallowing, and speech are associated with or label the secondary teeth for the purposes of communi‑
movements at the TMJs. The two joints move in unison cation and treatment, their locations are divided into four
and are limited and guided by dental occlusion during early quadrants: upper left (quadrant 1), upper right (quadrant 2),
opening and closing movements of the jaw. Therefore, the lower left (quadrant 3), and lower right (quadrant 4). When
TMJs and teeth are often referred to as a tri-joint complex. labeling or identifying deciduous teeth, the quadrants are
However, later movements, beyond 2 mm opening, are continued so that deciduous teeth would be found in quad‑
guided by the musculoligamentous components of the TMJ rants 5 through 8, with quadrant 5 being the deciduous “part‑
and are not related to dental occlusion or bite. Movements ner” of quadrant 1, used for secondary teeth and so on. In
at the TMJs have two components: rotation, which occurs each quadrant, the teeth are numbered from 1 (most medial)
during the very first stages of jaw opening, and translation, to 8 (most distal). Therefore, a mandibular right first molar
which occurs with wider opening. These movements are would be called tooth 4.6, or simply 46, and a first mandibu‑
guided by the various components of the TMJ system and lar deciduous molar on the right side would be labeled tooth
structure. The inferior compartment of the joint, between 8.5, or 85. Loss or restoration of teeth and malocclusion has
the mandibular condyle and the articular disk, functions as a been considered a major factor in the development of TMJ
hinge joint that allows mandibular rotation. The upper head pain. Although this used to be considered a major risk factor
of the lateral pterygoid muscle draws the disk ­anteriorly to for TMJ dysfunction, unless the occlusal changes are so great
prepare for condylar rotation. The ­superior compartment as to render the occlusion nonfunctional (e.g., no posterior
119

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120 THE TEMPOROMANDIBULAR JOINT

Mandibular eminence (tubercle)

Intraarticular disk
Mandibular fossa
Superior compartment
Inferior compartment
Mandibular condyle
Mastoid process
External auditory meatus
Styloid process
Coronoid process of mandible

A B
FIGURE 9-1 THE TEMPOROMANDIBULAR JOINT. A, Mouth closed: Mandibular condyle and disk lie within the mandibular fossa.
B, Mouth open: The mandibular condyle and disk glide forward and lie over the articular eminence.

occlusion at all), it is no longer considered as such (De Locking of the TMJs can be caused by subluxation of the
Boever, 2000). joint or, more likely, may be caused by anterior displacement
without reduction of the meniscus (i.e., TMJ disk). Clicking,
NERVE SUPPLY
popping, or snapping of TMJs, often bilateral, occurs when
the TMJ disk is positioned anterior to its normal position.
The TMJs are innervated by the auriculotemporal and mas‑ However, in contrast to a locked joint, opening movement
seteric branches of the mandibular division of the trigeminal that requires translation of the TMJs can cause popping or
nerve. clicking in one or both of these joints that may be audible
or at least detected by palpation. This phenomenon occurs
because the joint actually snaps back over the displaced
Temporomandibular Joint Pain disk, leading to the reestablishment of a normal relation‑
ship between the condyle and the central zone of the disk
and History Taking (Westesson, 1985). Other causes of clicking and popping
can include a meniscal tear, uncoordinated lateral pterygoid
Pain reported in the TMJ is a relatively common symptom, muscle action, and ­osteoarthritis (OA).
but it can have diverse causes. It may originate in the TMJ
itself, or it may be referred from the teeth, ear, parotid gland,
muscles of mastication, cervical spine, or head (Table 9-1).
Important points in the history include site, duration, char‑
Physical Examination
acter, radiation, and provocative factors of TMJ pain. The INSPECTION
physician may also inquire about any recent dental work and
whether a patient grinds the teeth. Both ­bruxism—forced The TMJs are inspected for pain, swelling, redness, sym‑
clenching and grinding of the teeth, especially during sleep— metry, clicking, crepitus, abnormal movements such as
and habitual nail biting have been associated with a tem‑ asymmetric translation, lack of movement, and hypermo‑
poromandibular disorder syndrome, which will be discussed bility. Effusion of the TMJ manifests as a rounded bulge
later. However, these are basically associations and to date just anterior to the external auditory meatus. Arthritis of
have not been demonstrated to be causal. That said, these the TMJs, particularly rheumatoid (and not OA), can pre‑
characteristics might have an impact on pain severity, tim‑ dispose to the development of an obvious anterior open
ing, and responsiveness to treatment. In fact, apart from TMJ bite, in which the patient cannot bring his or her anterior
pain syndromes that arise following ­hyperextension-flexion teeth together (e.g., to bite off a piece of thread). In children
injury, most of these conditions are idiopathic in nature this might also result in the development of a disturbance
(Romanelli, 1992; Goldberg, 1996; and Brooke, 1978). of bone growth leading to a shortened, recessed lower jaw

