A collection of medical and dental conditions affecting the TMJ and/or the muscles of mastication as well as contiguous tissue components.

2. Part- I
 Definition
 Anatomy of TMJ
 Types of mandibular
movements
 Epidemiology
 Examination of TMJ
apparatus
 Clinical signs and
symptoms
Part-II
 Classification of TMD’s
 Differential diagnosis of
TMD’s
 Management
 TMJ Imaging

3.  1996 NIH Consensus Conference:
 A collection of medical and dental conditions affecting the
TMJ and/or the muscles of mastication as well as contiguous
tissue components.

4.  3 Main Categories
• I Muscle Disorders
• I.a Myofascial pain
• I.b Myofascial pain with limited opening
• II Disk Displacements
• II.a Disc displacement with reduction
• II.b Disc displacement without reduction with limited opening
• II.c Disc displacement without reduction without limited opening
• III Other common joint diseases
• III.a Arthralgia
• III.b Osteoarthritis
• III.c Osteoarthrosis
Dworkin SF. LeResche L. Research diagnostic criteria for temporomandibular disorders : Review,
criteria, examinations and specifications, critique. Journal of Craniomandibular Disorders.
6(4):301-55,1992.

5. • Compound joint
• “Ginglymodiarthrodial” joint

7.  Rotational movement
 Horizontal axis of rotation
 Frontal (vertical) axis of rotation
 Sagittal axis of rotation
 Translational movement

8.  Around the horizontal axis (hinge axis)

9.  Around the frontal (vertical) axis

10.  Around the sagittal axis

12.  1% - 75% of general population showed at least 1 objective
TMD sign
 5%-33% reported subjective symptoms.
 Age range - 20-40 yrs
 30yrs - Disc Displacement
 50yrs - Inflammatory degenerative disorders

13.  Screening history and examination
 History taking
 Pain

14.  Cranial nerve examination
 Eye and ear examination
 Cervical spine examination

15.  Inspection- assymetry
 Palpation- Soft but firm pressure
 A single firm thrust of 1 or 2 seconds' duration
 Temporalis
 Massetter
 Sternocleidomastoid

16.  Functional manipulation
 Lateral pterygoid- sup. & inf.
 Medial pterygoid

17.  Maximum interincisal
distance- 53- 58 mm.
 Lateral movement- <8mm
 Alterations in the opening
pathway
 Extracapsular restrictions
 Intracapsular restrictions

18.  Stationary and dynamic
movements
 Joint sounds- crepitus and
clicking

19.  Mobility
 Pdl widening
 Osteosclerosis
 Hypercementosis
 Tooth wear
 Abfractions

20.  Guiding to CR
 Intercuspal position
- acute malocclusion
- arch intergrity
- VDO

21. Pain
Dysfunction

22. Pain
Myalgia
DentitionArthralgia

23.  Events –
 Local
 Trauma
 Source of constant deep pain
 Systemic
 Stress
 Immunological resistance
 Age
 Diet
 Viral infections

24. Protective
co-
contraction
Local
muscle
soreness
Centrally
mediated
myalgia
Myofascial
pain
Travell JG, Rinzler SH: The myofascial genesis of pain, Postgrad Med 11:425-434, 1952.

25.  It occurs to protect the muscles from injury
 Etiology –
 Any change in the sensory input from associated structures
 Feeling of muscle tiredness
 Key to identify – immediately follows an event

26.  1st response to prolonged co-contraction
 Since it is a source of deep pain – can cause Protective Co-
contraction
 Clinically,
 Tender on palpation
 Increased pain with function

27.  CNS responds secondary to
 Presence of deep pain input
 Increased emotional stress
 Changes in descending inhibitory system

28.  Regional myogenous pain condition characterized by
 Local areas of firm , hypersensitive bands of muscle tissue known as
TRIGGER POINTS
 Felt as taut bands when palpated and elicits pain
 Local rise in temperature, increased metabolic demand, reduction of
blood flow
 Unique character of trigger points - source of constant deep pain

29. Local
 Protracted cause
 Recurrent cause (e.g., bruxism, repeated trauma).
 Therapeutic mismanagement
Systemic
 Continue emotional stress
 Sleep disturbances
 Depression

30. Clicking Crepitus Dysfunction

31.  Derangements of the condyle-disc complex
 Structural incompatibility of the articular surfaces
 Inflammatory joint disorders

32. • Functional disc displacement
• Functional dislocation
- with reduction
- without reduction( closed
lock)

33.  Macrotrauma – direct and indirect
 Microtrauma – “chondromalacia”
 Bruxism and clenching
 Orthopaedic instability
“Occlusal conditions commonly associated with disc derangements”
• Skeletal Class II deep bite.
The important feature of an occlusal condition that leads to disc derangement
disorders is the lack of joint stability when the teeth are tightly occluded.
Celic R, Jerolimov V: Association of horizontal and vertical overlap with prevalence of
temporomandibular disorders, J Oral Rehabil 29:588-593, 2002.

