Tmj disorders /certified fixed orthodontic courses by Indian dental academy

TEMPOROMANDIBULAR
JOINT
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


1

“Those who fall in love with practice without
science are like a sailor who enters a ship
without a helm or compass, and who
never can be certain whither he is going.”
- Leonardo da Vinci


2

HISTORICAL PERSPECTIVE
• Dr James Costen -1934
• Late 50”s – investigations on TM disorders
• Shore -1959
• Late 70”s – occlusion and emotional stress
• 1980-dental profession recognized fully
and appreciate the complexity


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HISTORICAL PERSPECTIVE
• Costen –TMJ disturbances
• Shore – TMJ dysfunction syndrome
• Ramjford and Ash – functional TMJ
disturbances
• Bell –TM disorders

Temporomandibular disorders

4

History and examination
• Screening history-difficulty or pain in opening
-jaw getting “locked”
-pain during chewing
-history of sounds
-pain in ear, cheek
-headaches
-recent injuries
-previous treatment for joint problems

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• Pain-location
-behavior
-quality
-duration
-degree
• Dysfunction
• Onset
• Emotional stress

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• Clinical examination-Cranial nerve examination-5th and 7th
-cervical examination
-neuromuscular examination
-intracapsular disorders
-TMJ examination-pain ,sound,
restrictions.

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• Cranial nerve
•

•

examination-5th
Sensory-lightly
stroking face with a
cotton tipforehead,cheek,lower
jaw
Motor-asking the
patient to clench

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• 7th nerve• Sensory component-taste sensation
• Motor component- raise both eyebrows
,smile and showing lower teeth .


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• Cervical examination• Evaluating the neck
for pain and or
movement difficulties


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• Neuromuscular
examination-

• Temporalis muscle
-anterior
-middle
-posterior


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• Masseter muscle
-deep part
-superficial part


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• Sternocleidomastoid-


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• Posterior cervical
muscles-


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• Functional

manipulation-Inferior lateral
pterygoid
-Superior lateral
pterygoid
-Medial pterygoid


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• Evaluating Interincisal distance

“End Feel”


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• Differentiating Deviation

Deflection


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• TMJ examination
- joint pain


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• Examination of

dentition-mobility
-pulpitis
-tooth wear
-CR and CP
-occlusal contacts in
various movements


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Diagnostic Tests
• Imaging of TMJ1. Radiographic technique
- a pure lateral view of condyle is
impossible with conventional x-ray
• Panoramic
• Transcranial
• Transpharyngeal
• Transmaxillary

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Problems With TMJ Viewing


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Diagnostic Tests
1. Panoramic view –
- commonest .
-provides the screening
of the condyle.
-both condyles are
visible in a single film.
-for best view – mouth
open position.


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Diagnostic Tests
• Lateral transcranial view-good visualization of condlye and fossa
-quite popular
-patient-head positioner.
- rays are directed inferiorly .


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Diagnostic Tests
• Transpharyngeal view
-similar to panoramic
-rays are directed from either below the
angle of mandible or through the sigmoid notch
-demonstrates the condyle satisfactorily ,fossa is
not well visualized .


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Diagnostic Tests
• Transmaxillary

projection(AP) view
-mouth is wide open.
-condyles translated out
of the fossa.
- Excellent view for
evaluating fracture of
the condylar neck.

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Diagnostic Tests
• Tomography –
-introduced by Petrilli in 1936
-to overcome the problem of
superimposition
-ability to image an object in multiple
layers at desired tissue depth.


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Diagnostic Tests
• Technology and equipment• Uses coordinated motion of x-ray

•

source and film to produce varying
degree of image blurring ,minimized in
the plane of interest.
Anatomic layer of interest is placed at
the imaginary Crot.

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Diagnostic Tests


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Diagnostic Tests
• Disadvantage –
- Dense structure

-

parallel to the beam
may reduce image
clarity
Spurious contours


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Diagnostic Tests
• Useful for•
•
•
•

Diagnosis of osseous defects.
Condylar fractures ,lesions, tumors.
Signs of degenerative diseases.
Pain without clinical signs.


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Diagnostic Tests
• Arthrography
- Introduced by Norgaard-1947
- First imaging technique capable of providing
-

information on soft tissue status.
Involves injecting radiopaque contrast material
into one or both of the joint spaces ,outlining
the disk between the opaqued joint space.


