Temporomandibular Joint

Assessment and Management

Rolando Jaime r. Aldecoa, DMD FPAID

Dental Collaborations
ManilaMed Medical Center Manila
Functional Classification of Joints
(Based on Amount of Movement Allowed by the Joint)

oSynarthrodial-immovable joints
• Cranial sutures
oAmphiarthrodial-slightly movable joints
• Axial skeleton or vertebra
oDiarthrodial-freely movable joints
• Arms
• Legs
• Shoulders
• Also called synovial
Classification of Synovial Joints

o Arthodial joints – gliding movement

• Temporomandibular joint
o Gynglimoid – hinge movemment
• Elbow
• Knee
• TMJ
o Ball and socket – allows the greatest
fexibility of movement
• Shoulder
o Saddle joint
• Atlantoaxial bone of the vertebra
Temporomandibular Joint
description

o Articulation between
the mandible and the
temporal bone of the
cranium
o Paired articulation
o Diarthrodial joint
• Freely movable joint
o Has a rigid point of
closure
Temporomandibular Joint
description

o Gynglymoarthrodial
• Gynglimoid joints
perform hinge
movement
 First 20 mm of opening
• Arthrodial joints
perform sliding
movement
 Occurs as opening
exceeds 20mm
Temporomandibular Joint
description

o Gynglymoarthrodial
• Gynglimoid joints
perform hinge
movement
 First 20 mm of opening
• Arthrodial joints
perform sliding
movement
 Occurs as opening
exceeds 20mm
Temporomandibular Joint
description
o Compound joint –
articulation between
3 bones
• Temporal bone
• Mandible
• Articulating disc-
serves as non-
ossified bone
 TMJ Anatomy
Articular Fossa Articular Eminence

Superior Joint Space

Articular Disc

Retrodiscal tissue

Inferior Joint Space

Condyle

Lateral Pterygoid
Normal TMJ Translation
TMJ EVALUATION
 HISTORY
 Chief Complaint
 Initial Symptoms

 Duration of symptoms

 History of noise or

limited mouth opening

 Clenching and grinding habit

 Previous treatment
QUESTIONS TO BE ASKED:
Do you have pain in the face,front of ear and the temple area?
Do you get headaches , earaches , neckache , or cheek pain?
When is the pain at its worst ?
Do you experience pain when using the jaw?
Do you experience pain in the teeth?
Do you experience joint noises when moving your jaw or chewing?
Does your jaw ever lock or get stuck?
Does your jaw motion feel restricted?
Have you had any jaw injury?
Have you had treatment for jaw symptoms?if so , what was the effect?
Do you have any other muscle , bone , or joint problem such as arthritis?
TMJ EVALUATION
 PATIENT SELF ASSESSMENT
 Location of pain
 Pain level on forced mouth opening

 Amount of dysfunction
Pain Location Map

Right Left
Pain Level

PAIN LEVEL
Visual Analog Scale I (VAS I)
-)(
NO PAIN WORST PAIN
Amount of Dysfunction

Level of Pain on Forced Opening

Visual Analog Scale II (VAS II)
)(
NONE WORST
TMJ EVALUATION
 CLINICAL EXAMINATION
 Maximal range of motion
 Palpation

 Resistive test

 Presence of Noise
Range of Motion

o Refers to the full

potential movement of
a joint
• Maximum opening is 40-
50 mm inter-incisal
distance
• Maximum lateral
excursion is
approximately 12 mm
Deviation of opening

o Observe the opening pattern

for deviation
o Mandible often deviates
towards the affected side
during opening
o Muscle spasm or mechanical
locking by a displaced
meniscus
Palpation of lateral aspect of TMJ
• Palpate anterior to the tragus
over the joint while the patient
opens his mouth
• Extent of mandibular condylar
movement can be assessed
• Normally, condylar
• Movement is easily felt
• Condyle will move posteriorly
against your finger when patient
closes mouth slowly
Examine the hands
o Heberden's nodes of osteoarthrosis
o Ulnar deviation of rheumatoid
arthritis

Laboratory tests
o complete blood count
o erythrocyte sedimentation rate
o rheumatoid factor
o antinuclear antibody
o serum uric acid
Palpation Of The Muscle Of Mastication