34.  Breakdown or adherence of
articular surfaces
 Static loading of joint as in
“clenching”.
 Subluxation (hypermobility)
 Spontaneous dislocation
(open lock)

35.  Steepness of articular eminence
 Morphology of condyle and fossa
 Joint laxity
 Attachment of sup. lateral pterygoid muscle

36.  Synovitis
 Capsulitis- tenderness on lateral pole of tmj
 Retrodiscitis – increased by clenching
 Arthrtides- osteoarthritis- crepitus is common

38.  Headaches
- Common symptom associated with TMD’s
 Otological symptoms
 Ear fullness
 Tinnitus
 Vertigo

40.  Imaging
 Mounted casts
 EMG
 Mandibular tracking
devices
 Sonography
 Vibration analysis
 Thermography

41. Part- I
 Definition
 Anatomy of TMJ
 Types of mandibular
movements
 Epidemiology
 Clinical signs and
symptoms and applied
aspects
 Examination of TMJ
apparatus
 Diagnostic aids
 Classification of TMD’s
Part-II
 Differential diagnosis of
TMD’s
 Management

42. Adapted from McNeill C
Cranial bones
 Congenital and developmental
disorders: Aplasia, hypoplasia,
hyperplasia
 Acquired disorders: Neoplasia,
fracture
Temporomandibular joint
disorders
 Deviation in form, Disk
displacement
 Dislocation
 Inflammatory conditions (synovitis,
capsulitis)
 Arthritides (osteoarthritis,
osteoarthrosis, polyarthritides)
 Ankylosis (fibrous, bony)
 Neoplasia
Masticatory-Muscle Myofacial
pain
 Myositis
 Spasm
 Contracture

43. Extra capsular
 Psychologic : Tension,
anxiety, oral habits
 Iatrogenic : Excessive
depression of mandible
 Traumatic
 Dental : Occlusal
abnormalities
 Infections : Arising
outside the joint
 Otologic : Otitis
media
 Neoplastic : Parotid
gland neoplasm
Intra capsular
 Congenital : Agenesis
 Infections : Bacterial
infection within the joint
 Arthritic : Rheumatoid
arthritis, osteoarthritis,
psoriatic arthritis,
juvenile chronic arthritis
 Traumatic : Fractures, disc
tears
 Functional : Subluxation,
dislocation, disc
derangements,
hypermobility, ankylosis
 Neoplastic : Benign or
malignant tumors

45. C/f
 Unilateral or bilateral
 Deviation of the jaw
towards affected side

46. Primary condylar aplasia and
hypoplasia
 Mandibulofacial dysostosis
(Treacher Collins syndrome)
 Hemifacial microsomia (first
and second branchial arch
syndrome)
 Oculoauriculovertebral
syndrome (Goldenhar
syndrome)
 Oculomandibulodyscephaly
(Hallermann-Streiff syndrome)
 Hurler’s syndrome
Secondary condylar
hypoplasia

47.  Osteoplasty
 Orthognathic surgery with orthodontics
 Cosmetic surgery

48. Etiology
 Hormones
 Trauma
 Infection
 Heredity
 Hyper vascularity
Clinical features
 Males, < 20 years of age
 Chin deviated towards unaffected side
 Posterior open bite on the affected side
 Restricted mobility of the enlarged condyle

49. Differential diagnosis
 Osteochondroma
 Condylar osteoma
Treatment
 Orthodontics + orthognathic surgery before growth completion

50.  Vertical depression the
center of the condylar head
 Result from an obstructed
blood supply, embryopathy,
trauma.
Radiographic features
 Heart shape anteroposterior
silhouette
 Duplicate condylar head
 Mandibular fossa may
remodels

51. Clinical features
 Females, children
 A form of condylar hypoplasia
Radiographic features
 Characteristic “toadstool”
appearance
 Shortened condylar neck
 Deep antegonial notch

52. Differential diagnosis
 Destruction of the anterior
aspect of the condylar head
from rheumatoid arthritis
Treatment
 Intra-articular cortico steroid
injection
 Orthognathic surgery
 Orthodontic therapy

