Temporomandibular disorder (TMD)
• is a collective term used for a number of
clinical problems that involve the masticatory
muscle, temporomandibular joint (TMJ),
and/or associated structures.
The cardinal signs and symptoms for
TMD
• pain in the masseter muscle, TMJ, and/or
temporalis muscle regions.
- mouth - opening limitation.
- TMJ sounds.
• TMD can cause other
symptoms that are beyond
the masticatory
musculoskeletal system,
• e.g., nonotologic otalgia
(ear pain that is not caused
by the ear), dizziness,
tinnitus, neck pain and
toothache.
• TMD can contribute to
migraine and tension
headaches, myofascial pain
in the region.
TEMPOROMANDIBULAR DISORDERS
• PATHOLOGY OF THE TMJ classify into
• Nonarticular temporomandibular disorders
include muscle disorders such as myofascial
dysfunction, muscle spasm and myositis
ossificans progressiva, fibromyalgia .
• Articular disorders, often accompanied by
internal derangement, include
noninflammatory and inflammatory
arthropathies, growth disorders, neoplasms
and connective tissue disorders.
myositis ossificans
Myositis ossificans can be classified into two
types:
• the localized type "myositis ossificans
circumscripta" and
• the generalized form "myositis ossificans
generalisata".
• The localized myositis ossificans:
Definition : it involves a single muscle, which
is usually the masseter muscle.
Etiology: single severe trauma or repeated
minor trauma to the muscle.
Pathogenesis: trauma of adjacent periosteum
— the escape of osteoblasts into muscle —>
ossification —► metaplasia of intermuscular
connective tissue.
. Clinical picture:
1- Edema of the cheek.
2- Stiffness
3-Discomfort
4-Absence of hyperemia in the skin.
5-Limitation of the mobility of the lower jaw.
Radiograpgical finding :there are two
radiographic patterns :
- A feathery pattern
- Irregular radiopaque
Treatment:
Initial step —> Radiotherapy and steroide .
After six months when bony tissues formation has
stopped —► surgical excision of the ossified
mass
• The progressive type of myositis ossificans
Definition : congenital condition in which
ossification occurs in the soft tissues covering
the muscle fascicles.
Signs & symptom
1.A past history of swollen, painful joints.
1st —► swelling - Soft to hard - indurated - red
overlying skin - painless.
Later on -» swelling becomes painful due to
ulceration of overlying skin.
• Progression occurs until the entire groups of
muscles are involved leading to formation
calcifying island lead to false Ankylosis.
Treatment :
- early stages : forcible opening of mouth with
aid of muscles relaxants and G.A
- late stage : cornoidectomy and forcible
opening of mouth.
Fibromyalgia
is a systemic condition characterized by
widespread pain, aching and stiffness in muscles
and joints.
Fibromyalgia is often difficult to differentiate from
MPD and is treated with anti-inflammatory
medications, dietary modifications, bite
appliances, and physical therapy.
Wilkes Classification of Internal Derangements •
Classification based on findings from physical
examination, MRI, and possible arthroscopic finding
– Characteristics of the pain
Articular – Function—amount of mouth opening
disorders
– Disc location/condition
– Altered joint anatomy
Pain Opening Disc location Anatomy
Stage I Occasional No limitation Slightly forward Normal
painless click
Stage II Painful click Intermittent Moderate anterior disc Disc deformity
locking displacement with reduction
Stage III Pain during Locked and Complete disc displacement • Disc deformity
function restricted without reduction • No bony changes
motion or early changes
Stage IV Continuous Locked and Complete disc displacement Moderate
pain restricted without reduction degenerative bony
motion changes
Stage V Severe pain Locked and Perforation of retrodiscal Severe degenerative
severely tissue and possible disc bony changes
restricted motion perforation
Etiology
• 1-Parafunction (direct microtrauma,The
effects of psychological stress may cause the
masticatory system to spasm, thus
compressing and disrupting normal joint
articulation. Bruxism and clenching inflict
repetitive and abnormal overloading of the
joint and muscular system, causing spasm and
muscle pain to develop with intermittent
clicking.
