COMMON TMJ

DISORDERS/DYSFUNCTION
BDS5 ORAL SURGERY 2014

DR KANTARA TIIM
CMNHS
FNU
Anatomy Revision
Mouth Opening
 Muscular Action: Open/Close

Temporalis
Medial Pterygoid
Masseter

Lateral pterygoids
Geniohyoid
Mylohyoid
Anterior belly of digastric
 TOPICS
1. Myofascial Pain Dysfunction
2. Anterior Disc Displacement
3. TMJ dislocation
 1. MYOFASCIAL PAIN DYSFUNCTION
 Clinical Features
- Affects muscles only: neck, scalp,
masticatory
- Predominantly in young
- Affects women more than men
 Signs & Symptoms
• Pain
– Muscles painful during use, often painful in morning
– Specific tender spots on muscle
– Masticatory muscles may be tender to palpation
• Clicking
• Jaw locking
• Limitation of mouth opening/jaw movements
• Develops over weeks to months
• Condition self limiting: few wks – few years
 Aetiology
Several contributing factors
 Parafunctional activity e.g. clenching,
grinding
 Stress, psychological disturbance or
psychiatric illness
 Occlusal disturbance
 Wide opening of mouth
 True joint disease in TMJ
 Other local inflammatory conditions
 Treatment
 Reassurance/explanation of the benign and self-
limiting nature of the problem
 Minimizing chewing (e.g. soft diet and limitation of
movement)
 Watch and control daytime parafunction
 Anti-inflammatory analgesic (e.g.ibuprofen 400 mg
three times a day)
 Occlusal splint therapy esp. at night
 Local physiotherapy
 Consider referral to psychologist/psychiatrist (if
suspect severe anxiety/depression, psychiatric
disturbance)
2. ANTERIOR DISC DISPLACEMENT
 Classifications
2.1 Disc displacement with reduction
2.2 Disc displacement without
reduction
2.3 Disc adhesion
Anterior Disc Displacement
 Aetiology

 Traumatic injuries
 Chronic joint compressions (tooth
grinding and clenching)
2.1 Disc displacement with reduction

 Anteriorly displaced disc that

returns to normal position during
mouth opening
 Makes a Clicking noise
2.1 Disc displacement with reduction cont’d

TMJ Clicking
2.2 Disc displacement without reduction

 Anteriorly displaced disc does not

return to normal position during
mouth opening
 TMJ locking
 2.2 Disc displacement without reduction
cont’d

TMJ locking
 2.3 Disc adhesion

 Adhesion of the disc to the joint socket

 Occur most often in the upper joint space and can
result from 2 mechanisms:
- Synovitis  fibrin layer (instead of hyaluronic
acid) causing fibrous tissue  disc adhesion
- Hematoma  healing with capillary invasion 
transition to scar-like fibrous tissue
 Locking
 2.3 Disc adhesion cont’d

Disc adhesion
 DIAGNOSIS DEPENDS ON:
1. Range of motion

2. Assessment of TMJ function

3. Palpation of muscles and joints

 1. Range of Motion
• Measured from incisal edge of uppers to
incisal edge of lower central incisors (11/41
or 21/31)

• Normal opening = 40mm

• Lateral excursion = 7mm - 10mm
• Normal protrusion = 6mm - 9mm
• Non painful
 Limitation in Range of Motion
• Muscle “spasm” - jaw closing muscles
• Non reducing anteriorly displaced disc (closed
lock???)
• Interference in the coronoid process
• Fibrous ankylosis of the joint
• Joint inflamation
• Haematoma
• Neoplasm
• Infection
 Deviation in mouth opening

Deviates to side of disc

Deviates to affected displacement
side of the click and Does not correct itself
returns to centre Limitation in mouth
No limitation in mouth opening
opening
 2. Assessment of TMJ Function –
TMJ Sounds
• Detected by palpation or auditory
• Repetitive open/close and lateral/protrusive
movements
• Clicking, crepitus, “cluncking”
• Not an indication for treatment unless
associated pain or dysfunction
 3. Palpation of muscles & joints
• Tenderness in joints, muscles,
associated structures
• Myofascial pain
• Trigger points
 Treatment: Anterior Disc Displacement
TMJ clicking?
 Treated only when painful and socially
unacceptable
 Medical treatment of painful TMJ
clicking:
- Medications for relief of pain (NSAID’s)
- Soft, non-chewy diet
- Use of an occlusal splint to prevent
chronic tooth clenching and chewing
 Treatment: Anterior Disc Displacement cont…
TMJ clicking?
• Surgical treatment of painful TMJ clicking:
- arthroscopic surgery of the disc
- discoplasty (surgical disc repositioning)
3.TMJ DISLOCATION
 Classifications
1. Acute Dislocation
Usually managed by manual reduction
2. Chronic Recurrent
3. Chronic Persistent
2 & 3 are likely to be managed by surgical
intervention
 Classification of Anterior TMJ Dislocation

• Dislocation classified based on relationship of the

head of mandibular condyle to the articular
eminence seen on clinico-radiological evaluation
into three types (I-III).
• Type I - the head of condyle is directly below the
tip of the eminence
• Type II - the head of condyle is in front of the tip
of the eminence
• Type III - the head of condyle is high up in front of
the base of the eminence.
 Clinical Features
• Open mouth
• Symmetrical: bilateral TMJ dislocation
• Non-symmetrical: Unilateral
dislocation
 Conservative Treatment:
Manual Reduction with/without
sedation/GA
 Surgical Interventions
• To reposition condyle in fossa (There was
much restriction of movement)
e.g. Temporalis myotomy, Coronoidectomy or
both
• To correct fusion and restore the joint (There
was complete restriction of movement)
e.g. Low Condylectomy
 Surgical Interventions cont..
• To restrict condylar movement
e.g. Lateral pterygoid myotomy
• To recreate mechanical obstruction along
condylar path
e.g. Downward and inward fracture of zygomatic
bone
e.g. Eminoplasty with onlay bone gafts (Dautery
procedure)
 Surgical Interventions cont..
• To remove mechanical obstacle along condylar
path
e.g. Eminectomy
 References
1. Akinbami, B.O. (2011), Evaluation of the mechanism and principles of
management of temporomandibular joint dislocation. Systematic review
of literature and a proposed new classification of temporomandibular
joint dislocation, Head & Face Medicine 2011, 7:10
2. Scully,C. and D. H. Felix, D.H. (2006) , Oral Medicine — Update for the
dental practitioner Orofacial pain, British Dental Journal Vol. 200 (2):75-
83
3. http://www.youtube.com/watch?feature=player_embedded&v=73aR600
96ME
4. http://www.youtube.com/watch?v=-Zm7ev8LUAA