Disorders of the

Temporomandibular
Joint

OMR, BVUDCH, PUNE

 TMJ Disorders
Why should we learn?
Diagnosis & Management under
the purview of Dentistry

1. It is one of the maxillo-facial structures.

2. Its function intimately associated with
occlusion and masticatory muscles.
3. It is frequently affected by trauma.
4. Disorders cause pain and trismus.
Therefore, need to be considered in
differential diagnosis.

OMR, BVUDCH, PUNE

 TMJ Disorders
What shall we learn?
1. Review of its structure and function
2. Assessment of patient with TMJ disorder:
• History and Clinical examination
• TMJ imaging & other investigations
3. Disorders and classification
4. Pathogenesis, diagnosis and management of
myofascial pain dysfunction syndrome

OMR, BVUDCH, PUNE

 TMJ Disorders
TMJ Structure:
1. Osseous components:
• Glenoid fossa of temporal bone
• Condylar process of mandible

OMR, BVUDCH, PUNE

 TMJ Disorders
TMJ Structure:

Burket’s Oral Medicine, 10th Ed.

OMR, BVUDCH, PUNE

 TMJ Disorders
TMJ Structure:

3D CT Image

OMR, BVUDCH, PUNE

 TMJ Disorders
TMJ Structure:

2D CT Images

OMR, BVUDCH, PUNE

 TMJ Disorders
TMJ Structure:

OMR, BVUDCH, PUNE

 TMJ Disorders
TMJ Structure:
1. Osseous components:
• Glenoid fossa of temporal bone
• Condylar process of mandible
2. Non-osseous components:
• Articular disc
• Retro-discal tissue
• Joint capsule
• Synovial membrane

OMR, BVUDCH, PUNE

 TMJ Disorders
TMJ Structure:

Burket’s Oral Medicine, 10th Ed.

OMR, BVUDCH, PUNE

 TMJ Disorders
TMJ Structure:

Sagittal CT and MRI Images

OMR, BVUDCH, PUNE

 TMJ Disorders
TMJ Structure:

Sagittal section in cadaver.

Burket’s Oral Medicine, 10th Ed.

OMR, BVUDCH, PUNE

 TMJ Disorders
TMJ Function:
1. Ginglymo-arthroidal joint:
• Hinge movement along long axis
• Rotational movement along vertical axis
• Anterior sliding movement
2. Functional components:
• Articulating surfaces, disc, retro-discal tissue
• Masticatory muscles: temporalis, masseter,
lateral pterygoid, medial pterygoid,
• Other muscles: digastric, mylohyoid,
geniohyoid, genioglossus, buccinator
• Ligaments: lateral, spheno-mandibular, stylo-
mandibular
• Teeth, occlusion, periodontal ligament
OMR, BVUDCH, PUNE
 TMJ Disorders
TMJ Function:

OMR, BVUDCH, PUNE

 TMJ Disorders
Assessment of patient with TMJ disorder: History
1. Common complaints:
• Pain in and around the joint
• Trismus (partial, complete)
• Clicking noise on movement
• Jaw deviation on movement
• Hypermobility, dislocation
2. Record details viz.
• Origin (sudden, gradual, after dental treatment or
trauma), Duration, Progress
• Pain characteristics: intensity (severe, mild),
nature (sharp, aching), localization (well, poor)
• Initiating, aggravating or relieving factors

OMR, BVUDCH, PUNE

 TMJ Disorders
Differential diagnosis of trismus/ limited mouth
opening/ difficulty in opening:
1. Local causes (within the joint):
• Double condyle
• Ankylosis
• Arthritis
• Disc displacement without reduction
2. Focal causes (around the joint):
• Pericoronal abscess, cellulitis, jaw tumors, oral
malignancy, jaw fractures
• OSMF, severe erosive of ulcerative oral lesions
• MPDS
• Ear, throat, salivary gland infections
• Myositis ossificans

