Temporomandibular Joint Syndrome

Kushagra Maini; Anterpreet Dua.

Author Information

Last Update: December 14, 2019.

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Introduction
The temporomandibular joint syndrome is also known as temporomandibular disorder (TMD)
is a common type of musculoskeletal disorder in the orofacial region involving the
masticatory muscles, temporomandibular joint (TMJ) and associated structures. The typical
features are pain in TMJ, restriction of mandibular movement, TMJ sound, and facial
deformities.

TMJ Anatomy

The temporomandibular joint (TMJ), also known as ginglymoarthrodial joint, is a bi-

arthrodial joint that is composed of the temporal bone's articular surface and the head of the
mandible, enclosed in a fibrous capsule. The joint is separated into two synovial joint cavities
by an articular disc. The anterior portion of the disc is attached to the joint capsule, articular
eminence, and the upper area of the lateral pterygoid. The posterior portion relates to the
mandibular fossa and the temporal bone, also referred to as the retrodiscal tissue. The three
major ligaments, temporomandibular, stylomandibular, and sphenomandibular ligaments,
stabilize the TMJ.

Arterial blood supply to the TMJ is primarily from the superficial temporal and maxillary
branches of the external carotid. Other contributing branches include the anterior tympanic,
deep auricular, and ascending pharyngeal arteries. The sensory nerve supply to the TMJ is by
the auriculotemporal and masseteric branches of the mandibular nerve (V3), which is a
branch of the trigeminal nerve.

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Etiology
TMD etiology is multifactorial. Various theories, such as mechanical displacement, trauma,
biomedical, osteoarthritis, muscle theory, neuromuscular, psychophysiological, psychosocial
theory, have been proposed to cause TMD.[1][2][3][2][1] Several factors, either alone or in
combinations, are responsible for TMD.[4][5] Due to multifactorial etiology, the most
common factors are: 

1. Predisposing factors -The factors that increase the risk of TMD or orofacial pain. It
further subdivides into systemic, psychologic, structural, and genetic factors.
 2. Initiating factors -The factors that cause the onset of disorder such as trauma,
overloading of joint structure such as parafunctional habits.
3. Perpetuating factors -The factors that interfere with healing or complicate
management such as mechanical, muscular stress, and metabolic problems.

The factors can influence each other or act together.

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Epidemiology
Epidemiological studies from around the world confirm a very high prevalence of TMD
dysfunction. Reports indicate that 39.2% have at least one symptom of TMD. The incidence
rate is 3.9% among adults and 4.6 % among adolescents. Symptoms of TMD are common in
all age groups. Older age groups demonstrate slightly more symptoms than the young. 
Women are affected more than men, observed as 2 to 1 in population-based studies, and 4 to
1 in clinical settings. No gender differences have appeared in children, but the ratio becomes
2 to 1 in young adults (female to male ratio).[6]

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Pathophysiology
Classification:

Farrar (1972), Block (1980), Welden. E. Bell (1986) AACD (1990), Edmond truelove,
SamuelDwork and Linda LeResche, Suvinen et al. (2005), Stegenga (2010), Machado et al.
(2012), Peck et al. ( 2014), Schiffman et al. ( 2014) proposed various systems of
classification of TMD [7]. The Schiffman classification published the diagnostic criteria
(DC)/TMD represents the evolution of widely accepted research diagnostic criteria of TMD
in 1992. It is a two-axis system physical axis and psychosocial diagnosis. The physical
system divides into the most common joint problems and muscle conditions. The
classification proposes a more standardized, reliable self-reporting questionnaire, clinical
examination systems, scores, and decision trees. It integrates biophysical diagnosis to
disability index, which measures the impact of pain on patient behavior. The classification
depends on clinical examination procedures; the assessment of specific disorders is best
through imaging procedures not included in the classification. The most accepted
classification that aids in the understanding of the pathophysiology is Perk and Schiffman et
al. (2014)[8] and Bell (1986).

Weldon Bell presented a classification that logically categorizes these disorders, and the
American Dental Association adopted it with few changes. The use of such a logical
classification system benefits diagnostic capability as well as communication within the
profession. All temporomandibular joint disorders divide into four broad categories having
similar characteristics as follows:

I. Masticatory Muscle Disorders:

The most common type of pain observed in patients is pain in the masticatory muscles when
swallowing, speaking, and chewing. Pain increases with palpation or with manipulation of
muscles. It is associated with restricted mandibular movements.

