Prof .B. Srinivasan. B.

Sc , MDS
 As Dentist 2
Dental treatments - Aim

3/10/2023
Prompt 2023
ESTHETICS
&
FUNCTION
 Prompt 2023
3

3/10/2023
Occlusion
Changes in the oral cavity – effects 4
the Masticatory System !....

3/10/2023
Prompt 2023
 Prompt 2023
5

3/10/2023
Loss of Posteriors increase load to anteriors
6

3/10/2023
Prompt 2023
 Prompt 2023
7

3/10/2023
Masticatory
System
Changes in Joint effects the Occlusion
8
1. Rheumatoid Arthritis

3/10/2023
Prompt 2023
2. Idiopathic Condylar Hypoplasia
9

3/10/2023
Prompt 2023
TMJ – Unique Joint 10

3/10/2023
Prompt 2023
Functionally the TMJ,
upper part of the
cervical spine and
OCCLUSION are
inter-related.
Any disharmony in one of the regions
can manifest as a disease or
disturbance in the other
Masticatory system – position of the condyle
11

3/10/2023
Prompt 2023
TEMPEROMANDIBULAR DISORDER12
An Assorted Set of Clinical Condition

3/10/2023
Prompt 2023
▶

characterized by Pain and Dysfunction of

the Masticatory System .

▶ 1.5 to 2 times more prevalent in Women

than in Men

▶ 80%of patient treated for TMD are Women

 Types of TMD 13
▶ Extra capsular TMD ( Muscular Dysfunction )

3/10/2023
Prompt 2023
▶ Intra capsular TMD ( Directly Affects the TMJ )
▶ Derangement of Condyle Disc Complex
▶ Structural incompatibility of articular Surface
▶ Inflammatory Disorder .

Role of Dentist -Early Diagnosis & Primary care - to give a better

therapeutic prognosis
Prevention of the progressive disease ( Degenerative Changes )
T M D – Assesments & Diagnosis

Prof . Dr. Annamalai Thangavelu .MDS

Diplomat ,National Board of Oral & Maxillofacial Surgery
Fellow , Indian Board of Oral & Maxillofacial surgery
Head, Department of OMFS
omfsvat @ gmail.com
 Aim 15
▶ To Understand the relationship of the Muscle

3/10/2023
Prompt 2023
Joint and the occlusion .
▶ To know the Silent anatomical features and
function’s of TMJ.
▶ To have an idea of the TMD and its diagnosis and
management .
▶ To discuss various options in prevention and
management of TMD’s in Dental Rehabilitations.
 Classification of Joints 16

Mankin & Radin

3/10/2023
Prompt 2023
▶ Class I – Synarthrosis (Immovable union of
connective tissue e.g., Cranial sutures)

▶ Class II – Amphiarthrosis (Joints that allow only

slight movement e.g., Spinal cord)

▶ Class III – Diarthrosis (Completely movable joints

e.g., TMJ, Shoulder, Knee)
Temporomandibular Joint 17

Ginglymo-di-arthrodial joint

3/10/2023
Prompt 2023
▶

▶ Bilateral synovial joint

▶ Separated into upper and
lower cavities by meniscus
(fibrocartilage)
▶ Provides hinge and translatory
movement
Craniomandibular Articulation 18

3/10/2023
Prompt 2023
 Mandibular Condyle 19

Ovoid with narrow neck

3/10/2023
Prompt 2023
Mediolaterally –
13 to 25 mm
Anteroposteriorly –
5.5 to 16 mm

Articular part of the condyle is covered by fibrocartilage

and not hyaline cartilage - unlike other joints in the body
The Disc 20
Superior (Concavo - Convex)

3/10/2023
Prompt 2023
Inferior (Concave)

Divides the joint space in to

upper (1.2 ml) and lower (0.9 ml)
compartments

Anterior : Lat Pterigoid Muscle

Intermediate : Avascular zone
Posterior : Bilaminar Zone
21

Prompt 2023
3/10/2023
Ligaments 22

3/10/2023
Prompt 2023
Lateral or TM ligament
(check ligament)
prevents anterior jaw
excursion