OMR, BVUDCH, PUNE

 TMJ Disorders
Differential diagnosis of trismus/ limited mouth
opening/ difficulty in opening:
3. Systemic causes:
• Tetanus
• Tetany

Difficulty in closing the mouth:

1. Joint dislocation:
anterior and superior
placement of condyle
with muscle spasm
2. Le Forte III fracture

OMR, BVUDCH, PUNE

 TMJ Disorders
Assessment of patient with TMJ disorder:
Extra-oral Examination
1. Inspection:
• Facial symmetry
• Facial swelling, injury
• Deviation on movement
• Amount of mouth opening and lateral excursive
movements
• Audible click

OMR, BVUDCH, PUNE

 TMJ Disorders
Assessment of patient with TMJ disorder:
Extra-oral Examination

OMR, BVUDCH, PUNE

 TMJ Disorders
Assessment of patient with TMJ disorder:
Extra-oral Examination
2. Palpation: Pre-tragal or through external auditory
meatus
• Joint movement
• Joint tenderness
• Masticatory muscle tenderness
• Crepitus

3. Auscultation
• Joint sounds

OMR, BVUDCH, PUNE

 TMJ Disorders
Assessment of patient with TMJ disorder:
Extra-oral Examination

OMR, BVUDCH, PUNE

 TMJ Disorders
Assessment of patient with TMJ disorder:
Intra-oral Examination
1. Teeth, periodontium, occlusion, prosthesis
2. Signs of para-functional habits
• Grinding: flattening of cusps
• Clinching: deepening of central fossae (‘bruxo-
facets’)
• Tapping: Selective abrasion of opposing teeth
3. Over-closure or high points of restorations
4. Tongue: indentation on lateral border

OMR, BVUDCH, PUNE

 TMJ Disorders
Assessment of patient with TMJ disorder:
Intra-oral Examination

OMR, BVUDCH, PUNE

 TMJ Disorders
Assessment of patient with TMJ disorder:
Imaging and other investigations
1. Routine:
• Panoramic

OMR, BVUDCH, PUNE

 TMJ Disorders
Assessment of patient with TMJ disorder:
Imaging and other investigations
1. Routine:
• Panoramic

OMR, BVUDCH, PUNE

 TMJ Disorders
Assessment of patient with TMJ disorder:
Imaging and other investigations
1. Routine:
• Panoramic
• Transcranial, transpharyngeal, transorbital
• Reverse Townes
2. Advanced:
• CT
• MRI
• Arthrography
3. Other:
• Electromyography

OMR, BVUDCH, PUNE

 TMJ Disorders
Assessment of patient with TMJ disorder:
Imaging and other investigations
1. Routine:
• Panoramic
• Transcranial, transpharyngeal, transorbital
• Reverse Townes
2. Advanced:
• CT
• MRI
• Arthrography
3. Other:
• electromyography

OMR, BVUDCH, PUNE

 TMJ Disorders
TMJ projections:

OMR, BVUDCH, PUNE

 TMJ Disorders
Transcranial projection:
1. Patient position: Sitting upright with sagittal plane
perpendicular to floor with mouth closed or open
position.
2. Film placement: Centered over the TMJ.
3. Centering point: 2-3 inches above and 1 inch behind
the external auditory meatus of opposite side.
4. Direction of central ray: 25 degrees downward and
20 degrees forward.
5. Exposure parameters: 65 kVp, 10 mA, 2.5 S, 4.5 x
6.5 inches screen film.

OMR, BVUDCH, PUNE

 TMJ Disorders
Transcranial projection:

OMR, BVUDCH, PUNE

 TMJ Disorders
Transcranial projection:

OMR, BVUDCH, PUNE

 TMJ Disorders
Transpharyngeal projection (Parma modification):

OMR, BVUDCH, PUNE

 TMJ Disorders
Transpharyngeal projection (Parma modification):
1. Patient position: Sitting upright with sagittal plane
perpendicular to floor with mouth wide open.
2. Film placement: Centered over the TMJ.
3. Centering point: Sigmoid notch of opposite side.
4. Direction of central ray: 10 degrees upward and 10
degrees backward. The collimator tube is removed
from the tube head.
5. Exposure parameters: 65 kVp, 10 mA, 0.5 S, 4.5 x
6.5 inches screen film.

