Management Of

Temporomandibular Disorders

Prof. Riaz Ahmed Warraich

Head OMFS CMH LMC
 Learning Objectives
• Select Management options for TMD:
• Reversible:
• Patient Education
• Medications.
• Physiotherapy.
• Splint Therapy.
.
• Irreversible:
• Occlusion Modification.
• TMJ Surgery
 Learning Objectives
Enlist various TMJ Surgical options:
• Arthrocentesis
• Arthroscopy.
• Disc Repositioning.
• Techniques to manage Recurrent Dislocation.
• Disc Repair/Removal.
• Condylotomy/Arthroplasty.
• Joint Replacement.
• Distraction Osteogenesis.
TMJ Dysfunction

TMJ Dysfunction
(TMD)

Internal
Derangement External
Within TMJ capsule Derangement
Anterior displacement of Outside TMJ capsule
meniscus
 External derangement

Acute Chronic
External derangement
External derangements are the result of internal
derangement
Acute phase of external derangement will obscure the
diagnosis of internal derangement
Convert the acute phase chronic phase to
correctly diagnose the internal derangement

Flat splint therapy

 External derangement
• The muscles attempt to keep the mandibular condyles
correctly positioned on the meniscus when the patient is in full
occlusion
• Malocclusion prevents the correct condyle / mensicus
relationship State of hyperactivity.
 Acute phase of external derangement

Chronic phase of external derangement

Non-reducing Self- reducing

Pivotal splint therapy Anterior repositioning

splint
 Internal
derangement
Self reducing Non-reducing
(disc displacement (disc displacent without
with reduction) reduction)
• Deviation…no return to normal
• Deviation……returns to
normal • Limited opening
• Deviated
• Click
• Non-deviated
Anterior repositioning
splint • Limited lateral excrusion
• No noise

Pivot splint
 Internal derangement
• Disc displacement with reduction
• Reproducible clicking
• Disc displacement shown by imaging and absence of
degenerative bone disease
• There may be pain, deviation of jaw movements
• No limitation of opening
• Stabilization splint or anterior repositioning
splint
Pivotal splint
Management
Initial (conservative) Further (specialist)

Reassurance Psychological intervention

Education Antidepressants
Habit management Occlusal adjustment

Modification of function Intra-auricular steroids

Rest Manipulation under GA
NSAID, analgesics and muscle relaxants Arthroscopy

Removable occlusal splints Arthrocentesis

Physiotherapy / Jaw exercises Surgery
Working together:
 Dentists
 Orthodontists
 Psychologists
 Physical Therapists
 Ear, Nose, Throat Spesialist
 Physicians
 Alternative Medicine
Physical Therapy Treatment
Physical Therapy is an important aspect in the treatment for
TMD to:
 Relieve musculoskeletal pain
 Decrease inflammation
 Restore normal joint/muscular movements for oral motor function
 Correct poor posture
 Techniques:
Control of Jaw Muscles
• Begin with proper resting position of the jaw. Teach the patient
control while elevating and depressing the mandible throughout
the first half of the Range of Motion(ROM).
• Keeping the tongue on the roof of the mouth, the patient opens
the mouth while trying to keep the chin in midline. Use a mirror
for visual reinforcement.
• If the jaw deviates to one side, teach the patient to practice
lateral deviation to the opposite side without creating pain or
excessive motion.
Manual Therapy
• Massage Reduce pain
• Joint Mobilizations Increase mobility
• Muscle stretching (passive
and active) Restore oral range of motion
• Myofascial Release
• Manual Traction
• Trigger Points
• Relaxation techniques
 Electrophysical Modalities
 Increase blood flow to the  Moist Hot Pack
area  Cold Pack
 Relax tense muscles
 Ultrasound
 Reduce inflammation
 Transcutaneous Electrical
 Reduce pain
Nerve Stimulation (TENS)
 Increase range of motion for
joint opening and lateral  Laser
deviation  Shortwave Diathermy
Avoid: Perform:
Large bites, Relaxation techniques to
Excessive chewing, reduce stress/muscle
Removing food from teeth with tension,
tongue, Maintain good posture.
Gum chewing,
Chewy foods: nuts, etc.
Occlusal splint therapy

Commonly used types

Anterior
Soft vacuum-formed
Stabilization splint repositioning
splint
splint
 Stabilization splint
• Hard acrylic
• Technically demanding
• Maxillary appliance is easier to
adjust
• Worn at night
• Long-term use
• must provide ideal occlusion at
rest and function
• Thickness => free-way space
 Soft vacuum-formed splint
• Useful (?) in muscular signs and symptoms
• Bruxism may become worse in some patients
• Better tolerated in the lower jaw
• Quick and easy to make
• Different thickness
• No need for occlusal adjustment
 Anterior repositioning splint
• Maxillary or mandibular
• Hard acrylic, full coverage
• Upper and lower impressions and occlusal record with
mandible protruded
• Indicated for disc displacement with reduction
• Aims to allow disc to reposition
• Ideally used 24hrs/day for 12 weeks
• Avoid in adolescents
Anterior de-programmer
Surgical Management Of
Temporomandibular Joint Disorders And
Ankylosis
Surgical Techniques
Arthrocentesis
• Minimal invasive
• Joint lavaged with needles to break adhesions

