Tmj disorders 1 /certified fixed orthodontic courses by Indian dental academy

Temperomandibular Joint {TMJ}
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


• SURGICAL ANATOMY
• TRISMUS
• DISLOCATION
• INTERNAL DERANGEMENT
• ANKYLOSIS
• MYOFACIAL PAIN DYSFUNCTION

T.M.J = GINGLYMOARTHRODIAL JOINT
• GINGLYMUS – A HINGE (ROTATION)
• ARTHRODIAL – SLIDING MOVEMENT
CHARACTERISTIC FEATURES:
• DIARTHROIDAL, NONWEIGHT-BEARING JOINT
• BOTH THE JOINTS ARE INTERDEPENDENT
• BOTH ARE INTERDEPENDENT ON DENTITION

TMJ
BONY COMPONENTS
1. Glenoid fossa
2. Condylar head
3. Articular eminence



MUSCLES
1.
2.
3.
4.

Muscles of mastication
Muscles attached to the joint
Muscles of facial expression
Muscles of the neck

SOFT-TISSUE
COMPONENTS
1. Articular disk
2. Joint capsule
3. Ligaments

SURGICAL ANATOMY
BONY COMPONENTS:
• GLENOID FOSSA
• MANDIBULAR CONDYLE
• ARTICULAR EMINENCE


GLENOID FOSSA



Single layer of cortical bone separates fossa from



middle cranial fossa – Temporal lobe of brain




Covered by thin fibrous layer

CONDYLAR HEAD
 Oval

– mediolaterally – ‘Rugby ball’, ‘Date-stone’

 15-20

mm long (M-L); 8-10 mm wide (A-P);

 Medial

pole > lateral pole

 Posterior

surface > anterior surface

 Articulating

surface – Fibrous tissue

ARTICULAR EMINENCE

Sigmoid shape, Anterior & posterior slopes
 Saddle – shaped in coronal section – concave mediolaterally




With disc, guides mandibular movement during jaw opening

SOFT TISSUE COMPONENTS:
1. DISC –

•

FIBROCARTILAGENOUS, AVASCULAR

•

SEPARATES JOINT INTO TWO COMPARTMENTS

•

3 REGIONS:- CENTRAL ZONE- 1 MM THICK, ANTERIOR
ZONE- 2MM THICK, POSTERIOR ZONE-3MM THICK AND
BILAMINAR

•
•

INNERVATED BY AURICULOTEMPORAL NERVE
SUPERIOR SURFACE IS CONCAVO-CONVEX & INFERIOR IS
CONCAVE

•

ATTACHED TO THE MEDIAL AND LATERAL POLES OF THE
CONDYLE


ARTICULAR DISK




Position of articular disk


2. CAPSULE ATTACHED TO THE ARTICULAR MARGINS OF THE HEAD OF
THE CONDYLE & TO THE MARGINS OF THE GLENOID FOSSA
AND ARTICULAR EMINENCE

Fibrous, non-elastic membrane surrounding the
TMJ
Attachments
Post – squamotympanic fissure
Lat – glenoid fossa
Ant – articular eminence

 Thin

structure – reinforced by ligaments

 Inner

surface lined by syanovial membrane

Functions:
 Seals

joint space

 Provides

passive stability

 Active

stability - proprioceptive nerve-endings in
capsule



3. LIGAMENTS – TEMPOROMANDIBULAR LIGAMENT
{lateral}
– STYLOMANDIBULAR LIGAMENT
– SPHENOMANDIBULAR LIGAMENT


TMJ LIGAMENTS


FUNCTIONAL LIGAMENT
Fan-shaped reinforcement of lateral
wall of capsule
Obliquely from outer surface of
articular eminence & zygomatic
process
2 parts
Outer oblique – outer surface of
condylar neck
Inner horizontal – lateral pole of
condyle & lateral margin of disk

Functions:
1.
Prevents lateral (same side) & medial (contralateral)
dislocation
2.

