TMJ disorders / fellowships in orthodontics

TMJ DisordersTMJ Disorders
INDIAN DENTAL ACADEMY
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ContentsContents
 IntroductionIntroduction
 EpidemiologyEpidemiology
 EtiologyEtiology
 ClassificationClassification
 Clinical featuresClinical features
 Radiological featuresRadiological features
 Histopathologic featuresHistopathologic features
 TreatmentTreatment

IntroductionIntroduction

EpidemiologyEpidemiology
 Epidemiologic studiesEpidemiologic studies  60-70%60-70%
 20-40 years.20-40 years.

EtiologyEtiology
 Multifactorial:Multifactorial:
 Parafunctional habitsParafunctional habits
 StressStress
 TraumaTrauma

 Abnormal maxillo-mandibular relationships.Abnormal maxillo-mandibular relationships.
 Rheumatic / musculo-skeletal disorders.Rheumatic / musculo-skeletal disorders.
 Poor general health and unhealthy lifestyle.Poor general health and unhealthy lifestyle.

AnatomyAnatomy

Normal histology of TMJNormal histology of TMJ

ClassificationClassification(Etiology)(Etiology)
I.I. DevelopmentalDevelopmental
 AplasiaAplasia
 HypoplasiaHypoplasia
 HyperplasiaHyperplasia

II.II. TraumaticTraumatic
 AnkylosisAnkylosis
 Injuries of the articular diskInjuries of the articular disk

III. Fractures of the condyleIII. Fractures of the condyle
IV.IV. InflammatoryInflammatory
 ArthritisArthritis
 Rheumotoid arthritisRheumotoid arthritis
 OsteoarthritisOsteoarthritis

V.V. NeoplasticNeoplastic
VI.VI. Extra-articular disturbancesExtra-articular disturbances
VII. Temporomandibular jointVII. Temporomandibular joint syndrome (TMD)syndrome (TMD)
 TMD secondary to myofacial pain and dysfunctionTMD secondary to myofacial pain and dysfunction
(MPD)(MPD)
 TMD secondary to true articular disease.TMD secondary to true articular disease.

DEVELOPMENTALDEVELOPMENTAL
DISTURBANCESDISTURBANCES

Aplasia of the mandibular condyleAplasia of the mandibular condyle
 Unilateral / bilateral.Unilateral / bilateral.
 RareRare
C/FC/F
 Associated-- absent externalAssociated-- absent external earear ,under,under
developed ramus / macrostomia.developed ramus / macrostomia.
 Facial asymmetryFacial asymmetry

 TreatmentTreatment
 OsteoplastyOsteoplasty
 Orthodontic appliancesOrthodontic appliances
 Cosmetic surgeryCosmetic surgery

Hypoplasia of the mandibular condyleHypoplasia of the mandibular condyle::
 Under development / defective formationUnder development / defective formation
 Congenital hypoplasiaCongenital hypoplasia
 IdiopathicIdiopathic
 Characterized by uni / bilateral underCharacterized by uni / bilateral under
development of the condyledevelopment of the condyle

Acquired hypoplasiaAcquired hypoplasia
Forceps deliveriesForceps deliveries
External traumaExternal trauma
X-ray radiationX-ray radiation
InfectionInfection

 C/f:C/f:
 DependsDepends
 Degree of malformation.Degree of malformation.
 AgeAge
DDurationuration
 UnilateralUnilateral

 Limited lateral movementsLimited lateral movements
 Midline shiftMidline shift
 Lack of downward and forward growth of theLack of downward and forward growth of the
mandiblemandible
 Arrest of theArrest of the chief growth centerchief growth center of theof the
mandible i.e.,mandible i.e., condyle.condyle.

 Treatment & prognosis:Treatment & prognosis:
 Cartilage / bone transplantsCartilage / bone transplants
 Unilateral and bilateral osteotomyUnilateral and bilateral osteotomy

Hyperplasia of the mandibular condyleHyperplasia of the mandibular condyle::
 RareRare
 unilateral enlargement of the condyleunilateral enlargement of the condyle
 Causes:Causes:
-Obscure-Obscure
-Mild chronic inflammation.-Mild chronic inflammation.

