Drg. Reza Fajarsyah Putra, Sp.

BM Prodi IKG FK Univ YARSI

What is TMJ Disorder?

Different with Temporomandibular Disorder (TMD)
TMD affecting TMJ and Musculoskeletal TMJ Disorder involved only in TMJ Articular conditions

American Academy of Orofacial Pain Classification

Temporomandibular Joint Disorders Classification Congenital, developmental disorders and acquired disorders Disc derangement disorders : Disc displacement with reduction Disc displacement without reduction Temporomandibular dislocation Inflammatory disorders : Synovitis and capsulitis Polyarthritides

Osteoarthritis (non-inflammatory disorders) : Active Stable

Ankylosis Condylar fracture

Developmental Disorders
Include : Agenesis Aplasia Hypoplasia Hyperplasia

Acquired Disorders
Include : Benign

Osteoma, chondroma, synovial chondromatosis Squamous cell carcinoma, nasopharyngeal tumors

Malignant or metastatic neoplasma

Disc Derangement Disorders

Derangement : to disturb the order of arrangement disorder, confusion
Abnormal anatomic relationship or misalignment of

articular disc and condyle

Disc displacement with reduction Disc displacement without reduction Disc adhesion

Disc Derangement Disorders

Penelitian mengungkapkan berbagai posisi diskus

artikularis tanpa nyeri sendi, kebisingan sendi atau disfungsi sendi Peregangan atau robeknya ligament diskus sebagai penyebab diskus berpindah / displaced Diskus artikularis dapat displaced ke:
Anterior dan medial (lebih sering)

Lateral
Posterior

Disc displacement with reduction

Diskus berpindah tetapi masih terjadi reduksi

(kembali ke posisinya) Disk tereduksi saat condyle bergerak ke posisi yg lebih normal saat TRANSLASI menghasilkan suara clicking/ popping Saat menutup, condyle bergerak ke posterior dari diskus menghasilkan closing click 50-55% adult population jaw clicking as biologic variation Simtomatik (painful)/ asimtomatik (non-painful)

Disc displacement without reduction

Diskus gagal bergerak ke posisi anatomisnya
Akut atau kronik Acute condition painful with marked reduction in

condylar translation Chronic less painful, with normal near normal range of condylar translation Tissue adapt pain free range of motion increase articular changes on imaging

Classification of with and without reduction. Arrows indicate the disc. (A,B) The with reduction case; (A) closed mouth, (B) mouth open to maximum extent. (C,D) The without reduction case; (C) closed mouth, (D) mouth open to maximum extent

Disc Adhesion
Disc adhering to temporal component of fossa

static disc position altered joint mechanics Condyle translate on posterior band of disc 1st clicking continues to move beyond anterior band 2nd clicking During jaw closure clicking occurs at the same two places as opening

Closed mouth

Disc Adhesion On opening

Inflammatory Disorders
Inflammation of the articular surfaces of the joint
Synovitis Capsulitis

Etiologi : Trauma Infection Cartilage degeneration Sequelae systemic polyarthritic/ collagen disease (rheumatoid arthritis, lupus, Reiters syndrome)

Inflammatory Disorders
Common clinical manifestation: Localized joint pain Limited jaw movements
Polyarthritides :

type of arthritis which involves 5 or more joints simultaneously. usually associated with autoimmune conditions.

Synovitis
Synovitis follows a typical course of events

a) the posterior attachment becomes edematous; b) intracapsular pressure increases; c) the condyle becomes displaced anteriorly in the rest position causing a barely perceptible midline shift to the opposite side; d) ipsilateral disocclusion; and e) joint pain that is aggravated when the patient attempts to fully occlude the ipsilateral teeth and, thus, forcing the condyle backward against the inflamed posterior attachment.

Capsulitis
Capsular pain is provoked when the inflamed capsule

is stretched (e.g., by translatory movement of the capsule). The pain exacerbated by protrusion or lateral excursion of the mandible, contralateral chewing, and wide mouth opening. Capsulitis is further characterized by palpable tenderness or pain directly over the condyle and minor swelling over the joint may be detected.

Non-Inflammatory Disorders (Osteoarthritis)

Definisi OA : Kondisi degeneratif pada sendi tanpa inflamasi ditandai dengan kerusakan dan abrasi jaringan artikular yang kemudian terjadi remodeling tulang subchondral.
OA primer: etiology unknown OA sekunder: etiology can be identifed, gout, Cuhsings

disease, osteonecrosis, infections.

Causative factor of osteoarthritis is generally thought to be

the mechanical overloading of the articular structures of the joint

 OA tdd aktif dan stabil

OA aktif : Active change/degeneration in articular tissues OA stabil: Recortication of articular osseus structure without

further structural change

Osteophytes in OA
bony projections that form along joint margins
form because of the increase in a damaged joint's

surface area. most common from the onset of arthritis. limit joint movement and typically cause pain.[

Classification of with and without osteoarthritis. Arrows indicate the temporomandibular joint (TMJ). (A) Normal mandibular condyle, (B) Osteophyte mandibular condyle, (C) Osteophyte mandibular condyle with erosion, (D) Osteophyte mandibular condyle with flattening. The mandibular condyle in panel A was normal. The condyles in panels BD are examples of osteoarthritis

TMJ Dislocation
Hypermobility condition of the jaw
Condyle tiba-tiba berpindah lebih ke anterior dan

superior daripada eminensia artikularis saat membuka rahang atau gerak PROTRUSI dan tidak dapat mengembalikannya ke posisi menutup rahang Etiology:
Trauma

Extended period of mouth opening

Manifestation of joint hypermobility

TMJ Dislocation
Dislocation or open lock if need to reduce manually

the anteriorly positioned condyle Subluxation if patient able to self manipulate the jaw back to closed position

TMJ Ankylosis
Ankylosis stiffness of a joint due to abnormal adhesion and rigidity of the bones of the joint
Relationship between bone and condyle

fibrous tissue or bony adhesion

Etiology : Post trauma or post surgery Systemic infection (tuberculosis, psoriasis, rheumatoid arthritis) Local infection (otitis media, mastoiditis) Neoplastic (osteochondroma)

Classification of Ankylosis
Kazanjian(1938)

1. True(intraarticular):- fibrous or bony adhesion between the articular surfaces of TMJ. 2. False(extraarticular):- results from pathologic condition outside the joint, that results in limited mandibular mobility.
Another classification
According to relationship type

1. Fibrous 2. Fibroosseous 3. Bony According to degree of ankylosis 1. Partial 2. Complete

 Ankylosis complications: Difficulty in mastication, speech, appearance, oral hygiene affected TMJ as growth center of mandible Disturbance of mandibular growth (trauma in childhood) Compromise airway Facial asymetry

Fracture of Condyle
Condylar and subcondylar fractures constitute 26-40% of

all mandible fractures Unilateral or bilateral fracture Etiology:

Direct trauma to mandible

Clinical manifestation marked pain, dysfunction, and deformity Malocclusion, posterior premature contact, anterior open bite Asymmetry of the lower 1/3 of the face

Condyle Fracture Classification

 The dental occlusion can give

orientation about the fracture location. With a unilateral condylar process fracture and subsequent reduction of height in the ramus region, the clinician will see an ipsilateral premature occlusion and contralateral open bite. The dental midline will shift toward the side of fracture. The occlusion shows premature contact on the right with the deviation of the jaw to the affected side that is commonly seen with a right mandibular condyle fracture.