TMJ disorders / fellowships in orthodontics

TMJ DisordersTMJ DisordersINDIAN DENTAL ACADEMY

Leader in continuing dental education www.indiandentalacademy.com

www.indiandentalacademy.com

ContentsContents IntroductionIntroduction EpidemiologyEpidemiology EtiologyEtiology ClassificationClassification Clinical featuresClinical features Radiological features Radiological features Histopathologic featuresHistopathologic features TreatmentTreatment

IntroductionIntroduction

EpidemiologyEpidemiology

Epidemiologic studies Epidemiologic studies 60-70% 60-70%

20-40 years. 20-40 years.

EtiologyEtiology Multifactorial:Multifactorial:

Parafunctional habitsParafunctional habits StressStress TraumaTrauma

Abnormal maxillo-mandibular relationships. Abnormal maxillo-mandibular relationships.

Rheumatic / musculo-skeletal disorders. Rheumatic / musculo-skeletal disorders.

Poor general health and unhealthy lifestyle. Poor general health and unhealthy lifestyle.

AnatomyAnatomy

Normal histology of TMJNormal histology of TMJ

ClassificationClassification(Etiology)(Etiology)

I. I. Developmental Developmental

AplasiaAplasia

HypoplasiaHypoplasia

HyperplasiaHyperplasia

II. II. TraumaticTraumatic

AnkylosisAnkylosis

Injuries of the articular disk Injuries of the articular disk

III. Fractures of the condyleIII. Fractures of the condyle

IV. IV. Inflammatory Inflammatory

ArthritisArthritis

Rheumotoid arthritisRheumotoid arthritis

OsteoarthritisOsteoarthritis

V. V. NeoplasticNeoplastic

VI. VI. Extra-articular disturbancesExtra-articular disturbances

VII. Temporomandibular jointVII. Temporomandibular joint syndrome syndrome

(TMD)(TMD)

TMD secondary to myofacial pain and TMD secondary to myofacial pain and

dysfunction (MPD)dysfunction (MPD)

TMD secondary to true articular disease.TMD secondary to true articular disease.www.indiandentalacademy.com

DEVELOPMENTAL DEVELOPMENTAL DISTURBANCESDISTURBANCES

Aplasia of the mandibular condyleAplasia of the mandibular condyle Unilateral / bilateral. Unilateral / bilateral. Rare Rare

C/FC/F Associated-- absent external Associated-- absent external ear ear ,under ,under

developed ramus / macrostomia. developed ramus / macrostomia. Facial asymmetryFacial asymmetry

TreatmentTreatment

OsteoplastyOsteoplasty

Orthodontic appliancesOrthodontic appliances

Cosmetic surgeryCosmetic surgery

Hypoplasia of the mandibular Hypoplasia of the mandibular

condylecondyle:: Under development / defective Under development / defective

formation formation

Congenital hypoplasiaCongenital hypoplasia Idiopathic Idiopathic Characterized by uni / bilateral under Characterized by uni / bilateral under

development of the condyledevelopment of the condylewww.indiandentalacademy.com

Acquired hypoplasiaAcquired hypoplasia

Forceps deliveries Forceps deliveries

External traumaExternal trauma

X-ray radiationX-ray radiation

InfectionInfection

C/f:C/f: Depends Depends

Degree of malformation. Degree of malformation.

AgeAge

DDurationuration

UnilateralUnilateral

Limited lateral movementsLimited lateral movements

Midline shift Midline shift

Lack of downward and forward Lack of downward and forward

growth of the mandible growth of the mandible

Arrest of the Arrest of the chief growth centerchief growth center of of

the mandible i.e., the mandible i.e., condyle.condyle.

Treatment & prognosis:Treatment & prognosis:Cartilage / bone transplantsCartilage / bone transplants

Unilateral and bilateral Unilateral and bilateral

osteotomyosteotomy

Hyperplasia of the mandibular condyleHyperplasia of the mandibular condyle::

Rare Rare unilateral enlargement of the condyle unilateral enlargement of the condyle Causes: Causes:

-Obscure -Obscure

-Mild chronic inflammation.-Mild chronic inflammation.

C/f: C/f:

Elongation of the face Elongation of the face

deviation of the chin away from the deviation of the chin away from the

affected side. affected side.

