TMJ disorders/ General orthodontics

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

Introduction
“

Temporomandibular Joint
helps in openingAnd
closing
Temporomandibular Joint
helps in openingAnd
closing
Openingwww.indiandentalacademy.com

 Each is well and wisely placed in
nature
If disturbed results in
TEMPOROMANDIBULAR
JOINT DISORDERS(TMDS)

Diagnostic category Diagnosis
Cranial bones Congenital & developmental disorders
Aplasia
Hypoplasia
Dysplasia(1st
& 2nd
brachial arch
anomalies, hemifacial microsomia,
Pierre syndrome, Treacher Collin
syndrome)
Condylar hyperplasia
Prognathism, fibrous dysplasia.
Acquired disorders
Neoplasia
Fracture

Temporomandibular
joint
disorders
Deviation in form
Disk displacement
(with reduction; without reduction)
Dislocation
Inflammatory conditions (synovitis,
capsulitis)
Arthritides (osteoarthritis,
osteoarthrosis polyarthritides)
Ankylosis (fibrous, bony)
Neoplasia
Masticatory muscle
disorders
Myofascial pain
Myositis
Spasm
Protective splinting
Contracturewww.indiandentalacademy.com

1. Muscle tension (hypo/ hyper activity)
2. Muscle spasm (sustained)
3. Muscle inflammation
4. Myofascial pain and dysfunction
5. Fibrosis and contracture
6. Atrophy
7. Hypertrophy
8. Muscle tears/lacerations
9. Protective splinting
10. Fibromyalgia
11. Neoplasia

c. Psoriatic arthritis
d. Ankylosing spondylitis
e. Lupus erythematosus
3. Infectious arthritis
4. Metabolic diseases
a. Gout arthritis
b. Chondrocalcinosis
C. Capsulitis/ synovitis
D. Retrodiscitis
E. Fracture
F. Ankylosis www.indiandentalacademy.com

G. Developmental disturbances of TMJ
1. Condylar hyperplasia
2. Condylar hypoplasia
3. Condylar aplasia
H. Neoplasia

 This describes TMD in relation to the progressive
patterns of deformation in specific intracapsular
structures.
 This is most practical method for clarifying the exact
conditions.
Stage I….. Normal healthy joint
Stage II… Intermittent click.
Stage III a… lateral pole click.
Stage III b… ….Lateral pole lock.
Stage IV a….Medial pole click.
Stage IV b…. Medial Pole Lock.
Stage V a… Perforation with Acute Degenerative
Joint.
Stage V b… Perforation with Chronic Degenerative
Joint. www.indiandentalacademy.com

Physiologic tolerance
TMD
symptoms
Normal
function
+
event
>

CONTINUUM
OF FUNCTIONAL
CONTINUUM
OF FUNCTIONAL
DISORDERS OF THE TMJ
DISORDERS OF THE TMJ

 Disc maintains its position on condyle , due to
morphology and interarticular pressure
 If the morphology of disc is altered, the discal
ligaments are elongated , begins to slide.
 In resting closed position, the tonicity of the SLP causes
the disc to be forward and medially placed

 If the pull of the muscle is protracted over time,
The posterior border becomes thinned.
 As it thinned, it can be displaced further in
discal space, so that the condyle lies on the
posterior band.

 Longer the disc is displaced AM ,greater the thinning
of the posterior border, more elongation of discal
ligaments, greater the loss of elasticity in the superior
retrodiscal lamina.
 Disc becomes more flatter
 Loses its functional positioning ability.
Superior lateral pterygoid encourages anterior migration
of the disc completely thru the discal space.

 Articular surface are separated.
 If it conditions continues, the condyle will be
repositioned on retrodiscal space.
 Tissues breakdown occurs leading to tissues
inflammation.

 DEFINTIVE TREATMENT: refers to methods that are
directed towards controlling / eliminating the cause of
the disorder.
 SuppoRTIVE TREATMENT: refers to methods
directed towards altering the symptoms.

Negative biofeed back: electrodes are placed on
masseter lead to monitor. The monitoring device
is connected to sounding device, when ever
clenching occurs, the feedback mechanism is
activated & sound is heard.

 Diurnal activity: Patient education
: Relaxation.
: Biofeed back.
 Nocturnal : Occlusal therapy.
 Recently, the NTI(Nociceptive trigeminal inhibition):
prevents the nocturnal parafunctional &reduces the
muscle triggering component.
 Mainly indicated for treating migraine headaches.
 Anterior bite stop.