• Current surgical techniques usually involve the placement of at least two cannulas
into the superior joint space. One cannula is used for visualization of the procedure
• with the arthroscope, whereas instruments are placed through the other cannula to
allow instrumentation in the joint
Arthroscopy
• Technique to visualize superior joint space
• Arthroscope placed through cannula.
• Instruments can be placed through cannula to remove adhesions.
Disk Repositioning Surgery
Disk plication and repositioning through a variety of open approaches has been a
common surgical procedure performed to correct anterior disk displacement that
has not responded to nonsurgical treatment .

Open surgical exploration of the TMJ traditionally proceeds after conservative

techniques have been maximized.

Performed to correct anterior disk displacement that has not responded to nonsurgical
treatment and that most frequently results in persistent painful clicking joints or closed
locking.
• In this operation, the displaced disk is identified and repositioned into a more
normal position by removing a wedge of tissue from the posterior attachment of the
disk and suturing the disk back to the correct anatomic position.

• In some cases, this procedure is combined with recontouring of

• the disk, articular eminence, and mandibular condyle.
Wedge od tissue removed
Disk Repair or Removal
• Diskectomy without replacement was one of the earliest surgical procedures
described for treatment of severe TMJ internal derangements.
• Can be performed through arthroscopic techniques to minimize scar tissue
formation and preserve lubrication provided by the synovium.

• In advanced internal pathologic conditions of the joint, the disk may be severely
damaged and perforated but may have adequate remaining tissue so that a repair or
patch procedure can be accomplished.
Interpositional Arthoplasty

• Common techniques of interpositional arthroplasty

• Autogenous grafting , including the use of dermis, auricular cartilage, or temporalis
fascia. Dermis harvested from the abdomen or upper lateral thigh placed into the
joint functions as an interpositional disk.

• Rotation of a Temporalis muscle flap into the joint to provide interpositional tissue
between the condyle and the fossa is done. The posterior fibers of the temporalis
are mobilized from the temporal bone with an anterior pedicle originating from the
coronoid process.
• Anterior aspect of the temporalis muscle provides a blood supply to the flap.
Temporalis muscle flap
Modified Condyletomy
• The theory behind this operation is that muscles attached to the proximal segment
(i.e., segment attached to the condyle) will passively reposition the condyle.

• In this technique osteotomy is completed, but no wire or screw fixation is placed,

• and the patient is placed into intermaxillary fixation for a period
• ranging from 2 to 6 weeks.

• Advocated primarily for treatment of disk displacement with or without reduction.

• And some times for DJD and subluxation or dislocation
Management OF Chronic Recurrent
Disclocation
• Procedures are name as

• Capsulorrhapy
• Meniscectomy
• Eminectomy
• Capsular ligament plication and shortening
Total Joint Replacement
• Alloplastic joint prostheses are usually the only viable surgical option for patients
with significant destruction of TMJ structures or those who have had poor results
from previous surgical treatments that have resulted in severe pain, limited mouth
opening or ankylosis, and malocclusion.
Combined Orthognathic Surgery and Alloplastic
Temporomandibular Joint Reconstruction
• When a patient may present with both a skeletal-facial deformity and an end-stage
TMJ pathologic condition.
• Commonly the dentofacial deformity occurs as a result of the TMJ disease—either
DJD or abnormal condylar growth.
• TMJ disorders commonly associated with skeletal-facial deformities include reactive
arthritis, condylar hyperplasia or hypoplasia, idiopathic condylar resorption,
congenital deformation, trauma, or other end-stage TMJ pathologic conditions.
Postoperative Panorex of a patient who underwent a combined temporomandibular
joint reconstruction and orthognathic procedure.
Temporomandibular Joint Reconstruction
in the Growing Patient
• (A) A gap arthroplasty of at least 1 cm has been created in a pediatric patient with
temporomandibular joint ankylosis. (B) The cartilaginous cap of the costochondral
bone graft has been contoured to serve as a neocondyle.

A
B
• Screw fixation is used to stabilize the costochondral bone graft to the native
• mandible.
Distraction Osteogenesis
• Distraction osteogenesis has been used successfully to reconstruct the mandibular
condyle. This procedure involves exposing the mandibular ramus, usually through an
extraoral approach. The distractor is temporarily stabilized on the lateral surface of
• the mandible, an osteotomy of the posterior ramus is completed, and the distraction
appliance is attached to the osteotomized(condyle) segment and to the stable
portion of the ramus .
• Appliance is activated, producing approximately 1 mm
• of bone movement per day.
Distractor placement on the mandibular ramus with orientation
and vector toward glenoid fossa.
Questions ?