Republic of Iraq

Ministry of Higher Education and Scientific

Research
University of Baghdad College of Dentistry

Temporomandibular Joint Disorders

A Project Submitted to
The College of Dentistry, University of Baghdad, Department of
Pediatric and Preventive Dentistry in Partial Fulfillment for the Bachelor of Dental
Surgery

By

Lubna Zuhair Kaream

5th Grade

Supervised by:

Assist. lec. Shatha A.Abbas

B.D.S. M.Sc, Preventive Dentistry

2022/1443
Certification of the Supervisor
I certify that this project entitled"Temporo Mandibular Joint Disorders " was
prepared by the fifth year student Lubna Zuhair under my supervision at the
College of Dentistry/University of Baghdad in partial fulfilment of the graduation
requirements for the Bachelor Degree in Dentistry.

Supervisor Name:
Assist. Lec. Shatha A.Abbas
Date:
April /2022

I
 Dedication
To my home, my family and all my dear people in this life, and last but
not least myself for their tolerance and patience for all my mistakes and
their endless love and support till I am here in this place writing this
project

II
 Acknowledgment

Special thanks to Allah, the most giving and the most forgiving for everything
Given to me and for blessing me. I would like to give a grateful thanks for the dean
of College of Dentistry. University of Baghdad Prof. Dr. Raghad Al-Hashimi for
giving me the opportunity to learn. Deep thanks to Prof. Dr. Ahlam Taha the Head
of the Department of Pedodontics and Preventive dentistry. To my supervisor
assist. Lec. Shatha A.Abbas for her support and scientific care and also for her
clarification of all details and making the work on this project easier and more
enjoyable. To all my colleagues for their help all the past five years and being my
second family.
And last but not least to my dear parents for backup and engorgement, my sister
and my brothers

III
List of content
Title Pages

Certification of the Supervisor I

Dedication II

Acknowledgment III

List of content IV

List of figures VI

List of abbreviation VII

Introduction 1

Aim of the study 2

Review of Litetrture 2
1-The temporomandibular joint (TMJ) 3

2-Anatomy Of TMJ 4

2.1. Capsule 5

2.2 . Articular Disc (Meniscus) 6

2.3. Ligaments: 7

2.3.I. Functional ligaments 7

2.3.II. Accessory ligaments: 8

3. TMJ Musculature -: 9

IV
4.Vascular Supply of Masticatory System Structures 11

5. The nerve supply to the TMJ 11

6. The movement of the TMJ 12

7-Etiological factors of the TMJ disorder 13

8. Sign and symptoms of TMJ disorders: 12

9. Clinical significance 14

10. Diagnosis Of TMD 17

11. Imaging of TMJ: 20

12. Joints disorders 27

13. Joint diseases 30

14. Congenital/developmental disorders 31

15. Masticatory Muscle Disorders:- 33

16. Management of the TMJ 35

Conclusion 38

References 39

V
List of figures
Title Page
Figure(1):Temporomandibular Joint 4
Figure2:Anatomy of TMJ 5
Figure3:capsular Ligament 5
Figure4: A cadaver section through
the temporomandibular joint shows 7
the relationship of the condyle,
fossa, and articular disc .
Figure5:Musules of mastication, 10
Figure6: Nerve supply of TMJ 11

VI
List of abbreviation

Abbreviation The word

1. TMJ Temporomandibular Joint

2. TMD Temporomandibular Disorders

3. MPDS Myofascial Pain Dysfunction Syndrome

4. MRI Magnetic Resonance Imaging

5. OPG Orthopantomography

6. CT Computed Tomography

7. CBCT Cone beam computed tomography

8. RDC / TMD Research Diagnostic Criteria for

Temporomandibular Disorders

9. DJD Degenerative joint disease

10. OA Osteoarthritis

11. RA Rheumatoid arthritis

12. MRSA Methicillin-Resistant Staphylococcus

Aureus (MRSA)

13. HH Hemimandibular hyperplasia

14. HE Hemimandibular Elongation

15. NSAIDs Non-Steroidal Anti Inflammatory Drugs

16. MCV Maximum Voluntary Contraction

VII
Introduction

The temporomandibular joints (TMJ) are the two joints connecting the jawbone to
the skull. It is a bilateral synovial articulation between the temporal bone of the
skull above and the mandible below; it is from these bones that its name is derived.
This joint is unique in that it is a bilateral joint that functions as one unit. Since the
TMJ is connected to the mandible, the right and left joints must function together
and therefore are not independent of each other.

Temporomandibular disorders (TMDs) constitute a group of disorders that cause

pain or dysfunction in the jaw joint and muscles that control its movement
(Bumann &Lotzmann ,2003)

1
Aim of the study

During the last few decades, an increase in musculoskeletal pain conditions and
stress-related health problems have been observed worldwide. The overall aim of
this review was to acquire knowledge. Relating to temporomandibular disorders
(TMD) as well as to study factors that cause them and their treatment.

2
Review of Literature

1.The temporomandibular joint (TMJ):- is a hinge joint that connects the

jaw bone to the skull. The main component of TMJ is bilateral mandibular
condyle, meniscus, glenoid fossa, articular ligaments, and the
associated musculature . It is a bilateral synovial articulation between the temporal
bone of the skull above and the mandible below; it is from these bones that its
name is derived. This joint is unique in that it is a bilateral joint that functions as
one unit. Prevalence of temporomandibular joint disorder in Iraqi population had
been studied by many Iraqi researchers, some of those studies are: ( Fehrenbach
& Herring ,2012; List &Jensen ,2017(

*(Gaphor & Hameed,2010) stated that out of 500 university students (250
females, 250 males), ages ranged between 18-26 years, prevalence of one or more
symptoms of TMDs was 27%, while the prevalence of one or more signs of the
TMDs was 63.8% which was generally mild in severity.

* An Iraqi study by (Hussein et al.,2015) that examined reports of 1325 patients

aged from 10-79 years; 650 males (49.05%) and 675 females (50.94%) concluded
that out of 53 (0.04%) patients who complained of TMJ problems, 30 patients were
males (56.6%) and 23 patients were females (43.4%). The highest numbers of
patients were from the younger age groups (20-30 years; n= 37, 69.8%). The pain
was the most prevalent reported symptom followed by clicking in the joints and
more than half of patients reported emotional stress as a causative factor

* A recent Iraqi study examined 230 students with the age of 18-25 years reported
that most encountered symptoms were joint sounds (27.4%) and joint fatigue
(27.4%). (50%) of the students had some grade of temporomandibular disorder
(Yousif& Omer ,2021).
3
 Figure(1):Temporomandibular Joint(Koeing et al.,2017).