Attempt to identify the involved

muscle causing the pain
• Masseter
• Temporalis
• Lateral pterygoid
• Medial pterygoid
TMJ EVALUATION
RESISTIVE MUSCLE TEST
Test performed to evaluate muscle strength

• Opening
• Lateral movement
• Protrusive
TMJ EVALUATION
 DIAGNOSTIC IMAGING
 Panoramic
 Transcranial
 Tomograph
 Arthrograph
 CT scan
 Requires contrast
 High dose radiation

 Magnetic resonance imaging

• Only imaging that shows the disc
TMJ Disorders
o Mandibular dislocation
o Myofascial pain
• involves discomfort or pain in the
muscles that control jaw function.
• Internal derangement of the joint
• involves a displaced disc, dislocated
jaw, or injury to the condyle.
• Arthritis
• refers to a group of degenerative/
inflammatory joint disorders
Normal TMJ Translation
 Mechanism of a mandibular dislocation

o Condyle moves to
anteriorly
o Muscles of
mastication contract in
spasm
o Inability to return to
glenoid fossa
TMJ Myofascial Pain Dysfunction

o Typically occurs after a muscle

has been contracted repetitively
• Bruxism
• Clenching
o Persistent and progressive
o Interfere with daily activities
TMJ Myofascial Pain Dysfunction
Signs and symptoms:
o Deep, aching pain in a muscle
o Pain that persists or worsens
o A tenderness of a muscle to
palpation
o Difficulty sleeping due to pain
o May progress to myofibromyalgia
• Chronic condition that features
widespread pain.
TMJ Myofascial Pain Dysfunction
Diagnosis
o Pain will be the presenting complaint
of the patient
o No visible signs
o Functional test
• Limitation of opening
• Pain on force opening
• Muscle weakness
o Tenderness during muscle palpation
Most common causes of MPDS

Most common cause is

overuse, abuse and misuse of
the muscles of mastication
• Clenching
• Bruxism
• Biting nails
• Holding items clenced beteen
teeth
• Constant chewing
Treatment for Myofascial Pain Dysfunction
The management for MPD is directed towards
management of the pain and dysfuction

o Home care method

o Short term medication
o Physical therapy
o Splint therapy
o Injections
o Transcutaneous electrical
nerve stimulation (TENS)
Home Care Method
 Soft diet
 Ice packs
 Avoiding extreme jaw
movements
 Gentle jaw stretching
and exercises
 Stress management
techniques
Short Term Medication

 NSAID
o Primary medication
o Usually sufficient
 Sedatives
o To relax the muscles
o Benzodiazepines
 Antidepressant drugs
o Low doses help relieve pain
from night time bruxism
o Tricyclic antidepressant drugs
Physical Therapy
 Keep the synovial joint
lubricated
 Maintain the jaw motion
 Range of motion exercises
o Opening movement
o Protrusive Movement
 Thermal packs
o Warm Compress before
Therapy
o Cold Compress after
Therapy
 Therapy devices
o Therabite
 Splint Therapy
Interocclusal devices alleviate or
prevent degenerative forces
placed on the TMJ, muscles and
dentition
• Severe bruxism and clenching
• Use should be short term
• Occlusal surface should be flat
• Periodic adjustments performed
• Treatment should be reversible
• Conflicting results on effectivity
Injections
Substances for injection have been
used to address TMJ disorders
o Local anesthesia
• Diagnosis
• Pain alleviation
o Use should be short term
• Effective for reducing capsulitis
o Clostridium Botulinum (Botox)
• Eliminate muscle spasm
• Reduce strength of contraction
• Maintain voluntary muscle movement
• Presently not FDA approved
Transcutaneous Electric Nerve Stimulation
Method of electrical stimulation which provide a
degree of symptomatic pain relief by exciting
sensory nerves and thereby stimulating either the
pain gate mechanism and/or the opioid system
TMJ internal derangement
o Disruption within TMJ in which there is a
displacement of the disc from its normal
functional relationship with the
mandibular condyle temporal bone
o Classifications
• Disc displacement with reductions
 Anterior displacement
 Medial displacement
 Lateral displacement
 Disc displacement with reduction with
intermittent locking
• Disc displacement without reduction
 Disc Displacement with Reduction

o Most common type of TMJ

disorder
o Most posterior part of the disc lies
anterior to the condyle
o Stays in that position while mouth
is closed
o Assumes normal position over the
condyle when mouth opens
o Generally not associated with
pain or dysfunction
 Disc Displacement with Reduction