53.  Abnormality in position & morphology of articular disk
 Lateral and posterior displacements are rare
Etiology – multifactorial
 Disk returns to normal position - with reduction
 Disk remains displaced – non reduction

54. Clinical features
 Unilateral / bilateral
 Mandibular deviation to the affected side
 Click
 Noises may be absent in long standing cases
 Pain in the preauricular region / headaches

56. • Closed lock
• 10-15mm opening
• Pain on forced opening
• Deviation – affected
side
• Chronic- no pain and
limited movements
• MRI to confirm

57.  Occurs at retrodiskal tissue
 Detected by arthrographic
technique
 Dr Fleming Norgaard- 1947
 Single contrast arthrography
 Double contrast radiography
Ravikiran Ongole, Navjyot Panjrath et al Temporomandibular joint Arthrography an
overview Pakistan oral & dent. jr. 22 ( 1) june 2002

58.  Scar tissue
 Detected by
arthrographic
technique
 MRI with low signal
intensity
Remodelling
• Flattening of condyle

59.  Degeneration + Proliferation
 Occurs when adaptive capacity is exceeded
 Etiology – unknown, trauma , hypermobility, parafunction
Clinical features
 Any age, > females
 70% old age
 Asymptomatic
 Pain
 Crepitus
 Limited movement
Johansson A, et al: Gender difference in symptoms related to TMJ disorders in a population of
50yr old subjects. J OROFAC PAIN 2008; 17:29-35

60. Radiographic features
 CT or T1 weighted MRI
 Loss of cortex or erosion
 Ely’s cyst / subchondral bone
cyst
 Bony proliferation at
periphery – osteophyte
 Joint mice
 Glenoid fossa enlarges
K.L. Ferrazzo, L.B. Osorio et al CT Images of a severe
TMJ Osteoarthritis and Differential diagnosis with
other joint disorders. Case Rep Dent. 2013;
2013:242685

61. Differential diagnosis
 Rheumatoid arthritis
 Osteoma or osteochondroma
Treatment
 Relieve joint stress
 Relieve secondary inflammation
 Increase joint mobility

62.  Synovial membrane inflammation
Clinical features
 Females
 50% with TMJ involvement
 Any age
 Bilateral, symmetrical
 Swelling, pain, tenderness, stiffness on opening, crepitus
 Open bite

63. Radiographic features
 Decreased density of
condyle
 Pannus
 Sharpened pencil
appearance
 Entire condyle and
anterior eminence -
destroyed

64. Differential diagnosis
 Psoriatic arthritis
 Osteoarthritis
Treatment
 Pain relief
 Suppression of inflammation
 Physiotherapy
 Joint replacement surgery

65.  Juvenile rheumatoid arthritis, Still’s disease
 Chronic inflammatory disease, < 16 years
 Synovial hypertrophy
Clinical features
 Pain and tenderness
 Starts as unilateral, progress to bilateral
 Bird face
 Anterior open bite
 Micrognathia
 Jaw deviated to affected side

66. Radiographic features
 Decreased density
 Pencil shaped mandibular
condyle
 Impaired mandibular growth
 Deepening of antegonial
notch

67. Clinical features
 Any age
 No sex predilection
 Unilateral
 Pain
 Inability occlude
 Tender cervical lymph nodes
 Fever
 Mandible deviated towards unaffected side

68. Radiographic features
 Space between condyle and
roof of mandibular fossa
widened
 Sequestrum and periosteal
new bone formation
 Osseous ankylosis

69. Treatment
 Antimicrobial therapy
 Drainage of effusion
 Joint rest

70.  Synovial chondrometaplasia and osteochondromatosis
 Metaplastic formation of multiple cartilaginous nodules
 Nodules may detach
Clinical features
 4th or5th decades
 M:F- 2:1
 Asymptomatic or may complain of preauricular swelling,
pain
 Decreased range of motion
 Crepitus
 Unilateral

71. Radiographic features
 Joint space widened
 Radiopaque loose bodies
 Erosion through glenoid
fossa

72. Differential diagnosis
 Chondrocalcinosis
 Osteochondromatosis
 Chondrosarcoma
 Osteosarcoma
 Sarcoma
Treatment
 Removal of the loose bodies
 Resection of abnormal synovial tissue by
arthroscopic surgery
 Open joint surgery

73.  Pseudogout and calcium pyrophosphate dihydrate
deposition disease
Clinical features
 Unilateral
 Males
 Pain and joint swelling

74. Radiographic features
 Radiopacities are finer
 Increase in condylar bone
density
 Erosions of the glenoid
fossa –CT
 Soft tissue inflammation
and edema -MRI

75. Differential diagnosis
 Chondrocalcinosis
 Osteochondromatosis
 Chondrosarcoma
 Osteosarcoma
 Sarcoma
Treatment
 Surgical removal of crystalline deposits
 Steroids, aspirin and NSAIDS
 Colchicine alleviate acute symptoms and for
prophylaxis.