2.Anatomy of TMJ:-

TMJ is a bi-condylar, synovial, diarthrodial joint which functions

synchronously. It is classifed as ginglymus or ginglymoarthrodial joint as it
performs both hinge and sliding movements. This joint forms an articulation
between the mandibular condyle inferiorly and the fossa in the temporal bone
superiorly. Unlike most joints of the body which are lined by hyaline cartilage.
The articular surface of TMJ is lined by fibrocartilage/white fibrous tissue,
)Detamore&Athanasiou,2003;Granstrom&Linde,2003;Griffin&Sharpe,20
03;Kondoh,2003;Mills et al.,2003)

4
 Figure2:Anatomy of TMJ(Bordoni et al.,2020).

2.1.Capsule

The capsule is a dense fibrous membrane that surrounds the joint and
incorporates the articular eminence. It attaches to the articular eminence, the
articular disc and the neck of the mandibular condyle ,(Evelin,2019)

Figure3:capsular Ligament (Lipton et al.,2003;Terrin et al.,2020 ).

5
2.2. Articular Disc (Meniscus) :-

Dense fibrous connective tissue primarily consists of dense collagen fibers of

variable thickness is referred to as a disc and occupies the space between the
fibrocartilage coverings of each condyle and mandibular fossa . The disc
consists of collagen fibers, cartilage-like proteoglycans and elastic fibers. It
contains a variable number of cells that resemble fibrocytes and fibrochon-
drocytes. Collagen fibers in the center of the disc (often referred to as the
intermediate zone) are oriented perpendicular to its transverse axis ,
functionally aligned with loading on that zone. The collagen fibers become
interlaced as they approach the anterior and posterior bands, and many fibers
are oriented parallel to the mediolateral aspect of the disc. Cartilage-like
proteoglycans contribute to the compressive stiffness of articular cartilage.The
disc is primarily avascular and has little sensory innervation. It is thinnest in
the intermediate zone and thickens to form anterior and posterior bands
represented as a “bow tie” in sagittal sections. This arrangement is considered
to help stabilize the condyle in the glenoid fossa. Over time, discs may exhibit
changes in this conformation; the central intermediate zone may become
elongated or nonexistent, the anterior band may become thinner, or the
posterior band may become either thinner or thicker. These conformation
changes, while presumably affecting the ideal function of the disc in stabilizing
the condyle during loading, are currently regarded as a variation on normal in
the absence of any clinical manifestation of disordered function ,( Lipton et
al.,2003;Rinchuse et al.,2010;Gorenflo et al.,2020)

6
 .

Figure4: A cadaver section through the temporomandibular joint shows

the relationship of the condyle, fossa, and articular disc (Dworikin et
al.,2008).

2.3.Ligaments:
Ligaments associated with the TMJ are composed of collagen fibres and act
predominantly as restraints to motion of the condyle and the disk. There are
two groups of ligaments(functional ligaments and accessory ligaments)
associated with the temporomandibular joints: one major and two minor
ligaments. These ligaments are important in that they define the border
movements(Chandra ,2010; Bordoni&Varacallo,2020).

2.3.1.Functional ligaments (major ligaments) :

Are lateral temporomandibular ligament , capsular ligament and collateral

ligaments. The temporomandibular ligament, is actually the thickened lateral
portion of the capsule, and it has two parts: an outer oblique portion (OOP) and
an inner horizontal portion (IHP). These ligament prevents the excessive
7
retraction or moving backward of the mandible, a situation that might lead to
problems with the joint ,(Manfredini et al.,2011).

2.3.1.1.Capsular Ligament :

The capsular ligament is a thin inelastic fibrous connective tissue envelope

that attaches to the margins of the articular surfaces encompasses each joint,
attaching superiorly to the temporal bone along the border of the mandibular
fossa and eminence and inferiorly to the neck of the condyle along the edge of
the articular facet. It surrounds the joint spaces and the disk, attaching
anteriorly and posteriorly as well as medially and laterally, where it blends
with the collateral ligament, (Sanders et al.,2013).

2.3.1.2.The temporomandibular (lateral) ligaments:

Are located on the lateral aspect of each TMJ. Unlike the capsular and
collateral ligaments, which have medial and lateral components within each
joint,the temporomandibular ligaments are single structures that function in
paired fashion with the corresponding ligament on the opposite
TMJ(Mehrotra et al.,2011).

2.3.1.3.The collateral (or diskal) ligaments:

Are short paired structures attaching the disk to the lateral and medial poles of
each condyle. Their function is to restrict movement of the disk away from the
condyle, thus allowing smooth synchronous motion of the disk-condyle
complex. Although the collateral ligaments permit rotation of the condyle with
relation to the disk, their tight attachment forces the disk to accompany the
condyle through its translatory range of motion(Detamore et al.,2003).
8
 2.3.2.Accessory ligaments:
Sphenomandibular and stylomandibular are considered accessory ligaments
because, although they are attached to osseous structures at some distance from
the joints, they serve to some degree as passive restraints on mandibular
motion,(Bender et al.,2018)

2.3.2.1.The sphenomandibular ligament:

Arises from the spine of the sphenoid bone and descends into the fan-like
insertion on the mandibular lingula, as well as on the lower portion of the
medial side of the condylar neck. The sphenomandibular ligament serves to
some degree as a point of rotation during activation of the lateral pterygoid
muscle, thereby contributing to translation of the mandible,(Wolpertet
al.,2017)

2.3.2.2.The stylomandibular ligament:

Descends from the styloid process to the posterior border of the angle of the
mandible and also blends with the fascia of the medial pterygoid muscle. It
functions similarly to the sphenomandibular ligament as a point of rotation and
also limits excessive protrusion of the mandible,(Rinchuse et al.,2010)

3.TMJ Musculature:-

TMJ is associated with different muscles which aid in joint function. The
muscles involved to elevate/close the jaw are masseter, temporalis, medial
pterygoid muscle. The muscles that depress/open the jaw are lateral pterygoid,
geniohyoid, mylohyoid and digastric muscle ; however, a total of 12 muscles
actually influence mandibular motion, all of which are bilateral. Muscle pairs may

9
function together for symmetric movements or unilaterally for asymmetric
movement(Chandra et al., 2010 ; Devi , 2019).

Figure5:Musules of mastication,(Schmader et al.,2001).