Etiology
• 2- Dentofacial deformities and malocclusions
(direct microtrauma). Articular dysfunction
occurs from disharmonious motion between
the maxillary and the mandibular arches.
Like in vertical maxillary excess (VME) in
combination with mandible
retrognathia/hypoplasia.
Etiology
• 3- Direct macrotrauma. Direct trauma
involves an acute direct trauma to the
mandible with or without fracture
Etiology
• 4-Indirect macrotrauma. patients reporting
injuries of the acceleration-deceleration type
phenomenon followed by progressive
symptoms consisting of muscle and joint
noise.
Etiology
• 5-Systemic disease :
• rheumatoid arthritis (RA),
• systemic lupus erythematosus (SLE),
• benign or malignant tumors.
Evaluation and Diagnosis of the TMJ
disorders
• The criteria for TMJ dysfunction include
• TMJ pain.
Masticatory muscle pain
Limited range of motion.
I – history taking
Evaluation
and
Diagnosis 2- Clinical examination
of the TMJ
disorders 3-Imaging of the
Temporomandibular
Joint
Evaluation and Diagnosis of the TMJ disorders
I – history taking:
1. Chief complaint.
2. Duration: including the time of onset and
duration of the pain. The time of individual
episodes of pain (minutes, hours, days).
3. history of obvious trauma, psychological
or emotional stresses.
Evaluation 4. Loss of comfortable rest position of the
teeth.
and
Diagnosis
5. The presence of any pernicious habits
of the TMJ (Nail biting, pen biting), bruxism or
clenching.
disorders
6. Previous treatment procedures.
II. Clinical examination
Evaluation 1- Masticatory system: muscular
hypertrophy or asymmetry:
and
2-TMJ:
Diagnosis
of the TMJ 3-Examination of occlusion to
evaluate
disorders 4-Determine the range of mouth
opening
5- Determine the direction and
degree of deviation
Evaluation and Diagnosis
of the TMJ disorders
1- Masticatory
II. Clinical system: muscular
examination hypertrophy or
asymmetry:
Examination of the
Temporomandibular Joint
Clinical examination of TMJ
Examination of occlusion
Imaging of the Temporomandibular
Joint
• Conventional Imaging:
• 1- Transcranial view
Transmaxillary or Transorbital
Reverse Towne Projection
Lateral Oblique Views
Panoramic Radiography
Conventional Linear and
Multidirectional Tomography
Advanced Imaging Modalities
• Computed Tomography
Radionuleotide imaging
Evaluation of tmj pathology
It is sensitive for bony activity but it cannot differentiate between degnerative
changes or none repair.
MRI
Diagnostic aids with potential
therapeutic effects
• 1-Selective local anesthesia block
Selective blocking of the auriculotemporal
nerve with a long acting local anaesthetic with
vasoconstrictor will eliminate or reduce the
associated muscle pain if it is due to joint
problem.
2-Medication therapy
• The use of medication on a trial basis may not
only be therapeutic, but may actually be
useful in confirming a diagnosis (e.g.,
carbamazepine in trigeminal neuralgic patient
and muscle relaxants in muscle hyperactivity
of a patient).
3-Splints
If the joint pain, muscle pain or both are
decreased with the use of splints, this helps to
confirm the diagnosis of myofascial pain and
secondary joint pain.
4.Arthroscopy
It is generally considered to be a therapeutic
technique, but may be of high benefit to
confirm or rule out specific diagnosis
(Meniscal pathology). It allows for direct
visualization of the joint structures
Laboratory evaluation
• A complete blood count (CBC) may be useful
in cases of rheumatoid and systemic lupus
erythematosus
• Elevated erythrocytic sedimentation rate (ESR)
values are noted in rheumatoid collagen
vascular diseases as well as acute and chronic
infections.
• C reactive protein level is elevated in almost
all active rheumatoid arthritic patients.
• In rheumatoid arthrits an increase in serum
proteins (fibrinogen and IgG.
• Synovial fluid analysis can be used to
differentiate between several conditions that
may affect the joint such as rheumatoid
arthritis, systemic lupus erythematosus,
osteoarthritis and gout