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 THE TEMPOROMANDIBULAR JOINT 121

TABLE 9-1 freeway space between the anterior teeth (normal range 2
to 4 mm) (Kerr, 1974). By palpating the condyle and noting
DIFFERENTIAL DIAGNOSIS OF
its location within the mandibular fossa with the patient’s
TEMPOROMANDIBULAR JOINT (TMJ) PAIN
mouth closed, partially open, and wide open, the examiner
Arthritis of the TMJ can determine various degrees of dislocation.
Osteoarthritis (OA) When assessing for pain, one generally tries to main‑
Rheumatoid arthritis (RA) tain a consistent force of palpation. If tissues are clinically
Psoriatic arthritis (PsA) tender, it is generally recommended that the force needed
Ankylosing spondylitis (AS) to evoke a meaningful pain reaction is that which, when
Juvenile idiopathic arthritis (JIA) pressing the finger on a tabletop, the fingernail bed will
Trauma
blanch. If the pressure is too light, clinically tender tis‑
Infection
Gout
sues will not be identified; similarly, if too much force is
applied, even normal tissues will be perceived as painful.
Temporomandibular Disorder Syndrome (TMDS)
For the purposes of standardization, it is also helpful to
Internal Derangement due to Meniscal Displacement grade a patient’s pain reaction following palpation of the
Condylar Agenesis, Hypoplasia (Retrognathism), TMJs and surrounding musculature. In this case, a discon‑
and Hyperplasia (Prognathism) tinuous but relatively reliable scale has been developed, as
Neoplasms of the TMJ (rare) shown in Table 9-2.
Chondroma
Osteochondroma
RANGE OF MOVEMENT
Osteoma
Referred TMJ Pain Active TMJ movements include opening and closing of the
From the parotid salivary gland mouth, protrusion, retrusion, and lateral or side-to-side
From the paranasal sinuses excursions of the mandible. During opening (depression)
From the ear and closing (elevation or occlusion) of the mouth, the two
From the teeth TMJs (inferior compartments) work in unison to produce
From the nasopharynx a smooth, unbroken arc of movement without any asym‑
From the cervical spine metry or sideways movement. Deviation of the chin to one
Other Causes of Facial Pain side is generally caused by ipsilateral TMJ, severe degenera‑
Trigeminal neuralgia tive changes that would generally be seen only in rheumatoid
Giant cell (temporal) arteritis arthritis, physical trauma (e.g., fracture of the neck of the
Migraine headache ipsilateral condyle), and, in some cases, spasm of the mas‑
Cerebral tumors, tetanus, Parkinsonism seter or lateral or medial pterygoid muscles.
Fibromyalgia The range of vertical movement during opening and
Psychosomatic TMJ pain closing of the mouth is determined by measuring, with a
ruler or calipers, the distance between the maxillary and
mandibular central incisors during maximal unassisted or
and excessive overjet. While excessive overjet may result assisted opening (see the discussion that follows on pas‑
from various causes, be they congenital or acquired, there sive movements of the TMJ). This range is often referred
are no studies revealing a conclusive relationship between to as the interincisal range of opening (normal range 35
factors of occlusion, such as overjet and overbite, with the to 60 mm). Although this measurement is relatively repro‑
development of temporomandibular dysfunction (TMD) ducible, inaccurate measurements can be made in patients
(Gersh et al, 2004). It should also be recognized that other wearing dentures or in those who have otherwise lost max‑
diseases can cause lysis or destruction of one or both TMJs, illary anterior teeth that have then been replaced prostheti‑
including neoplasia (benign or malignant), and these must cally. In hypomobile TMJs, the distance is less than 35 mm,
be ruled out in the absence of a history consistent with adult and the displacement can be so severe as to be less than or
or juvenile rheumatoid disease. equal to 1.5 cm, therefore only rotational movement of the
condyles would be detected.
PALPATION
Protrusion and retrusion of the mandible occur at the
superior compartment. Normally, the individual can both
The TMJs can be located by placing the tip of the index finger protrude the lower jaw out past the upper teeth and retract
just anterior to the external auditory meatus and asking the the lower teeth behind the upper teeth. Lateral or side-to-
patient to open the mouth about halfway. The lateral poles of side movement of the mandible occurs at the superior com‑
the TMJs will then become palpable by the tip of the exam‑ partment. This can be measured with a ruler, with the mouth
iner’s finger. The joint is palpated for warmth, tenderness, partially open and the lower jaw protruded, as the range of
synovial thickening, effusion (a fluctuant mass), crepitus, movement of the midpoint of the mandible (i.e., the space
or snapping or clicking with movement. With the patient’s between two central incisors) in relation to that of the max‑
mouth open, the TMJ can be palpated with the little finger illa (normal range 10 to 20 mm).
placed in the external auditory meatus (fleshy part anteri‑ As alluded to earlier, jaw opening can be characterized
orly). The patient is then asked to close the mouth when the as being assisted or unassisted. Unassisted opening is gen‑
examiner first feels the condyle touch the finger. With the erally close to assisted opening in extent, when there is no
mouth closed, the TMJs are in the resting position with a pain or other disease associated with either the TMJs or their