II.Temporomandibular Joint Disorders:

Temporomandibular joint disorders subdivide into three major categories:

1. Derangement of the condyle-disc complex:

The derangement of the condyle disc complex arises due to breakdown in the rotational
function of the disc. This condition can result from the lengthening of ligaments (discal
collateral and inferior retro-discal ligaments) or thinning of the posterior disc border. The
contributing factors can be micro or macro trauma. The derangements are of three types:

     i. Disc displacements:

In the event of constant stretching of the inferior retro-discal lamina and the discal collateral
ligament, the discs get positioned anteriorly due to the function of the superior lateral
pterygoid muscle. The changes in disc and muscle position lead to a translator shift of the
condyle during the opening. The movement is associated with click or sound in either or both
during the opening and closing of the mandible.

     ii. Disc dislocation with reduction:

The disc displacement can either lead to partial or complete disarticulation of the disc from
discal space in condyle – disc assembly leading to disc dislocation. The dislocation is reduced
in situations when the patient can manipulate the mandible to reposition the condyle to the
disc position. The condition clinically presents with a controlled range of jaw opening and
jaw deviation in the process of opening the mouth. The reduction of the disc creates loud pop
during disc reposition. The interincisal distance of disc reduction during opening is greater
than when the disc is re dislocation during the closure.

     iii. Disc dislocation without reduction:

The repositioning of the disc can become problematic due to the loss of elasticity in the
superior retro-discal lamina. This situation causes forward translation of the condyle forcing
the disc in front of the condyle. It presents as a locked jaw in closure, and a normal opening is
not achievable. Clinically it is represented as difficulty in maximum opening. The mandibular
opening is around 25 to 30 mm, deflects towards the involved joint, and associated with pain.
The bilateral manipulation technique of loading the joint is painful due to the position of the
condyle in the retro-discal tissues. 

    2. Structural incompatibility with articular surfaces:

The disorder results from changes in the smooth sliding surfaces of the TMJ. The alteration
causes friction, stickiness, and inhibits joint function. The structural incompatibility classifies
as a deviation in form, adhesions, subluxation, and spontaneous dislocation

     i. Deviation in form:
The physiological, aging, or minor degenerative alterations in the condyle, disc, and fossa can
cause deviations and dysfunction, which significantly affects the mandibular movements.

     ii. Adherences and adhesions:

An adherence represents a brief hold of the articular surfaces. Adhesion can happen between
the condyle- disc or amidst the disc or between the disc-fossa. Adhesions are created by the
development of fibrous connective tissue or due to loss of lubrication between the structures.
It characteristically demonstrates restriction in the normal translation of the condyle
movement with no pain. In chronic situations, the patient senses an inability to get the teeth
back to occlusion during the closure.

     iii. Subluxation and luxation (hypermobility):

It is a non-pathologic condition, repeatable clinical phenomena characterized by a sudden

forward movement of the condyle past the crest of the articular eminence during the final
stages of mouth opening. The steep, short posterior slope of the articular eminences and the
longer anterior slope, which is more superior to the crest, causes the condyle to
subluxate. The examiner can witness it by requesting the patient to open wide, and this also
creates a small void or depression behind the condyle.

    iv. Dislocations:

Dislocations are the result of hyperextension of the TMJ. It causes the fixing of the joint in an
open position during the opening of the mouth. Open-lock prevents the translation of the
mandible. The imaging displays the posterior position of the disc in relationship to the
condyle. The anterior teeth are usually separated, and the posterior teeth closed, the patient
shall find difficulty in closing the mouth, and pain is associated with it.  

     3. Inflammatory disorders of the TMJ:

The joint disease of inflammatory origin characteristically presents with deep continuous pain
that commonly gets accentuated on functional movement.  The continuous pain can trigger
secondary excitatory effects. It expressed as referred pain, sensitivity to touch, protective
contraction, or a combination of these problems. Inflammatory joints also get classified
according to the structures involved, such as synovitis, capsulitis, retro-discitis, and arthritis.

     i. Synovitis/capsulitis:

Trauma or abuse can cause inflammation of the synovial tissues (synovitis) and the capsular
ligament (capsulitis). Clinically it is difficult to differentiate, and arthroscopy is useful for
diagnosis. It presents as continuous pain, tenderness on palpation, and limited mandibular
movement.

     ii. Retrodiscitis:

It is caused due to trauma or due to progressive disc displacement and dislocation. The

patient complains of pain, which increases with clenching. Limited jaw movement, swelling
of retro discal tissues, and acute malocclusion are associated with the disease.
    iii. Arthralgia