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Diagnostic Tests
• Single contrast arthrography –
-medium is injected into the lower joint
space
-with fluoroscopy or tomography .
• Double contrast arthrography-sequential injections of contrast material
with small amount of air.

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Diagnostic Tests
• Computerized tomography• it is one of the first techniques which applies

•

•

computer and data storage technology to
enhance the capabilities of the conventional
techniques.
Provides both hard and soft tissue information
on both joints from a single examination.
No invasive injections .

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Diagnostic Tests


34

Diagnostic Tests


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Diagnostic Tests
• Magnetic Resonance Imaging (MRI)
• Introduced by Helms, Ketzberg
• It exploits the varying proton (water) content of
•
•

different tissues .
Protons in tissue fluids are polar .
When they are exposed to strong magnetic field
of the MRI scanner ,some protons align parallel
with direction of the external field.

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Diagnostic Tests


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Diagnostic Tests
• Is useful in-obtaining cross sectional images at varying
tissue depth
-better visualization of the soft tissues.
-disc displacement.
-Amount of synovial fluid .


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Diagnostic Tests
• Sonography• It is a technique of recording and

graphically demonstrating joint sounds.
• Some utilizes audio amplifying devices
while others rely on ultrasound echo
readings
• Reliability is questionable.

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Diagnostic Tests
• Thermography –
• It is a technique that records and

graphically illustrates surface skin
temperature .
• Various temperatures are recorded by
different colours producing a map that
depicts the surface being studied.

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Diagnostic Tests
• In summary• Radiographs alone have limited role in

diagnosis TMD.
• Transcranial and panoramic views are
used as screening devices .
• Tomography is reserved for patients if
screening radiographs reveal a possible
abnormality .

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Diagnostic Tests
• Arthrography is a specialized diagnostic

tool to be used only when doubt exists
regarding the position of the articular disc.
• CT and MRI-to be used only when
additional information will significantly
improve the establishment of a proper
diagnosis .


42

TMD
• TMD-in a broad sense are to be

considered a cluster of joint and muscle
disorders in the orofacial area
characterized primarily by pain, joint
sound and irregular or deviating jaw
functions


43

TMD

N

A
P

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Classification system of TMD’s
• Masticatory muscles disorder- Protective co contraction
- Local muscle soreness
- Myofacial pain
- Myospasm
- Myositis

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• TMJ disorders

I-Derangement of the condyle disc complex
1. disc displacement
2. disc dislocation with reduction.
3. disc dislocation without reduction.
II-Structural incompatibility of articular surface
1.Deviation in form
2.Adhesions
3.Subluxation
4.Spontaneous dislocation.

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• Inflammatory disorders of the TMJ
-synovitis.
-capsulitis.
-retrodiscitis.
-arthritides.
-inflammatory disorders of associated
structures.

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• Chronic mandibular hypomobility
-ankylosis.
-muscle contracture.
-coronoid impedance.
• Growth disorders-agenesis
-hypoplasia
-hyperplasia
-neoplasia

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• Congenital and developmental disorders-hypertrophy
-hypotrophy
-neoplasia.


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Masticatory Muscle Model


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Anatomy of the joint space


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TMD’s
Derangement of condlye
disc complex
1.Disc displacement• Etiology- breakdown of the
normal rotational
function of the disc
- elongation of the discal
ligament and inferior
retrodiscal lamina.

52

TMD’s
• History –of trauma associated with the

onset of joint sound
• C/F – joint sound during opening and
closing.
-when reciprocal clicking is present
,two clicks normally occur at different
degree of opening and closing


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TMD’s
2.Disc dislocation with reduction• Further thinning of the posterior border leads to
the slipping of the disc completely
• History –long history of clicking and more recent
catching sensation.


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TMD’s
• C/F –unless the jaw is shifted to the point
of reducing the disc ,pt. presents with
limited range of movement.
-in some cases sudden loud pop is
heard


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TMD’s
3.Disc dislocation without reduction
• Elasticity of superior retrodiscal lamina is lost
,recapturing of the disc becomes more difficult
• When this happens condyle merely forces the
disc in front of the condyle.