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122 THE TEMPOROMANDIBULAR JOINT

TABLE 9-2
PAIN REACTIONS FOLLOWING PALPATION/EXAMINATION
Grade 0 Grade 1 Grade 2 Grade 3
No pain reaction at all Pain reaction not visible, Visible pain reaction (movement, Visible pain reaction, often with
but when asked, patient pupillary reaction) to palpation; marked avoidance on the part
confirms pain patient does not have to be of the patient as well as audible
asked if there is pain reaction (That hurts!); might note
grade 2–like reaction even before
normal palpation force has been
achieved

When using this scale for the purpose of research studies, the first two categories are often concatenated and considered negative pain reactions, and
grades 2 and 3 are concatenated and considered positive. This permits two-by-two analyses to be done and helps to reduce the effects of intraexam-
iner and interexaminer variability on outcomes. Finally, an extremely important diagnostic feature of palpation, particularly when considering diagnosis
of pain, is whether or not the patient’s chief pain complaint has been exacerbated following this type of examination. If not, the patient’s primary
pain might be related to another condition or to pain in other structures (e.g., the muscles that can be palpated separately). However, if the patient’s
primary pain is exacerbated following TMJ palpation, then the patient’s pain is likely emanating from one or both TMJs.

associated muscles, and it is measured by having the patient orofacial pain can arise as a consequence of dentoalveolar
open his or her mouth to its widest extent or to the point disease or neuropathy, which underscores the importance of
where pain interferes with such movement. Assisted opening carrying out an appropriate neurological assessment as well.
is measured, with the examiner wearing gloves, by placing For neurological assessment, the patient is asked to close
the middle finger on the incisal edges of either the maxillary the jaws tightly for assessment of size, firmness, and strength
or mandibular teeth and the thumb on the incisal edges of of the temporalis and masseter muscles. Resisted isomet‑
the opposing incisors. The thumb and middle finger are then ric testing of the muscles that close the mouth is then per‑
brought together gently and slowly, in a scissors movement, formed, including the temporalis (innervated by facial or
to determine whether it is possible to assist the mandible cranial nerve VII), the masseter (trigeminal or cranial nerve
to open more than it did with unassisted opening. In these V), and the medial pterygoid (trigeminal nerve). This is fol‑
cases, there might be too much pain to even do this. How‑ lowed by assessment of the muscles that open the mouth:
ever, in most cases this maneuver can still be done. Presum‑ the lateral pterygoid (trigeminal nerve) and the suprahyoid
ing no intraarticular disease, such as an anteriorly displaced muscles—digastric (cranial nerves V and VII), mylohyoid
TMJ meniscus without reduction, and as long as there is no (cranial nerve V), and geniohyoid (cranial nerve XII and
extremely severe pain, the mandible can be coaxed to open, the first cervical nerve, C1). Side-to-side movements of the
sometimes another 1 to 2 cm. This is also parallel to the con‑ mandible are a function of the medial and lateral pterygoids.
cept of a springy feeling at maximal opening and would gen‑ Protrusion of the mandible is a function of the lateral ptery‑
erally be consistent with a diagnosis of muscular pain and/ goids, whereas retrusion is produced by the posterior fibers
or muscle trismus that is causing a restriction in unassisted of the temporalis. In patients with hypocalcemic tetany, tap‑
opening. Alternatively, if the mandible can only be coaxed ping of the facial nerve, as it runs just in front of the tragus,
to open another 1 to 5 cm, a so-called hard feeling will be produces a momentary spasm of the ipsilateral half of the
detected. The latter finding often suggests intraarticular dis‑ face (positive Chvostek test). The jaw reflex is mediated by
ease, such as an anteriorly displaced TMJ disk without reduc‑ the trigeminal nerve.
tion. Another condition that could cause this type of finding When testing for pain in the muscles of mastication, it is
might be TMJ ankylosis related to trauma or other bone/ important to examine the external muscles—masseter, tem‑
joint disease, including infection, and it may require surgical poralis, medial pterygoid at the angle of the mandible, and
intervention (Straith, 1948). Conditions associated with TMJ sternocleidomastoid—by palpation. The internal muscles
disk position and shape will be discussed in more detail later must also be palpated; these include the masseter at its zygo‑
(see Temporomandibular Joint Pain and History Taking). matic attachment and the coronoid attachment of the tem‑
poralis. One can also palpate the medial pterygoid muscles,
but this can also induce gagging, which makes it difficult
MUSCLE TESTING AND NEUROLOGICAL
to assess for pain reactions. The lateral pterygoid muscles
ASSESSMENT
are also palpated, but in reality, it is doubtful that they can
Although there is no question that patients will present with actually be reached during a physical examination. The
jaw-associated pain because of TMJ disease, it must also be same amount of digital pressure on the muscles of mastica‑
recognized that pain in the surrounding muscles can also tion as described for palpation of the TMJs should be used.
cause pain; in most instances, this is in fact the case (Dworkin, Similarly, the patient’s pain reactions can be gauged using
1990). Moreover, most patients present with both muscular the measurement system described in Table 9-2. Equally as
and TMJ pain. In cases of combined joint and muscle pain, important, as discussed with respect to examination of the
the overall symptom profile and responses to treatment sug‑ TMJs, a patient might or might not feel pain following pal‑
gest that it is the muscular pain that is of paramount impor‑ pation; if the patient does feel pain, and the patient’s chief
tance as opposed to pain strictly in the TMJ (Hapak, 1994). pain complaint has been exacerbated following palpation
Therefore in addition to assessment of the TMJ itself, it is of the muscles of mastication, it can be concluded that the
critically important to also test for muscle pain. Furthermore, principal source of pain is muscular. That said, patients