10
4.Vascular Supply of Masticatory System Structures :
The external carotid artery (ECA) is the main blood supply for the
structures of the masticatory system. The ECA leaves the neck and courses
superiorly and posteriorly, embedded in the substance of the parotid gland,
sending two important branches, the lingual and facial arteries, to the region.
At the level of the mandibular condylar neck, the external carotid bifurcates
into the superficial temporal artery and the internal maxillary artery. These
two arteries supply the muscles of mastication and the TMJ. Arteries within
the temporal bone and mandible also send branches to the capsule,(Bordoni
& Varacallo , 2020)
5.The nerve supply to the TMJ :-
Is predominantly from branches of the auriculotemporal nerve with anterior
contributions from the masseteric nerve and the posterior deep temporal
nerve, ) Johansson & Isberg , 1990)

Figure6: Nerve supply of TMJ(Branches of the auriculotemporal nerve supply

sensory innervation of the TMJ. This nerve arises from the mandibular division in
the infratemporal fossa and sends branches to the capsule of the joint) (Ivers et
al.,2012).
11
6.The movement of the TMJ:
Two types of movement are possible in TMJ: rotation and translation
,(Bender et al., 2018)
I.Rotational movement:
This is the initial movement of the jaw when the mouth opens. The upper
joint compartment formed by the articular disc and the temporal bone is
involved in this movement.
II.Transtional movement
Is the secondary gliding motion of the jaw as it is opened widely. The part
of the mandible which mates to the under-surface of the disc is the condyle
and the part of the temporal bone which mates to the upper surface of the
disk is the articular fossa or glenoid fossa or mandibular fossa.

7.Etiological factors of the TMJ disorder

The causes of temporomandibular disorders are complex and multifactorial.
There are numerous factors that can contribute to temporomandibular
disorders .It can be divided in to :- Predisposing factors , Initiating factors
and Perpetuating factors, (Bhat et al., 2010).

7.1.Predisposing factors:
Factors that increase the risk of temporomandibular disorders. Predisposing
factors are pathophysiologic, psychological or structural processes that alter
the masticatory system sufficiently to increase the risk of development of
temporomandibular disorders .While the main occlusion problems that
predispose to TMJ disorders are ,(Lipton et al.,2003) :-
*Open bite
*Overjet greater than 6-7 mm
12
*Retruded contact position/intercuspal position with sliding greater than 4
mm.
*Unilateral lingual cross-bite
*Five or more missing posterior teeth
*Faulty restorations and ill-fitting prosthesis.
7.2.Initiating factors :
Those causing the onset of temporomandibular disorders. .Initiating factors
lead to the onset of the symptoms and are related primarily to trauma or
adverse loading of the masticatory system,(Zhi et al.,2009)

7.3.Perpetuating factors:
Factors that interfere with healing or enhance the progression of
temporomandibular disorder. The following may be included as
aperpetuating factors, (Mehrotra et al.,2011) :-
* Behavioral factors (grinding, clenching and abnormal head posture)
* Social factors (could affect perception and influence the learned response
to pain)
* Emotional factors (depression and anxiety)
* Cognitive factors (negative thoughts and attitudes which can make
resolution of the illness more difficult).

8.Sign and symptoms of TMJ disorders:

Signs and symptoms of TMJ disorders may include:
*Pain or tenderness of the jaw
*Pain in one or both of the temporomandibular joints
*Aching pain in and around the ear
*Difficulty in chewing or pain while chewing
*Aching facial pain
13
 *Locking of the joint, making it difficult to open or close the mouth.
TMJ disorders can also cause a clicking sound or grating sensation when the
mouth opened or during chewing . But if there's no pain or limitation of
movement associated with the jaw clicking, a treatment for TMJ disorder is
not indicated,( Wolpert et al.,2017).
9. Clinical significance
9.1.The differentiation of pain
The differentiation of pain originating within the joint from that coming
from extraarticular structures is essential to successful treatment. However
,the distinction cannot always be made from the history and both intra- and
extraarticular structures may be involved simultaneously. The patient with
stress-related MPDS(Myofacial Pain Dysfunction Syndrome) usually
complains of constant, dull pain that may or may not be exacerbated by
mastication or mandibular movement and relieved by jaw rest. Quite often,
this pain is worse in the morning, if related to nighttime parafunctional
clenching or bruxism. To be more clarify for example ,the patient with
intraarticular TMJ pain due to arthritis has the pain relieved by jaw rest and
may be pain free except when moving the mandible or masticating solid
food. Unfortunately,intraarticular TMJ disease often involves the masticatory
muscles secondarily so that both types of pain (intra- and extraarticular) are
experienced simultaneously by the patient(Bumann &Lotzmann ,2003).
9.2.Joint noise.
During function is highly suggestive of intraarticular disease. Grinding or
crepitus often indicates an arthritic or other degenerative process and is caused
by contact of roughened bony surfaces during function. Clicking or popping in
the joint is usually associated with displacement of the fibrocartilaginous disk

14
(meniscus) that separates the joint into upper and lower compartments. The
followings facts should be understand by the examiner of the TMJ (Bhargava et
al.,2021).
*Jaw popping without accompanying pain is not typically a cause for concern.
* If certain health conditions underlie the popping, medical intervention may be
needed.
* The cause of jaw popping is not completely understood. Jaw popping can often
be treated at home, especially if there is no pain or other symptoms. However,
anyone of any age or gender can experience jaw popping, which may be linked
to behaviors such as:
* grinding the teeth
*chewing gum regularly or excessively
*nail-biting
* clenching the jaw
* biting the inside of the cheek or lip
Also, several medical conditions can lead to jaw popping, including arthritis
which is a disease of the joints. Two of the most common forms of arthritis are
rheumatoid arthritis and osteoarthritis, both of which can result in cartilage
damage in the TMJ. As a result destruction of the TMJ cartilage tissue can make
jaw movements difficult and can cause a popping sound and clicking sensation
in the joint,(Bumann & Lotzmann,2003; Demir et al.,2010).

9.3.Limitation:-
Limitation of mandibular opening may be due to reflex spasm of masticatory
muscles secondary to MPDS, other reasons are fibrous or bony ankylosis of the
joint, fracture of the mandibular condyle,or total anterior displacement of the
15
joint meniscus that blocks normal forward movement of the mandibular condyle.
In physical examination for temporomandibular disorders, measurement and
recording of mandibular movements should be completed for opening, lateral
and protrusive movements. The quality and symmetry of jaw movement should
be noted and diagrammed. During the clinical examination of a study a
significant differences in the amplitude of jaw opening between TMD patients
and control subjects. While comparing active maximum mouth opening, and
temporomandibular stiffness values of temporomandibular disorder patient
subgroups and a control group. The temporomandibular disorder patient
subgroups consisted of myogenous pain patients and arthrogenous pain patients
with a "closed lock" and arthrogenous pain patients without a "closed lock." Both
myogenous patients and the "closed lock" patients showed great differences for
all parameters ,(Bumann &Lotzmann,2003; Terrin et al.,2020).
9.4.Hyper mobility:-
Hyper mobility can result in excessive anterior movement of the jaw and
the articular disc. This will result in deviation of the jaw away from the
affected side. There are usually some clicking sounds in the TMJ and there
may or may not be a pain. Hyper mobility may be related to connective
tissue disorders such as Marfan syndrome or conditions such as Down’s
syndrome and cerebral palsy. Long term hyper mobility can cause the
articular disc to elongate and degenerate. The disc can then fail to reduce on
closing, causing the TMJ to become stuck in an open position (Open Lock).
This can often occur after opening the mouth to an extreme position, such as
when singing or yawning or after a prolonged dental procedure, (Bumann,
Lotzmann,2003;Bader et al.,2010).

