TEMPOROMANDIBULAR

JOINT
DISORDERS

PRESENTED BY
D.RAMYA PRIYA
CRI

What is TMJ?
TMJ is similar to
other joints of the
body that is
composed of
osseous and soft
tissue components,
how ever it is
different in that:
1-It is a

double joint

in function.

2-The movement of the joint is not bone to fossa but sliding (from
glenoid to forward till the eminence), and with different directions a
joint that is capable of hinge-type movements (ginglymos) and gliding
movements).
3-It is the most used joint in the body.

ANATOMY
Temporomandibular joint.
A true synovial joint capable of
gliding, sliding and slight
rotation.
Tmj complex
Condyle of mandible.
Mandibular fossa.
Articular tubercle of the
temporal bone
Articular disk (meniscus)
Two synovial membrane:
superior/ inferior.

DISORDER OF TMJ
Temporomandibular joint
disorder(TMJDorTMD), orTMJ
syndrome, is a broad term
coveringacuteorchronic
inflammationof the temporo
mandibular joint.
The temporo mandibular joint is
susceptible to many of the
conditions that affect other joints in
the body, includingankylosis,
arthritis, trauma,dislocations,
developmental anomalies, and
neoplasia.

The etiologic factors of TMJ disorders:

Multiple factors may be involved in TMJ
disorders:
1. Para functional habits (eg: nocturnal bruxing,
tooth clenching, lip or cheek biting).
2. Emotional distress (tension and spasm of
muscle of mastication cause facial pain,
headache and it may affect the joint movement
and lead to irreversible alteration of the joint
structures).
3. Acute trauma from blows or impacts
4. Trauma from hyperextension (eg: dental
procedures, oral intubation for general
anaesthesia, yawning, hyperextension
associated with cervical trauma).

5. Instability of maxillomandibular
relationships.
6. Laxity of the joint.
7. Co morbidity of other rheumatic or
musculoskeletal disorders
(Behet's syndrome, S.L.E., scleroderma,
gout, vit.d deficiency, Paget's disease
,hyperparathyroidisim, pericoronitis,
parotitis, dental abscesses, hypoplasia,
hyperplasia, osteoma, osteogenic sarcoma,
chondrosarcoma).
8. Poor general health and an unhealthy
lifestyle.

Signs and symptoms

Signs and symptoms of temporomandibular joint disorder vary in their
presentation and can be very complex. On average the symptoms will
involve more than one of the numerous TMJ components: muscles,nerves,
tendons,ligaments,bones,connective tissue , and theteeth. Ear pain associated
with the swelling of surrounding tissue is a symptom of
temporomandibular joint disorder.

Symptoms associated with TMJ disorders may be:

Biting or chewing difficulty or discomfort

Clicking, popping, or grating sound when opening or closing the mouth
Dull, aching pain in the face
Earache
Headache
Jaw pain or tenderness of the jaw
Reduced ability to open or close the mouth
Tinnitus

Developmental
defects:
Anomalies in size and
shape of condyle.
hyperplasia,
hypoplasia,
bifid condyle.

local factors such as

trauma and infection can
initiate condylar growth
disturbance.
Condylar hyperplasia
occur after puberty and is
completed by 18-25 years
of age.
Limitation of opening,
deviation of the
mandible to the side of
the enlarged condyle, and
facial asymmetry
may be observed.

INFLAMMATORY DISORDER

1) TRAUMATIC ARTHRITIS.
2) INFECTIVE ARTHRITIS.
3)RHEUMATOID ARTHRITIS.

INFECTIOUS ARTHRITIS
Is infection and inflammation of
the joint.
Rare.
Infection may invade the TMJ.
Aetiology.
ROUTES OF INFECTION:
Direct spread of organisms.
Direct extension of osteomyelitis
of mandible.
Hematogenous spread- common.
Infection from the middle ear.
Staphylococcus aureas is the
most common organism.