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 THE TEMPOROMANDIBULAR JOINT 123

suffering from chronic muscle pain syndromes such as ­ ovements, but it is independent of any local oral, nasal, den‑
m
fibromyalgia, which is a common comorbid condition for tal, or ear disease. Tenderness of the muscles of mastication
patients with TMJ or associated pain in the muscles of can be identified, too; but if the condition is related mainly to
mastication (Dao, 1997), might report severe pain follow‑ joint disease, palpation of the joints, not the muscles, would
ing palpation; but their chief pain complaints might not be expected to exacerbate the patient’s chief pain complaints.
be exacerbated. This latter type of finding should suggest a
diagnosis of fibromyalgia, which would need further medi‑ INTERNAL DERANGEMENTS
cal assessment, such as examination by a rheumatologist,
neurologist, or physiatrist—three appropriate medical sub‑ The disk displacements discussed previously are also referred
specialties concerned with these conditions. to as internal derangements. The etiology is not understood
fully, but impaired lubrication due to TMJ overloading has
been implicated. Known causes include direct or indirect
Common Musculoskeletal trauma (blow to the jaw, endotracheal intubation), abnor‑
Disorders of the TMJ mal functional loading of the joint (bruxism, chronic teeth
clenching), and OA. It is noteworthy that internal derange‑
ment is so common that it has been suggested that, unless
TEMPOROMANDIBULAR ARTHRITIS
associated with pain or severely restricted opening, it is more
Temporomandibular (TM) arthritis can be caused by a variation of normal as opposed to true disease.
trauma, infection, OA, rheumatoid arthritis (RA), psori‑ Clinically, there is a painless incoordination phase ini‑
atic arthritis (PsA), ankylosing spondylitis (AS), juvenile tially, during which the patient experiences a momentary
idiopathic (rheumatoid) arthritis (JIA), or crystal-induced catching sensation on mouth opening. This is followed by
arthritis—such as gout, and even pseudogout—or calcium the clicking and popping associated with anterior disk dis‑
pyrophosphate dihydrate deposition arthropathy (Pritz‑ placement and reduction into the normal position with
ker, 1994). In some rare cases, TM arthritis may be caused mouth opening. Some patients may subsequently develop
by malignant metastatic or primary disease. The pain of TM restricted jaw movements with intermittent or permanent
arthritis may radiate to the teeth, face, or ear, and it is made locking caused by anterior disk displacement without reduc‑
worse by jaw movements during eating, chewing, and speak‑ tion on attempted mouth opening. The common factor here
ing. With regard to OA, pain usually occurs once there is loss is that in such cases, almost all patients would have reported
of the fibrous articular joint surface. As a result, the loss of this prior TMJ noises with jaw opening and/or closing (a recipro‑
protective layer exposes the innervated and vascularized osse‑ cal click) prior to the development of closed lock. Further‑
ous tissue to the effects of movement and forces that result more, on development of a closed lock caused by anterior
