Tmj disorders /certified fixed orthodontic courses by Indian dental academy

TMJ Disorders
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Contents
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Introduction
Epidemiology
Etiology
Classification
Clinical features
Radiological features
Histological pathologic features
Treatment

Introduction


TMD – cluster of joint and muscle disorders in the
orofacial area characterized primarily by


Pain



Joint sound and



Irregular or deviating jaw functions


Epidemiology


Epidemiologic studies has shown that 60-70% of the
general population have functional disturbances of the
masticatory apparatus.



Most prevalent between the ages of 20-40 years and
predominantly affects women.


Etiology


Multifactorial


Parafunctional habits .



Emotional stress.



Acute trauma from blows / impacts.



Trauma from hyperextension.



Instability of maxillo-mandibular relationships.



Laxity of the joints.



Rheumatic / musculo-skeletal disorders.



Poor general health and unhealthy lifestyle.


Classification
MUSCULAR DISORDERS

Hyperactivity, spasm, and trismus

Inflammation (myositis)

Trauma

Myofascial pain and fibromyalgia

Atrophy or hypertrophy
ARTHROGENIC DISORDERS

Disc displacement (internal derangement)

Hypomobility of the disc (adhesions or scars)

Dislocation and subluxation

Arthritis

Infections

Metabolic disease {gout, chondrocalcinosis)

Capsulitis, synovitis

Ankylosis (fibrous, bony)

Fracture

Condylar hyperplasia, hypoplasia, aplasia

Neoplasia

Neville

Classification


Developmental anomalies


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Osteoarthrosis
Rheumatoid arthritis
Inflammatory arthritis
Infective arthritis








Ex. Condylar hyperplasia.
Condylar hypoplasia.
Condylar Aplasia

Local middle ear infection
Systemic infection (e.g. gonococcal).

Neoplasia
Metabolic disease (ex. Gout, chondrocalcinosis).
Synovial disease (Ex. PVNS)
Miscellaneous conditions (Ex: Paget’s disease of bone, acromegaly).

CD Franklin

Classification


Intracapsular disorders of the TMJ
Source

Disorder

Degenerative
(non-inflammatory)

Degenerative joint disease

Inflammatory

Rheumatoid arthritis
Psoriatic arthritis

Infections

Spread from contiguous site

Developmental

Condylar hyperplasia, hypoplasia and agenesis

Traumatic

Condylar fracture, ankylosis, dislocation and disc
displacement.

Burket’s

Classification
I. Developmental disturbances of the TMJ




Aplasia of the mandibular condyle
Hypoplasia of the mandibular condyle
Hyperplasia of the mandibular condyle

II. Traumatic disturbances of the TMJ




Luxation and subluxation (complete and incomplete dislocation)
Ankylosis (hypomobility)
Injuries of the articular disk (meniscus)

III. Fractures of the condyle
IV. Inflammatory disturbances of the TMJ




Arthritis
Rheumotoid arthritis
Osteoarthritis (degenerative joint disease, hypertrophic arthritis)


Classification
V. Neoplastic disturbances of the TMJ
VI. Extra-articular disturbances of the TMJ
VII. Temporomandibular joint syndrome
(TMD)
TMD secondary to myofacial pain and dysfunction
(MPD)
 TMD secondary to true articular disease.



1. Aplasia of the mandibular condyle



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Cl/ft:








Condylar aplasia or failure of development of the mandibular condyle 
which may occur unilaterally or bilaterally.
It is a rare condition
Associated with other anatomically related defects such as a defective /
absent external ear an under developed mandibular ramus or
macrostomia.
Unilateral condylar aplasia  Facial asymmetry
A shift of the mandible towards the affected side occurs during opening
In bilateral cases this shift is not present

Treatment




Osteoplasty
Orthodontic appliances
Cosmetic surgery  in correcting facial deformity