Close Click
Open Click
Anterior Disc Displacement with Reduction
Medial Disc Displacement with Reduction
 Disc Displacement with Reduction

o Conditions that are not

painful nor dysfunctional
do not require treatment
o Monitoring is required
o Symptomatic cases
should be addressed
• Management directed at
pain and dysfunction
• Anterior repositoning
appliances are sometimes
worn
Anterior Repositioning Appliance

Guidelines for fabrication and use:

• Mandible is guided forward until the
disc is reduced
• This position iis indexed on to the
appliance
• Maintain a reduced disc prevents
pinching of the retrodiscal tissue
• Worn all day for 5-7 day
• Reduced to night time use after
• Limiting use minimizes possibility of
irreversible occlusal changes
resulting in posterior open bite
Disc Displacement with Reduction with
Intermittent Locking
Identical to disc displacement with
reduction, but with occasional
limited mandibular opening
o Depends on frequency of locking
o Rare and insignificant locking may be
treated similar to those without locking
Disc Displacement with Reduction with
Intermittent Locking
If frequent enough to be
bothersome:
o Attempt to increase lubrication of
articular surfaces
o Full through mandibular movement in
all directions of movement after
capturing disc
• Open
• Protrusive
• Retrusive
• Laterotrusive
Yoda T, Sakamoto I\ et al. A randomized controlled trial of therapeutic exercise for
clicking due to disk anterior displacement with reduction in the temporomandibular
joint. Cranio 2003;21:10-6
Anterior Displacement without Reduction

o Disc consistently remains

positioned anterior to the condyle
regardless of the mouth being
open or not
• Without limited opening
• With limited opening
Anterior Displacement without Reduction
Anterior Displacement without Reduction
without Limited Opening

o Usually follows disc displacement

without reduction with limited
opening
o Does not obstruct condylar
translation
• May be displaced far anteriorly
allowing space for movement before
contact
• Disc may have become foleded and
compressed allowing free movement
Anterior Displacement without Reduction
with Limited Opening

o May or may not involve pain

o Dysfunction is present
o Limited joint movement
results in:
• Limited synovial fluid cycling
• Accumulation of inflammatory
agents
• Damage during long period of
limited mobility
Anterior Displacement without Reduction
with Limited Opening

• Requires management
because of dysfunction
• In the acute stage, disc
mobility may be restored by
manual manipulation
• Exercises focused on a range
of motion can reduce the risk
of joint damage
Joint Manipulation

• Unaffected side should be

stabilized firmly
• Affected side pressed
inferiorly to clear the
height of the disc
• Then brought anteriorly to
seat the condyle on the
disc
• Mandible is slide
anteriorly and posteriorly
to lubricate disc
Arthrocentesis
o Lavage of the upper joint
space, hydraulic pressure
and manipulation to
release adhesions
o Main objectives
• Wash out inflammatory
mediators
• Release the disc
• Break up adhesions
• Eliminate pain
• Improve joint mobility
Arthroscopy
Form of surgery in which a very thin
(1/8th inch in diameter) surgical
telescope is placed into your upper TMJ
space through a very small (1/4 inch)
incision directly in front of your ear
Arthroplasty
o Open joint procedure that
may involve disc
repositioning, articular surface
recontouring, disc removal or
a combination thereof
o More aggressive nature
increases the incidence and
severity of complications
• Changes occlusion
• Numbness
• Facial paralysis is worst
complication
• May lead to ankylosis
The conservative and reversible forms of
therapy are preferred as opposed to the
irreversible forms of therapy
Donald J. Rinchuse, D.M.D., MS., M.D.S., Daniel J. Rinchuse, D.M.D., MS., M.D.S.Am
J Orthod, June 1983