in pain (Okeson, 2005). Rheumatoid arthritides (includ‑ displacement without reduction, the patient will also report
ing JIA) occur as a result of proliferation of inflamed syno‑ that the clicking is no longer present. The diagnosis of inter‑
vial membranes onto the articular surfaces (Okeson, 2005). nal derangement can be confirmed by magnetic resonance
Other symptoms include stiffness, restriction of movement imaging (MRI); but in fact, history and clinical examination
with inability to fully open the mouth, swelling, clicking, are just as sensitive (Romanelli et al, 1993).
and sometimes locking. Local tenderness, swelling, synovial
thickening, effusion, fine or coarse crepitus, and sometimes
a palpable click are the main findings. In chronic arthritis, Management
excessive play of the TMJ is common.
Although abnormal TMJ signs, mostly joint noises or clicking,
are relatively common, symptoms are less frequent, and only
TEMPOROMANDIBULAR DISORDER
a minority of patients seek medical advice for them. Treat‑
SYNDROME
ment of painless TMJ clicking is not recommended, unless
Temporomandibular disorder syndrome (TMDS) is cur‑ the condition is seriously bothering the patient. If the clicking
rently referred to as temporomandibular disorder (TMD) is painful, treatment is indicated and can include treatment
in recognition of the fact that this condition can be caused with an intraoral appliance known as a biteplane. Some cli‑
by TMJ pain and muscle pain, as well as combined TMJ and nicians advocate for a biteplane that positions the mandible
muscle pain as described previously. When the condition is anteriorly so as to “recapture” the disk (Gelb, 1979). In some
predominantly caused by pain in the muscles of mastication, cases arthroscopic surgery is performed, also to recapture
it can also be referred to as myofascial pain and dysfunction and/or repair the disk, and this might be aided by viscosup‑
(MPD). The first descriptions of this condition were made by plementation, placement of hyaluronate into the TMJ capsule
Costen in 1934. TMD is a relatively frequent cause of chronic following arthroscopic surgery. Alternatively, a procedure
head and neck pain associated with dysfunction of the mas‑ called arthrocentesis has also been shown to be effective in
ticatory muscles. The pain is dull, achy in character, rarely either reducing the symptoms of clicking or at least reducing
relieved by analgesics, and when associated primarily with the the associated pain. In fact, arthrocentesis is a component of
muscles of mastication, is fairly diffuse. This is in contrast to arthroscopic surgery, which will be discussed in more detail
TMJ-associated pain from one of the arthritides mentioned later, and could actually be the most important part of the
previously, in which the pain is typically localized to the joint treatment that leads to improvement (Tenenbaum, 1999).
area (i.e., just anterior to the external auditory meatus, also The goals of arthrocentesis are not to recapture or repair the
often mistaken for otitis media). The pain of TMD related joint but to lavage inflammatory byproducts out of the joint
to joint disease is often unilateral and is aggravated by jaw capsule and to then replace the joint fluid with hyaluronate