Enlarged condyleEnlarged condyle

may or may not be painfulmay or may not be painful

severe malocclusionsevere malocclusionwww.indiandentalacademy.com

R/F:R/F: Elongated neck and enlarged Elongated neck and enlarged

condylar head condylar head

Treatment and prognosis:Treatment and prognosis: Condylectomy Condylectomy Orthognathic surgery Orthognathic surgery Resection of condyleResection of condyle

Condylar hyperplasia

Bifid condyleBifid condyle Double headed.Double headed. Medial & lateral head. Medial & lateral head. //Anterior & Anterior &

posterior head.posterior head.

Etiology:Etiology: Uncertain.Uncertain. Traumatic in origin.Traumatic in origin. Abnormal muscle attachmentAbnormal muscle attachment

C/F:C/F: UnilateralUnilateral AsymptomaticAsymptomatic Pop or click of TMJ Pop or click of TMJ

R/F:R/F: Bilobed appearance Bilobed appearance

Asymptomatic Asymptomatic no no treatment necessary.treatment necessary.

Histologic section of bifid Histologic section of bifid condylecondyle

TraumaticTraumatic

Luxation and subluxationLuxation and subluxation

Dislocation of the TMJ Dislocation of the TMJ Luxation of the joint Luxation of the joint

SubluxationSubluxation

Luxation Luxation ‘acute’, due to a sudden ‘acute’, due to a sudden

traumatic injury resulting in the fracture of traumatic injury resulting in the fracture of

the condyle. the condyle.

Yawning / wide opening of mouthYawning / wide opening of mouthwww.indiandentalacademy.com

Unilateral condylar dislocationwww.indiandentalacademy.com

Bilateral condylar dislocationwww.indiandentalacademy.com

Luxation & SubluxationLuxation & Subluxation C/f:C/f:

Sudden locking and immobilization of the Sudden locking and immobilization of the

jaws. jaws.

Prolonged spasmodic contraction of the Prolonged spasmodic contraction of the

temporal, internal pterygoid and masseter temporal, internal pterygoid and masseter

muscles. muscles.

Luxation & SubluxationLuxation & Subluxation

Treatment:Treatment: Relaxation of the muscles and then guiding the Relaxation of the muscles and then guiding the

head of the condyle under the articular eminence head of the condyle under the articular eminence into its normal position by an inferior and posterior into its normal position by an inferior and posterior pressure of the thumbs in the mandibular molar pressure of the thumbs in the mandibular molar area.area.

AnkylosisAnkylosis Fusion of head of the condyle Fusion of head of the condyle temporal temporal

bone.bone.

EtiologyEtiology:: Idiopathic Idiopathic

Traumatic injuriesTraumatic injuries

InfectionInfection

Rheumatoid arthritisRheumatoid arthritiswww.indiandentalacademy.com

AnkylosisAnkylosis C/f:C/f:

11stst decade decade Before 10 yearsBefore 10 years M = FM = F Unilateral /BilateralUnilateral /Bilateral In ability to open the jawsIn ability to open the jaws Pain, tenderness and malocclusion Pain, tenderness and malocclusion

Unilateral ankylosis

AnkylosisAnkylosisIntra-articular Intra-articular ankylosisankylosis

Extra-articular Extra-articular ankylosisankylosis

-Destruction of the -Destruction of the

meniscusmeniscus

-Flattening of the -Flattening of the

mandibular fossa mandibular fossa

thickening of the head thickening of the head

of the condyle of the condyle

-narrowing of the joint -narrowing of the joint

spacespace

-Fibrous adhesion-Fibrous adhesion

External fibrous / External fibrous /

osseous encapsulation.osseous encapsulation.

AnkylosisAnkylosis R/F:R/F:

Abnormal / irregular shape of the Abnormal / irregular shape of the head of the condylehead of the condyle

Treatment:Treatment: Surgical osteotomy / removal of Surgical osteotomy / removal of

section of bone below the condyle.section of bone below the condyle. Fibrous ankylosis can be treated by Fibrous ankylosis can be treated by

functional methods. functional methods. www.indiandentalacademy.com

Injuries of the articular Injuries of the articular diskdisk

MalocclusionMalocclusion Loss of adaptation of the disk to Loss of adaptation of the disk to

the condyle.the condyle.

Precipitating factorsPrecipitating factors Blow / fallBlow / fall Rheumatoid arthritisRheumatoid arthritis

C/f:C/f: FemalesFemales

Young adults Young adults frequently affected. frequently affected.

Pain, snapping or clicking and Pain, snapping or clicking and

crepitation. crepitation.