3

Oblique part – resists excessive dropping of condyle
- limits extent of mouth –opening/rotational
opening – unique to humans
- prevents impingement on vital
submandibular & retromandibular
structures
Horizontal part – limits posterior movement of
condyle
& disc
- protects RDT from trauma
- protects lateral pterygoid from
overlengthening or extension

 SPENOMANDIBULAR LIGAMENT

– no role

 STYLOMANDIBULAR LIGAMENT

– limits excessive

protrusive movements


SYNOVIAL MEMBRANE LINES BOTH THE CAVITIES & FILLED WITH SYNOVIAL
FLUID

Functions:
Medium for metabolic exchange to avascular articulating
surfaces
Lubricant – minimizes www.indiandentalacademy.com
friction



LATERAL PTERYGOID
MUSCLE – 2 HEADS;
– UPPER HEAD

ATTACHED TO THE
DISC,
– LOWER TO THE

CONDYLE

INFERIOR LATERAL PTERYGOID
Both –protrusion
Unilateral – mediotrusive on same side
With depressors – lowers mandible
- condyles glide downward & forward on articular eminence

SUPERIOR LATERAL PTERYGOID
Does not act with inferior head
Protractor of disk
Power stroke with elevators


NERVE AND BLOOD SUPPLY




SENSORY – AURICULOTEMPORAL NERVE

VASCULAR – SUPERFICIAL TEMPORAL
ARTERY


TMJ MOVEMENTS


CLASSIFICATION OF TMJ DISORDERS
MUSCULAR DISORDERS
• Myositis
• MPDS
DISC-CONDYLE
INCOORDINATION
• Internal derangement
• Subluxation
• Dislocation
STRUCTURAL
• Capsulitis
FRACTURE OF TMJ
NEOPLASIA

ARTHRITIS OF TMJ
• Non inflammatory
• Inflammatory
• Rheumatoid
• Infectious
• Metabolic-gout
DEVELOPMENTAL
• Condylar hyperplasia
• Condylar hypoplasia
• Condylar aplasia
ANKYLOSIS OF TMJ
• Fibrous
• Bony


HYPOMOBILITY (TRISMUS)
• SYSTEMIC FACTORS:
• TETANUS
• TETANY
• INTRACRANIAL CAUSES
 EXTRAPYRAMIDAL LESIONS
 EPILEPSY
• DRUG INDUCED – STRYCHNINE POISONING
• PSYCHOGENIC – HYSTERIA

• LOCAL FACTORS:
• INFECTION
 INTRA-ARTICULAR – ARTHRITIS
 EXTRA-ARTICULAR - PERICORONITIS
• TRAUMA
 FRACTURE OF MANDIBLE
 IMPROPER IAN BLOCK
• TMJ DYSFUNCTION SYNDROME
• TMJ ANKYLOSIS
• ORAL SUBMUCOUS FIBROSIS
• POST RADIATION FIBROSIS
• NEOPLASMS INVOLVING MUSCLES

TMJ DISLOCATION
• INCIDENCE – 3 %, HIGHER IN FEMALES
• MOST COMMONLY IN ANTERIOR DIRECTION
• SUBLUXATION – INCOMPLETE DISLOCATION
• LUXATION = DISLOCATION
• RECURRENT DISLOCATIONS - REPEATED DISLOCATIONS
WITH NO STRONG PSYCHOLOGICAL COMPONENT
• HABITUAL DISLOCATIONS – AT THE WILL OF THE PATIENT
• UNILATERAL OR BILATERAL; ACUTE OR CHRONIC
• HYPERMOBILITY – PREDISPOSING FACTOR

ETIOLOGY

INTRINSIC TRAUMA:

•

OVER EXTENSION INJURY

•

YAWNING, VOMITING

•

WIDE BITING, SEIZURE DISORDER
EXTRINSIC TRAUMA:

TRAUMA
•

FLEXION- EXTENSION INJURY TO THE MANDIBLE

•

INTUBATION

•

ENDOSCOPY

•

DENTAL EXTRACTIONS

•

FORCEFUL HYPEREXTENSIONS

CONNECTIVE TISSUE DISORDERS:
• HYPERMOBILITY SYNDROME
• EHLER’S DANLOS SYNDROME
• MARFAN SYNDROME
MISCELLANEOUS CAUSES:
• INTERNAL DERANGEMENT
• LOST VERTICAL DIMENSIONS
• OCCLUSAL DISCREPANCIES
PSYCHOGENIC:
• HORIZONTAL DISLOCATION
• TARDIVE OROFACIAL DYSKENESIA
DRUG INDUCED:
• PHENOTHIAZINES