Pain originating in the joint that is affected by jaw movement, function, or para-function and
replication of this pain occurs with provocative testing of the TMJ.

    iv. Arthritis

Pain originating in the joint with clinical characteristics of inflammation or infection over the
affected joint that is edema, erythema, and/or increased temperature. Associated symptoms
can include dental occlusal changes (e.g., ipsilateral posterior open bite if intraarticular with
unilateral swelling or effusion). This disorder is also known as synovitis or capsulitis,
although these terms limit the sites of nociception. TMD is a localized condition; there should
be no history of systemic inflammatory disease.

a) Osteoarthritis :

It is an inflammatory disorder that arises due to an increased overload of the joint. The

increased forces soften the articular surfaces and resorb the subarticular surface. The
progressive loading and the subsequent regeneration causes loss of subchondral layer, bone
erosion, and osteoarthritis. It is evidenced by pain in joints and increases with the jaw
movements and associated with disc dislocation or perforation.

b) Osteoarthrosis:

Arthrosis is the adaptive unaltered arthritic changes of the bone due to decreased bone
loading. It occurs after the overloading of the joint, mainly due to parafunctional activity and
often associated with disc dislocation.

c) Systemic arthritis

 Several types of arthritides can affect the TMJ, including traumatic arthritis, infectious
arthritis, and rheumatoid arthritis.

III. Chronic Mandibular Hypomobility:

It is a long term painless restriction of the mandible. Pain occurs only when using force to
attempt opening beyond limitations. The classification of the condition is according to the
cause, as ankylosis, muscle contracture, or coronoid process impedance.

IV. Growth Disorders:

TMDs resulting from growth disturbances may be the result of a variety of causes. The
growth disturbances may be in the bones or the muscles. Common growth disturbances of the
bones are agenesis (no growth), hypoplasia (insufficient growth), hyperplasia (excessive
growth), or neoplasia (uncontrolled, destructive growth). Common growth disturbances of the
muscles are hypotrophy (weakened muscle), hypertrophy (increased size and strength of the
muscle), and neoplasia (uncontrolled, destructive growth). It results from deficiencies or
alterations in growth that typically result from trauma.

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History and Physical
History and examination of TMD

The objective of eliciting history and examination is to recognize the clinical signs and
symptoms. The factors to be included in history are[9][10][11][12][13]:

1) Chief complaints that include:

 Location, onset, and characteristic of pain

 Aggravation and relieving factors
 Past treatments if any and their result
 Any other pain disorders.

2) Past medical and dental history 

3) General systematic assessment

4) Psychologic assessment

Physical examination findings of TMD include decreased range of motion, signs of bruxism,
abnormal mandibular movements, tenderness of muscles of mastication, neck, and shoulder,
pain with dynamic loading, and postural asymmetry. It is vital to perform an oral and dental
examination to look for signs of tooth wear and a neurology examination to look for any
cranial nerve abnormalities. A click, crepitus, or popping sensation which may accompany
joint opening or closing may be associated with anterior disc displacement or osteoarthritis.
[14] Careful palpation of masticatory muscles and surrounding neck muscles may be
associated with myalgia, trigger points, myospasm, or referred pain syndrome.[15][16]

The following baseline records should normally be part of the workup for patients suspected
of having a TMJ disorder:

 Clinical examination
 Radiographic examination of teeth and TMJ
 Diagnostic casts

The initial and most helpful study in diagnosing TMD is plain or panoramic radiography,
which may reveal acute fractures, arthritis, or disc displacements. Further imaging studies
like computed tomography (CT) or magnetic resonance imaging (MRI) are beneficial in
severe, chronic, or suspected structural abnormalities of TMJ.[17][18] Additionally, newer
techniques of nerve blocks, botulinum toxin injections, arthrography, and mandibular motion
data can prove to be of significant diagnostic benefit.

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Evaluation
Signs and symptoms of TMD[19][20]:
1) Pain:

Pain from the TMJ and muscles of mastication is a common symptom. It can be constant or
periodic dull ache over the joint, the ear, and temporal fossa. It is more observed during the
mandibular movement or by palpation of the affected regions. The pain can be myogenic
caused due to mechanical trauma and muscle fatigue. Articular pain arising due to
inflammation of articular and periarticular tissues either by overloading, trauma, or
degenerative changes.

2). Joint Sounds:

The two common joint sounds observed are clicking and crepitations.