Transient / prolonged locking of the Transient / prolonged locking of the

jaw may occur. jaw may occur. www.indiandentalacademy.com

Normal disc position Normal disc position Anterior disc Anterior disc displacement displacement

R/F:R/F:No +ve findingsNo +ve findings

Treatment:Treatment: Immobilization Immobilization Menisectomy / surgical Menisectomy / surgical

removal of the disk.removal of the disk.www.indiandentalacademy.com

Fractures Fractures

Condylar fracture:Condylar fracture:

Traumatic injuryTraumatic injury

Limitation of motionLimitation of motion

Pain and swellingPain and swelling

Displaced anteriorly and medially into Displaced anteriorly and medially into

the infratemporal regionthe infratemporal regionSurgical reduction

Unilateral

Bilateral www.indiandentalacademy.com

INFLAMMATORY INFLAMMATORY DISTURBANCES DISTURBANCES

Arthritis.Arthritis.3 types :3 types :

1.1. Arthritis due to a specific infection.Arthritis due to a specific infection.

2.2. Rheumatoid arthritis.Rheumatoid arthritis.

3.3. Osteoarthritis / degenerative joint Osteoarthritis / degenerative joint

disease.disease.www.indiandentalacademy.com

UncommonUncommonNeisseria gonorrhea, Str, Staph. Neisseria gonorrhea, Str, Staph. Pneumococci, tubercle bacilli, H. Pneumococci, tubercle bacilli, H. influenzaeinfluenzae

Direct spread of a local infection or blood Direct spread of a local infection or blood stream / lymphatic metastasis.stream / lymphatic metastasis.

C/F:C/F:- - Severe pain in the joint.Severe pain in the joint. Extreme tendernessExtreme tenderness Healing Healing results in ankylosis. results in ankylosis.

H-PH-P Destruction Destruction articular cartilage and articular cartilage and

articular disc.articular disc. Obliteration of joint space Obliteration of joint space by the by the

development of granulation tissuedevelopment of granulation tissue Transforms into scar tissue.Transforms into scar tissue.

Rx:Rx: Antibiotics – in the acute phase Antibiotics – in the acute phase

Meniscetomy / condylectomy is advocated in Meniscetomy / condylectomy is advocated in the advanced cases.the advanced cases.www.indiandentalacademy.com

Rheumatoid arthritisRheumatoid arthritis Chronic autoimmune disorder Chronic autoimmune disorder non-suppurative inflammatory non-suppurative inflammatory

destruction of the joints.destruction of the joints. Etiology: Etiology:

UnknownUnknown Cross reaction of antibody against Cross reaction of antibody against

microorganisms deposited in the synovial microorganisms deposited in the synovial

membrane.membrane. www.indiandentalacademy.com

A reactive macrophage – laden A reactive macrophage – laden fibroblastic proliferation from the fibroblastic proliferation from the synovium creeps onto the joint synovium creeps onto the joint surface.surface.

↓↓

Releases collagenases & proteasesReleases collagenases & proteases

↓↓

Destroys the cartilage & boneDestroys the cartilage & bone TMJ involvement TMJ involvement 20%20%

C/F:C/F:

M:F = 1:3M:F = 1:3

M = 25-30 yrs;M = 25-30 yrs; F = 35-45 yrs F = 35-45 yrs

Early stages manifestsEarly stages manifests

Rheumatoid arthritisRheumatoid arthritis

Pain, swelling and stiffness joint Pain, swelling and stiffness joint

Clenching the teeth on one side Clenching the teeth on one side

produces pain of contra lateral joint. produces pain of contra lateral joint.

Destruction of condylar head Destruction of condylar head

receding chin & malocclusionreceding chin & malocclusion

R/F:R/F:

Flattened condylar headFlattened condylar head

An irregular surface of temporal fossaAn irregular surface of temporal fossa

Anterior displacement of the condyleAnterior displacement of the condyle

High resolution CT High resolution CT erosions of the erosions of the

condyle & glenoid fossae.condyle & glenoid fossae.

H-P :H-P :

Hyperplasia Hyperplasia of synovial lining cells of synovial lining cells

Hyperemia, edema Hyperemia, edema and inflammation of the and inflammation of the

synovial tissues synovial tissues

diffuse infiltration of chronic inflammatory diffuse infiltration of chronic inflammatory

cells into the articular architecture.cells into the articular architecture.

destruction destruction of articular surface of the condyle.of articular surface of the condyle.

Invasion of the cartilage and its replacement by Invasion of the cartilage and its replacement by

granulation tissue. granulation tissue.

Perforation of meniscusPerforation of meniscus

Lab findings:Lab findings: 80% of patients 80% of patients ↑rheumatoid ↑rheumatoid

factorfactorANA detected in ANA detected in

50%50%↑↑ESRESRMild anemia Mild anemia

Rx & Prognosis:Rx & Prognosis:

Anti-inflammatory drugsAnti-inflammatory drugs

Corticosteoids.Corticosteoids.