Accessory ligaments
- Spehonmandibular
- Stylomandibular
 Synovial Tissue 23
▶ Connective tissue membrane lining the joint

3/10/2023
Prompt 2023
cavities or spaces
▶ Secretes synovial fluid (ultrafiltrate of blood
plasma and mucin) aiding in lubrication
▶ Viscous (highly polymerized hyaluronic acid)
enabling the joint to withstand shearing forces
▶ Other functions: nutrition, phagocytosis and
immunological response
 FDI CDE 2019
Prompt 2023
THE MUSCLES
24

3/10/2023
 Joint Movements 25

Three Sets of Mandibular Movements

3/10/2023
Prompt 2023
▶ Depression & Elevation (Opening & closing)
▶ Side to Side/ lateral (grinding) movements
▶ Protraction & Retraction (Protrusion &
Retrusion)
 26

Prompt 2023
3/10/2023
OPENING
27

Prompt 2023
3/10/2023
 Mouth Opening – I I D 28
( Inter Incisal Distance )

3/10/2023
Prompt 2023
 Symptoms of TMD 29
❑ Abnormal joint sounds

3/10/2023
Prompt 2023
(TMJ Clicking & locking )
❑ Change in Occlusion.
( Difficulties in Chewing and Biting )
❑ Altered Range of Motion.
( Difficulty in Mouth Opening )
❑ Pain & Referred Pain
 Clinical Examination 30

3/10/2023
Prompt 2023
❑ TMJ (Joint proper )

❑ Muscles (Muscles
of Mastication)

❑ Occlusion
 31

Prompt 2023
3/10/2023
On Palpation
Range of Movements 32

3/10/2023
Prompt 2023
Examinations of Muscles
33

3/10/2023
Prompt 2023
Examination under Local Anasthesia 34

3/10/2023
Prompt 2023
Auriculo 35

temporal

3/10/2023
Prompt 2023
nerve
Block
 36

Prompt 2023
3/10/2023
Referred Pain
 37

Prompt 2023
3/10/2023
Diagnostic Block
Centrally orginated “ P A I N”
38

3/10/2023
Prompt 2023
▶ Localized
treatment
will not
help !....
▶ Should
treat
centrally
MUSCLE VS JOINT PAIN (Intra Capsular)
39

3/10/2023
Prompt 2023
Capsular ligament and Condylar movement
40

3/10/2023
Prompt 2023
DISC - MOUTH OPENING
41

Prompt 2023
3/10/2023
CLOSED LOCK

CLICK
 EXAMINATION OF OCCLUSION 42

3/10/2023
Prompt 2023
❑ Centric
❑ Anterior Guidance
❑ Canine Guidance
❑ Group Function
Alterations in hard and soft tissues
43
of the TMJ

3/10/2023
Prompt 2023
Radiological Investigations 44

3/10/2023
Prompt 2023
Conventional
Vs
Advanced
TRANSPHARYNGEAL VIEW 45

3/10/2023
Prompt 2023
 OSTEOARTHRITIS
SHOWING A SEPARATED OSTEOPHYTE IN JOINT SPACE
46

3/10/2023
Prompt 2023
 47

Prompt 2023
3/10/2023
TRANSORBITAL VIEW
PANORAMIC RADIOGRAPHY 48

3/10/2023
Prompt 2023
Advanced Radiographs & CT 49

3/10/2023
Prompt 2023
MAGNETIC RESONANCE IMAGING
50

3/10/2023
Prompt 2023
OPEN MOUTH
CLOSED MOUTH
ARTHROSCOPIC – DIAGNOSIS 51

3/10/2023
Prompt 2023
52

Prompt 2023
3/10/2023
 CLASSIFICATION OF TMJ DISORDERS
53
▶ Developmental
Aplasia, Hypoplasia, Hyperplasia

3/10/2023
Prompt 2023
▶ Inflammatory
Rheumatoid arthritis, Osteoarthritis, Still’s disease etc…

