Temporomandibular Disorders

Disc Of the TMJ Muscles of Mastication Functional movement

Normal Anatomy Made up of dense fibrous tissue 1.Masseter muscle Free movements
2 cynovial joints 2 compartments large superficial and small -Rotary(hinge) movement –
bones – head of the condyle of provide passive movable articular deep masseter – elevator mainly occurs between disc
mandible & squamous surface and condyle in lower jaw
divided into 3 bands – Anterior
temporal bone of the skull 2.Temporalis muscle compartment
intermediate & posterior
Articular surfaces – 3 parts -anterior , middle & - Translatory (sliding) –
mandibular condyle Retrodiscal tissues posterior -elevate the mandible articular eminence and disc in
Glanoid fossa & Articular posteriorly disk divided into upper compartment
eminence (restricted forward 1.Upper lamina – loose fibro 3.medial pterygoid muscle –
movement of the mandible) elastin tissue with high elastin elevate the mandible translation occurs with rotary
TMJ – Ginglymo arthrodial content movement
joint 4. lateral pterygoid muscle - include – opening & closing
hinging + gliding 2.Lower lamina – only collagen rises from 2 heads - protusion & retrusion
movement fibers superior - - lateral shifts
inferior – insert to periphery of
tissue , between 2 lamiana- highly
pterygoid fovea
vascular loose areolar tissue

Articular Capsule other muscles in mastication

type 1 collagen fibers - digastric muscle
circumferentially attached to - mylohyoid muscle
glenoid fossa & neck of the -Geniohyoid muscle
condyle -stylohyoid and infrahyoid
laterally reinforced by TM muscles
ligaments
limit movement of the mandible

synovial membrane
highly vascularized layer of CT

Accessory ligaments
1.stylomandibular ligament –
limit excesive protrusion of the
mandible
2.Sphenomandibular ligament –
protection for blood vessels and
nerves passing through
mandibular canal
Examination of TMJ
• Mandibular range of motion – evaluation of degree of mouth opening , lateral movement and protrusion
• degree of mouth opening - unassisted pain free mouth opening – open without feeling pain
- maximum mouth opening – open as much as possible even with pain
- restricted mouth opening – less 40mm
- end feel – placing fingers between maxillary & mandibular incisors , gentle force to open mouth
soft – limitation due to muscle problem
hard – limitation due to mechanical obstruction within joint
• lateral movement - any movement less than 8mm is concidered as abnormal
degree of lateral displacement is measured from mand midline to midline of maxilla
• deviation – strait line – normal
- diviation -midline shift to the affected side and come back to midline with maximum opening
• deflection – move toward the affected side grater with maximum mouth opening .
• Palpation – can only be palpated laterally and posteriorly . , feel joint sound .
• Ascultation – “click” – sharp single sound of short duration
“Crepitation” – multiple grating sound often complicated
Examination of muscles of mastication
healthy muscles do not produce pain during palpation

Masseter muscle Temporalis

Palpated at superior and inferior attachments 3 functional areas separately
fingers are placed over sygomatic arch just anterior to TMJ & move slowly 1.Anterior region – palpated above sygomatic arch antrior to TMJ
downward (part attach to zygomatic arch) 2.middle region – palpated above the zygomatic arch & derectly over the TMJ
fingers move further downward to inferior part ( attach to ramus ) 3.posterior region – palpated above and behind the ear

temporalis tendon – bi manual palpation method (index finger both hand intra &
extra oral
- intra oral finger is rolled over ramuus until coronoid process and temporalis
tendon is palpated
 Bite on a tongue blade Chlenching Mouth opend wide Protrution
Medial pterygoid ++(pain+) +++ +++ ---(no pain)

Lateral pterigoid --- +++ +++ ---

Superior head
Lateral pterigoid --- +++ +++
inferior head +++

Examination of neck muscles

• could be symptomatic several TMJ disorders
• may have trigger areas which may be primary source of pain
Sternocledomastoid muscle Trapezius muscle