Clinical features
Any age, no gender predilection.
Redness and swelling over the
joint.
Trismus, severe pain on opening
mouth. unilateral.
Inability to occlude the teeth,
large, tender cervical nodes.
Fever, malaise, mandible
deviated to unaffected side

Radiographic features
Early stages of disease- no radiographic
signs may be present.
Space b/w condyle and mandibular fossa
widened.
Evident bony changes- 7-10 days after
clinical symptoms.

HISTOPATHOLOGI
CAL PICTURE

This figure show decalcified parafiin process

section of infected bone was stained by
modified gram stain. Gram +ve bacteria
(blue). Embeded deep in the bone(red)

RHEUMATOID ARTHRITIS
This is the non organ specific autoimmune
systemic disorder.
Involve Multiple joints of the body.
Inflammation of the synovial membranes.
In severe cases osseous tissues are resorbed.
More commonly associated with joint of
hands , wrist.
Also occur in tmj, always bilateral
Condylar support lost- malocclusion

Clinical features
Incidence higher in females, increases with
age.
Small joints of hand, wrist, feet, knees,
affected in bilateral symmetric fashion.
Tmj involement- swelling, pain, tenderness,
stiffness on opening mouth, limited range of
motion and crepitus.
Radiographic features.
Generalized osteopenia of condyle & temporal
bone component.
Erosion of the anterior and posterior condylar
surfaces

Examples of TMJ erosions for the 4 grades. A, very slight erosion in condyle
B, erosion of top of condyle . C, half of condyle eroded. D, condyle completely

eroded

 Commonest variant of rheumatoid arthritis.

Juvenile rheumatoid arthritis(stills disease)
Is a chronic inflammatory disease that appears
before age of 16 yrs.
Chronic intermittent synovial inflammation,
Joint effusion, swollen and painful joint.
As the disease progresses cartilage and bone are
destroyed.
Clinical features :
Patient has pain, tenderness in affected joint.
Disease can be asymptomatic

Juvenile rheumatoid
arthritis
Chronic changes in mandible
condyle, such as flattening and
beaking. (radiological pic)

Internal derangment:
Abnormal positional and functional
relationship between disc, condyle and
temporal bone.
Early stage:
When there is clicking early in opening and
late in closing movement.
Intermediate stage:
Episodes of pain and tenderness in the TMJ,
clicking and noises.
there is history of locking or interference in
closing movement.
The mandible may deviate laterally.
Late stage:
Crepitus on examination,
chronic restriction of motion,and
episodes of pain.
The patient is unable to open more than 20
mm.

disc

condyl
e

Internal Derangement

Treatment Internal
Derangement
Modalities: Iontophoresis, electrical stimulation, cold
ice massage
Manual therapy Joint distraction
Joint protection techniques: Limit motion to no
noise, soft food diet or chewing behaviors
Home exercise instruction
Change parafunctional behaviors
Self joint distraction techniques
Tongue positioning for relaxation

Postural instruction and controlled

opening/neuromuscular re-education

Dislocation of mandible:
Condyle is positioned anterior
to the articular eminence and
can not return to it is normal
position with out assistance,
usually result from muscular
in coordination in wide
opening during eating or
yawing, and less commonly
from trauma, they may be
unilateral or bilateral.
The typical complaint of the
patient with dislocation ,in
ability to close the jaws and
pain related to muscle spasm.

Repositioning of mandible
by thumbs on the molar
area and other fingers of
each hand placed under
chin, condyle repositioned
by a downward (by thumb)
and backward movement.
(by raising chin with other
fingers).

 Capsulitis
Usually a result of another disorder unless
post surgery
Modalities, MT and HEP

Subluxation
Excess opening (>40 mm)
Usually a component of myofascial pain
dysfunction, and treated with exercises and
controlled opening

Diagnosis:
1-History taking:
Asking the patient various kinds
of questions that lead to the point
of problem.
pain in the face, in front of the
ear?headaches, neck ache? pain in
the teeth?

pain when using the jaw (opening

wide, yawning, chewing, speaking,
or swallowing)?
joint noises when moving jaw or
when chewing (clicking, popping,
or crepitus)
jaw motion restricted?