 Pharmacologic therapy: NSAIDS.
 Corticosteriods.
Anxiolytic agents.
Muscle relaxants.
Antidepessants.
Physical therapy:Thermotherapy.
: coolant therapy.
: ultrasound.
: phonophoresis.

 TENS
 Neuralogic- pain
inhibition of small C
fibers by forcing the
large myelinated A fibers
to carry light touch
sensation
 Physiologic-increasing
the blood circulation
 Pharmacologic-by
release of endorphins
 Psychologic-Placebo
effect

 Soft tissue mobilization.
 Joint mobilization.
 Muscle conditioning

 Chronic Tmd often not resolved by simple dental
procedures(occlusal appliance),,,, mostly due to
psychosocial issues.
 Dr peter bertrand:
 Addressing the pain & fatigue as a physiologic
disturbance in need of correction.
 Managing autonomic dysregulation.
 Altering dysfunctional breathing.
 Improving the sleep.

 Disc displacement divided in to stages based On signs
symptoms combined with imaging findings
• Anterior disc displacement with reduction (clicking joint)
• Anterior disc displacement without reduction (closed lock)

Well informed patient play a significant role
in therapy
 Patient should instructed to
- Decrease loading of joint as much as
possible
- Soft food diet
- Slower chewing
- Smaller bites
- Not to allow joint to click
-Not to open his mouth forcefully
If Inflammation is present than NSAIDS.

 Moist heat or ice.
 PSR: Reduces the loading to the joint & generally down
regulate the central nervous system.

 When the condition is acute, the initial therapy is to
reduce the disc by manual manipulation.(first episode).
 Technique for manual manipulation.
 First point: The Level of activity in the sup. Lateral
pterygoid muscle …. Relaxed.
 Second point: The Disc space must be increased so
that disc can be repositioned .
 Third point: The Condyle must be in the maximum
forward position.

 If the disc is dislocated permanently?????
 Patients with disc dislocation should be given a
stabilization appliance that will reduce forces to
retrodiscal tissues.
 If this fails than surgical repair.

 Educating the patient, of the restricted mouth opening,
if attempted than more pain .
 Decrease hard biting, gum chewing.
 If pain is there than anti-inflammatory drugs.

 Arthrocentesis coupled with lavage and manipulation
has been the procedure of choice
 Joint is anesthetized by LA and the patient is under
conscious sedation, 20-gauge needle is placed in the
upper compartment about 1 cm in front of the ear,
hydraulic pressure is created by injecting about 2ml of
Ringer’s Lactate Solution
 The second 20-gauge is placed about 1cm anterior to
the first needle and the joint is irrigated with 50-100ml
of Ringer’s Lactate Solution

 A single needle is introduced to the joint & fluid can be
forced in to space in an attempt to free articular
surfaces.This is called “Pumping The Joint.”

 The cannula attached to the rigid arthroscope is
inserted in the upper joint compartment and the
arthroscope is connected to a television camera
equipped with video monitor
 The upper joint compartment is thoroughly examined
either directly through ocular or indirectly from the
monitor
 The most common procedures performed by
arthroscopy are lysis and lavage
 Improvement reported is 73 % to 93 %

STAGE OF CONDITIONSTAGE OF CONDITION PROCEDUREPROCEDURE
DISK DISPLACEMENT WITH REDUCTIONDISK DISPLACEMENT WITH REDUCTION
MECHANICALMECHANICAL
INTERFERENCEINTERFERENCE
ARTHROTOMYARTHROTOMY
SMOOTH MOVEMENTSMOOTH MOVEMENT ARTHROTOMYARTHROTOMY
MODIFIED CONDYLECTOMYMODIFIED CONDYLECTOMY
DISK DISPLACEMENT WITHOUT REDUCTIONDISK DISPLACEMENT WITHOUT REDUCTION
ACUTEACUTE ARTHROCENTESIS, LAVAGE ANDARTHROCENTESIS, LAVAGE AND
MANIPULATION, ARTHROSCOPYMANIPULATION, ARTHROSCOPY
WITH LAVAGE, LYSISWITH LAVAGE, LYSIS
CHRONICCHRONIC ARTHROTOMY OR RTHROSCOPYARTHROTOMY OR RTHROSCOPY
WITH LAVAGE, LYSISWITH LAVAGE, LYSIS
DISK DISPLACEMENT WITH PERFORATIONDISK DISPLACEMENT WITH PERFORATION
ARTHROTOMYARTHROTOMY

 Cause
 Created by actual changes in the smooth articular
surface of the joint & disc.
Flattening of the condyle & fossa,
Even bony protuberance on the condyle
Perforation & thinning of the disc.