16
10. Diagnosis Of TMD
10.1. History and clinical examination:-
There are different clinical protocols used to establish TMD diagnoses but
the Research Diagnostic Criteria for TMD (RDC/TMD) most common used.
The diagnosis of TMD is based largely on history and physical examination
findings. The symptoms of TMD are often associated with jaw movement
(e.g., opening and closing the mouth, chewing) and pain in the preauricular,
masseter, or temple region. Another source of orofacial pain should be
suspected if pain is not affected by jaw movement. Adventitious sounds of
the jaw (e.g., clicking, popping, grating, crepitus) may occur with TMD.
Other symptoms may include dizziness or neck, eye, arm, or back
pain(Gorenflo et al.,2020)

Chronic TMD is defined by pain of more than three months’ duration.

Physical examination findings that support the diagnosis of TMD may
Include but are not limited to abnormal mandibular movement, decreased
range of motion, tenderness of masticatory muscles, pain with dynamic
loading, signs of bruxism, and neck or shoulder muscle tenderness.
Clinicians should assess for malocclusion (e.g., acquired edentulism,
hemifacial asymmetries, restorative occlusal rehabilitation), which can
contribute to the manifestation of TMD. Cranial nerve abnormalities should
not be attributed to TMD,(Tayeb et al.,2017).
A clicking, crepitus, or locking of the TMJ may accompany joint
dysfunction. A single click during opening of the mouth may be associated
with an anterior disk displacement. A second click during closure of the
mouth results in recapture of the displaced disk; this condition is referred to
as disk displacement with reduction. When disk displacement progresses and
17
 the patient is unable to fully open the mouth (i.e., the disk is blocking
translation of the condyle), this condition is referred to as closed lock.
Crepitus is related to articular surface disruption, which often occurs in
patients with osteoarthritis. Reproducible tenderness to palpation of the TMJ
is suggestive of intra-articular derangement. Tenderness of the masseter,
temporalis, and surrounding neck muscles may distinguish myalgia,
myofascial trigger points, or referred pain syndrome. Deviation of the
mandible toward the affected side during mouth Opening may indicate
anterior articular disk displacement (Gauer & Semidey , 2015 )

10.2. Imaging of TMJ:

Imaging can assist in the diagnosis of TMD when history and physical
examination findings are equivocal. Although infrequently used, multiple
imaging modalities are available to obtain additional information about
suspected TMD etiologies. The initial test should be:-

10.2.1.plain radiography (transcranial and transmaxillary

views) or panoramic radiography:-
Acute fractures, dislocations, and severe degenerative articular disease are
often visible in these views. Panoramic Radiography (OPG) is used to detect
if there is any gross osseous abnormalities . They can be used to evaluate
only the bony elements of the TMJ. They do not give useful information
when it comes to the non-bony elements such as cartilage or adjacent soft
tissues. They also do not give useful information concerning joint effusions,
which are commonly associated with pain and disc displacements. Another
disadvantage radiographs is the problem of superimposition of adjacent
structures( many different views such as the submentovertex, transmaxillary,
18
 and the transcranial are used to reduce superimposition.) Limited value for
diagnosis of specific conditions causing temporomandibular joint
dysfunction because mild degenerative disease is seen equally in
symptomatic and asymptomatic people. OPG is not recommended as a
routine investigation in all patients who present with TMJ symptoms. Only
patients with clinical evidence of significant TMJ disease or a lack of
response to conservative type of treatment(Bhargava ,2021).

10.2.2.Computed tomography(CT)
Is superior to plain radiography for evaluation of subtle bony morphology.
Computed tomography has been used to detect bony abnormalities of the
TMJ and in rare conditions such as synovial osteochondromatosis. It has also
previously been used for the diagnosis of internal disc derangement, arthritis
and other miscellaneous conditions of the TMJ. The followings conditions
could be detected by the CT(Aiyer et al.,2020) :-
A-Internal disc derangement.
B- Erosive arthritis.
C-Osseous erosions are frequently seen in association with disc
displacement.
D-Idiopathic condylar resorption a more severe form of condylar erosion
associated with high grade internal derangement is recognized
E-Ankylosis.
F-Osteoarthritis.
G- Condylar fractures.
H-Osteochondroma

19
10.2.3.Magnetic Resonance Imaging(MRI):-
Is the optimal modality for comprehensive joint evaluation in patients with
signs and symptoms of TMD therapy has been ineffective, or in those with
suspected internal joint derangement. The first step in MRI imaging of the
TMJ is to evaluate the articular disk, or meniscus also morphologic features
and location relative to the condyle in both closed and open-mouth positions.
Abnormal disk morphologic features, disk displacement, joint effusion,
osteoarthritis, as well as new indirect and also rupture of retrodiskal layers.
Disk injuries ,the irregular and rounded morphologic features are universally
considered to indicate disease in the TMJ, (Bhargava ,2021).
10.2.4.Ultrasonography:
Is a noninvasive, dynamic, low-cost technique to diagnose internal
derangement of the TMJ when magnetic resonance imaging is not readily
available. Common Indications are:-
• Pain in front of the ears
• Jaw clicking / locking
• Reduced / Painful mouth opening ( Bhargava ,2021).