Surgical interventionSurgical intervention

OsteoarthritisOsteoarthritis

Disorder of articular cartilage, Disorder of articular cartilage, subcondral bone with secondary subcondral bone with secondary inflammation of the synovial membraneinflammation of the synovial membrane

Etiology:Etiology: unknown. unknown. GeneticGenetic Aging process.Aging process. Chronic microtrauma Chronic microtrauma Primary Primary above 50 yrs & asymptomatic above 50 yrs & asymptomatic Secondary Secondary due to trauma, metabolic due to trauma, metabolic

diseasediseasewww.indiandentalacademy.com

C/F: C/F: Unilateral pain over the condyle & Unilateral pain over the condyle &

over muscles of masticationover muscles of mastication Limitation of mandibular opening Limitation of mandibular opening Crepitus and stiffness Crepitus and stiffness Deviation of mandible towards painful Deviation of mandible towards painful

sideside

R / F:R / F: Obliteration of the joint spaceObliteration of the joint space Surface irregularities and Surface irregularities and

protruberancesprotruberances Flattening of the articular surface.Flattening of the articular surface. Radiolucent subchondral cystsRadiolucent subchondral cysts Ossification within the synovial Ossification within the synovial

membranemembranewww.indiandentalacademy.com

H-P /F:H-P /F:

Degeneration of cartilage cellsDegeneration of cartilage cells

infiltration of chronic inflammatory cellsinfiltration of chronic inflammatory cells

Loss of osteocytes Loss of osteocytes

fatty degeneration & necrosis of the marrowfatty degeneration & necrosis of the marrow

Large degenerative space beneath the Large degenerative space beneath the

articular cartilage (Subchondral cysts)articular cartilage (Subchondral cysts)

Rx:Rx: NSAIDs, heat, soft diet, rest and NSAIDs, heat, soft diet, rest and

occlusal splintsocclusal splints ArthroplastyArthroplasty Orofacial physiotherapy.Orofacial physiotherapy.

NEOPLASTIC NEOPLASTIC

Neoplasms and tumor-like growths, benign Neoplasms and tumor-like growths, benign

and malignant, may involve the TMJ. and malignant, may involve the TMJ. Etiology: Etiology: UnknownUnknown From embryonic mesenchymal remnants From embryonic mesenchymal remnants

of synovium.of synovium. That become metaplastic, calcify, break off That become metaplastic, calcify, break off

into the joint spaceinto the joint space Chondromas, osteomas and Chondromas, osteomas and

osteochondromas are common benign osteochondromas are common benign tumors. tumors.

Osteochondroma – bone capped with Osteochondroma – bone capped with cartilage and dense collagenous tissuecartilage and dense collagenous tissuewww.indiandentalacademy.com

CT scan and arthroscopy is CT scan and arthroscopy is necessary for accurate diagnosis.necessary for accurate diagnosis.

Rx:Rx: Conservative and surgical removal Conservative and surgical removal

of involved synovium and articular of involved synovium and articular disk.disk.

EXTRA-EXTRA-ARTICULARARTICULAR

A variety of extraarticular disturbances A variety of extraarticular disturbances may manifest themselves clinically as TMJ may manifest themselves clinically as TMJ problems.problems. Impacted molar teethImpacted molar teeth Sinusitis & Middle ear diseaseSinusitis & Middle ear disease Infratemporal cellulitisInfratemporal cellulitis Neuritis of the 3Neuritis of the 3rdrd division of the trigeminal division of the trigeminal

nerve.nerve. Odontolgia.Odontolgia. Overclosure of the mandible due to severe Overclosure of the mandible due to severe

dental attrition.dental attrition. Costen’s syndrome.Costen’s syndrome.

TEMPORO MANDIBULAR TEMPORO MANDIBULAR JOINTJOINT

SYNDROME SYNDROME

Most common cause of facial pain Most common cause of facial pain

after toothache.after toothache.

TMD can be classified broadly as:TMD can be classified broadly as: TMD secondary to myofacial pain and TMD secondary to myofacial pain and

dysfunction (MPD).dysfunction (MPD).

TMD secondary to true articular diseaseTMD secondary to true articular disease

Etiology: Etiology:

Tissue injuryTissue injury

Physical stress Physical stress Bruxism and day time Bruxism and day time

jaw clenching in a stressed and anxious jaw clenching in a stressed and anxious

person.person.