76.  1934 – Costen’s Syndrome
 1940 – Travell- Muscle spasm could be a source of pain
 1959 – Shwartz-Postulated TMJ dysfunction syndrome
- Psychological make up as a
predisposing factor
- Stress causes clenching and
grinding resulting in spasm

77.  1969 –Laskin
 Unilateral pain in preauricular region, worse on awakening
 Tenderness on one or more muscles of mastication on palpation
 Limitation or deviation of mandible on opening

78.  Occlusal disturbances
 Intracapsular disorders
 Emotional turmoil.
 Major and minor trauma
 Poor nutritional status
 Genetic predisposition

79.  Chronic, focal regional
muscle pain
 Unilateral, may occur in
one or more muscles
 Trigger points are present
 Continuous, dull to sharp
pain in TMJ region
 Present at rest and with
movements
 Pain upon awakening

81.  History taking
 Examination of face
 Examination of TMJ
 Examination of muscles of mastication & neck muscles
 Intraoral examination
 Examination of other structures

82.  Voluntary opening tests
 Passive stretch test
 Soft end feel and Hard end feel
 Anesthetic nerve and muscle blocking
 Magnetic resonance spectroscopy
 Thermography and Biopsy

83.  Electromyography and Jaw tracking

84. Non-
surgical Surgical

85. Initial therapy
 Patient re-assurance
 Diet
 Rest
 Thermotherapy
Pharmacological therapy
 Analgesics- NSAIDS and Opioids
 Anxiolytics – Benzodiazepines
 Muscle Relaxants- chloroxazone, cyclobenzaprine,
thiocolchicoside

87.  Hydrocollator
• Short wave diathermy
• Ultrasound

88. Laser therapy
0 Increases capillary permeability
Low power Laser therapy
0 Alter cellular function
0 reduces short term pain
Cryotherapy
Acupuncture

89. Physiotherapy
 Spray and stretch
 Soft pressure and continuous massaging
 Continuous exercises
 Electric galvanic stimulation
 TENS

90.  Splint therapy
 Directive and permissive splints

91.  Condylotomy
 High condylectomy
 Menisectomy
 Myotomy
 Arthroscopy
 Botulinim Toxin A injections

92. • Types
• Clinical features
• Radiographic features
• Treatment

93. Types
 Osteomas, osteochondromas,
osteoblastomas,
Chondroblastomas,
fibromyxomas
Clinical features
 Grow slowly
 TMJ swelling, pain and
decreased range of motion
 Facial asymmetry, malocclusion
 Deviation of the mandible to the
unaffected side

94.  Chondrosarcoma, osteogenic
sarcoma, synovial sarcoma,
and fibrosarcoma of the
joint capsule
 Breast, kidney, lung, colon,
prostate and thyroid gland
tumors metastasize to TMJ
Clinical features
 Swelling over TMJ
 Pain
 Limited mandibular opening
 Mandibular deviation
Radiographic features
 Variable degree of bone destruction
with ill defined, irregular margins
 Lack tumor bone formation except
osteogenic sarcoma
 Chondrosarcoma may appear as an
indistinct – resemble pseudo gout
 Nonspecific condylar destruction

95.  Management of Temporomandibular Disorders and Occlusion by Jeffrey P.
Okeson 6th edition
 Manual of Temporomandibular Disorders – Edward F. Wright
 Daniele Manfredini, DDS,Fabio Piccotti, DDS,Luca Guarda-Nardini, et al
Research diagnostic criteria for temporomandibular disorders: a
systematic review of axis I epidemiologic findings Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2011;112: 453-462)
 Shirish Ingawale, Tarun GoswamI et al. Temporomandibular Joint:
Disorders, Treatments, and Biomechanics. Annals of Biomedical
Engineering, Vol. 37, No. 5, May 2009 ( 2009) pp. 976–996
 Thomas CA, Okeson JP: Evaluation of lateral pterygoid muscle symptoms
using a common palpation technique and a method of functional
manipulation, Cranio 5:125-129,1987.
 Celic R, Jerolimov V: Association of horizontal and vertical overlap with
prevalence of temporomandibular disorders, J Oral Rehabil 29:588-593,
2002.
 Oral and Maxillofacial Pathology by Neville, Damn, Allen – 3rd edition

96. THANK YOU