DIAGNOSIS
• GOOD HISTORY
• ASCERTAIN TYPE & DETERMINE CAUSE
• CLINICAL SIGNS AND SYMPTOMS
• PALPATION OF MUSCLES
• INVESTIGATIONS


BILATERAL:
•

PAIN – TEMPORAL FOSSA

•

INABILITY TO CLOSE THE MOUTH

•

TENSE MASTICATORY MUSCLES

•

DIFFICULTY IN SPEECH

•

EXCESSIVE SALIVATION

•

PROTRUDED CHIN

•

OPEN BITE

•

DISTINCT HOLLOW IN FRONT OF THE TRAGUS

•

PROTUBERANCE ANTERIOR AND BELOW THE
ARTICULAR EMINENCE

UNILATERAL:
•

MANDIBLE SWUNG AWAY FROM SIDE OF DL

•

CROSS & OPEN BITE - CONTRALATERALLY

•

PROTRUSIVE OCCLUSION

•

HOLLOW IN FRONT OF TRAGUS – INVOLVED SIDE

•

SEVERE PAIN IN THE INVOLVED SIDE


RADIOGRAPHS
• ORTHOPANTOMOGRAPH
• TRANSCRANIAL VIEW & LAT. TOMOGRAMS
• ARTHROGRAPHY
• CT SCANS
• ELECTROMYOGRAPHY


NON SURGICAL TREATMENT
ACUTE DISLOCATIONS:
GOAL – RELIEF OF PAIN, ANXIETY, REDUCTION
& IMMOBILIZATION
• REASSURANCE OF THE PATIENT
• TRANQUILIZER / SEDATIVE
• MASSAGE OVER THE CORONOID PROCESS
• INJECTION OF L.A. INTO THE DEPRESSION
• MANIPULATION & REDUCTION
• IMMOBILIZATION FOR 4 WEEKS
• RESTRICTED www.indiandentalacademy.com
MOUTH OPENING

MANIPULATION TECHNIQUES
• HIPPOCRATES METHOD
• COMMON METHOD
• ROTH’S METHOD
• YURINO’S METHOD


COMMON METHOD


LONG STANDING DISLOCATIONS:
• MUSCLE SPASM & FIBROSIS
• MANIPULATION UNDER G.A.
• IMMOBILIZATION FOR 4 WEEKS
• MUSCLE RELAXANTS
• CLASS III ELASTICS
 AIDS IN COMPLETE REDUCTION

RECURRENT DISLOCATIONS:
• SIMPLER THAN ACUTE DL
• UNSTABLE AFTER REDUCTION - LAXITY
• PHYSICAL THERAPY – ISOMETRIC EXERCISES
• NSAIDS, MUSCLE RELAXANTS
• OCCLUSAL TREATMENT
• CHEMICAL CAPSULORRAPHY (SCLEROSANTS)
 SODIUM TETRADECYL SULPHATE
 SODIUM PSYLLIATE
 HOMOGENOUS BLOOD

SURGICAL TREATMENT
INDICATIONS:
 LONG STANDING DL
 DISABLING RECURRENT DL
3 CATEGORIES:
• PROCEDURES TO LIMIT TRANSLATION
• ELIMINATION OF BLOCKING FACTORS
• COMBINATION PROCEDURES


PROCEDURES TO LIMIT TRANSLATION
ANCHORING PROCEDURES:
• CAPSULORRAPHY
• CAPSULAR PLICATION
• LIGAMENTOPEXY
• FLAPS SECURED TO CAPSULE
• SLINGS BETWEEN CONDYLE & ZYGOMATIC PROCESS
• SECURING DISC TO CAPSULE
• ANCHORING CORONOID PROCESS TO ZYGOMA

PROCEDURES TO LIMIT TRANSLATION
LATERAL PTERYGOID MYOTOMY:
• SUPERIOR BELLY IS CUT
• ELIMINATES FORCE RESPONSIBLE
BLOCKING PROCEDURES:
• CREATES AN OBSTACLE FOR THE CONDYLE
• SOFT TISSUE PROCEDURES
• BONY PROCEDURES