▶ Trauma
Condylar fractures

▶ Tumor
Osteoma ,Chondroma, Osteosarcoma, Chondrosarcoma

▶ Glenocondylar mobility disturbances

Hypomobility (ankylosis), Hypermobility, Subluxation & Dislocation

▶ Disc condylar disturbances

Internal derangement

▶ Miscellaneous
MPDS
Internal Derangement
 INTERNAL DERANGMENT 55

3/10/2023
Prompt 2023
▶ Localized disturbance & uncoordinated
movement between the disc and the
head of the condyle
 ETIOLOGY 56

▶ Trauma – Micro/ Macrotrauma

3/10/2023
Prompt 2023
▶ Functional Overloading
▶ Joint Laxity
▶ Masticatory Muscle Spasm
▶ Degenerative Joint Disease
▶ Increased Friction
 CLASSIFICATION 57

Deviation in form

3/10/2023
Prompt 2023
▶

▶ Functional disc incoordination

▶ Articular surface defects
▶ Disc thinning and perforation

▶ Disc Displacement
▶ Partial anteromedial disc displacement
▶ Anteromedial disc displacement with reduction
▶ Anteromedial disc displacement with intermittent locking
▶ Anteromedial disc displacement without reduction
▶ ADD with perforation of retrodiscal tissue
 58

Adhesive Disc Hypomobility

3/10/2023
Prompt 2023
▶

▶ Displacement of the Disc-condyle

▶ Subluxation
▶ Dislocation
 SIGNS & SYMPTOMS 59

3/10/2023
Prompt 2023
Pain ( on mandibular movements )

Click – Open (early, intermediate, late), closed & reciprocal

Restricted Mouth Opening

 Partial ADD 60

3/10/2023
Prompt 2023
Clinical features
1. No collapse of joint space (there
is no or minimum interference of
joint function)
2. No clicking
,
3. Slight early deviation
4. Discomfort in the joint area after
prolonged clenching
 ADD with Reduction 61

3/10/2023
Prompt 2023
1, Hinge opening
2, Lock - Pain
3, Deviation away from the
painful side and returns to the mid line
4. Clicking ( Open Click)
5. Full translatory mouth opening
6. Clicking (Reciprocal)
7. Translatory mouth closure
A. Resting, 62
closed joint position

3/10/2023
Prompt 2023
B. Early stage of
translation

C. Reduction of the disc, that is

accompanied by opening click
•----Normal Disc Morphology 63
•----Laxity of attachments allowing mobility
•----Atrophy & Distortion of retrodiscal tissues with loss

3/10/2023
Prompt 2023
of elasticity
•----Loss of spontaneous reduction
 ADD without Reduction
64

Hinge opening

3/10/2023
Prompt 2023
▶

▶ Pain
▶ Deflection towards painful side
▶ Pain (Painful side remains
locked)
▶ Translatory opening of the
opposite side
 65
Resting,

3/10/2023
Prompt 2023
closed joint position

Early stage of reduction showing the

condyle pushing the disc forward

Late stage of translation shape and

jamming of the disc in front of the
condyle preventing normal translatory
movement
 ADD with Intermittent locking 66

Disc remains displaced for prolonged periods of time

3/10/2023
Prompt 2023
▶

▶ Change in shape of disc from biconcave to

biconvex, making passage of condyle under disc
more difficult

▶ Characterized by intermittent locking and more

pronounced in the morning after prolonged
clenching
ADD without Reduction 67

Displaced meniscus

3/10/2023
Prompt 2023
Restricted forward
translation

Pressure effects leading to

disc perforation

Direct bone to bone

contact
68

Prompt 2023
3/10/2023
 ADD with perforation 69

3/10/2023
Prompt 2023
▶ Chronic condition
▶ Pain
▶ Referred pain
▶ Tinnitus, headache
▶ Crepitus
▶ Diffuse muscle tenderness
Adhesive Disc Hypomobility 70

3/10/2023
Prompt 2023
Microtrauma
Damage to the disc
Bleeding
Repair
Fibrous tissue
Adhesion
Restricted movement
A. Closed B. Open: A n adhesion occurring between the disc and the fossa
preventing normal translatory movement creating a closed lock with a vertical
opening of 25 to 30 mm . No collapse of the joint space and no displacement of the
disc
Displacement of the Disc-Condyle Complex
71

