TMJ Disorders
Dr.Afifa Razi
Associate Professor
Head of Department
Oral Medicine & Diagnosis
Normal Anatomy
Osseous structures
Soft tissue components
Osseous Structures
Glenoid fossa
Articular eminence
Mandibular condyle
Post-glenoid tubercle
Normal Disk Position
Partially Displaced Disk
Fully Displaced Disk
Stages of TMJ disc
displacement
Stage I: Disc displacement with reduction DDWR (hearing and
palpating joint noises during opening and closing, protrusive opening
and closings stops the reciprocal click)
Stage II: Disc displacement without reduction DDWoR (history of
clicking and popping with or without intermittent locking, complaint of
limited mouth opening)
Stage III: Chronic disc displacement without reduction (hearing
multiple noises during opening and closing (crepitus), with normal or
near normal mandibular dynamics
Diagnosis
History
Examination
Investigations
HISTORY NOT TO BE MISSED
Pain history if present
H/O trauma
Habits
Any change in the bite
Any stressful event in life
Disorders of the joints elsewhere
Generalized painful conditions
Previous treatment
Psychosocial history
VISUAL INSPECTION FROM DIFFERENT ANGLES
PALPATION OF TM JOINT (OPEN &
CLOSED MOUTH)
INTRA AURICULAR PALPATION OF
TM JOINT
PALPATION OF TEMPORALIS MUSCLE
(ORIGIN & INSERSION )
SIDE
VIEW
ORIGIN
FRONT INSERTION
VIEW OF MUSCLE
PALPATION OF MASSETER MUSCLE
(EXTRA & INTRAORAL)
ORIGIN INSERTION
PALPATION OF LATERAL PTERYGOID MUSCLE
(INTRA & EXTRAORAL)
LATERAL EXCURSION
INSERTION
INTRAORALY
OPENING
PALPATION OF STERNOCLEIDOMASTOID MUSCLE
OCCLUSION
NORMAL BITE CROSS BITE
MOUTH OPENING & INTER-INCISAL DISTANCE
NORMAL MOUTH OPENING
NIL OPENING
PROTRUSION ON
LATERAL MOVEMENT DEVIATION ON
OPENING
MEASURE OPENING
TMJ Disorders
Muscles, joint structures & associated tissues as a result of defective
physical activity.
Pathological change in the joint itself.
CLASSIFICATION OF TMJ DISORDERS
1. Developmental Disorders
2. Inflammatory Disorders
3. Osteoarthritis
4. Functional Disorders
5. Loose Bodies in TMJ
6. Neoplasms
7. Age changes in TMJ
8. Trismus
DEVELOPMENTAL DISORDERS
1. Aplasia of the condyle
2. Hypoplasia of the condyle
3. Hyperplasia of the condyle
Hyperplasia
INFLAMMATORY DISORDERS
1. Traumatic Arthritis
2. Infective Arthritis
3. Rheumatoid Arthritis
Condylar fracture
Condylar fracture
CLASSIFICATION OF TMJ DISORDERS
1. Developmental Disorders
2. Inflammatory Disorders
3. Osteoarthritis
4. Functional Disorders
5. Loose Bodies in TMJ
6. Neoplasms
7. Age changes in TMJ
8. Trismus
TMJ with osteoarthritis
Normal TMJ
Osteoarthritis or Degenerative Joint Disease
CLASSIFICATION OF TMJ
DISORDERS
1. Developmental Disorders
2. Inflammatory Disorders
3. Osteoarthritis
4. Functional Disorders
5. Loose Bodies in TMJ
6. Neoplasms
7. Age changes in TMJ
8. Trismus
FUNCTIONAL
DISORDERS
1. Myofacial Pain-Dysfunction Syndrome
2. Disc Displacement
MYOFACIAL PAIN DYSFUNCTION SYNDROME
(MPDS)
• Temporomandibular joint dysfunction
• Facial arthromyalgia
• Mandibular dysfunction
• TMJ disorder
• Craniomandibular disorder
Myofacial Pain
Multifactorial in origin
Can be associated with multiple joints & systemic connective tissue
problems
Myofacial pain as “ a regional, dull, aching muscle pain with the
presence of localized tender sites (trigger point) in muscle, tendon,
or fascia”.
TMD patients may have masticatory and/or cervical myofacial pain.
Contd..
Myofacial Pain
History & Examination
Investigations
Diagnosis
Contd..
MPDS
History
Pain with function (chewing, talking).
Parafunctional habits or postural problem.
Headache ( tension type ).
Acute recurrent malocclusion
Ear symptoms ( earache, tinnitus, stuffiness, sense
of disequilibrium ).
Toothache ( but endodontic tests are within
normal limits)
Contd..
MPDS
Clinical finding
Open Bite
Limited interincisal opening
Altered mandibular range of motion
Limited cervical range of motion
MPDS Clinical Findings
Missing Teeth
New Prosthesis (Full mouth rehabilitation e.g.,Bridge,denture)
Masticatory muscles and/or cervical muscles tender to palpation.
Trigger points referring pain to other sites
PATHOPHYSIOLOGY
MANAGEMENT
MPDS
Acute Chronic
Management of Acute MPDS
Step 1 Counselling & Reassurance
Step 2 Identify the problem
Step 3 Liquid / Soft Diet
Step 4 Pharmacotherapy
a) Analgesic appropriate for pain level
b) Muscle relaxant
c) Tricyclic antidepressant
d) Anxiolytic
e) Antibiotics??
Step 5 Follow ups Contd..
Management of Chronic
MPDS
Step 1 Counseling & Reassurance (Patient education and self-care)
Step 2 Behavior modification
a) identify problem
b) cognitive-behavioral self-regulation jaw exercises
c) myotherapy/physical therapy referral
Step 3 Pharmacotherapy
a) analgesic appropriate for pain level
b) muscle relaxant
c) tricyclic antidepressant
d) anxiolytic
Step 4 Occlusal splint appliance therapy: muscle relaxation
Step 5 Follow-ups
Contd..
Diagnosis Drug Treatment
Inflammatory pain NSAIDS eg. ??
Myofascial pain Analgesics, tricyclics,
dysfunction centrally-acting
muscle relaxants,
glucocorticoids
Neuropathic pain, Carbamazepine,
neuralgias phenytoin, baclofen,
tricyclics, gabapentin,
others?