 Cause is change in the articular surface so treatment is
to return altered form, surgery.
 Various options are:
 Bony compatibility smoothed & round the
surface.
 If the disc is perforated discoplasty.

 Most of cases : Education.
 Patient will learn a manner of opening & chewing that
minimizes the dysfunction.

b.Adherences and Adhesions
Disc to condyle
Disc to fossa
Mechanism
Static loading Exhaustion of weeping lubrication Adherence
Persistent
adherence,hemarthrosis

Adherence in superior joint space
Limited to rotation
Adherence freed click may be felt

Permanent adhesion between
disc and fossa
Condyle moves onto anterior
border of disc
Fixed disc

 Decrease the loading of the joint
 For nocturnal a stabilization appl
 For diurnal patient awareness & PSR.
 When adhesions , breaking of fibrous attachment is
done arthroscopic surgery.
Diurnal
clenching
nocturnal

 Adhesions: passive exercises
: ultrasound.
: distraction of the joints.
learn the pattern of opening.

 It is due to variation in anatomic , with steep short
posterior slope of articular eminence &longer flat
anterior slope.
 During the final opening, the condyle can be seen
suddenly jump forward with a Thud sensation.
 Pre auricular depression.
 No clicking.

Normal condyle-disc relation
Maximum translation
Disc pulled forward anterior
capsular ligamentwww.indiandentalacademy.com

 The main objective of the treatment is to increase the
discal space& allow the superior retrodiscal lamina to
retract the disc.
 Forceful closure should be avoided elevator
muscle spasm & aggravate the dislocation.
 Reduction should be done.

 Patient ask to open widely as in yawning, will activate
the mandibular depressors & inhibit the elevators.
 At the same time , slight posterior pressure is applied
to the chin will reduce a spontaneous dislocation.

 If the dislocation is chronic than , patient should be
taught self reduction.
 If the condition is intolerable than Eminectomy.
 Conservative treatment is botulinum toxin, inject it in
inferior lateral pterygoid bilaterally.
Supportive treatmentSupportive treatment
 Prevention , which begin with same supportive therapy
as for subluxation.
 Recurrent than self reduction.

 a.Synovitis/Capsulitis
 b.Retrodiscitis
 c.Arthritides
_ Osteoarthritis
_ Osteoarthrosis
_ Polyarthritides

Clinical characteristics
Capsular ligament can be palpated by finger on lateral
pole.
Limited Mandibular opening.
If the edema is present condyle may be displaced
inferiorly ,disocclusion of ipsilateral posterior teeth

 When the cause is trauma , the condition is self
limiting ,as trauma is absent.
 No definitive treatment for inflammatory condition.
Supportive therapySupportive therapy
o Restrict the movements within painless limits.
o Soft Diet, slow movements & small bites.
o NSAIDS, thermotherapy.
o Ultrasound.
o Acute traumatic injury ,, corticosteroids.

Extrinsic Trauma: cause is macro trauma, becoz is
generally not present , no definitive treatment.
Supportive therapy.Supportive therapy.
 When acute malocclusion is not evident; than
analgesics , thermotherapy, corticosteroids.
 When acute malocclusion is evident , stabilization
appliance for occlusal stability.

 Cause : intrinsic trauma, like anterior displacement,
treatment is towards the cause.
 Restricting the use of mandible with in painless limits.
 Analgesics ,
 Thermotherapy,
 Corticosteroids

 DJD : is also referred to as osteoarthosis, osteoarthritis,
degenerative arthritis, is primarily a disorder of
articular cartilage and subchondral bone, with
secondary inflammation of the synovial fluid .
 Body response to increase loading , the articular
surfaces are softened, the subarticular bone begins
to resorb, thin & fibrilation breaks away
during activity.

 C/f:
 Limited mandibular opening
Crepitation
 Lateral palpation + manual loading of the condyle
increases the pain .
 Radiographs: structural changes in subarticular
surfaces.

 Decrease the mechanical loading of the joint.
 Attempt to correct the condyle- disc relationships.
 Since osteoarthritis are associated with chronic
derangements , anterior positioning are not always
helpful.
 Stabilization appliance…… muscle hyperactivity.
.