3/10/2023
Prompt 2023
SUBLUXATION
WILKIES STAGING OF INTERNAL DERANGEMENTS
72
STAGE CHARACTERISTICS IMAGING
1. Early Slight forward disc. Normal

3/10/2023
Prompt 2023
Painless clicking. No restricted
motion osseous contours

2. Early Intermediate Occasional painful clicking. Slightly forward disc Early disc
Intermittent locking Headaches deformation Normal osseous
contours

3. Intermediate Pain, Joint tenderness Headaches Anterior Disc displacement

Restricted motion Painful Moderate thickening of disc
chewing Normal osseous contour

4. Intermediate late Chronic pain Headache Anterior disc displacement

Restricted motion Marked disc thickening Abnormal
bony contours

5. Late Variable pain Joint crepitus Anterior disc Displacement

with perforation Degenerative
osseous changes
73

Prompt 2023
3/10/2023
74

Prompt 2023
3/10/2023
75

Prompt 2023
3/10/2023
Management of I D of TMJ as per the Staging
STAGE CHARACTERISTICS IMAGING
76
1. Early Painless clicking. No restricted Slight forward disc. Normal

3/10/2023
Prompt 2023
motion osseous contours
(Medical and physical)
2. Early Intermediate Occasional painful clicking. Slightly forward disc Early disc
Intermittent locking Headaches deformation Normal osseous
(Medical and physical) contours

3. Intermediate (Artherocentesis Pain, Joint tenderness Headaches Anterior Disc displacement

& lavage and Arthroscopic Restricted motion Painful Moderate thickening of disc
procedure ) chewing Normal osseous contour

4. Intermediate late Chronic pain Anterior disc displacement

( Arthroscopy &SURGERY ) Headache Marked disc thickening Abnormal
Restricted motion bony contours

5. Late Variable pain Anterior disc Displacement

( SURGERY ) Joint crepitus with perforation Degenerative
osseous changes
 MANAGEMENT 77
▶ Medical
( Muscle relaxant, Anti Depressent )

3/10/2023
Prompt 2023
▶ Physical therapy.
▶ Occlusal Deprograming ( SPLINT )
( Functional correction of the Occlusion )
▶ Prolotherapy
▶ Artherocentesis & Lavage
( Release of the adhesion )
▶ Arthroscopic Surgery
▶ Open Joint Surgery ( Discectomy , Meniscoplasty)
 MEDICAL THERAPY
78

Tricyclic antidepressants-

3/10/2023
Prompt 2023
▶

Dothiepin 75mg
Amitryptilline
Fluoxetine 20mg

Conventional NSAIDS do not seem to be effective

 79
The Role of Relaxin Hormone in Internal

3/10/2023
Prompt 2023
Derangement
Z U M J – Sept 2013

Synovial fluid of ID TMJ – Raise in Relaxin

( Elisa test)
One week after Arthrocentesis the hormone
level decreases
80

Prompt 2023
3/10/2023
 PHYSICAL THERAPY 81

3/10/2023
Prompt 2023
▶ EXERCISE THERAPY
▶ ELECTROTHERAPY

INDICATIONS:
INFLAMMATION
HYPERMOBILITY
HYPOMOBILITY
 82

Prompt 2023
3/10/2023
Exercise
 83
LASER

3/10/2023
Prompt 2023
SOFT LASERS ( L I L T )

INDICATIONS
TISSUE HEALING
 SPLINT THERAPY 84
Diagnostic & Therapeutic

3/10/2023
Prompt 2023
Alter the Occlusal plane
Prevent attrition
Treat Myalgia
Decrease Para function
Alter the structural relation of the TMJ*
 THEORIES OF SPLINT (CLARKES,1984) 85

3/10/2023
Prompt 2023
1. Occlusal disengagement theory
(restore neuromuscular balance)
2. Maxillomandibular realignment theory
(restore neuromuscular balance)
3. Restored vertical dimension theory
4. TMJ repositioning theory
5. Cognitive awareness theory (placebo effect)
MUSCULAR DEPROGRAMING 86

3/10/2023
Prompt 2023
 TYPES OF SPLINTS: 87

SOFT BITE GUARD (SBG)

3/10/2023
Prompt 2023
A soft splint made of polyvinyl of uniform thickness)
Arch - maxillary or mandibular
Records - none
Contacts - not needed
Usage - at night / 6 weeks to 3
months
Indication 1. Absorb Occlusal forces
2. Habit breaker
 88

Prompt 2023
3/10/2023
SOFT BITE GUARD
 D. ANTERIOR REPOSITIONING 89

APPLIANCE ARPS)

3/10/2023
Prompt 2023
It is a splint which repositions the mandible in a
protrusive position where there is no click when the
patient opens and closes.