2-Clinical examination:
Include:
extra oral examination and
facial asymmetry,
general medical condition of
a systemic diseases
intra oral examination
include:
The soft tissue condition,
teeth,
jaw relation,
mouth opening and,
Para functional movements.

3-Radiographic examinations:
A-Orthopantomograph (O.P.G.)
B-Cephalometric and lateral view
C-Transcranial
D-Tomography (body sectioning
technique shows blurring image except
the sectional focused area, so it is more
accurate).
E-Arthrography (the upper and lower
joint spaces can be filled with radio
opaque medium-water soluble iodine-.
F-C.T.scan (using computer for the
analysis of the radiation).

4-Magnetic resonance
imaging (by using a strong
magnetic field).
5-Arthroscope (used for
diagnosis and treatment of
joints by injecting a fluid and
debridement of the waste
products out of the joint
spaces).
6-Electromyography(used to
detect the action of muscles
by inserting two electrodes in
the muscle affected by spasm
and drawing a line on a paper
or on the screen to monitor
changes activity and the
response to the therapy.

Management of TMJ disorders:

The primary aim of the treatment in all patients is to:
Relief pain and discomfort.
Restoring the function.
To do so, it is important to find the main causes of disorder and
the interrelated factors which complicate the symptoms.

1- Behaviourial modification:
It is not simple but effective therapy with habitual muscle
contraction, to prevent clenching, bruxism, and repetative
protrusion, especially when the patient informed on the
effects.
Many other habits should also be discontinued, if interfere
with therapy and lead to chronic changes of the TMJ structure
and internal derangement.

3-physical therapy:
2-Medications:
For both acute and chronic,
analgesics and non steroidal
anti inflammatory drugs
(Aspirin, hypnotic) could be
used to relief pain and restore
function.
Muscle relaxant and
tranquilizers are used to relief
myofacial pain and spasm of
muscle of mastication.

In myofacial pain
exercising the muscles of
mastication by stretching
and opening and closing
against forces.
Massage of the area and
heat application will
enhance the circulation to
remove the waste products,
and offers relaxation of the
muscle and relief of pain.

4-Occlussal treatment:
Restoring the occlusion by restorative
procedures, orthodontic appliances or
prosthesis will restore the relation of the
condyle to disc and improve the symptoms.
5-Occlusal splint:
Most of the principles of good occlusion can be
built in to a bite or occlusal splint.

6-Surgery:
In some cases the removal of third molar is required to
restore function of the joint.
So restoring function and relieving pain could be
performed by minor surgical procedures.
How ever in some other cases more radical surgery is
required to restore occlusion like correction of class
three and treating class two jaw relation and may
required surgical repositioning of the disc.
In advanced cases of complications, condylectomy may
required as in patients with ankylosis.

Ankylosis of the Temporo mandibular

joint:
An arthrogenic disorder of the TMJ in which fusion of joint
components takes place by fibrous or bony union resulting
into loss of function.

UNILATERAL TMJ ANKYLOSIS

Fibrous Ankylosis

Bony ankylosis

Produced by adhesions within the TMJ affecting

the fibrous components

The union of bones of the TMJ by proliferation

bone cells, resulting in immobility of the joint

Not usually associated with pain

Limited range of motion on

opening

pain

Deviated to the affected side

Limited laterotrusion to the

More marked limitation on

opening

contralateral side
No radiographic findings other

Not usually associated with

Theres more marked

ipsilateral deviation

Theres more marked

that absence of ipsilateral

limitation of contralateral

condylar translation

lateral movment

Theres a radiographic
evidence of bone
proliferation

SEQUELAE OF TMJ
Speech
impairment
ANKYLOSIS
Facial growth distortion
Nutritional impairment
Respiratory disorders
Malocclusion
Poor oral hygiene
Multiple carious and impacted
teeth