Clicking is a sound of the short event observed during the mandibular movement caused by
the uncoordinated movement of the condylar head and the articular disc. Crepitations are
compound sounds that are caused by the roughened, irregular articular surfaces of the joint 
and observed during mandibular movement

3). Limitation of Mandibular Movement:

The restrictions in movement of the mandible are observable either in all or in part of
opening, closure, protrusion, and lateral movement. It can be due to muscular restriction, disc
displacement, ligaments restriction.

4). Dislocation:

It is the displacement of the condyle from fossa, and the patient may be unable to close the
mouth. The patient can reduce the dislocation himself or report to the clinician for reduction.

5). Dental Symptoms:

Tooth mobility, pulpitis, tooth wear are the commonest dental symptoms elicited in TMD
patients.

6). Otologic Symptoms:

TMJ pain in the auricular regions is more noticeable posteriorly. Tinnitus, itching in the ear,
and vertigo are other symptoms associated with auricular pain.

7). Recurrent Headaches:

Patients perceive the pain and tenderness of masticatory muscles along the temporal region as
headaches. Additionally, it can correlate with other headaches, such as migraine pain.

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Treatment / Management
Treatment of Temporomandibular disorders[21][22][23][22][24][25][24]:
The identification of the disorder and management could be a challenging task.  It is
imperative to determine the disorder with adequate evidence before initiating the treatment.
The treatment plan decision can be from among the various options available.

The first step in treating TMJ disorders is symptomatic care, which usually consists of (a) a
soft diet, (b) mild inflammatory agents, (c) moist heat packs alternating with ice, and (d)
voluntary disengagement of the teeth.

Further treatment modalities can group into definitive and supportive treatment.

1. Definitive treatment:

The definitive treatment identifies the disorder and treats the cause of the disorder. The
various treatment methods are

a) Occlusal therapy:

The modifications in dental occlusion are the primary treatment method of TMD. This
treatment focuses on altering the mandibular positioning. It identifies and removes
derangements in occlusion and contact interference. It classifies as either reversible or
irreversible occlusal therapy.

i) Reversible occlusal therapy:

CLinicians achieve this result with an occlusal splint that alters patient occlusion briefly. The
splints are made of acrylic, fixed over the teeth of one arch. The creation of the opposing
surface of the splint accounts for a new mandibular position. The mandible returns to the
original position on discontinuation of the splint. A stabilizing splint is the commonest splint
used. It aids in stabilizing the musculoskeletal position of the mandible.

ii) Irreversible occlusal therapy:

The occlusal surfaces are altered forever in irreversible occlusal treatment. The tooth
interference or the default occlusal position of the teeth are identified and permanently
changed either by selective grinding of the tooth surface or by tooth restorations.

b) Emotional stress therapy:

Generally, TMD is associated with the emotional and psychological state. Muscle activities
become altered due to increased levels of emotional stress.

Stress management can be with patient behavioral therapy in the following ways:

i) Patient awareness:

The patient receives education regarding the relationship between stress and muscle
hyperactivity. This understanding aids in better behavioral management and improves
psychological health and the condition.

ii) Restrictive use:

In the majority of TMD situations, patients complain of pain in TMJ and restricted
mandibular movement. The clinician should instruct the patient to move the mandible within
a trouble-free range of motion, which promotes psychological health and pain disorder.

iii) Voluntary avoidance:

The teeth contact can trigger the pain in patients. The patients must try to reduce tooth
contact time. Except during mastication, swallowing, and speaking, the clinician directs
patients to disengage the tooth to diminish the pain or discomfort coercively. A simple
exercise of lip puffing can voluntarily disengage teeth and enhance patient health.

iv) Relaxation therapy:

Relaxation is perceptive. Among the numerous relaxation techniques, patients are encouraged
to follow one that suits them to relax the muscles and promote psychological health.  The
stretch-relax procedure and progressive relaxation techniques are commonly followed and
effective among TMD patients.

2. Supportive Therapy:

Patient symptom management is through supportive therapy. The cause of TMD may not be
relieved with supportive treatment.