11.Joint disorders
A. Disc disorders
Internal Derangement OF The TMJ:
Wilkes Classifcation of Internal Derangements Disc- Condyle disorders can
be staged based on the characteristics of the pain, amount of mouth opening,
disc Location/condition, and altered joint anatomy, as observed from
physical examination, MRI, and arthroscopy( Gauer et al.,2015).
20
I)Disc Displacement with Reduction:
A diagnosis of disc displacement with reduction is made when the patient
presents with a history of a click or pop and it can be felt when the patient
moves the mandible. As the patient opens the mouth, the condyle translates
forward and moves on to an intermediate zone of the disc (reduced position)
that may cause the opening click or pop. As the mouth continues to open, the
condyle continues to translate forward with the disc and remains in the
intermediate zone of the disc. As the patient closes the mouth, the condyle
retrudes and moves back under the posterior band onto the retrodiscal tissue,
which may again cause the closing click or pop. As the mouth continues to
close, the condyle remains on the retrodiscal tissue. If both opening and
closing click/pop is present, then the opening click/pop occurs at a wider
opening than the closing click/pop. Rather, it should be heard by the patient
at least once in the last 30 days and by the examining dentist during at least
a third of the mandibular movements. Because the disc reduces during
condylar translation, range of motion is not limited. However, movements
may not be as smooth as a normal TMJ because of the momentary sliding of
the condyle on and off of the disc (De Leeuw & Klasser,2018).
II)Disc Displacement with Reduction with Intermittent
Locking
A diagnosis of disc displacement with reduction with intermittent locking is
made when the patient has a disc displacement with reduction and reports that
occasionally the TMJ structure that normally causes the click blocks the
condyle’s movement, inhibiting the mouth for obtaining its normal opening.
This lock suddenly occurs, may last for seconds to days, and then suddenly
releases. When the limited opening occurs, a maneuver may be needed to unlock

21
the TMJ. History is positive for any noises present with jaw movement or
function in the last 30 days or during the examination itself and report of
intermittent locking with limited opening in the last 30 days or evidence of
intermittent locking during clinical examination(Rinchuse & Kandasamy
,2010).
III)Disc Displacement without Reduction with Limited Opening:
A diagnosis of disc displacement without reduction with limited opening
(closed lock) is made when a patient has a suddenly occurring continuous
marked limited opening (less than 40 mm). The patients themselves are usually
aware that the TMJ structure that normally caused the click is now blocking
them from obtaining their normal opening. They may also report of their TMJ
catching at that location or intermittently having had this problem (lasting
seconds to days), which suddenly released and allowed them to regain their
normal opening. As the mouth opens, the condyle first rotates and then attempts
to translate forward, but the condyle cannot slide under the disc’s posterior band
to reduce onto the intermediate zone of the disc. The translation is limited by the
disc, and typically, the patient is initially able to open only between 20 and 30
mm(Kalaykova et al., 2011) .
IV)Disc Displacement without Reduction without Limited Opening:
A diagnosis of disc displacement without reduction without limited opening is
made when the patient has a history of sudden-onset limited opening that
gradually increased to 40 mm or greater. This suggests that the patient had a disc
displacement without reduction with limited opening and over time, the
retrodiscal tissue stretched and enabled the disc to move forward, thereby
allowing the condyle to translate further and permitting the patient to open wider.
History is the same as defined for disc displacement without reduction with
limited opening, (Kalaykova et al., 2011).
22
V)Posterior Disc Displacement :
Posterior disc displacement has been described as the condyle slipping over the
anterior rim of the disc during opening, with the disc being caught and brought
backward in an abnormal relationship to the condyle when the mouth is closed.
The disc is folded in the dorsal part of the joint space, preventing full mouth
closure. The Clinical features are ( Blankestijn & Boering , 1985).
(1) a sudden inability to bring the upper and lower teeth together in maximal
occlusion.
(2) pain in the affected joint when trying to bring the teeth firmly together.
(3) displacement anteriorly of the mandible on the affected side.
(4) restricted lateral movement to the affected side.
(5) no restriction of mouth opening.
B. Hypomobility disorders other than disc disorders:-
I)Adherence/Adhesions:
Adherence refers to a transient sticking of the articular surfaces. However,
prolonged periods of adherence may result in true adhesions, wherein fibrous
bands of connective tissue form between the articulating surfaces of the
condyle or mandibular fossa, the disc, or surrounding tissues. Adhesions
occur secondary to prolonged static loading of the TMJ’s surfaces (for
example, jaw-clenching during sleep). The patient presents with history of
loss of jaw mobility and no history of TMJ clicking (historically to
differentiate from disc displacement without reduction with limited
opening(Okeson,2011).

II -Ankylosis
Ankylosis is the firm restriction of the condyle due to fibrous bands or
osseous union within the TMJ, most commonly resulting from trauma to the

23
mandible and/or TMJ. It is a Chronic, painless,limitation jaw motion. The
involved condyle may not be able to translate and may have limited rotation,
causing the patient to have a very limited opening, depending on the type and
extent of the ankylosis. Ankylosis of the temporomandibular joint (TMJ)
most often results from trauma or infection, but it may be congenital or a
result of rheumatoid arthritis. When ankylosis leads to arrest of condylar
growth, facial asymmetry is common. Intra-articular (true) ankylosis must be
distinguished from extra-articular (false) ankylosis, which may be caused by
enlargement of the coronoid process, depressed fracture of the zygomatic
arch, or scarring resulting from surgery, irradiation, or infection.
In most cases of true ankylosis, x-rays of the joint show loss of normal bony
architecture. A late and rare finding; in some cases, it affects both. In severe
cases, there is a loss of mandibular condylar support with resultant
retrognathia. Congenital temporomandibular joint ankylosis is a rare
maxillofacial disorder characterized by significant reduction in mouth
opening (i.e. from a few millimeters to a few centimeters) in the absence of
acquired factors (e.g. trauma, infection) contributing to the ankylosis. It is
associated with variable degrees of facial dysmorphism (i.e. lateral deviation
of the mandible and chin, lower facial asymmetry, retrognathia,
micrognathia, dental malocclusion) and patients typically present with
feeding and breathing difficulties,also developmental delay, hypotonia,
seizures, and additional dysmorphic feature.Clinical differential diagnosis of
ankylosis should include pseudoankylosis of extra-articular pathology
occurring in hypomobility of the joint due to coronoid hyperplasia (Jacob
disease), fbrous adhesions between coronoid and tuberosity of maxilla or
zygoma, depressed zygomatic arch fracture, dislocated zygomatic complex

24
 fracture, temporalis muscle scarring, or myositis ossifcans,(Bumann &
Lotzmann,2003; Zhi et al.,2009).
Ankylosis may be fibrous or osseous.
*Fibrous Ankylosis:-
Fibrous ankylosis results when fibrotic tissue forms between the articulating
surfaces of the condyle or mandibular fossa, the disc, or surrounding tissues.
There are no gross bony changes and no radiographic findings other than
absence of ipsilateral condylar translation on opening. Patient findings include
history of progressive loss of jaw mobility; positive findings for severe limited
range of motion on opening, uncorrected jaw deviation to the affected side,
marked limited laterotrusion to the contralateral side; and positive CT/CBCT
imaging finding of decreased ipsilateral condylar translation on opening and a
joint space between ipsilateral condyle and eminence.(Okeson,2019).
*Osseous Ankylosis:-
Bone formation between the condyle and fossa usually results in osseous
ankylosis, the patient has a more restricted opening than with fibrous ankylosis
or even complete immobility of the joint. The characteristic findings include
radiographic evidence of bone proliferation with marked defection to the affected
side and marked limited laterotrusion to the contralateral side. Patient findings
include history of progressive loss of jaw mobility, positive examination
findings such as absence of or severely limited jaw mobility with all movements
and CT/CBCT being positive for imaging-based evidence of bone proliferation,
with obliteration of part or all of the joint space (Okeson,2019).