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124 THE TEMPOROMANDIBULAR JOINT

and/or a corticosteroid. Interestingly, most evidence suggests ­ resuming the patient is in pain at the time of presentation,
p
that in spite of treatment, displaced TMJ menisci are not the patient’s pain is likely not emanating from the joint. This
recaptured and do not return to a normal position—and yet would mean that another source of pain should be consid‑
patients still report clinically significant improvement in their ered; as alluded to earlier, this is likely to be muscular, pre‑
pain symptoms, if not the clicking (Nitzan, 1991 and Free‑ suming other sources of pain, such as dentoalveolar pain and
man, 1997). Another useful, noninvasive treatment modality otitis media, have been eliminated diagnostically. Therefore,
is physiotherapy that involves manipulation, massage, moist injection of the TMJ is not only a possible therapeutic mea‑
heat, and jaw exercises (Rocabado, 1982). sure, it can be used for diagnostic purposes as well.
Arthroscopic methods can be used to guide aspiration and
injection along with surgical management of intraarticular dis‑
LOCAL ASPIRATION AND INJECTION/
ease. Interestingly, studies focused on the use of arthroscopic
ARTHROSCOPIC TREATMENTS
surgery have shown that surgical outcomes can be affected by
When considering treatment of an inflamed TMJ, local the presence and/or severity of a psychopathological disorder
aspiration and injection of the joint may be required, with a (Freeman, 1997; Dworkin, 1994; and Murray, 1996). The vari‑
steroid and/or with hyaluronate. With the patient sitting or ous investigations have demonstrated that the biomechanical
reclining and the head supported, the joint line is palpated as aspects of jaw function—as measured directly and objectively,
a depression located 1 to 2 cm anterior to the tragus, and the as with maximal mandibular opening (MMO)—were unal‑
mandibular condyle is felt as it moves during mouth open‑ tered following arthroscopic surgery. In parallel, the incidence
ing and closing. With the patient’s mouth open, a 27 gauge and severity of TMJ sounds did not change following surgical
needle is inserted into the joint perpendicular to the skin and treatment. However, there were marked reductions in pain
directed slightly posteriorly, medially, and superiorly, with (> 60%). Moreover, although there were no changes in the
care being taken not to inject directly into the intraarticu‑ objective measurements of either MMO or joint noises, based
lar disk (Figure 9-2). The ease of injection and/or aspiration on measurements made with visual analog scales, patients per‑
of fluid is the best guide to ensure that the needle’s point is ceived at least 60% reductions in joint noises that also correlated
within the joint cavity. Generally speaking, local anesthesia with similar perceptions in their maximal jaw opening. These
should be established as per routine when carrying out such data suggest that although biomechanical function might be
procedures. More recent developments in this approach, and an important parameter insofar as joint function is concerned,
with arthrocentesis in particular, require a similar approach pain might be the overriding symptom; when pain is reduced,
but also involve the development of a draining channel with patients seem to perceive that their biomechanical problems
a second needle. This allows for inflammatory cytokines (i.e., maximal jaw opening) have improved to a similar extent.
(e.g., prostaglandins) to be flushed from the joint capsule,
followed by placement of the steroid and/or hyaluronate. INJECTION OF MUSCLES OF MASTICATION
It should be noted that if a patient’s pain is not alleviated
following local anesthetic administration into the joint, When it is suspected that a patient’s symptoms are related to
painful muscles of mastication, diagnostic, and in some cases
therapeutic, injection of local anesthetics may be considered
with or without a corticosteroid. As suggested for injection
of the TMJ, the administration of a local anesthetic prior
to placement of a steroid, if a steroid is to be used, should
also lead to elimination or at least reduction in the patient’s
chief pain complaints. These injections can be therapeutic
(Wheeler, 2004) or at least diagnostic. Both internal and
external muscles of mastication can be injected, depending
on what muscles were shown to be tender to palpation; in
general it is suggested that when the muscles are injected
with a local anesthetic, it should be done without a vasocon‑
strictor. Dry needling has also been used, but its effectiveness
is questionable (Furlan et al, 2003).