2. Hypoplasia of the mandibular condyle


Under development / defective formation of the mandibular condyle


Congenital hypoplasia





Idiopathic
Characterized by uni / bilateral under development of the condyle

Acquired hypoplasia
May be due to any agent which interferes with the normal development of the
condyle.
Causes:
 Forceps deliveries
 External trauma
 X-ray radiation
 Infection




Cl/ft:





Condylar hypoplasia depends upon whether the disturbance has affected
one or both condyles and upon the degree of malformation.
Age of the patient at the time of involvement
The duration of the injury and its severity
Unilateral involvement is the most common clinical type



Cl/ft



Limitation of lateral excursion on one side



Mandibular midline shift during opening and closing



The distortion of the mandible results in lack of downward and forward
growth of the body of the mandible





Facial asymmetry

Due to arrest of the chief growth center of the mandible i.e., condyle.

Treatment & prognosis


Cartilage / bone transplants



Unilateral and bilateral osteotomy to improve the appearance of the
patient with asymmetry and retrusion.

3.Hyperplasia of the mandibular condyle
Condylar hyperplasia is a rare unilateral enlargement of the condyle
Causes:
Obscure
Sugg. Factors  Mild chronic inflammation which stimulates the growth
of the condyle or adjacent tissue.




Cl/ft: patient is usually exhibit






A unilateral, slowly progressive elongation of the face with deviation of
the chin away from the affected side.
The enlarged condyle may be clinically evident
The affected joint may or may not be painful
A severe malocclusion is a usual sequela of the condition




R/F:





Condyle with an elongated neck and enlarged condylar head
Scintigraphy using 99mTc-MDP used for assessing degree of
bone activity in condylar hyperplasia.

Treatment and prognosis




If growth is occurring  condylectomy
If growth is ceased  orthognathic surgery is performed
Resection of condyle restore normal occlusion.


Developmental disturbance of TMJ
Bifid condyle
 Double headed mandibular condyle.
 They have a medial and lateral head divided by A-P groove.
 Some condyles may be divided into an anterior and posterior
head.
Etiology:
 Uncertain.
 A-P bifid condyle  traumatic in origin.
 Mediolaterally divided condyles  trauma, abnormal muscle
attachment, teratogenic agents.

Developmental disturbance of TMJ
C/F:




Unilateral
Asymptomatic
Pop or click of TMJ

R/F:


Bilobed appearance of the
condylar head.

Rx & Prognosis:


Asymptomatic  no treatment
necessary.

1. Luxation and subluxation (complete & incomplete dislocation)


Dislocation of the TMJ
↓



when the head of the condyle moves anteriorly over the articular
eminence into such a position that cannot be returned voluntarily to its
normal position.



Luxation of the joint  complete dislocation while subluxation is a
partial / incomplete dislocation



Luxation may be ‘acute’, due to a sudden traumatic injury resulting in the
fracture of the condyle.



Yawning / having the mouth opened too widely.




Cl/ft:





Sudden locking and immobilization of the jaws when the mouth is open.
Accompanied by prolonged spasmodic contraction of the temporal,
internal pterygoid and masseter muscles with protrusion of the jaw.

Treatment:


Relaxation of the muscles and then guiding the head of the condyle under
the articular eminence into its normal position by an inferior and
posterior pressure of the thumbs in the mandibular molar area.


2. Ankylosis (hypomobility)





Etiology





Most incapacitating of all diseases involving the TMJ.
It involves fusion of head of the condyle to the temporal bone.
Traumatic injuries
Infection in and about the joint

Straith & Lewis:

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Abnormal intrauterine development
Birth injury
Trauma to the chin forcing the condyle against the glenoid fossa,
particularly with bleeding into the joint space.
Malunion of condylar fracture.
Injuries associated with fracture of the molar zygomatic compound.
Loss of tissues with scarring
Congenital syphilis
Primary inflammation of the joint



Straith & Lewis:







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Inflammation of the joint secondary to a local inflammatory process.
Ex. Otitis media; mastoiditis; osteomyelitis of the temporal bone /
condyle.
Inflammation of the joint secondary to a blood stream infection
Ex: Septicemia
Metastatic malignancies
Inflammation secondary to radiation therapy.