Arch - Maxillary
Records - Protrusive record
Contacts - All occlusal surfaces in anterior
position of mandible
 90
Duration - 24 hours a day (even while
eating) 6-12 weeks

3/10/2023
Prompt 2023
Indication
1. Internal derangement of the TMJ
with a displaced disc which
reduces on opening.
2. Intermittent or chronic locking
3. Inflammatory disorders like Retro
discitis.
ANTERIOR REPOSITIONING APPLIANCE
91
(ARPS)

3/10/2023
Prompt 2023
ANTERIOR REPOSITIONING APPLIANCE
92
(ARPS)

3/10/2023
Prompt 2023
Reversible Occlusal Therapy 93

3/10/2023
Prompt 2023
 OCCLUSAL THERAPY 94
(IRREVERSIBLE)

3/10/2023
Prompt 2023
When it has been proved beyond
reasonable doubt that the existing
occlusal condition is responsible for the
TMD.
Irreversible Occlusal Therapy 95

3/10/2023
Prompt 2023
 Occlusal 96

Adjustments

3/10/2023
Prompt 2023
MINIMAL INVASIVE TECHNIQUE
 98

Prompt 2023
3/10/2023
ARTHEROCENTESIS
99

Prompt 2023
3/10/2023
Arthrocentesis in TMJ – evaluation 100

of 100 patients with ID

3/10/2023
Prompt 2023
JOMS 59:874-877: 2001
▶ Severe Pre Operative pain
▶ Relapse in amount of mouth opening
▶ Boney changes of the condyle

▶ 73 % - satisfied the criteria for success.

Internal derangements of the temporomandibular
101
joint: A review of the anatomy, diagnosis, and
management

3/10/2023
Prompt 2023
Andrew L. Young
Jr of In Prostho Society | Jan-Mar 2015 | Vol 15 | Issue 1

The self-limiting nature of most TMDs, and the

high efficacy of low-cost conservative care
indicate that such treatment should be the initial
treatment of choice.
Only after failed attempts at conservative care
should more aggressive methods be considered
Internal Derangement of Temporomandibular 102
joint: Role of arthocentesis with Steriod
Altaf Hussain Malik

3/10/2023
Prompt 2023
Plast Aesthet Res / Vol 1 / Issue 1/ Jun 2014
Pain - Vasoconstriction and Release of nitric oxide,
reactive oxygen species (ROS), and Thiobarbituric acid.
Elevated ROS levels in synovial fluid may result from
mechanical stress and high pressures directed to the upper
compartment during clenching and jaw movement
Lavage and decreases intra-articular pressure. Furthermore,
the elimination of nitric oxide and ROS relieves the pain.
 103

Prompt 2023
3/10/2023
Arthroscopy
104

Prompt 2023
3/10/2023
105

Prompt 2023
3/10/2023
Arthroscopy Lysis and lavage in 106

ID of TMJ

3/10/2023
Prompt 2023
458 patients (611 joints ) Wilkies 2-5

Stage 4 ( Closed Lock) – max results

J Oral maxillofacial Surg : 69:2513-2524:2011

Arthroscopy Lysis and lavage in 107

ID of TMJ

3/10/2023
Prompt 2023
458 patients (611 joints ) Wilkies 2-5

Stage 4 ( Closed Lock) – max results

J Oral maxillofacial Surg : 69:2513-2524:2011

Surgical Arthroscopy as preferred 108

treatment for Internal

3/10/2023
Prompt 2023
derrangement

Only in acute condition and not relied on for

definitive therapy for all stages of diseases

JOMS :59:308-312: 2001

 109

Prompt 2023
3/10/2023
MENISECTOMY
 110

Prompt 2023
3/10/2023
Discectomy
 111

Prompt 2023
3/10/2023
CONDYLECTOMY
Sub Sigmoid Osteotomy 112

3/10/2023
Prompt 2023
113

Prompt 2023
3/10/2023
Surgery for TMJ internal derangement 114
(Evaluation of treatment outcome and criteria for
success)