25
C- Hypermobility disorders
I)Subluxation (Partial Dislocation):
This is a condition involving the disc-condyle complex and the articular
eminence. A diagnosis of subluxation is made when in the opened mouth , the
disc-condyle complex is positioned anterior to the articular eminence and is
unable to return to normal closed-mouth position without a manipulative
maneuver by the patient. Causes of subluxation include looseness of the joint
capsule and ligaments, as in overextension injury, following dental procedures
that require prolonged mouth opening or excessive yawning, extrinsic trauma
(intubation, endoscopy), and connective tissue disorders (Ehlers-Danlos
syndrome, Marfan syndrome). History is positive for jaw locking or catching in a
wide-opening mouth position, even for a moment, so the patient could not close
from the wide-open position in the last 30 days and for inability to close the
mouth from wide opening without a self-maneuver. No examination findings are
required(Okeson & Leeuw ,2011).
II)Luxation (Dislocation, Open Lock) :
This is a condition in which the disc-condyle complex is positioned anterior to
the articular eminence and is unable to return to the fossa without a specifc
manipulative maneuver by a clinician. This is also referred to as open lock.
Causes of luxation include post-traumatic capsular loosening, prolonged wide
mouth opening, chronic subluxation, seizure disorders, Parkinsonism, drug-
induced tardive dyskinesia (neuroleptics like phenothiazines), defects in the bony
surface (shallow articular eminence), or a genetic predisposition (Ehlers-Danlos
syndrome, Marfan syndrome). Patient reports of inability to close from wide
opening and that mouth closing can be achieved only with a specifc mandibular
maneuver by the clinician. Examination is positive for wide opening mouth,

26
protruded jaw position, and lateral position to the contralateral side if
unilateral,(Okeson & Leeuw ,2011).

12.Joint diseases
12.1.Degenerative joint disease
-Osteoarthrosis
-osteoarthritis
12.1.1. Osteoarthrosis:
Osteoarthrosis is a multifactorial disease associated with TMJ overloading.
Though it is synonymous with osteoarthritis in medical orthopedic literature , in
dental TMJ literature, it has been recently identifed as a chronic low
infammatory degenerative progressive loss of articular cartilage in the TMJ
resulting from an imbalance between predominantly chondrocyte-controlled
reparative and degradative processes. Patient generally presents with no
symptoms. The past history may reveal a period of time when symptoms were
present (osteoarthritis) that can only be confrmed through radiographs.
Crepitation is a common finding. In the absence of clinical symptoms like joint
pain, treatment of this arthritides is contraindicated. The only treatment that may
need to be considered is if the bony changes in the condyle have been signifcant
enough to alter the occlusal condition and, in such cases, dental therapy may
need to be considered(Okeson , 2008).
12.1.2.Osteoarthritis(Degenerative Joint Disease, DJD)
Degenerative joint disease (DJD), is primarily a disorder of articular cartilage
and subchondral bone, with secondary minimal inflammation of the synovial
membrane. It is a localized joint disease without systemic manifestations.
The process begins in loaded articular cartilage that thins, clefts (fibrillation),
and then fragments leading to sclerosis of underlying bone, subchondral cysts,
27
and osteophyte formtion. The articular changes are essentially a response of the
joint to chronic microtrauma or pressure. Microtrauma may be in the form of
continuous abrasion of the articular surfaces as in natural wear associated with
age or due to increased loading related to chronic parafunctional activity. The
fibrous tissue covering in patients with degenerative disease is preserved. This
may be a factor in remodeling and the recovery that is usually expected in
osteoarthrosis and osteoarthritis of the TMJs(Morel et al.,2021).
Osteoarthritis presentation:-
The patients who develop (OA) present with a variety of symptoms including
pain on opening, limited movement to the opposite side, coarse grinding noise on
function, history of clicking that has now stopped, and deviation on opening to
the affected side. An unusually large percentage of those diagnosed are women
around the age of 35. In addition patients have had a macrotrauma usually from a
maximal voluntary contraction (MVC) force or even a blow to the mandible. The
clinical findings are pain on palpation of lateral pole, decreased range of motion
findings , heavy occlusion on second molar on the affected side, facial
asymmetry, and tipped Curve of Wilson. Some other indicators include loss of
condylar bone which traumatizes the posterior molar on the same side, pain
referral pattern to the ear, pain on eating, talking, or function of the jaw joint, jaw
locking, and pain in the front tooth of a bridge (due to torque forces on two
molars). In summary, a picture of pain, dysfunction, and disability is involved in
osteoarthritis of jaw joint. with flattened condyle, osteophytes on condyle(could
be noticed by Xray findings,(Bumann& Lotzmann,2003;Manfredini et
al.,2011).
12.2.Rheumatoid arthritis (RA)
Is a chronic, systemic, autoimmune inflammatory disorder that is characterized
by joint inflammation, erosive properties and symmetric multiple joint
28
involvement. Temporomandibular joint (TMJ) is very rare to be affected in the
early phase of the disease, thus posing diagnostic challenges for the dentist.
Conventional radiographs fail to show the early lesions due to its limitations.
More recently cone-beam computed tomography (CBCT) has been found to
diagnose the early degenerative changes of TMJ and hence ,aid in the diagnosis
of the lesions more accurately.
Some common clinical symptoms of Rheumatoid arthritis include TMJ
sounds/noises, TMJ pain, facial pain, headaches, limited range of mandibular
movement, change in occlusion, masticatory difficulty, earaches, tinnitus,
vertigo, and neck, shoulder, and back pain. Some patients may have pathological
internal derangement of the TMJ, however, are asymptomatic or have relatively
innocuous clinical symptoms,( Bumann & Lotzmann ,2003;List et al;2017).
12.3.Infection arthritis:-
Infection arthritis of the temporomandibular joint (TMJ) may result from direct
extension of adjacent infection or hematogenous spread of bloodborne organism.
The area is inflamed, and jaw movement is limited and painful. Local signs of
infection associated with evidence of a systemic disease or with an adjacent
infection suggest the diagnosis. X-Ray results are negative in the early stages but
may show bone destruction later. If suppurative arthritis is suspected, the joint is
aspirated to confirm the diagnosis and to identify the causative
organism(diagnosis must be made rapidly to prevent permanent joint damage).
Treatment includes antibiotics, proper hydration, pain control, and motion
restriction. Parenteral penicillin G is the drug of choice until a specific
bacteriologic diagnosis can be made on the basis of culture and sensitivity
testing. For methicillin-resistant Staphylococcus aureus (MRSA) infections of
the oral structures, IV vancomycin is the antibiotic of choice. Suppurative
infections are aspirated or incised. Once the infection is controlled, passive jaw-
29
opening exercises help prevent scarring and limitation of motion. The Most
common symptoms include , difficulty in mouth opening due to pain, fibrous
adhesions, anterior disc displacement, muscle contracture, inflammation, or more
severe degeneration,(Bumann & Lotzmann,2003;Gorenflo et al.,2020).
12.4.Traumatic arthritis:
Rarely, acute injury (eg, due to difficult tooth extraction or endotracheal
intubation) may lead to arthritis of the TMJ. Pain, tenderness, and limitation of
motion occur. Diagnosis is based primarily on history. X-ray results are negative
except when intra-articular edema or hemorrhage widens the joint space.
Treatment includes NSAIDs, application of heat, a soft diet, and restriction of
jaw movement (Bumann & Lotzmann,2003;Okeson et al.,2011).
12.5. Osteochondrosis Dissecans:
Osteochondritis dissecans is a disorder of unclear pathophysiology wherein
fragments of articular cartilage and bone freely move within the Synovial fluid
(“joint mice”). It usually occurs in the knee and elbow and is often related to
sports. Reports have described this condition in the TMJ but little is known about
the signs and symptoms. History is positive for arthralgia as previously defined
and joint noises with mandibular movement or swelling. Examination is positive
for similar clinical findings as operationalized for arthralgia, or crepitus detected
by the examiner during palpation or reported by patient during mandibular
movements or maximum assisted opening with vertical overlap ,(Aiyer et
al.,2020).
13.Neoplasm:-
A neoplasm is new, often uncontrolled growth of abnormal tissue arising or
involving the TMJ or supporting structures. Tumors of the TMJ are rare, can be
malignant or benign, and present with symptoms similar to intra-articular