KONJETZNY PRODECURE
CREATES A CLOSED LOCK


DAUTERY PROCEDURE
INCREASES HEIGHT OF THE EMINENCE


ELIMINATING BLOCKING FACTORS
DISKECTOMY


ELIMINATING BLOCKING FACTORS
EMINECTOMY


COMBINATION PROCEDURES

• LATERAL PTERYGOID MYOTOMY WITH DISKECTOMY
• CONDYLOTOMY
• CONDYLECTOMY


CONDYLECTOMY


INTERNAL DERANGEMENT OF TMJ
AN ABNORMAL RELATIONSHIP OF THE ARTICULAR
DISK TO THE MANDIBULAR CONDYLE, FOSSA &
ARTICULAR EMINENCE

• MENISCUS ASSUMES ABNORMAL POSITION
• ASSOCIATED WITH CLICKING


ETIOLOGY

• LATERAL PTERYGOID MUSCLE SPASM
• TRAUMA
• CHRONIC FUNCTIONAL OVERLOAD
(CLENCHING)
• DEGENERATIVE JOINT DISEASES


CLINICAL DIAGNOSIS
HISTORY• PAIN
• CLICKS
• OCCLUSAL DISHARMONY
• HISTORY OF PREVIOUS TREATMENT
• PSYCHOLOGICAL EVALUATION
• ANY OTHER RELEVANT INFORMATION

CLINICAL EXAMINATION• OCCLUSAL DISHARMONIES
• INTER-INCISAL DISTANCE DURING MO
• RANGE OF MANDIBULAR MOVEMENTS
• MIDLINE DEVIATION
• CORRELATION OF CLICKING WITH PAIN & MO
• PALPATION OF JOINT & MUSCLES


PALPATION


SPECIAL INVESTIGATIONS• PLAIN RADIOGRAPHS – OPEN & CLOSED
• ARTHROGRAPHY – INJ. OF CONTRAST MEDIA
• CT SCANS
• MRI
• TMJ ARTHROSCOPY
• ACOUSTIC EVALUATION

CLINICALLY, 3 STAGES:
A) INITIAL STAGE –
•

ANT. DISPLACEMENT WITH REDUCTION

B) INTERMEDIATE STAGE –
•

ANT. DISPLACEMENT WITHOUT REDUCTION

C) TERMINAL STAGE –
•

ANT. DISPLACEMENT WITH PERFORATION

MANAGEMENT
1. INITIAL TREATMENT•

AIM - NORMAL JOINT – SYMPTOMATIC

•

EXPLAIN THE NATURE AND PROGNOSIS

•

RELIEVE THE JOINT FROM TRAUMA –
 SOFT DIET, AVOID BRUXISM, ETC.

•

MEDICATIONS – NSAID’S

•

MUSCLE RELAXANTS – DIAZEPAM;

•

LIMIT MOUTH OPENING

•

APPLICATION OF HEAT, COLD

•

INTRA-ARTICULAR INJECTIONS
 TRIAMCINALONE / HYDROCORTISONE

2. SUPPORTIVE THERAPYA) APPLIANCES (SPLINTS)
•

STABILIZATION SPLINTS

•

REPOSITIONING SPLINTS

B) PHYSIOTHERAPY
•

JOINT MOBILIZATION

•

MOVEMENT EDUCATION

C) OCCLUSAL REHABILITATION
•

SELECTIVE GRINDING

•

ORTHODONTICS

SURGICAL MANAGEMENT
• EMPLOYED FOR END STAGE DISORDERS
• INTRACTABLE PAIN - UNRESPONSIVE
• CHRONIC CLOSED LOCK
• DISC PERFORATIONS

 ARTHROCENTESIS
 ARTHROSCOPY

1. MENISECTOMY
2. HIGH CONDYLECTOMY
3. CONDYLECTOMY
4. CONDYLOTOMY
• BASED ON FINDING OF CONDYLAR #
- ELIMINATION OF JOINT SOUND
• WARD (1961)- CLOSED CONDYLOTOMY –
CONDYLE ASSUMES NEW POSITION
5. EMINECTOMY• REMOVAL OF ARTICULAR EMINENCE

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Tmj disorders 1 /certified fixed orthodontic courses by Indian dental academy

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