PREDICTION OF TREATMENT
OUTCOMES FOR TMD AND ASSOCIATED
MUSCULOLIGAMENTOUS PAIN
CONDITIONS
Predicting treatment outcome in chronic pain cases, and
with temporomandibular disorders in particular, is one of
the most challenging aspects of managing these conditions.
Unlike more conventional medical and dental models, in
which the response to treatment is based on a number of
well-defined interventions, chronic pain management pro‑
vides numerous challenges not observed in other conditions.
FIGURE 9-2 ARTHROCENTESIS OF THE TEMPOROMANDIBULAR JOINT. The biopsychosocial model used to explain the etiology of

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 THE TEMPOROMANDIBULAR JOINT 125

chronic pain may provide some insight into the variability and thereby funnel patients into therapies to improve mem‑
of patient outcomes. Additionally, the originating trigger to ory and cognition, which may in turn improve outcomes
the complaint, such as a motor vehicle accident, and other overall. Similarly, it has been demonstrated that these find‑
cofactors, including sleep disturbance and fibromyalgia, ings may be extrapolated to other chronic pain conditions,
have been shown to play a significant role in determining the such as irritable bowel syndrome, with consistent findings
outcome of therapy. noted (Grossi, 2008).
In general, patients presenting with idiopathic TMD One of the overriding factors associated with chronic
(iTMD)—those conditions not associated with a traumatic pain, and with TMD in particular, is the presence of a
origin—recover in approximately 75% to 80% of cases sleep disturbance. Chronic diffuse myalgia, fibromyalgia,
(Brooke, 1977). Contrary to this observation, those patients and chronic fatigue syndrome are just some of the condi‑
presenting with signs and symptoms associated with a tem‑ tions associated with chronic sleep disturbance (Moldofsky,
poromandibular disorder with an onset in conjunction with 1993). Along with that, it has been demonstrated that post-
a motor vehicle accident (pTMD) tend to do poorly in treat‑ traumatic TMD patients are more likely to claim to suffer
ment and require more modalities of therapy than those from a sleep disturbance and other symptoms related to
patients that do improve. In fact, only about 48% of post- affect than a comparative nontraumatic TMD population
traumatic temporomandibular disorder sufferers suggest that (60% vs. 14%) (Romanelli, 1992). However, in those that are
they improved following conservative therapy (Romanelli, considered refractory to treatment, it was demonstrated that
1992). It has been suggested that those suffering from signs on average, the nonresponding TMD population performed
and symptoms associated with pTMD demonstrate a greater worse on most cognitive tests than those TMD patients who
incidence of sleep disturbance, decreased energy level, mood responded to treatment. Additionally, results of the Uni‑
swings, problems with cognitive functioning, and memory versity of Toronto Sleep Assessment Questionnaire (SAQ)
and concentration disturbances. These characteristics are indicated that elements of a sleep disturbance may have been
similar to those seen in patients suffering from post-trau‑ present in the nonresponsive TMD group, although the diag‑
matic stress disorder (PTSD) (Afari, 2008). Yet in most TMD nosis of a sleep disturbance could not be definitively made
populations, there is no overt neurological deficit identified. (Grossi, 2001). Overall, however, studies on TMD and sleep
Thus, it has been suggested that further characterization of disturbance are limited. It has been reported that as many
these conditions, in particular those temporomandibular as 77% of those suffering from orofacial pain suffer from a
disorders that are more refractory to treatment, via the use of sleep disturbance (Riley, 2001). The sleep–pain relationship