OMR, BVUDCH, PUNE

 TMJ Disorders
Transpharyngeal projection (Parma modification):

OMR, BVUDCH, PUNE

 TMJ Disorders
Transpharyngeal projection (Parma modification):

OMR, BVUDCH, PUNE

 TMJ Disorders
Transorbital projection:

OMR, BVUDCH, PUNE

 TMJ Disorders
Transorbital projection:
1. Patient position: Sitting upright with sagittal plane
perpendicular and Frankfurt plane parallel to floor.
Head is rotated about 30 degrees to the side to be
examined with mouth wide open.
2. Film placement: Over the back of the head centered
over the TMJ.
3. Centering point: Inner canthus of orbit of same side.
4. Direction of central ray: 10 degrees downward.
5. Exposure parameters: 65 kVp, 10 mA, 1.0 S, 4.5 x
6.5 inches screen film.

OMR, BVUDCH, PUNE

 TMJ Disorders
Transorbital projection:

OMR, BVUDCH, PUNE

 TMJ Disorders
Transorbital projection:

OMR, BVUDCH, PUNE

 TMJ Disorders
What shall we learn?
1. Review of its structure and function
2. Assessment of patient with TMJ disorder:
• History and Clinical examination
• TMJ imaging & other investigations
3. Disorders and classification
4. Pathogenesis, diagnosis and management of
myofascial pain dysfunction syndrome

OMR, BVUDCH, PUNE

 TMJ Disorders
What shall we learn?
1. Review of its structure and function
2. Assessment of patient with TMJ disorder:
• History and Clinical examination
• TMJ imaging & other investigations
3. Disorders and classification
4. Pathogenesis, diagnosis and management of
myofascial pain dysfunction syndrome

OMR, BVUDCH, PUNE

 TMJ Disorders
Classification:
1. Cranial and mandibular bone abnormalities
• Developmental: aplasia, hypoplasia, hyperplasia,
double condyle, prognathism, Pierre Robin
syndrome, Treacher Collins syndrome
• Acquired: neoplasia, fracture
2. TMJ disorders:
• Disk displacement (with or without reduction)
• Dislocation
• Inflammatory conditions: synovitis, capsulitis
• Arthritis: degenerative osteoarthritis, rheumatoid
• Ankylosis: fibrous, bony

OMR, BVUDCH, PUNE

 TMJ Disorders
Classification:

Condylar Hyperplasia
OMR, BVUDCH, PUNE
 TMJ Disorders
Classification:

Dislocation
OMR, BVUDCH, PUNE
 TMJ Disorders
Classification:

Bony Ankylosis
OMR, BVUDCH, PUNE
 TMJ Disorders
Classification:

Bony Ankylosis
OMR, BVUDCH, PUNE
 TMJ Disorders
Classification:
1. Cranial and mandibular bone abnormalities
• Developmental: aplasia, hypoplasia, hyperplasia,
double• condyle,
Describeprognathism,
etiology, clinical and
Pierre Robin
radiographic
syndrome, features
Treacher Collins of
syndrome
• Acquired:degenerative and rheumatoid
neoplasia, fracture
2. TMJ disorders:
arthritis.
• Disk displacement (with or without reduction)
• Dislocation
• Inflammatory conditions: synovitis, capsulitis
• Arthritis: degenerative osteoarthritis, rheumatoid
• Ankylosis: fibrous, bony

OMR, BVUDCH, PUNE

 TMJ Disorders
Classification:
3. Masticatory muscle disorders
• Myofascial pain dysfunction
• Masseteric hyperplasia
• Myositis, myositis ossificans
• Spasm