Cl/ft:



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Occurs at any age
Most cases occur before the age of 10 years
Distribution is equal between the genders
The patient may / may not be able to open his mouth to any appreciable
extent, depending on the type of ankylosis



Ankylosis


Unilateral





Occurs at early age
The chin is displaced laterally and backward on the affected side
because of a failure of development of the mandible.

Bilateral




In childhood results in underdevelopment of the lower portion of the
face, a receding chin and micrognathia.
The maxillary incisors often manifest overjet due to failure of this
mandibular growth.




TMJ Ankylosis (depending on anatomic sites of ankylosis)

Intra-articular ankylosis

Extra-articular ankylosis

Joint undergoes progressive

Results in a “splinting” of the TMJ

destruction of the meniscus

by a fibrous or bony mass external

Flattening of the mandibular fossa

to the joint proper

and. thickening of the head of the

But movement is possible in this

condyle & narrowing of the joint

type

space




R/Ft:




Reveals abnormal / irregular shape of the head of the condyle

Treatment:




Surgical osteotomy / removal of section of bone below the
condyle.
Fibrous ankylosis can be treated by functional methods.


3. Injuries of the articular disk (meniscus)




Malocclusion
The adaptation of the disk to the condyle is lost which results in disk
derangement.
Precipitating factors





Blow / fall
Inflammatory condition such as Rheumatoid arthritis

Cl/ft:





Common in females
Young adults are more frequently affected.
Pain, snapping or clicking and crepitation in the joint area.
Transient / prolonged locking of the jaw may occur, when the mouth is
closed






R/Ft:




Does not give any positive findings

Treatment:




Immobilization of the jaws is necessary in cases of severe
pain
Menisectomy / surgical removal of the disk.


III. Fractures of the condyle
Condylar fracture


Acute traumatic injury to the jaw



Limitation of motion, pain and swelling over the involved condyle



Deformity is noted upon palpation and loss of normal condylar excursion.



The fractured condyle fragment is frequently displaced anteriorly and medially
into the infratemporal region because of the forward pull of the external
pterygoid muscle and reduction of the fracture is often difficult because of
this displacement.



Healing of such fracture without reduction results in loss of function,
limitation of motion or any other complication.

IV. INFLAMMATORY DISTURBANCES OF THE
TMJ


Arthritis / inflammation of the joints, is one of the
most frequent pathological condition affecting the TMJ.



TMJ may suffer from any form of arthritis but there are
3 common types given by Mayne and Hatch.


Arthritis due to a specific infection.



Rheumatoid arthritis.



Osteoarthritis / degenerative joint disease.


1. Arthritis due to a specific infection / infective arthritis:
Septic arthritis of TMJ is uncommon
↓
Like Neisseria gonorrhea, str, staph. aureus, pneumococci, the
tubercle bacilli, H. influenzae
 Caused by direct spread of a local infection or blood stream /
lymphatic metastasis.
C/F:
 Pt suffering from acute infection arthritis.
C/o: Severe pain in the joint.
 Extreme tenderness
 Healing of this form of arthritis often results in ankylosis.

H-P features


There is a variable amount of destruction of the
articular cartilage and articular disk.



The joint spaces become obliterated in the healing
phase by the development of granulation tissue



Subsequently transforms into scar tissue.

Rx:


Antibiotics – in the acute phase


Meniscetomy / condylectomy is advocated in the advanced
cases.

IV. INFLAMMATORY DISTURBANCES OF THE TMJ
2) Rheumatoid arthritis
 Is a chronic multisystem disease of unknown antigen triggers an autoimmune
response in genetically susceptible individual.
 Proinflammatory kinins and cytokines play important role in pathogenesis of
rheumatoid arthritis.
 TMJ involvement  20%
C/F:
 M:F 2:1
 Rh. Arthritis early stages manifests
 Slight fever.
 Loss of weight
 Fatigability.
 Joints affected are swollen
 Patient c/o pain and stiffness on movement of the jaw.
 Involvement of TMJ may occur with the other joint lesions.
 Ankylosis of the joint over a period of time.