 C/f:C/f:
 Elongation of the faceElongation of the face
 deviation of the chin away from the affected side.deviation of the chin away from the affected side.
 Enlarged condyleEnlarged condyle
 may or may not be painfulmay or may not be painful
 severe malocclusionsevere malocclusion

 R/F:R/F:
 Elongated neck and enlarged condylar headElongated neck and enlarged condylar head
 Treatment and prognosis:Treatment and prognosis:
 CondylectomyCondylectomy
 Orthognathic surgeryOrthognathic surgery
 Resection of condyleResection of condyle

Condylar hyperplasia

Bifid condyleBifid condyle
 Double headed.Double headed.
 Medial & lateral head.Medial & lateral head. //Anterior & posterior head.Anterior & posterior head.
Etiology:Etiology:
 Uncertain.Uncertain.
 Traumatic in origin.Traumatic in origin.
 Abnormal muscle attachmentAbnormal muscle attachment

C/F:C/F:
 UnilateralUnilateral
 AsymptomaticAsymptomatic
 Pop or click of TMJPop or click of TMJ
R/F:R/F:
 Bilobed appearanceBilobed appearance
 AsymptomaticAsymptomatic  no treatmentno treatment
necessary.necessary.

Histologic section of bifid condyleHistologic section of bifid condyle

TraumaticTraumatic

Luxation and subluxationLuxation and subluxation
Dislocation of the TMJDislocation of the TMJ
 Luxation of the jointLuxation of the joint
 SubluxationSubluxation
 LuxationLuxation  ‘acute’, due to a sudden traumatic injury‘acute’, due to a sudden traumatic injury
resulting in the fracture of the condyle.resulting in the fracture of the condyle.
 Yawning / wide opening of mouthYawning / wide opening of mouth

Unilateral condylar dislocation

Bilateral condylar dislocation

Luxation & SubluxationLuxation & Subluxation
 C/f:C/f:
 Sudden locking and immobilization of the jaws.Sudden locking and immobilization of the jaws.
 Prolonged spasmodic contraction of the temporal,Prolonged spasmodic contraction of the temporal,
internal pterygoid and masseter muscles.internal pterygoid and masseter muscles.

Luxation & SubluxationLuxation & Subluxation
 Treatment:Treatment:
 Relaxation of the muscles and then guiding the head of theRelaxation of the muscles and then guiding the head of the
condyle under the articular eminence into its normal positioncondyle under the articular eminence into its normal position
by an inferior and posterior pressure of the thumbs in theby an inferior and posterior pressure of the thumbs in the
mandibular molar area.mandibular molar area.

AnkylosisAnkylosis
 Fusion of head of the condyleFusion of head of the condyle  temporal bone.temporal bone.
 EtiologyEtiology::
 IdiopathicIdiopathic
 Traumatic injuriesTraumatic injuries
 InfectionInfection
 Rheumatoid arthritisRheumatoid arthritis

AnkylosisAnkylosis
 C/f:C/f:
 11stst
decadedecade
 Before 10 yearsBefore 10 years
 M = FM = F
 Unilateral /BilateralUnilateral /Bilateral
 In ability to open the jawsIn ability to open the jaws
 Pain, tenderness and malocclusionPain, tenderness and malocclusion

Unilateral ankylosis

AnkylosisAnkylosis
Intra-articular ankylosisIntra-articular ankylosis Extra-articular ankylosisExtra-articular ankylosis
-Destruction of the meniscus-Destruction of the meniscus
-Flattening of the mandibular-Flattening of the mandibular
fossa thickening of the headfossa thickening of the head
of the condyleof the condyle
-narrowing of the joint space-narrowing of the joint space
-Fibrous adhesion-Fibrous adhesion
External fibrous / osseousExternal fibrous / osseous
encapsulation.encapsulation.

AnkylosisAnkylosis
 R/F:R/F:
 Abnormal / irregular shape of the head of theAbnormal / irregular shape of the head of the
condylecondyle
 Surgical osteotomy / removal of section of boneSurgical osteotomy / removal of section of bone
below the condyle.below the condyle.
 Fibrous ankylosis can be treated by functionalFibrous ankylosis can be treated by functional
methods.methods.

Injuries of the articular diskInjuries of the articular disk
 MalocclusionMalocclusion
 Loss of adaptation of the disk to the condyle.Loss of adaptation of the disk to the condyle.
 Precipitating factorsPrecipitating factors
 Blow / fallBlow / fall
 Rheumatoid arthritisRheumatoid arthritis

 C/f:C/f:
 FemalesFemales
 Young adultsYoung adults  frequently affected.frequently affected.
 Pain, snapping or clicking and crepitation.Pain, snapping or clicking and crepitation.
 Transient / prolonged locking of the jaw mayTransient / prolonged locking of the jaw may
occur.occur.

Normal disc positionNormal disc position Anterior discAnterior disc
displacementdisplacement

 R/F:R/F:
 No +ve findingsNo +ve findings
 ImmobilizationImmobilization
 Menisectomy / surgical removal of theMenisectomy / surgical removal of the
disk.disk.