OMR, BVUDCH, PUNE

 TMJ Disorders
Classification:
3. Masticatory muscle disorders
• Myofascial pain dysfunction
• Masseteric hyperplasia
• Myositis, myositis ossificans
• Spasm

OMR, BVUDCH, PUNE

 TMJ Disorders

Myofascial Pain Dysfunction Syndrome (MPDS):

1. Introduction:
• Syndrome: Several symptoms experienced by
patient either simultaneously or in random order.
Also, symptoms are experienced either in TMJ
itself, or muscles, or in surrounding structures.
• Many adults suffer transient form of syndrome,
but in some individuals it becomes a chronic
troublesome condition.
• No obvious abnormality is seen in joint or
musculature. So, it may get labeled as ‘imaginary’
pain. Patients consult several different specialists
(medical & dental) without relief.

OMR, BVUDCH, PUNE

 TMJ Disorders

Myofascial Pain Dysfunction Syndrome (MPDS):

1. Introduction:
• Dentist may be the best person to identify the
condition correctly, and guide in proper
management.
• Laskin gave the name ‘Myofascial Pain
Dysfunction Syndrome’ in 1969.
• Schwartz called it ‘TMJ pain Dysfunction
Syndrome’ in 1956.
• Based upon the description by Costen (1934), it
was labeled ‘Costen’s Syndrome’.

OMR, BVUDCH, PUNE

 TMJ Disorders

Myofascial Pain Dysfunction Syndrome (MPDS):

2. Pathogenesis:
• Uncertain.
• Costen suggested abnormal occlusion as its
cause.
• Schwartz felt it is muscular dysfunction.
• Laskin suggested it to be caused by psychosocial
disorder.
• Currently, it is considered to be multi-factorial
pathogenesis with some factors initiating the
condition, some factors perpetuating it and some
other factors aggravating it.
• ‘Psycho-physiologic theory’

OMR, BVUDCH, PUNE

 TMJ Disorders

Myofascial Pain Dysfunction Syndrome (MPDS):

2. Pathogenesis: the vicious cycle
Anxiety, Para-functional
Depression Stress habit

Excessive strain
Neuro-muscular on muscles
imbalance, Chronicity

Muscle fatigue
& Pain • Malocclusion
• Jaw injury, surgery
• Occlusal trauma
OMR, BVUDCH, PUNE
 TMJ Disorders

Myofascial Pain Dysfunction Syndrome (MPDS):

3. Diagnosis:
• 80%-90% patients are females over the age of 40
years.
• Based upon symptoms and signs, and absence of
radiographic changes.
• Symptoms:
 Poorly localized, intermittent, dull aching pain
of many months duration in or around joint
 Restricted mouth opening (locking)
 Clicking sound in joint
 Other: morning jaw stiffness, masticatory
muscle weakness

OMR, BVUDCH, PUNE

 TMJ Disorders

Myofascial Pain Dysfunction Syndrome (MPDS):

3. Diagnosis:
• Signs:
 Tenderness over the joint or in one or more
muscles of mastication, most commonly
masseter or lateral pterygoid
 ‘Trigger point’ in muscle

• Particularly tender taut

band in muscle

OMR, BVUDCH, PUNE

 TMJ Disorders

Myofascial Pain Dysfunction Syndrome (MPDS):

3. Diagnosis:
• Signs:
 Tenderness over the joint or in one or more
muscles of mastication, most commonly
masseter or lateral pterygoid
 ‘Trigger points’ in muscle
 Reduced mouth opening
 Jaw deviation on movement
 Clicking

OMR, BVUDCH, PUNE

 TMJ Disorders

Myofascial Pain Dysfunction Syndrome (MPDS):

3. Diagnosis:
• Signs:
 Other: signs of para-functional habit,
tenderness in sternocleidomastoid or
trapezeus
• Other features that may co-exist: stress-related
conditions like migraine headache, hypertension,
acidity, unexplained pains in other muscles or
joints, ulcerative colitis

OMR, BVUDCH, PUNE

 TMJ Disorders

Myofascial Pain Dysfunction Syndrome (MPDS):

4. Natural course:
• Unpredictable.
• Periods of exacerbation and remission.
• The symptoms eventually reduce even without
treatment.
• Management therefore is symptomatic and
conservative. Treatments that cause irreversible
changes (e.g. surgery, extensive occlusal
changes) should be avoided.