H-P features:
 The joints show edema and inflammation of the synovial tissues
and diffuse infiltration of chronic inflammatory cells into the
articular architecture.
 With increase in bone resorption there is a destruction of
articular surface of the condyle.
 Invasion of the cartilage and its replacement by granulation
tissue
Rx & Prognosis:
 No specific treatment for Rh. Arthritis.
 Administrations of ACTH/ Cortisone.
 Surgical intervention in the form of condylectomy may be
necessary to regain movement.

3. Osteoarthritis (degenerative joint disease, hypertrophic arthritis).


Is most common type of arthritis associated with aging process.

Etiology: unknown.
C/F:


Signs and symptoms of an absent since it is not a weight bearing
joint.



Pts. c/o of clicking and snapping in the TMJ due to atypical disk
motion.



H-P features:


The cartilage cells often exhibit degeneration and areas
of dystrophic calcification may occur and this can
progress to actual ossification also there may be
necrosis of the disk.

Rx:


Condylectomy.


V. NEOPLASTIC DISTURBANCES OF THE TMJ








Neoplasms and tumor-like growths, benign and
malignant, may involve the TMJ.
It is very uncommon.
Origin:
Within the bone of the mandibular condyle.
Joint capsule or articular disk.
Chondromas, osteomas and osteochondromas are
common benign tumors.


VI. EXTRA-ARTICULAR DISTURBANCES OF THE
TMJ


A variety of extraarticular disturbances may manifest themselves
clinically as TMJ problems.











Impacted molar teeth
Sinusitis
Middle ear disease
Infratemporal cellulitis
Impingement of coronoid process on the tendon of the temporal muscle.
Neuritis of the 3rd division of the trigeminal nerve.
Odontolgia.
A foreign body in the infratemporal fossa.
Overclosure of the mandible accompanied by severe dental attrition.
Costen’s syndrome.

VII. TEMPOROMANDIBULAR JOINT SYNDROME
(TM disorder)


TMJ syndrome or TMD is the most common cause of facial
pain after toothache.



TMD can be classified broadly as:



1.

TMD secondary to myofacial pain and dysfunction (MPD).
TMD secondary to true articular disease

MPD type forms the majority of the cases of TMD 
↓ and is associated pain without apparent destructive changes
of the TMJ on x-ray.



bruxism and day time jaw clenching in a stressed and anxious
person.

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


(TM disorder)
2. True intra-articular disease :










Disk displacement disorder.
Chronic recurrent dislocations.
Degenerative joint disorders.
Systemic arthritis conditions
Ankylosis.
Infection
Neoplasms.

Etiology:








Multifactorial and includes:
Malocclusion.
Jaw clenching.
Bruxism.
Personality disorders
Increased pain sensitivity.
Stress and anxiety.


(TM disorder)
C/F:



1.
2.
3.
4.





Affects young woman aged 20-40 yrs.
M:F – 1:4.
4 cardinal signs and symptoms of the syndrome:
Pain
Muscle tenderness.
Clicking / popping noise in the TMJ.
Limitations of the jaw motion unilaterally / bilaterally with
deviation on opening.
The pain is usually periauricular.
Associated with chewing and may radiate to head.
May be unilateral or bilateral in MPD.
But it is unilateral in TMD of articular origin.

