TEMPOROMANDIBULAR JOINT, DISORDERS AND

APPROACHES
S. Baskan, A. Zengngul
Dicle University, Faculty of Dentistry, Department of Prosthodontics, Diyarbakr, Turkey

ABSTRACT
The study of temporomandibular joint (TMJ) and its relationship to function of the stomathognathic system has been a topic of interest in dentistry for many years. This relationship has proved to be quite complex. The TMJ is certainly one of the most complex
joints in the body. As knowledge of the anatomy and physiology of the TMJ increases, and
instruments and techniques for measuring dynamic skull-fossamandibular factors are developed, many more general dentists are attempting to and are expected to- diagnose
and treat TMJ-oriented problems. Temporomandibular disorders (TMD) include clinical
disorders involving the masticatory muscles, the TMJ and the adjacent structures. TMD
was recognized as a main source for pains in the orofacial area, which are not caused
from dental origin, and is defined by the American Academy of Orofascial Pain (AAOP)
as a sub-group within the frame of musculoskeletal disorders. The main etiology for TMD
has not been found yet.

Introduction

chewing, swallowing, and parafunctional

activities (3, 4, 16, 23).
The human TMJ is classified as a diarthrosis, or freely movable joint (10, 23).
TMJ provides for hinging movement in one
plane and therefore can be considered a
ginglymoid joint. However, at the same
time it also provides for gliding movements, which classifies it is an arthroidal
joint. Thus it has been technically considered a ginglymoarthroidal joint (3, 17). So
that inputs from these joints to the central
nervous system (CNS) require integration
that is probably somewhat different from
other joints (1, 10).
The TMJ consist of the condyle of the
mandible, separated by the meniscus or
interarticular disc, which is articulated with
the glenoid fossa of the inferior border of
the temporal bone and mediated by ligaments and muscles (23). The TMJ is classified as a compound joint. By definition, a
compound joint requires the presence of at
least three bones, yet the TMJ is made up
of only two bones. Functionally, the ar-

The temporomandibular joint (TMJ) is

critical functional components in the
physiology of the stomathognathic system
(4, 23). It has some unique features that
distinguish it from all others (10). First, the
joints on both sides always function simultaneously. Since an extremely large force is
applied per unit area of the joint, it is covered with fibrocartilage, which makes it
different from the surface of most other
joints. The greatest distinguishing characteristic however, is the existence of teeth,
which restrict the movement of the TMJ
(10, 16).
The area where craniomandibular articulation occurs is called the TMJ (17, 23).
Within certain border limits imposed by
structure, the joints permit complete freedom of mandibular movement in (1) opening and closing, (2) protrusion and retrusion, and (3) lateral excursive movements.
The TMJs aid in stabilizing the mandible
against the maxilla during the complex interaction of muscular forces exerted in
151

Biotechnol. & Biotechnol. Eq. 20/2006/2

ticular disc serves as a nonossified bone

that permits the complex movements of the
joint. Since the articular disc functions as a
third bone, the craniomandibular articulation is considered a compound joint (3, 17,
23).
The following are important characteristics of the joint:
1. The articular surfaces (condyles and
eminences) are regular and smooth.
2. The condyle is well centered in the fossa
(Table 1).
3. There is a uniformity of the interarticular
surfaces (23).
Unlike most synovial joints, the articular
surfaces of the TMJ are not composed of
hyaline cartilage (4, 10, 16). The articular
surfaces, as well as the central portion of
the articular disc, composed of dense fibrous connective tissue devoid of any
blood vessels or nerve fibers (3, 4, 17).
The articular capsule envelopes TMJ
structures and the lateral ligament and the
associated ligaments, the sphenomandibular and stylomandibular ligaments, protect
the joint and prevent excess movement of
the joint (10). Many muscles are involved
with the function of the TMJ, namely the
masticatory muscles, including the lateral
pterygoid muscle that inserts directly into
the pterygoid fovea if the condylar neck
and the articular disc, the facial muscles,
and the muscles in the anterior part of the
neck (7, 10).