FracturesFractures

Condylar fracture:Condylar fracture:
 Traumatic injuryTraumatic injury
 Limitation of motionLimitation of motion
 Pain and swellingPain and swelling
 Displaced anteriorly and medially into theDisplaced anteriorly and medially into the
infratemporal regioninfratemporal region
Surgical reduction

Unilateral
Bilateralwww.indiandentalacademy.com

INFLAMMATORYINFLAMMATORY
DISTURBANCESDISTURBANCES

Arthritis.Arthritis.
3 types :3 types :
1.1. Arthritis due to a specific infection.Arthritis due to a specific infection.
2.2. Rheumatoid arthritis.Rheumatoid arthritis.
3.3. Osteoarthritis / degenerative joint disease.Osteoarthritis / degenerative joint disease.

UncommonUncommon
Neisseria gonorrhea, Str, Staph. Pneumococci,Neisseria gonorrhea, Str, Staph. Pneumococci,
tubercle bacilli, H. influenzaetubercle bacilli, H. influenzae
 Direct spread of a local infection or blood stream /Direct spread of a local infection or blood stream /
lymphatic metastasis.lymphatic metastasis.
C/F:C/F:
-- Severe pain in the joint.Severe pain in the joint.
 Extreme tendernessExtreme tenderness
 HealingHealing  results in ankylosis.results in ankylosis.

H-PH-P
DestructionDestruction  articular cartilage and articular disc.articular cartilage and articular disc.
 Obliteration of joint spaceObliteration of joint space  by the development ofby the development of
granulation tissuegranulation tissue
 Transforms into scar tissue.Transforms into scar tissue.
Rx:Rx:
 Antibiotics – in the acute phaseAntibiotics – in the acute phase
 Meniscetomy / condylectomy is advocated in the advancedMeniscetomy / condylectomy is advocated in the advanced
cases.cases.

Rheumatoid arthritisRheumatoid arthritis
 Chronic autoimmune disorderChronic autoimmune disorder
 non-suppurative inflammatory destruction of thenon-suppurative inflammatory destruction of the
joints.joints.
 Etiology:Etiology:
 UnknownUnknown
 Cross reaction of antibody against microorganismsCross reaction of antibody against microorganisms
deposited in the synovial membrane.deposited in the synovial membrane.

 A reactive macrophage – laden fibroblasticA reactive macrophage – laden fibroblastic
proliferation from the synovium creeps onto theproliferation from the synovium creeps onto the
joint surface.joint surface.
↓↓
Releases collagenases & proteasesReleases collagenases & proteases
↓↓
Destroys the cartilage & boneDestroys the cartilage & bone
 TMJ involvementTMJ involvement  20%20%

C/F:C/F:
 M:F = 1:3M:F = 1:3
 M = 25-30 yrs;M = 25-30 yrs; F = 35-45 yrsF = 35-45 yrs
 Early stages manifestsEarly stages manifests
Rheumatoid arthritisRheumatoid arthritis

 Pain, swelling and stiffness jointPain, swelling and stiffness joint
 Clenching the teeth on one side produces pain ofClenching the teeth on one side produces pain of
contra lateral joint.contra lateral joint.
 Destruction of condylar headDestruction of condylar head  receding chin &receding chin &
malocclusionmalocclusion

R/F:R/F:
 Flattened condylar headFlattened condylar head
 An irregular surface of temporal fossaAn irregular surface of temporal fossa
 Anterior displacement of the condyleAnterior displacement of the condyle
 High resolution CTHigh resolution CT  erosions of the condyle &erosions of the condyle &
glenoid fossae.glenoid fossae.

H-P :H-P :
 HyperplasiaHyperplasia of synovial lining cellsof synovial lining cells
 Hyperemia, edemaHyperemia, edema and inflammation of the synovialand inflammation of the synovial
tissuestissues
 diffuse infiltration of chronic inflammatory cells into thediffuse infiltration of chronic inflammatory cells into the
articular architecture.articular architecture.

 destructiondestruction of articular surface of the condyle.of articular surface of the condyle.
 Invasion of the cartilage and its replacement byInvasion of the cartilage and its replacement by
granulation tissue.granulation tissue.
 Perforation of meniscusPerforation of meniscus

Lab findings:Lab findings:
 80% of patients80% of patients  ↑rheumatoid factor↑rheumatoid factor
ANA detected in 50%ANA detected in 50%
↑↑ESRESR
Mild anemiaMild anemia

Rx & Prognosis:Rx & Prognosis:
 Anti-inflammatory drugsAnti-inflammatory drugs
 Corticosteoids.Corticosteoids.
 Surgical interventionSurgical intervention