 Reassurance to the patient.
 Anti-inflammatory drugs.
 When symptoms are intolerable after 1-2 months of
supportive therapy, single injection of corticosteroid
can be used.
Surgical therapy.
 When tmj pain persist r/g changes are, than surgery is
indicated.
 An arthroplasty , which removes osteophytes & erosive
products is c/m preferred.

 Temporalis tendonitis
 Stylomandibular ligament inflammation

Chronic hyperactivity of this muscle can create
tendonitis
C/F : Pain during function .
: Retrorbital pain
Definitive treatment: resting of muscle.
A Stabilization appliance if bruxism.
PSR.
Supportive therapy.
Analgesics if pain .
Ultrasound, thermotherapy.

 Ankylosis.
 Muscle contracture
 Coronoid process impedance
 The predominant feature of this disorder is inability to
open the mouth to a normal range.
 Rarely accompained by painful symptoms.

 Abnormal immobility of a joint.
 Two types : bony
: fibrous.
o A fibrous is common & occur b/w
the condyle & disc or disc & fossa.
o A bony ankylosis occur b/w the
condyle & fossa.
o It is more chronic & extensive.

 Treatment:Treatment:
 If the movements are not restricted than no treatment.
 If function is inadequate than surgical.
 Arthroscopic surgery.
 Surgical removal of osseous bridge
 Condylectomy
 Osteoarthroplasty (gap arthroplasty)
 Interpositional arthroplasty
• Silastic implant, tentalum foil, teflon.
• Ear cartilage graft
• Temporalis muscle flap

 It is the fibrosis of the ligament, the movement of the
condyle is restricted.
Definitive treatment is contraindicated.
 1) The Fibrosis restricts only outer movement & not
functional problem of the patient.
 2) becoz surgery can cause this disorder.
 As it is asymptomatic so no treatment.

 Is a painless shortening of muscle.
 Myostatic
 Myofibrotic
Myostatic contracture.
 Results when a muscle is kept from fully lengthening
for a prolonged period of time.
 Often due to another disorder.
Definitive Treatment:
Disorder should be eliminated.
Than toward lengthening of the muscle.

 Two types of exercise :
 passive stretching
 Resistant opening.

 Occur as result of excessive tissue adhesions within the
muscle or its sheath, which prevents the muscle fibers
from sliding over themselves, disallowing full
lengthening.
 C/F: painless limited opening.
Definitive treatmentDefinitive treatment:
 The muscles fibers can relax but the muscle length
does not increase. It is permanent.
 some elongation can occur by elastic traction.
 Surgical detachment & reattachment.

 It is often difficult to diagnose the two by history &
examination, the key to diagnosis lies in treatment.
 When muscle regains muscle length, myostatic
contracture is confirmed.

 Bone disorders
 Muscle disorders.
 Bone disorders: Agenesis
: Hypoplasia
: Hyperplasia
: Neoplasia.

 Enlargement & occasionally deformity of the condylar
head.
 Have a secondary effect on mandibular fossa as it
remodels to accommodate.
 Etiology:
 Overactive cartilage,
 Persistent cartilaginous rests
 Increasing thickness of entire cartilaginous &
precartilaginous layers.

 Failure of the condyle to attain normal size.
 Condyle is small but condylar morphology is normal.
 Inherited or acquired.
 Early injury or injury to articular cartilage by birth
trauma or intraarticular inflammatory lesion.

 Hypotrophy
 Hypertrophy
 Neoplasia.
 The Common characteristic is feeling of muscle
weakness with hypertrophy.
 Hypotrophy is difficult to recognize only.
 Large masseter in case of hypertrophy.

 Definitive treatmentDefinitive treatment:
 Must be tailored to the patient’s condition.
 Treatment is restore the function, while minimizes the
trauma.
 When hypertrophy is present secondary to bruxism
than muscle relaxation procedure.

THANK YOUTHANK YOU

o Management of temporomandibular disorders & occlusion-5th
edition
o Jeffrey P Okeson
o 2Clinical management of temporomandibular disorders and orofacial.
o Richard A Pertes
o .Bell’s Orofacial pain -5th
edition. Okeson
o Evaluation Diagnosis and treatment of occlusal problems 2nd
edition
Peter E Dawson
o Surgery of temporomandibular joint David keith 2th edition.
o Jips 2005,5(2) 56-61.
o Dental update 2007.

Thank you
For more details please visit

TMJ disorders/ General orthodontics

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