3/10/2023
Prompt 2023
Combine modalities are often more
effective than single approach .
(Medical, Physical ,and Surgical)

Int. J Oral Maxillofac. Surg 1993; 22:75-77

Discectomy for painful ID 115

3/10/2023
Prompt 2023
In cases with no improvement after
non surgical treatment – this
procedure shows good results in pain
control following adaptive changes .

JOMS :59:750-758 :2001

The Role of Surgery in the
116
management of disorders of TMJ-
Review of Literature ( G. Dimitroulis )

3/10/2023
Prompt 2023
The Literature is unequivocal in support for surgery in
management of certain disorder of TMJ ( Internal
Derangement )

Non Surgical – works better and surgical option

relegated to last resort.

Int J Oral & Maxillofac Surg.34;231-237:2005

Temporomandibular Joint Surgery 117
for Internal Derangement
M. Franklin Dolwick, DMD, PhD

3/10/2023
Prompt 2023
Dent Clin N Am 51 (2007) 195–208

Plays a small, but important role in the

management of patients with TMDs.

The literature has shown that about 5% of the

patients who undergo treatment for TMDs
require Surgical Intervention
20 year Follow – up of Disc 118

repositioning Surgery for ID

3/10/2023
Prompt 2023
Effective surgical treatment in Disc
Displacement in TMJ internal
Derrangement .

JOMS ; 68:239-242:2010
Quality of the life – In Discectomy 119
Pre & Post

3/10/2023
Prompt 2023
Discectomy with Dermis fat grating –
Positive quality of life , Reducing Pain
and increase in ROM in Stage 4 ID

JOMS 68:101-106:2010
TMJ interposition with Dermis Graft in
120
Internal Derangement – a critical
review ( G. Dimitroulis)

3/10/2023
Prompt 2023
No Ideal Interposition material that Satisfies all
Criteria for replacement of articular disc
following TMJ Discectomy

Int J Oral &Maxillofacial Surg :40:561-568:2011

Scientific Evidence in Surgery for the Treatment of
Temporomandibular joint Internal Derangement 121
Raúl González-García

3/10/2023
Prompt 2023
Stomatological Dis Sci 2019;3:5
Based on the present review, the studies with highest evidence
conclude that:
(1) High-degree evidence is insufficient in relation to the effect of surgery
(2) Surgery is useful in patients refractory to conservative treatment;
(3) There are not differences among surgical techniques
(4) Arthroscopy and Arthrocentesis are effective in the treatment of chronic
closed lock.
(5 ). Arthroscopy is preferred as the first option due to its
Minimal invasive nature
Total joint replacement 122

3/10/2023
Prompt 2023
123

Prompt 2023
3/10/2023
 Conclusion
▶ Alterations in the occlusion can Damage the TMJ
124
▶ Pathologies in the TMJ can alter the occlusion .

3/10/2023
Prompt 2023
▶ In any Dental Rehablitaion , Masticatory system should be taken care and
should be examined completely before treatment .
▶ Dental Rehablitation is not complete with out considering the Muscle of
head & Neck & Tempromandibular Joint
▶ Muscle Deprograming should be considered before definitive therapy
▶ Managing Pain and Dysfunction in the TMJ is mandatory before Dental
Rehabilitation
▶ Irreversible alteration in the Teeth, Muscle and TMJ should be reserved as
the last option
▶ Assessments & Diagnosis is Very Important
▶ Non Invasive , Minimal Invasive , and Invasive Management
 TMJ Association
126

3/10/2023
Prompt 2023
▶ Good Patient Feed Back

▶ Discourages Splint &

Surgical Procedure for
Internal Derangement
 127

3/10/2023
Prompt 2023
To Know More !.....
 128

3/10/2023
Prompt 2023
Thank you all
Have a Nice day