OsteoarthritisOsteoarthritis
Disorder of articular cartilage, subcondral boneDisorder of articular cartilage, subcondral bone
with secondary inflammation of the synovialwith secondary inflammation of the synovial
membranemembrane
Etiology:Etiology: unknown.unknown.
 GeneticGenetic
 Aging process.Aging process.
 Chronic microtraumaChronic microtrauma
 PrimaryPrimary  above 50 yrs & asymptomaticabove 50 yrs & asymptomatic
 SecondarySecondary  due to trauma, metabolic diseasedue to trauma, metabolic disease

C/F:C/F:
 Unilateral pain over the condyle & over muscles ofUnilateral pain over the condyle & over muscles of
masticationmastication
 Limitation of mandibular openingLimitation of mandibular opening
 Crepitus and stiffnessCrepitus and stiffness
 Deviation of mandible towards painful sideDeviation of mandible towards painful side

R / F:R / F:
 Obliteration of the joint spaceObliteration of the joint space
 Surface irregularities and protruberancesSurface irregularities and protruberances
 Flattening of the articular surface.Flattening of the articular surface.
 Radiolucent subchondral cystsRadiolucent subchondral cysts
 Ossification within the synovial membraneOssification within the synovial membrane

H-P /F:H-P /F:
 Degeneration of cartilage cellsDegeneration of cartilage cells
 infiltration of chronic inflammatory cellsinfiltration of chronic inflammatory cells
 Loss of osteocytesLoss of osteocytes
 fatty degeneration & necrosis of the marrowfatty degeneration & necrosis of the marrow
 Large degenerative space beneath the articularLarge degenerative space beneath the articular
cartilage (Subchondral cysts)cartilage (Subchondral cysts)

Rx:Rx:
 NSAIDs, heat, soft diet, rest and occlusalNSAIDs, heat, soft diet, rest and occlusal
splintssplints
 ArthroplastyArthroplasty
 Orofacial physiotherapy.Orofacial physiotherapy.

NEOPLASTICNEOPLASTIC

 Neoplasms and tumor-like growths, benign andNeoplasms and tumor-like growths, benign and
malignant, may involve the TMJ.malignant, may involve the TMJ.
Etiology:Etiology: UnknownUnknown
 From embryonic mesenchymal remnants ofFrom embryonic mesenchymal remnants of
synovium.synovium.
 That become metaplastic, calcify, break off into theThat become metaplastic, calcify, break off into the
joint spacejoint space
 Chondromas, osteomas and osteochondromas areChondromas, osteomas and osteochondromas are
common benign tumors.common benign tumors.

Osteochondroma – bone capped with cartilage and denseOsteochondroma – bone capped with cartilage and dense
collagenous tissuecollagenous tissuewww.indiandentalacademy.com

 CT scan and arthroscopy is necessary forCT scan and arthroscopy is necessary for
accurate diagnosis.accurate diagnosis.
Rx:Rx:
 Conservative and surgical removal of involvedConservative and surgical removal of involved
synovium and articular disk.synovium and articular disk.

EXTRA-ARTICULAREXTRA-ARTICULAR

 A variety of extraarticular disturbances mayA variety of extraarticular disturbances may
manifest themselves clinically as TMJ problems.manifest themselves clinically as TMJ problems.
 Impacted molar teethImpacted molar teeth
 Sinusitis & Middle ear diseaseSinusitis & Middle ear disease
 Infratemporal cellulitisInfratemporal cellulitis
 Neuritis of the 3Neuritis of the 3rdrd
division of the trigeminal nerve.division of the trigeminal nerve.
 Odontolgia.Odontolgia.
 Overclosure of the mandible due to severe dentalOverclosure of the mandible due to severe dental
attrition.attrition.
 Costen’s syndrome.Costen’s syndrome.

TEMPORO MANDIBULAR JOINTTEMPORO MANDIBULAR JOINT
SYNDROMESYNDROME

 Most common cause of facial pain afterMost common cause of facial pain after
toothache.toothache.
 TMD can be classified broadly as:TMD can be classified broadly as:
 TMD secondary to myofacial pain andTMD secondary to myofacial pain and
dysfunction (MPD).dysfunction (MPD).
 TMD secondary to true articular diseaseTMD secondary to true articular disease

Etiology:Etiology:
 Tissue injuryTissue injury
 Physical stressPhysical stress  Bruxism and day time jawBruxism and day time jaw
clenching in a stressed and anxious person.clenching in a stressed and anxious person.
 Psychological & behavioural abnormalitiesPsychological & behavioural abnormalities
 Poor nutritional statusPoor nutritional status
 Genetic predispositionGenetic predisposition