Psychological & behavioural abnormalitiesPsychological & behavioural abnormalities

Poor nutritional statusPoor nutritional status

Genetic predisposition Genetic predisposition www.indiandentalacademy.com

DIGAMMATIC RERESENTATION OF ETIOLOGY OF MPDS

PSYCHOPHYSIOLOGIC THEORY OF MPDS(Modified by LASKIN in 1969)

C /F:C /F: Constant diffuse unilateral painConstant diffuse unilateral pain Severe in the morning and worsens as Severe in the morning and worsens as

day progressesday progresses Radiates to cervical region, shoulders Radiates to cervical region, shoulders

and backand back Limitation of jaw movement Limitation of jaw movement Deviation to the affected siteDeviation to the affected site

VII. TEMPOROMANDIBULAR JOINT VII. TEMPOROMANDIBULAR JOINT SYNDROME (TM disorder)SYNDROME (TM disorder)

Cl / Ft:Cl / Ft:

Tenderness in MMTenderness in MM

Angle of mandibleAngle of mandible

Anterior temporal region & coronoid Anterior temporal region & coronoid

aspectaspectwww.indiandentalacademy.com

Rx:Rx:

Physiotherapy Physiotherapy moist heat, TENS, moist heat, TENS,

Aucpressure, Acupuncture.Aucpressure, Acupuncture.

Behavioural and relaxation techniquesBehavioural and relaxation techniques

Occlusal splint therapyOcclusal splint therapy

NSAIDs, Muscle relaxants NSAIDs, Muscle relaxants www.indiandentalacademy.com

2. True intra-articular disease :2. True intra-articular disease : Disk displacement disorder.Disk displacement disorder.

Chronic recurrent dislocations.Chronic recurrent dislocations. Degenerative joint disorders.Degenerative joint disorders.

Ankylosis.Ankylosis. InfectionInfection

Etiology:Etiology: Malocclusion.Malocclusion. Jaw clenching.Jaw clenching. Bruxism.Bruxism. Personality disordersPersonality disorders Increased pain sensitivity.Increased pain sensitivity. Stress and anxiety.Stress and anxiety.

C/F:C/F: Affects young woman aged 20-40 yrs.Affects young woman aged 20-40 yrs.

M:F – 1:4.M:F – 1:4.

In TMD pain is unilateral associated with In TMD pain is unilateral associated with

clicking, popping and snapping sounds.clicking, popping and snapping sounds.

Limited jaw opening due to pain / disk Limited jaw opening due to pain / disk

displacement.displacement.

Associated with chewing and may radiate to Associated with chewing and may radiate to

head.head.www.indiandentalacademy.com

Treatment & Prognosis:Treatment & Prognosis:1. Self limiting.1. Self limiting.2. Conservative treatment involving 2. Conservative treatment involving

self care practices.self care practices. Rehabilitation aimed at Rehabilitation aimed at

eliminating muscle spasms.eliminating muscle spasms.3. NSAIDs 3. NSAIDs Prognosis is good.Prognosis is good.

Investigations Investigations TMJTMJ TMJ imaging TMJ imaging

Panoramic radiographsPanoramic radiographs Transcranial viewTranscranial view Transpharyngeal viewTranspharyngeal view Transorbital viewTransorbital view Reverse Towne’s viewReverse Towne’s view Submento-vertex (SMV) viewSubmento-vertex (SMV) view Conventional tomographyConventional tomography ArthrographyArthrographywww.indiandentalacademy.com

Computed tomography (CT)Computed tomography (CT)

Magnetic resonance imaging (MRI)Magnetic resonance imaging (MRI)

ArthroscopyArthroscopy

Bone scanBone scan

ReferencesReferences Shafer’s Textbook of Oral Pathology. 5Shafer’s Textbook of Oral Pathology. 5thth edition. edition. Neville: Oral & Maxillofacial Pathology. 2Neville: Oral & Maxillofacial Pathology. 2ndnd edition. edition. Jaffery P. Okeson – Management of Jaffery P. Okeson – Management of

Temporomandibular disorders and occlusion.Temporomandibular disorders and occlusion. Martin S. Greenberg, Michael Glick – Burkit’s oral Martin S. Greenberg, Michael Glick – Burkit’s oral

medicine and diagnosis.medicine and diagnosis. Franklin C.D.: Pathology of the temporomandibular Franklin C.D.: Pathology of the temporomandibular

joint. Current Diagnostic Pathology (2006): 12, 31-39.joint. Current Diagnostic Pathology (2006): 12, 31-39.

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