MANAGEMENT

Non
management

surgical

Surgical treatment

SURGICAL MANAGEMENT
Aims and Objectives of surgery

To release ankylosed mass and creation of a gap to mobilize

the joint
Creation of functional joint (improve patients oral hygiene,
nutrition and good speech)
To reconstruct the joint and restore the vertical height of the
ramus
To prevent re-occurrence
To restore normal facial growth pattern
To improve esthetic appearance of the face (cosmetic reason)
Physiotherapy follow-up

SURGICAL MANAGEMENT
Procedures
1. Condylectomy
2. Gap arthroplasty
3. Interpositional arthroplasty

SURGICAL MANAGEMENT
CONDYLECTOMY
This procedure is usually indicated when the joint space is
obliterated with the deposition of fibrous bands; but, there hasnt
been much deformity of the condylar head. Usually employed in
cases of fibrous ankylosis.
Pre-auricular incision is made
Horizontal cut carried is out at the level of the condylar neck
The head (condyle) should be separated from the superior
attachment carefully
The wound is then sutured in layers
The usual complication of this procedure is an ipsilateral deviation to
the affected side. And anterior open bite if the procedure was
bilaterally.

SURGICAL MANAGEMENT
GAP ARTHROPLASTY
This procedure is employed in an extensive bony ankylosis.
The section here consists of two horizontal osteotomy cuts
And removal of bony wedges for creation of a gap between
the roof of the glenoid fossa and the ramus of the mandible.
This gap permits mobility
The minimum gap should be 1cm to avoid re-ankylosis

SURGICAL MANAGEMENT
INTERPOSITIONAL ARTHROPLASTY

This is actually an improvement/modification on gap

arthroplasty
Currently the surgical protocol of choice
Materials are used to interpose between the ramus of the
mandible and base of the skull to avoid re-ankylosis
The procedure involves the creation of gap, but in addition, a
barrier is inserted between the two surfaces to avoid
reoccurrence and to maintain the vertical height of the ramus

SURGICAL MANAGEMENT

INTERPOSITIONAL ARTHROPLASTY

SURGICAL MANAGEMENT
MATERIALS USED IN INTERPOSITIONAL
ARTHROPLASTY
Autogenous

Heterogenous

Alloplastic

I.

I.

chromatised
submucosa of pigs
bladder

Metallic: tantalum foil

and plate, 316L
stainless steel,
Titanium, Gold.

II.

lyophilized bovine
cartilage

Nonmetallic: silastic,
Teflon, acrylic, nylon,
ceramic

Temporalis muscles

II. Temporalis fascia

III. Fascia lata
IV. Cartiligenous grafts
Costochondral
Metatartsal
Sternoclavicular
Auricular graft
V. Dermis

SURGICAL MANAGEMENT
Advantages of this procedure

(interpositional arthroplasty)

Autografts, such as skin, temporalis muscle, or fascia lata, are

presently considered the material of choice for interposition.
In more recent years, a pedicled temporalis myofascial or
temporalis fascia flap has been advocated in TMJ surgery to
treat the TMJ ankylosis.
Advantages of these flaps in TMJ reconstruction include
close proximity to the TMJ without involving an additional
surgical site,

adequate blood supply,

autogenous origin grafts can be used,

and maintenance of attachment to the coronoid process,
which provides movement of the flap during function,
simulating physiologic action of the disc.

SURGICAL MANAGEMENT
Advantages of this procedure
Post -OP

(interpositional arthroplasty)

SURGICAL MANAGEMENT
Complications of the surgery
Anaesthesia
Aspiration of blood clot, tooth or foreign body
Falling back of the tongue causing airway obstruction
Intra-Operative
Haemorrhage (damage of any superficial temporal vessels, transverse
facial artery, etc)
Damage to the external auditory meatus
Damage to the Zygomatic and temp. branch of facial nerve
Damage to the Glenoid fossa
Damage to the Auriculotemporal nerve
Damage to the Parotid gland
Damage to the teeth
Post Operative
infection
open bite
re-occurrence of ankylosis