30
disorders. Occasionally metastatic tumors have also been reported. Presenting
symptoms include reduced mouth opening which is progressive, joint pain,
malocclusion, swelling in the TMJ region, skin reactions in the TMJ region,
lymphadenopathy, and crepitus. If the condyle is involved, there is frequently
development of a facial asymmetry with a midline shift as that noticed in
condylar hyperplasia. Diagnostic imaging and biopsy are essential when a
neoplasm is suspected. Treatment options include surgery, radiotherapy, and
chemotherapy (Mehrotra et al., 2011).
14. Congenital/developmental disorders
14.1. Hyperplasia
Is the overdevelopment of the mandible or cranial bones that occurs unilaterally
or bilaterally as a localized enlargement such as condylar hyperplasia or as an
overdevelopment of the entire mandible or side of the face. Hyperplasia normally
occurs during adolescence, leading to facial asymmetry, mandibular deviation,
and a malocclusion . Facial asymmetry resulting from excessive condylar growth
is of two types :
• Type I: Hemimandibular hyperplasia (HH).
• Type II: Hemimandibular elongation (HE).
To diagnose hyperplasia, the history must be positive for progressive
development of mandibular or facial asymmetry, and the examination must
confirm this history. Imaging using panoramic radiography and/or CT/CBCT
and single-photon emission CT is positive for asymmetry in mandibular ramus
height and there is an increased uptake of technetium-99 m hydroxy
diphosphonate on bone scintigraphy scan (nuclear imaging)(Mehrotra et al.,
2011).

31
14.2. Hypoplasia :-
An incomplete development or underdevelopment of the cranial bones or the
mandible occurs often secondary to trauma during adolescence. It may result in
asymmetric growth of the mandible, and may be associated with malocclusion
that includes open bite. History must be positive for progressive development of
mandibular asymmetry or micrognathia from birth or early childhood and
development of malocclusion, which may include posterior open bite.
Examination must confirm this history. Imaging using CT/CBCT will show at
least one of the following:
hypoplasia of the fossa, hypoplasia of the condyle, or shortened mandibular
ramus height(Nakano et al.,2009).
14.3. Aplasia:-
A failure of the condyle to develop or incomplete development of the articular
fossa and eminence is usually associated with congenital anomalies such as
oculo-auriculo-vertebral spectrum (Goldenhar syndrome), hemifacial
microsomia, and mandibulofacial dysostosis (Treacher Collins syndrome). Such
aplasia is unilateral, causing facial asymmetries, and might cause a malocclusion.
In rare occasions, it may be bilateral, without facial asymmetry, but with a
definitive micrognathia and open bite. History must be positive for progressive
development of mandibular asymmetry or micrognathia from birth or early
childhood and development of malocclusion, which may include posterior open
bite. Examination reveals mandibular asymmetry, with deviation of the chin to
the affected side or micrognathia and inability to detect the condyle upon
palpation during mandibular movements. Imaging will show severe hypoplasia
of the fossa and eminence and aplasia of the condyle ,(Nakano et al., 2009).

32
15. Masticatory Muscle Disorders:-
15.1. Trismus :-
Also called locked jaw, is reduced opening of the jaws (limited jaw range of
motion). It may be caused by spasm of the muscles of mastication or a variety of
other causes. Usually temporary trismus occurs much more frequently than
permanent trismus. It is known to interfere with eating, speaking, and
maintaining proper oral hygiene. This interference, specifically with the patient’s
ability to swallow properly, results in an increased risk of aspiration. In some
instances, trismus presents with altered facial appearance. The condition may be
distressing and painful for the patient. Examination and treatments requiring
access to the oral cavity can be limited, or in some cases impossible,due to the
nature of the condition itself, (Bumann& Lotzmann,2003;Gröbner et
al.,2018).
15.2. Myalgia :-
Myofascial pain or myalgia is the most common muscle disorder characterized
by pain and dysfunction that arises from pathologic and functional processes in
the masticatory muscles. It is diagnosed when the patient’s muscle pain is
aggravated by mandibular movement, function, or parafunction and can be
reproduced by palpating the painful muscles such as temporalis or masseter.
Types: Myalgias can be acute or chronic and are of three subtypes,(Fricton et
al.,2010):-
• Local myalgia.
• Myofascial pain with spreading.
• Myofascial pain with referral.