neuropsychological testing similar to that used in the post- is complicated by mood (Menefee et al, 2000), with poor
traumatic TMD group may be helpful in not only assessing sleepers endorsing higher scores on measures of depression
common features but may assist in formulating a more accu‑ and anxiety (Haythornthwaite, 1991). In a sample of patients
rate diagnosis early in therapy. with orofacial pain, sleep quality was predicted by depressed
A number of neuropsychological tests are available mood or psychological distress and greater pain severity and
for assessment of cognitive functioning. However, some less perceived life control (Yatani et al, 2002). However, in
of the more common tests include a simple and complex a study assessing psychological and cognitive variables that
reaction-time test, the California Verbal Learning Test, the may be predictive of positive outcomes in TMD patients
Peterson-Peterson Consonant Trigram Test, and the Symp‑ undergoing physiotherapy treatment, it was determined
tom Checklist-90 revised (SCL 90R). It has been suggested that neuropsychological test results, as well as sleep quality,
that individuals who have suffered from a head injury may were not able to predict treatment outcome in any mean‑
develop difficulties with information processing. Therefore, ingful way (Bielawski, 2008). Although many factors may
the reaction-time tests and memory tests that assess the abil‑ contribute to the etiology and pathogenesis of TMDs, it is
ity to encode information, including short and long-term still beyond our ability to accurately predict those who will
memory function, may all be reflective of a cognitive deficit or will not respond to therapy, no matter which modality is
despite a normal neurological examination. It has been dem‑ utilized.
onstrated by Goldberg et al (1996). that patients presenting
with TMD symptoms associated with a motor vehicle acci‑
dent did worse on reaction time and cognitive function tests Conclusions
compared to those suffering from a TMD of an idiopathic
origin. Clearly, factors that affect chronic pain in other joints and
Following up on this work, it was suggested that neuro‑ associated musculature within the body play an equally
psychological deficits may play an integral role in mediat‑ important role with regard to problems surrounding the
ing poor treatment outcomes in TMD patients. Accordingly, TMJ and the muscles of mastication. What makes this struc‑
using various neuropsychological testing tools, as was done tural complex so different is that pain in and around the
in the pTMD population, may provide some form of pre‑ TMJ and its muscles can arise from several sources, rang‑
dictor in terms of poor treatment outcomes in the iTMD ing from dentoalveolar to muscular origins. Moreover, it is
population. Although reaction-time testing was shown to be also clear from findings now reported in the literature, and
a poor predictor of treatment outcomes, other neuropsycho‑ as described in this final section, that higher-center con‑
logical parameters described in the California Verbal Learn‑ trol of pain and suffering (i.e., the central nervous system)
ing Test and the Peterson-Peterson Consonant Trigram Test plays an extremely important role in relation to chronicity
were able to discriminate between responders and nonre‑ of pain regardless of the anatomical location of the pain.
sponders in an iTMD population (Grossi, 2001). Conceiv‑ Mounting data suggest that apart from clearly biomechani‑
ably, these tests might be utilized to predict poor outcomes cal problems associated with joint movements, and indeed

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126 THE TEMPOROMANDIBULAR JOINT

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