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• History-

•

TMD’s

-pt. give a precise history of when the
dislocation occurred.
-pain may be present but not always
C/F-range of mand. opening is 25-30mm
-maximum point of opening reveals a
hard end feel


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TMD’s
• Structural incompatibilities of articular surface
1.Deviation in formEtiology-change in the shape of the articular
surfaces
History –presence of a long term dysfunction.
C/F –dysfunction occurs at a particular point
of movement .


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TMD’s


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TMD’s
2.Adhesions –
Etiology-prolonged static loading
-macrotrauma
-surgery
C/F-superior joint space adhesion
-translation is inhibited –only rotational .
-mandibular opening of 25 – 30 mm.
-fixed disc /posterior disc dislocation.


60

TMD’s
• C/F-inferior joint space adhesion
- difficult to diagnose
-normal translation but rotational –lost.
- catching or jumping on maximum opening.


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TMD’s
3.Subluxation (hypermobility) –
-Sudden forward movement of the condyle
during later phase of mouth opening .
Etiology –normal joint movement as a result
of certain anatomic features.
History- jaw “going out” during wide
opening

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TMD’s
• C/F
-can be observed clinically by asking the
pt. to open wide.
-as the condyle jumps out a small void or
depression is visible.
-midline pathway shows a deviation.
-no pain is associated unless repeated often.

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TMD’s
• Spontaneous dislocation• Represents a hyperextension of the TMJ
•

leading to anterior dislocation of the disc.
Etiology –same as in joints with subluxation


64

TMD’s
• History –dislocations are usually

associated with wide mouth opening
procedures .

• C/F-pain
- “open lock”.


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TMD’s
• Arthritides –refers to the inflammation of the
•
•

•
•

articular surface.
Osteoarthriitis and osteoarthrosisEtiology-when articular surface of the joint can
no longer tolerate the effect of loading.
History-unilateral joint pain
-constant pain
C/F-limited mandibular opening
-crepitations
-structural changes in the radiograph.

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TMD’s
• Ankylosis• By definition –means abnormal immobility
of the joint.
• Classified as-based on the
1.Site
2.Tissue involved.
3.Jaw joint .


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TMD’s
• Etiology-Macrotrauma
-abnormal intrauterine development
-birth injuries
-condylar fractures
-inflammation of the joint
-surgery
-infection.

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TMD’s
• C/F-diminished growth of the mandible
-total immobility
-micrognathia
-deviation during mouth opening
-poor oral hygiene.


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General considerations in the
treatment of TMD’s
• Three conditions exist that tend to
promote this condition-

1. Lack of adequate scientific evidence .
2. Etiologic factors –difficult to control.
3. Some factors that are yet to identified .


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Treatment approach

Definitive
treatment

Supportive
treatment


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• Definitive treatment-Occlusal therapy -reversible
-irreversible
-Emotional stress therapy
- patient awareness.
-voluntary avoidance.
-relaxation therapy.

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• Occlusal therapy –is considered to be any kind

of treatment that is directed towards altering
the mandibular position and/or occlusal contact
pattern of the teeth.

1. Reversible
- that alters patient occlusal
condition temporarily


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2. Irreversible –which
permanently alter the
occlusal condition and
/or mandibular position
Reversible

Irreversible

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• Emotional stress
therapy-

- Patient awareness .
- Voluntary avoidance .
- Relaxation therapy.
-substitutive
-active

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I. Supportive therapy
-Pharmacological therapy
-analgesics
-antianxiety
-antiinflammatory
-muscle relaxants
-LA

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II.Physical therapy - modalities
- manual techniques.
Thermotherapy
- utilizes heat as a prime
mechanism


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Coolant therapy
- relaxation of muscles
Ultrasound therapy - increase in the temperature
at the interface of the tissue
and therefore affects
deeper tissue


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• Iontophoresis –is a technique by which

certain medications can be introduced into
the tissues .
• TENS –brings about continuous
stimulation of cutaneous nerve fibers
thereby decreasing pain perception.


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TENS

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• Manual technique- Soft tissue mobilization-

-

gentle massage of the
soft tissue overlying the
painful area.
Restricted use ,relaxation
therapy.


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Joint distraction

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Tmj disorders /certified fixed orthodontic courses by Indian dental academy

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