33
15.3. Tendonitis
Tendonitis involves pain of tendon origin aggravated by mandibular
movement, function, or parafunction, and it can be reproduced by provocation
testing of the painful tendon. Limitation of mandibular movements secondary to
pain may be present. The only masticatory muscle tendon that can be palpated
separately from the muscle is the temporalis muscle tendon, which can be
palpated intraorally. Also, the temporalis tendon is a common site of tendonitis
with referred pain to the teeth or other structures,(Nakano et al., 2009;Fricton
et al.,1985).
15.4. Spasm
Spasm refers to the sudden, involuntary, reversible tonic contraction of a
muscle that is diagnosed when the muscle meets the criteria for myalgia, it
causes a limited range of motion. The pain and limited range of motion had an
immediate onset. Acute malocclusion may be present. Certain local muscle
conditions known to predispose to muscle spasm include muscle fatigue,
alteration in local electrolyte balance, and deep pain. The patient usually
complains of inability to put the ipsilateral posterior teeth together without
excruciating pain (the first tooth contact is in the area of the contralateral canine)
and a difficulty in translating the condyle forward leading to a marked limited
opening. To diagnose a spasm, the patient must report immediate onset of
muscle pain modifed by function and parafunction as operationalized in myalgia
and immediate report of limited range of jaw motion, (Fricton et al.,2010).
15.5. Myositis
Myositis is diagnosed when the muscle meets the criteria for myalgia and has
clinical characteristics of infammation or infection: edema, erythema, and/or
increased temperature. Onset of symptoms is usually acute, related to direct

34
trauma to the muscle or infection of the muscle from orodental causes such as
pericoronitis or cellulitis, or it can occur chronically from an autoimmune
disease. To diagnose myositis, the patient must have local myalgia, and the
examination of the temporalis or masseter muscle must confrm both of the
following:
• Local myalgia.
• Presence of edema, erythema, and/or increased temperature over the
muscle,(Fricton et al.,2010).
15.6. Myofascial Pain with Referral:
Myofascial pain with referral is diagnosed when the disorder meets the criteria
for myalgia and the referral of pain beyond the boundary of the masticatory
muscles being palpated. To diagnose myofascial pain with referral, the patient
must have myalgia, and the examination of the temporalis or masseter muscle
must confrm both of the following:
• Familiar muscle pain with palpation.
• Pain with muscle palpation beyond the boundary of the muscle.
Other masticatory muscles may be examined as required. Though it is not
signifcant to differentiate between local myalgia and myofascial pain with
spreading, when a patient’s pain is due to referred pain from a muscle, it should
be diagnosed as myofascial pain with referral (Fricton et al.,2010).
16. Management of the TMD
16.1. Nonpharmacologic Management:
Patient education is the recommended initial treatment for TMD. Adjunctive
measures include jaw rest, soft diet, moist warm compresses and passive
stretching exercise . On the other hand TMJ immobilization has shown no
benefit and may worsen symptoms as a result of muscle contractures, muscle

35
fatigue, and reduced synovial fluid production. Patients should be counseled on
behavior modifications such as stress reduction,elimination of parafunctional
habits (e.g., teeth Grinding, pencil or ice chewing, teeth clenching), and
avoidance of extreme mandibular movement (e.g., excessive opening during
yawning, tooth brushing, and flossing),(Bordoni et al.,2019).
16.1.1. Physical Therapy:-
There is evidence that supports the use of physical therapy for improving
symptoms associated with TMD. Techniques may be Active or passive (e.g.,
scissor opening with fingers, use of medical devices) with the goal of improving
muscle strength, coordination, relaxation, and range of motion. Specialized
physical therapy options such as ultrasound, , electrotherapy, or low-level laser
therapy have been used in the management of TMD(Bender et al.,2018)
16.1.2 . Acupuncture
Acupuncture is a commonly used strategy for pain relief in which an
acupuncture needle or, more often acupuncture needles are inserted around the
ear, face and jaw, and the trigger points are the masseter, the lateral pterygoid,
the medial pterygoid, and the temporalis muscles. Acupuncture can help with
muscle relaxation and reduce muscle spasms of the TMJ (Lee & Ernst, 2011).

16.2. Pharmacological Management

Pharmacologic treatments for TMD are largely based on expert opinion. Several
classes of medication are used to treat the underlying pain associated with TMD.
Nonsteroidal anti-inflammatory drugs (NSAIDs; including salicylates and
Cyclooxygenase inhibitors), benzodiazepines, anti-epileptic agents, and muscle
relaxant. Despite the multiple choices of NSAIDs available, only naproxen
(Naprosyn) has proven benefit in reduction of pain ,also muscle relaxants can be
prescribed with NSAIDs if there is evidence of a muscular component to TMD.
36
Tricyclic antidepressants—most commonly amitriptyline, desipramine
(Norpramin), doxepin, and nortriptyline (Pamelor)—are used for the
management of chronic TMD pain. Benzodiazepines are also used, but are
generally limited to two to four weeks in the initial phase of treatment ,diazepam
[Valium], Clonazepam [Klonopin], gabapentin [Neurontin] may provide more
benefit than Shorteracting agents. Opioids are not recommended and, if
prescribed, should be used for a short period in the setting of severe
pain(Kalaykova et al.,2011;Michael et al.,2021).
16.3. Dental occlusal splinting and permanent occlusal adjustment
Occlusal splint has been the mainstays of TMJ disorder treatment. It can be
defined as “the art and science of establishing neuromuscular harmony in the
masticatory system by creating a mechanical disadvantage for parafunctional
forces with removable Appliances.” . Other goals of treatment are to improve
jaw-muscle function and to relieve associated pain by creating a stable balanced
occlusion. Two main types of splinting are available occluding and non-
occluding Occluding splints, also called stabilization splints are specially
fabricated to improve the alignment of the upper and lower teeth. Non-Occluding
splints ,also called simple splints ,primarily open the jaw to release muscle
tension ,and prevent the teeth clenching, usually made of a soft –vinyl and are
easier and cheaper to fabricate(Bender et al.,2018;Michael et al.,2021).
16.4. Surgical intervention
Surgical intervention is appropriate only when: (Michael et al.,2021).
1) There is identifiable pathology amenable to surgical intervention.
2) There is resultant loss of mechanical function
3) There is pain related to joint pathology.

37
Conclusion
TMD are common, more prevalent in women, and are conditions that dental
professionals are likely to encounter in everyday clinical practice. TMD can be
caused or exacerbated by physical changes, stress and parafunctional jaw habits.
TMD includes a constellation of symptoms, of which pain is the most common.
Other symptoms include joint sounds, limited jaw opening and deviation on
opening. A brief screening history regarding pain and activities that make the
pain worse can help determine if a patient has a potential TMD problem. A
clinical examination that incorporates an assessment of pain and joint sounds on
opening and excursive movements is recommended. The examination should
also include palpations of the muscles of mastication and the TMJ, and findings
from the clinical examination are used to determine the diagnoses. Dental
professionals recommended that conservative and reversible self-management
treatment strategies are beneficial for most patients, with very few patients
requiring non-reversible surgical treatment.

38
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