Start from its insertion at mastoid process behined the ear Presence of trigger points
palpated upto origin at clavicle palpated at superior border behined the origin of SCM

Aetiology of Temporomandibular Disorders - multifactorial

Predisposing factors Initiating factors Perpetuation factors

Factors that interfere with healing or
++ risk of development of TMD Micro- trauma – repeatedly over facilitate the progression of TMD
Systemic long time period
- emotional stress → hypothalumus , reticular system , Mechanical stress
limbic system → increase muscular activity → increase Macro- trauma – sudden force Muscular stress
tonicity reflex contraction - direct Metabolic problems
- indirect Behavioural problems
Physiological Social problems
Physiological tolerance can be influenced by both local and Emotional problems
systemic factors less – dysfunction , more – no disfunction

Structural
 Imaging of TMJ
• plain radiography - TMJ view , DPT
• Tomography - Conventional – linear & spiral
Computed – spiral & cone beam
• MRI
• Arthroscopy
• Scinitigraphy
• ultrasonography

Disorders Mechanism Signs & symptoms / diagnosis Management of TMD

Masticatory muscle disorders First response of a muscle to a injury History – constant deep pain and increased
not a disease but physiological response of a emotional stress
Protective co – contraction
muscle clinical examination -restricted range of
(muscle splinting )
due to motion and increased pain during function
1. altered sensory/ propeoceptive input
2.presence of constant deep pain 1.constant deep pain in muscles
3.increase emotional stress 2.increased emotional stress
if persists → local muscle soreness 3.restricted mouth opening and reduce
range of mandibular motion
4.increased pain during function
Local muscle Soreness Local changes of muscles History – constant deep pain and increased
pathophysiology still unknown emotional stress
clinical – restricted mandibular range of
motion and severe pain during function

1.constant deep pain

2.increased emotional stress
3.restricted mandibular range of motion
4.severe pain during function
5.local muscle tenderness on palpation
Myofascial Pain Common condition of muscle pain characterized Clinical features + exclusion of other
(trigger point myalgia) by presence of local areas of firm hypersensitive pathological condition of the muscles
bands (trigger points)
local muscle pain or referred pain at other sites presence of trigger points with or without
mimic headache , facial pain , earache or pain
toothache
Trigger points in muscles of mastication → 1.complaint of muscle pain
 structural dysfunction 2.pain aggravated by function
3.Reduced mandibular range of motion
4.trigger points
5.Referred pain
Myospasm Involentary Central nervous system induce muscle Clinical
contraction 1.severely restricted mandibular range of
associated with local muscle metabolic conditions motion
due to - 2.pain at function as well at rest
1.continuous deep pain input 3.tense muscle with tenderness
2.Local metabolic factors of muscles 4.generalized muscle tightness
3.idiopathic mechanisms
diagnosis
1.Localized pain
2.Reduced mandibular range of motion
3.increased electromyographic activity

Myofibrotic contracture Painless shortening of muscle due to fibrossis in & Clinical

around contractile muscle Painless limited mandibular motion
Abnormal resistance to passive stretching
After trauma or infection of muscle usually after a Diagnostic criteria
prolonged limitation of muscle movement 1.severely restricted mandibular motion
2.no pain
3.severe resistance to passive stretching
(Hard and feel

Centrally mediated myalgia Continues chronic muscle pain originated from Diagnostic criteria
central nervous system . 1.prolonged continuous muscle pain
= imflamatory muscle disorder hence called as 2.significantly limited mandibular range of
chronic myosistis motion
no features of inflammation 3.pain at rest & aggravated with function
etiology 4.muscle tenderness on palpation
. prolonged presence of pain causing substances
(alogens) in muscle
. neurogenic inflammation

prolonged muscle soreness/ Centrally meadiated

myofacial pain myalgia
Fibromyalgia Continuous disabling generalized muscle disorder Tender points on muscles of body
unknown etiology not only in masticatory muscles
Neoplasia Benign / malignant Present as swelling , pain or difficulty
primary / secondary .

Temeromandibular Joint
articular disorders
- Growth