In MPD the pain, bruxism, jaw clenching, stress and
anxiety.
 In TMD pain is associated with clicking, popping and
snapping sounds.
 Limited jaw opening due to pain / disk displacement.
 TMD acts as a trigger in pt prone to headaches.
Lab findings:









Blood examination.
Blood count
Rheumatoid factor
ESR
Antinuclear antibody.
Uric acid



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


Investigations


TMJ imaging is used as an additional diagnostic aid in cases of
suspected pathology of





Morphology of bony components of joint
Functional relationship b/w condyle and fossa

Two dimensional imaging


Panoramic radiographs



Transcranial view



Transpharyngeal view



Transorbital view



Reverse Towne’s view



Submento-vertex (SMV) view



Conventional tomography



Arthrography


Investigations


Three dimensional imaging


Computed tomography (CT)



Magnetic resonance imaging (MRI)



Arthroscopy



Bone scan


Two dimensional imaging
 Panoramic radiographs
 Used as screening projection


Indications
 Reserved for assessing
 Gross changes in the condyles
 Asymmetries
 Extensive erosions
 Large osteophytes
 Fractures
Disadvantages
 No information about condylar position or function is provided
 Osseous changes are obscured because of superimposition by
the skull and zygomatic arch

Transcranial projection - modified Schuller
method
 Provides sagittal view of lateral aspects of
condyle and temporal component
Indication
 Gross changes on the lateral aspect of joint
 Displaced joint fractures
 Range of motion (open view)



Transpharyngeal projection
 Provides sagittal view of the medial pole of the
condyle
Indications
 To visualize gross erosive changes of the condyle


Transorbital view
 Also known as Transmaxillary, antero posterior view
 Provides an anterior view of the TMJ perpendicular to the
transcranial and transpharyngeal views


Mainly for detection of condylar neck fractures

Reverse Towne’s view



Similar to transorbital view
Useful for viewing medial displacements of the condyle


Submentovertex (SMV) projection
 Provides view of the base of the skull with condyles superimposed on the
condylar neck and rami

Conventional tomography
 Provides the most definitive diagnostic information about the
osseous structures of the TMJ
 Provides visualization of anatomic stc’s free from
superimposition


Arthrography







Provides information regarding soft tissue of the joint
Technique – intra- articular administration of radio-opaque
iodinated contrast agent is done under fluoroscopic guidance
After both the joint spaces are filled with the the contrast agent
the disk function is studied using fluoroscopy supplemented by
tomography
Adv – it is adv over MRI in identifying any perforations b/w the
superior and inferior joint compartments
Disadvs –
1. expensive
2. ptn may develop allergy to contrast medium
3. invasive

Three dimensional imaging
 Computed tomography
 Incorporates the principles of
direct digital (computed) electronic
imaging & cross sectional
radiography (tomography)
 Provides visualization in all 3
planes
 Sagittal (lateral)
 Coronal (frontal)
 Axial

Advantages –
 Reformatting of sequence of axial images into images
of other planes or 3D images is possible
 Complete elimination of superimposition
 Intravenous contrast media can be used to differentiate
one soft tissue type from another
Disadvantages
 Expensive
 Requires trained personnel to obtain scans and interpret
scans

CT in TMJ imaging
 Used to visualize bony changes of the condyle
and articular eminence


Magnetic resonance imaging (MRI)
 It does not use ionising radiation (X-rays) but
utilizes Hydrogen atoms in the body which react
in a certain way when subjected to a magnetic
field









Used to image soft tissues of the TMJ to
visualize
Joint effusion
Disk position
Disk shape
Inflammatory changes


Advantages
 Offers best resolution of tissues of low inherent
contrast
 Multiplanar imaging is possible without re-orienting the
ptn
Disadvantages
 Long imaging time
 Cannot be used for ptn’s with pacemakers
 The machine makes a tremendous amount of noise
during a scan
 Claustrophobic patients cannot be scanned

Arthroscopy
 It is a surgical procedure used to visualize,
diagnose & treat problems inside a joint
Why is it necessary?

To confirm the pathology & make a final
diagnosis which may be more accurate than
through “open” surgery or from x-ray studies.


Bone scan / Radionuclide imaging
 A radiolabeled material –Tc-pertechnetate 99m
is injected into the blood stream & this
concentrates in the area of rapid bone turnover
 A gamma scintillating camera is used to image
this.
 Useful in determining a active (osteoarthritis)or
dormant (osteoarthrosis) pathologic condition

References






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


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