Temporomandibular Disorders
Temporomandibular disorders (TMD) are,
according to the Guidelines of the American Academy of Orofacial Pain, 'a collective term embracing a number of clinical
problems that involve the masticatory musculature, the temporomandibular joints and
associated structures, or both (3, 5, 16, 19).
More than 100 diseases can affect the
musculoskeletal system, and many of these
may also involve the TMJ. Some of these
diseases are relatively common and wellknown, such as osteoarthrosis/osteoarthritis
Biotechnol. & Biotechnol. Eq. 20/2006/2

TABLE 1
Average condyle position
Condyle to eminence
Condyle to roof of fossa
Condyle to center of meatus

( 1.0)
( 1.5)
( 2.0)

1.5 mm
2.5 mm
7.5 mm

and rheumatoid arthritis, while others, such

as infectious and metabolic diseases, are
rare and of less clinical interest to the general practitioner (2, 3, 17). Common diseases of the TMJ; disc interference disorders,
traumatic
diseases,
osteoarthrosis/osteoarthritis, rheumatoid arthritis (3,
17). The classification used for diagnosing
TMD is summarized in Table 2.
One of the most important challenges
that the dental profession faces is to teach
all dentists:
1. To recognize the symptoms of temporomandibular joint-related syndromes
2. To diagnose the cause
3. To treat the problem in the most conservative way that is practical (4).
Symptoms and signs
1. Pain, headache, and muscle spasms.
2. Clicking, snapping, popping, grating
noises in the TMJ.
3. Dizziness and possible nausea.
4. Earache, ringing in the ears (tinnitus), a
fullness or pressure backlog in the ear.
5. Pain or burning sensation of tongue.
6. Partial or complete inability to open the
mouth.
7. Limited range of function of the mandible in one or more directions, with or
without pain.
8. Tender areas on face and head where
palpation elicits painful response either
in the area palpated or to a referred pain
area.
9. Neckaches and backaches (3, 4, 17, 23,
26).

Etiology of Temporomandibular
Disorders
Three main groups of etiologic factors
were proposed: anatomic (including the
occlusion and the joints), neuromuscular,
152

TABLE 2
The classification of temporomandibular disorders
I. Masticatory muscle disorders
1. Protective co-contraction
2. Local muscle soreness
3. Myofascial pain
4. Myospasm
5. Myositis
II. Temporomandibular joint disorders
1. Derangement of the condyle- disc
complex
a. Disc displacements
b. Disc dislocation with reduction
c. Disc dislocation without reduction
2. Structural incompatibility of the
articular surfaces
a. Deviation in form
i. Disc ii. Condyle
iii. Fossa
b. Adhesions
i. Disc to condyle
ii. Disc to fossa
c. Subluxation (hypermobility)
d. Spontaneous dislocation
3. Inflammatory disorders of the TMJ
a. Synovitis
b. Capsulitis

c. Retrodiscitis
d. Arthritides
i. Osteoarthritis
ii. Osteoarthrosis
iii. Polyarthritides
e. Inflammatory disorders of
associated structures
i. Temporalis tendonitis
ii. Stylomandibular ligament
inflammation
III. Chronic mandibular hypomobility
1. Ankylosis
a. Fibrous
b. Bony
2. Muscle contracture a. Myostatic
b. Myofibrotic
3. Coronoid impedance
IV. Growth disorders
1. Congenital and developmental bone
disorders a. Agenesis b.Hypoplasia
c.Hyperplasia d.Neoplasia
2. Congenital and developmental muscle
disorders
a. Hypotrophy
b. Hypertrophy
c. Neoplasia

and psychologic (3, 5, 18).

Etiologic factors such as trauma, emotional stres, orthopedic instability, and
muscle hyperactivitiy were implicated as
significant components (17, 19). A further
development has been to talk about contributing as well as etiologic factors and to
classify these as either predisposing, initiating, or perpetuating. Predisposing factors
can be systemic (general health), psychologic (personality, behaviour), or structural
(occlusion, joint). Initiating (or precipitating) factors usually involve trauma, overloading, or parafunction. Perpetuating (or
sustaining) factors often include behavioral, social and emotional problems and
other forms of stress and general health.
Signs and symptoms of TMD often become
chronic and continue long after the precipitating factor occured. Therefore, among
the etiologic components, perpetuating
factors may be even more important than
precipitating ones (3, 5, 7, 16).
153