The following methods are the currently adopted approach for treating these patients:

 a) Pharmacologic therapy: Analgesics, Non-steroidal anti-inflammatory drugs (NSAIDs),

corticosteroids, anxiolytic agents, muscle relaxants, anti-depressants, local anesthetics can be
either administered locally or systematically to reduce the patient symptoms. Typically,
10 to 14 days course of NSAIDs is the recommended course for acute pain. Muscle relaxants
are an optional adjunct to treat myospasm. If a patient reports poor response in two to three
weeks, tricyclic antidepressants (TCA) are another option, especially if the pain is associated
with bruxism.[26][27][28] 

Invasive strategies include intra-articular long-acting corticosteroid or hyaluronic acid

injections and trigger point botox injections. These interventions are recommended once
conservative therapies have failed or in severe acute exacerbations. Intra-articular steroids are
a recommended intervention for acute treatment of osteoarthritis of TMJ, but multiple doses
can lead to the destruction of articular cartilage.[29][30] There is only limited evidence
regarding the efficacy of hyaluronate injections in treating acute exacerbations.[31]
Botulinum toxin injections only for painful trigger points or chronic bruxism, but a recent
Cochrane study had inconclusive evidence for myofascial pain.[32][33]

 b) Physical therapy: Physical therapy is commonly advocated as an adjuvant to definitive

treatment. Modalities used in physical therapy involve thermotherapy, coolant therapy,
ultrasound, phonophoresis, iontophoresis, electro galvanic stimulation therapy, TENS,
acupuncture, and cold laser. The commonly followed manual techniques are soft tissue
mobilization, joint mobilization, muscle conditioning, resistance exercises, passive muscle
stretching, assisted muscle stretching, and postural training.

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Differential Diagnosis
Various other disorders can present as facial or ear pain or even headaches.  A thorough
history and physical exam with basic labs like blood counts, kidney and liver function tests,
and sedimentation rate help in localizing the lesion for most presentations of TMJ pain.[15]
[34]

  Common causes of facial pain include trigeminal, glossopharyngeal, or post-herpetic

neuralgia, sinusitis, salivary gland disorders, and carotidynia.
  Common causes of headaches include migraines, cluster headaches, strokes, and
temporal arteritis.
  Common causes of ear pain or stuffiness are middle ear infections, injuries,
barotrauma, and Eustachian tube dysfunction. 

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Prognosis
Most patients with TMJ pain have a favorable response to treatment, whereas a small number
of patients develop refractory or persistent TMD. There are no known risk factors associated
with chronic TMD. Recent data published did correlate heightened sympathetic tone with
chronic TMJ pain.[35]

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Complications
There are no reported complications. 

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Consultations
Referral to an oral maxillofacial surgeon (OMFS) is the usual recommendation for:

1. Refractory TMD with no response to noninvasive or minimally invasive techniques like

intraarticular injections, trigger point injections or botulinum toxin injections

2. Structural or articular abnormalities

Imaging is diagnostic for most structural abnormalities. Surgical techniques include

arthroscopy, arthrocentesis, reconstructive jaw procedures, discectomy, and condylotomy.
[36][37]

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Deterrence and Patient Education

TMD conditions are among the most perplexing and intractable problems in clinical
dentistry. Undoubtedly, the most salient and vexing TMD symptom is pain, often
accompanied by a restricted range of mandibular motion. Pain control is considered the
primary goal of TMD management. Once pain control is accomplished, improvement and
restoration of acceptable mandibular function are likely.

A thorough history and physical examination to arrive at the diagnosis are critical.

Utilizing a biopsychosocial strategy, consisting of physical therapies, pharmacotherapy,

dental remedies, and psychological assistance, can lead to effective management and may
curb the negative repercussions of TMD upon the quality of life and daily functioning.

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Enhancing Healthcare Team Outcomes

TMD conditions are among the most perplexing and intractable problems in clinical
dentistry. Undoubtedly, the most salient and vexing TMD symptom is pain, often
accompanied by a restricted range of mandibular motion. Pain control is considered the
primary goal of TMD management. Once pain control is accomplished, improvement and
restoration of acceptable mandibular function are likely.

A thorough history and physical examination to arrive at the diagnosis are critical.

It is essential to communicate and collaborate between providers, as most patients with TMD
require a combined approach of both pharmacologic and non-pharmacologic measures, which
can help reduce suffering and alleviate the maximal symptoms of TMJ disorder. The
interprofessional team consists of primary care providers, dentists, oral surgeons, physical
therapists, nurses, and pharmacists. Nurses often provide education, monitor patient response,
and keep all team members updated on the patient's condition. Nurses also can serve as a
coordination point between different members of the interprofessional healthcare team.
Pharmacists provide instructions to patients about medications, reviewing dosing and side
effects, and check for any potential drug interactions; reporting potential concerns to the
team. [Level 5]

Utilizing a biopsychosocial strategy, consisting of physical therapies, pharmacotherapy,

dental remedies, and psychological assistance, can lead to effective management and may
curb the negative repercussions of TMD upon the quality of life and daily functioning.