OMR, BVUDCH, PUNE

 TMJ Disorders

Myofascial Pain Dysfunction Syndrome (MPDS):

4. Management:
• Patient counseling:
 Explaining the condition and its pathogenesis.
 Making the patient aware of habit.
 Diary to note occurrence of pain and
associated events.
 If necessary, psychological counseling and
treatment.
• Physiotherapy:
 Hot, moist compresses on painful muscles
 Coolant sprays
 Passive controlled jaw exercises
 Jaw exercises against resistance
OMR, BVUDCH, PUNE
 TMJ Disorders

Myofascial Pain Dysfunction Syndrome (MPDS):

4. Management:
• Patient counseling:
 Explaining the condition and its pathogenesis.
 Making the patient aware of habit.
 Diary to note occurrence of pain and
associated events.
 If necessary, psychological counseling and
treatment.
• Physiotherapy:
 Hot, moist compresses on painful muscles
 Coolant sprays
 Passive controlled jaw exercises
 Jaw exercises against resistance
OMR, BVUDCH, PUNE
 TMJ Disorders

Myofascial Pain Dysfunction Syndrome (MPDS):

4. Management:
• Analgesic:
 Ibuprofen: 400 mg tds x 5 days
 Topical application of counterirritants like
piroxicam or capsaicin
• Anxiolytic & muscle relaxant:
 Diazepam 5 mg at bedtime x 7-10 days
 Extended therapy should be avoided to
prevent dependence.
 Patient warned about sedative effect and
reduced motor co-ordination during the day.

OMR, BVUDCH, PUNE

 TMJ Disorders

Myofascial Pain Dysfunction Syndrome (MPDS):

4. Management:
• Analgesic:
 Ibuprofen: 400 mg tds x 5 days
 Topical application of counterirritants like
piroxicam or capsaicin
• Anxiolytic & muscle relaxant:
 Diazepam 5 mg at bedtime x 7-10 days
 Extended therapy should be avoided to
prevent dependence.
 Patient warned about sedative effect and
reduced motor co-ordination during the day.

OMR, BVUDCH, PUNE

 TMJ Disorders

Myofascial Pain Dysfunction Syndrome (MPDS):

4. Management:
• Local anesthetic:
 2% lignocaine (without adrenaline) in the
trigger point
• Splints:
 Habit-breaking
 Mandibular re-positioning devices
• Minor occlusal corrections to remove
interferences such as steep canine guidance,
replacement of faulty restorations or prosthesis
• Trans-cutaneous electric nerve stimulation
(TENS)
• Biofeedback, hypnosis
OMR, BVUDCH, PUNE
 TMJ Disorders

Myofascial Pain Dysfunction Syndrome (MPDS):

4. Management:
• Local anesthetic:
 2% lignocaine (without adrenaline) in the
trigger point
• Splints:
 Habit-breaking
 Mandibular re-positioning devices
• Minor occlusal corrections to remove
interferences such as steep canine guidance,
replacement of faulty restorations or prosthesis
• Trans-cutaneous electric nerve stimulation
(TENS)
• Biofeedback, hypnosis
OMR, BVUDCH, PUNE
 TMJ Disorders

Myofascial Pain Dysfunction Syndrome (MPDS):

5. Prognosis:
• Unpredictable in terms of time required for
improvement and in terms of which treatment
would be most effective.
• With active patient participation and controlling
the perpetuating factors, prognosis is generally
good.

OMR, BVUDCH, PUNE