DIGAMMATIC RERESENTATION OF
ETIOLOGY OF MPDS
PSYCHOPHYSIOLOGIC THEORY OF MPDS
(Modified by LASKIN in 1969)

C /F:C /F:
 Constant diffuse unilateral painConstant diffuse unilateral pain
 Severe in the morning and worsens as daySevere in the morning and worsens as day
progressesprogresses
 Radiates to cervical region, shoulders and backRadiates to cervical region, shoulders and back
 Limitation of jaw movementLimitation of jaw movement
 Deviation to the affected siteDeviation to the affected site

VII. TEMPOROMANDIBULAR JOINTVII. TEMPOROMANDIBULAR JOINT
SYNDROME (TM disorder)SYNDROME (TM disorder)
Cl / Ft:Cl / Ft:
 Tenderness in MMTenderness in MM
 Angle of mandibleAngle of mandible
 Anterior temporal region & coronoid aspectAnterior temporal region & coronoid aspect

Rx:Rx:
 PhysiotherapyPhysiotherapy  moist heat, TENS, Aucpressure,moist heat, TENS, Aucpressure,
Acupuncture.Acupuncture.
 Behavioural and relaxation techniquesBehavioural and relaxation techniques
 Occlusal splint therapyOcclusal splint therapy
 NSAIDs, Muscle relaxantsNSAIDs, Muscle relaxants

2. True intra-articular disease :2. True intra-articular disease :
 Disk displacement disorder.Disk displacement disorder.
 Chronic recurrent dislocations.Chronic recurrent dislocations.
 Degenerative joint disorders.Degenerative joint disorders.
 Ankylosis.Ankylosis.
 InfectionInfection

 Etiology:Etiology:
 Malocclusion.Malocclusion.
 Jaw clenching.Jaw clenching.
 Bruxism.Bruxism.
 Personality disordersPersonality disorders
 Increased pain sensitivity.Increased pain sensitivity.
 Stress and anxiety.Stress and anxiety.

C/F:C/F:
 Affects young woman aged 20-40 yrs.Affects young woman aged 20-40 yrs.
 M:F – 1:4.M:F – 1:4.
 In TMD pain is unilateral associated with clicking,In TMD pain is unilateral associated with clicking,
popping and snapping sounds.popping and snapping sounds.
 Limited jaw opening due to pain / disk displacement.Limited jaw opening due to pain / disk displacement.
 Associated with chewing and may radiate to head.Associated with chewing and may radiate to head.

 Treatment & Prognosis:Treatment & Prognosis:
1. Self limiting.1. Self limiting.
2. Conservative treatment involving self care2. Conservative treatment involving self care
practices.practices.
 Rehabilitation aimed at eliminating muscleRehabilitation aimed at eliminating muscle
spasms.spasms.
3. NSAIDs3. NSAIDs
 Prognosis is good.Prognosis is good.

InvestigationsInvestigations  TMJTMJ
 TMJ imagingTMJ imaging
 Panoramic radiographsPanoramic radiographs
 Transcranial viewTranscranial view
 Transpharyngeal viewTranspharyngeal view
 Transorbital viewTransorbital view
 Reverse Towne’s viewReverse Towne’s view
 Submento-vertex (SMV) viewSubmento-vertex (SMV) view
 Conventional tomographyConventional tomography
 ArthrographyArthrography www.indiandentalacademy.com

 Computed tomography (CT)Computed tomography (CT)
 Magnetic resonance imaging (MRI)Magnetic resonance imaging (MRI)
 ArthroscopyArthroscopy
 Bone scanBone scan

ReferencesReferences
 Shafer’s Textbook of Oral Pathology. 5Shafer’s Textbook of Oral Pathology. 5thth
edition.edition.
 Neville: Oral & Maxillofacial Pathology. 2Neville: Oral & Maxillofacial Pathology. 2ndnd
edition.edition.
 Jaffery P. Okeson – Management ofJaffery P. Okeson – Management of
Temporomandibular disorders and occlusion.Temporomandibular disorders and occlusion.
 Martin S. Greenberg, Michael Glick – Burkit’s oralMartin S. Greenberg, Michael Glick – Burkit’s oral
medicine and diagnosis.medicine and diagnosis.
 Franklin C.D.: Pathology of the temporomandibularFranklin C.D.: Pathology of the temporomandibular
joint. Current Diagnostic Pathology (2006): 12, 31-39.joint. Current Diagnostic Pathology (2006): 12, 31-39.

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