It is important when evaluating a patient

to identify both signs and symptoms
clearly. A sign is an objective clinical
finding revealed during an examination. A
symptom is a description or complaint by
the patient. Patients are acutely aware of
their symptoms, yet they may not be aware
of their clinical signs (5, 17).
Trauma
Two general types of trauma need to be
considered: macrotrauma and microtrauma1. A force that exceeds normal
functional loading can lead to injury of the
affected structures (3, 7). Macro trauma is
any sudden force to the joint that causes
structural alterations (4, 17). Macrotrauma
can also occur when the teeth are together
(closed mouth trauma) or can produce a
sudden displacement of the condyle within
the fossa (open mouth trauma)(7, 16, 17).
Occlusion
The question of what role occlusal factors
play in the etiology of TMD has been anBiotechnol. & Biotechnol. Eq. 20/2006/2

swered with conflicting statements over the

years (3, 7, 21). Previous studies have supported the concept of a multifactorial etiology of TMD, the occlusal factor in general
being of minor importance (5, 19).
Some malocclusions were associated
with signs or symptoms of TMD but tended
to occur only rarely:
- overbite
- overjet
- symmetry of retruded contact position
(RCP)
- crossbite
- skeletal anterior open bite
- posterior occlusal support (7, 8, 9, 19,
21, 23)
In terms of the multifactorial problem of
temporomandibular disorders they should
be seen as cofactors. The results, together
with those of other population-based studies, revealed no specific, i.e. recurring
malocclusions (or other occlusal factors)
presenting as risk markers14 and t has
been suggested that occlusal interference
may increase habitual activity in the jaw
muscles and may lead to temporomandibular disorders (TMD) (15, 20).
Several activities of the masticatory system seem to have no functional purpose
and are therefore referred to as parafunctions (3). Occlusal parafunctions include
bruxism (teeth grinding or clenching), lipbiting, thumb-sucking, and abnormal posturing of the jaw (4, 16, 23). Bruxism has
been suggested as an initiating or perpetuating factor in a certain subgroup of temporomandibular disorders (TMD), however,
the exact association between bruxism and
TMD remains unclear (6, 11).
Occlusion is of great importance in all
aspects if clinical dentistry, and the risk of
introducing unfavorable occlusal relationships in restorative dental procedures must
be minimized (3, 9, 18, 22).
General Health
Several epidemiologic studies have shown
that individuals with impaired general
health tend to suffer more frequent and
Biotechnol. & Biotechnol. Eq. 20/2006/2

severe TMD signs and symptoms than

healthy people. The most common systemic conditions are rheumatologic diseases (3, 4, 7, 23).
Psychosocial Factors
The role of psychologic disturbances in the
etiology of TMD also is controversial (3, 8,
14). It is widely recognized that psychological factors may be involved in the pain
perception process. Although the etiology
of TMD has not been established, psychological factors have been implicated in the
predisposition, initiation, and perpetuation
of TMD and psychological therapies have
been found to be beneficial for some TMD
patients (6, 12, 15, 26).
Congenital Anomalies
The TMJ can be affected by several developmental anomalies, embryonic and
postembryonic. Congenital anomalies of
the TMJ are rare (4, 16).

Treatment plan
The ultimate goal of any dental treatment
should be to provide optimum oral health
(4). When optimum oral health is the goal,
diagnosis and treatment planning can be
condensed into two fundamental objectives.
1. Finding all factors that contribute in any
way to deterioration of oral health
2. Determining the best method of eliminating each factor of deterioration (4, 16).
Over the past 70 years, temporomandibular disorders (TMDs) have been subject
to shifts in conceptual understanding. Unable to account for disease patterns, the
mismatch between case assignment and
treatment need, and very different interventions producing similar treatment outcomes (except for the risk to patients),
emerging theories make persuasive arguments in support of alternative explanations
(22, 25).
The dentist should evaluate the joint or
muscular problem, and seriously consider
the various available treatments before deciding to use the appliance as a means of
treatment.
154

The major treatment objectives for TMD are:

1. Control of pain and discomfort, usually
by symptomatic reversible treatment
2. Improvement of impaired function by
controlling precipitating or supporting
factors
3. Treating the residual pathological sequelae (16).
Initial symptomatic treatment can be limited to reversible measures, such as counseling/reassurance, medication, and physical therapy (3, 4, 16, 17, 23).
The customary treatments for this disorder include treatment with occlusal splints,
physiotherapy, behavioral-cognitive treatment, hypnosis, acupuncture and surgery
that should be considered only if all conservative treatments were unsuccessful.
Occlusal splint is the most common and
efficient treatment for TMD patients
proved by many studies with a successful
rate of 70-90% (13).
Stabilization splints are often used to
treat musculoskeletal disorders of temporomandibular joints. Historically, the centric relation is advocated as the reference
position for a stabilization splint. Centric
relation as the reference position is subject
of discussion, since this position has been
defined for a healthy stomatognathic system. In case of temporomandibular disorders, the temporomandibular joints and
muscles are compromised. Apart from degenerative changes in all components of
the temporomandibular joints, the presence
of pain may influence the establishment of
a therapeutic position (24).
The increased knowledge in TMJ, pain
and chronic pain disorders has taught that
some patients who present with longstanding signs and symptoms associated
with TMD require treatment in specialist
clinics.
REFERENCES
1. Ash M., Ramfjord S. (1995) W.B.Saunders
Company, 2-7, 111-157, 261-269.
2. Brodine A.H., Hartshorn M. (2004) Journal of
Prosthetic Dentistry, 91, 268-73.

155

3. Carlsson G.E., Magnusson T. (1999) Quintessence Publishing Co. 9, 13, 19-23, 25-32, 87-91.
4. Dawson P.E. (1974) Occlusal Problems. Mosby
Company., 17-46, 103-106.
5. De Boever J.A., Carlsson G.E., Klineberg I.J.
(2000) Journal of Oral Rehabilitation, 27(5), 367-380.
6. Fujii T., Torisu T., Nakamura S. (2005) Cranio, Apr., 23(2), 113-118.
7. Gerber A., Steinhardt G., Carmichael R.P.
(1990) Quintessence Publishing Co. 21-29.
8. Gesch D., Bernhardt O., Kocher T., John U.,
Hensel E., Alte D. (2004) Angle Orthod., Aug.,
74(4), 512-20.
9. Gesch D., Bernhardt O., Alte D., Kocher T.,
John U., Hensel E. (2004) J. Orofac. Orthop. Mar.,
65(2), 88-103.
10. Ide Y., Nakazawa K. (1991) Quintessence Publishing Co. 12, 30, 62-63, 66.
11. Laat A.D., Steenberghe D., Lesaffre E. (1986)
Journal of Prosthetic Dentistry, 55, 116-121.
12. List T., Dworkin S.F. (1996) J. Orofacial Pain.,
10, 240-53.
13. Littner D., Perlman-Emodi A., Vinocuor E.
(2004) Refuat Hapeh Vehashinayim, Jul. 21(3), 52-8,
94.
14. Melzack R., Wall P.D. (1995) Science, 150,
971-979.
15. Michelotti A., Farella M., Gallo L.M., Veltri
A., Palla S., Martina R. (2005) J. Dent. Res., Jul.,
84(7), 644-648.
16. Mohl N.D., Zarb G., Carlsson G.E, Rugh J.
(1988) Quintessence Publishing Co., 81-89, 271-272.
17. Okeson J.P. (1993) Mosby Year Book, 149-171,
302-305.
18. Pullinger A.G., Seligman D.A. (2000) Journal
of Prosthetic Dentistry, 83, 66-75.
19. Pullinger A.G., Seligman D.A., Gornbein J.
(1993) J. Dent. Res., 72(6), 968-979.
20. Pullinger A.G., Solberg W., Hollender L.,
Petersson A. (1987) J. Orthod. Dentofac. Orthop.,
91, 200-206.
21. Seligman D.A., Pullinger A.G. (1991) Journal
of Craniomandibular Disorders, 5(2), 96-105.
22. Seligman D.A., Pullinger A.G. (2000) Journal
of Prosthetic Dentistry, 83, 76-82.
23. Solnit A., Curnutte C.D. (1988) Quintessence
Publishing Co., 20, 93-96, 121-132.
24. Steenks M.H., The G.L., Aaftink H.M. (2005)
Ned Tijdschr Tandheelkd., 112(8), 279-282.
25. Stohler C.S. (2004) Orthod. Craniofac Res.,
Aug., 7(3), 157-161.
26. Yap A., Tan K., Chua E., Tan H. (2002) Journal of Prosthetic Dentistry, 88, 479-484.

Biotechnol. & Biotechnol. Eq. 20/2006/2