TMJ Print

Temporomandibular Joint
Disorders
TMD
DR. Rehab Tarek Elsharkawy
Ph.D. Medical College of Georgia, USA.
Prof. of Oral and Maxillofacial Surgery
Faculty of Dentistry Cairo University
Anatomy of the TMJ
• Bony Structures (Temporal
bone and the mandible)
• The Articular Disk
• Cartilage
• Synovium
• Ligaments
• Retrodiskal Tissue
• Musculature
• Vascular Supply
• Innervation
Prof. Rehab Elsharkawy
Bony Structures
1.Articular fossa (temporal bone), a concave structure extending
from the posterior slope of the articular eminence to the
postglenoid process, which is a ridge between the fossa and the
external acoustic meatus. The surface of the articular fossa is
thin and may be translucent on a dry skull.
2.The articular eminence (temporal bone), is a transverse bony
prominence that is continuous across the articular surface
mediolaterally. The articular eminence is usually thick and serves
as a major functional component of the TMJ.
3.preglenoid plane, a flattened area
anterior to the eminence.
4. The articular surface of the condyles
of the mandible
TMJ CORONAL VIEW

TMJ LATERAL VIEW

Articular Cartilage
• Lining the inner aspect of all synovial joints, are two types
of tissue: articular cartilage and synovium.
• The space bound by these two structures is termed the
synovial cavity.
• The synovial cavity is filled with synovial fluid.
• The articular surfaces of both the temporal bone and the
condyle are covered with dense articular fibrocartilage.
• This fibrocartilage covering has the capacity to regenerate
and to remodel under functional stresses
• There are few blood vessels in the cartilage and it is
nourished primarily by diffusion from the synovial fluid.
Synovial membrane
• Lining the capsular ligament is the synovial
membrane, a thin, smooth, richly innervated
vascular tissue.
• Synovial cells, somewhat undifferentiated in
appearance, serve both a phagocytic and a
secretory function

Synovial Fluid
• Synovial fluid is considered an ultrafiltrate of plasma.
• It contains a high concentration of hyaluronic acid,
which is responsible for the fluid’s high viscosity.
• The proteins found in synovial fluid are identical to
plasma proteins; albumin and globulin.
• Leukocytes are also present in synovial fluid but with
low conc.
• Only a small amount of synovial fluid, usually less than
2 mL, is present within the healthy TMJ.
• Functions of the synovial fluid: lubrication of the joint,
phagocytosis of particulate debris, and nourishment of
the articular cartilage
The Articular Disk
• The articular disk is composed of dense fibrous connective
tissue
• It is nonvascularized and noninnervated (an adaptation that
allows it to resist pressure).

The Articular Disk
• Anatomically the disk can be divided into the anterior band,
the central zone, and the posterior band.
• The thickness of the disk appears to be correlated with the
prominence of the eminence. The intermediate zone is
thinnest and is generally the area of function between the
mandibular condyle and the temporal bone.
• The articular disk is attached to the capsular ligament
anteriorly, posteriorly, medially, and laterally.
• Some fibers of the superior head of the lateral pterygoid
muscle insert on the disk at its medial aspect to stabilize the
disk to the mandibular condyle during function.

The Articular Disk (meniscus)

Retrodiskal Tissue
These are highly vascular, highly
innervated structures that blend
posteriorly with the articular disk.
The superior retrodiskal lamina:
• Contains elastic fibers
• Attached to the tympanic plate
• Functions as a restraint to disk movement in extreme
translatory movements.
Inferior retrodiskal lamina:

• Consists of collagen fibers.
• It connects the articular disk to the condyle
• Functions to prevent extreme rotation of the disk on the
condyle in rotational movements.
TMJ LIGAMENTS
• Functional ligaments: collateral, capsular, and TMJ ligaments.
• They serve as a major anatomic components of the joints.
• The collateral (or diskal) ligaments are short paired structures attaching
the disk to the lateral and medial poles of each condyle. Their function is
to restrict movement of the disk away from the condyle, thus allowing
smooth synchronous motion of the disk-condyle complex.
• The capsular ligament attaching superiorly to the temporal bone along
the border of the mandibular fossa and eminence and inferiorly to the
neck of the condyle along the edge of the articular facet. It surrounds
the joint spaces and the disk, attaching anteriorly and posteriorly as well
as medially and laterally, where it blends with the collateral ligaments.
The function of the capsular ligament is to resist medial, lateral, and
inferior forces, thereby holding the joint together. And it contains the
synovial fluid within the superior and inferior joint spaces.
• TMJ ligament: The outer oblique portion descends from the outer aspect
of the articular tubercle to the outer posterior surface of the condylar
neck. It limits the amount of inferior distraction that the condyle may
achieve in translatory and rotational movements.
• The inner horizontal portion also arises from the outer surface of the
articular tubercle and runs horizontally backward to attach to the lateral
pole of the condyle and the posterior aspect of the disk. The function is
to limit posterior movement of the condyle, which serves to protect the
retrodiskal tissue.
TMJ LIGAMENTS
• Accessory ligaments: sphenomandibular and
stylomandibular are attached to osseous
structures at some distance from the joints.
• They serve to some degree as passive
restraints on mandibular motion.

Musculature
Muscles of mastication
Medial Lateral
Masseter Temporalis
Pterygoid Pterygoid
Suprahyoid muscles
Geniohyoid Mylohyoid Sternohyoid Digastric
Infrahyoid muscles
Omohyoid Sternohyoid Sternothyroid Thyrohyoid

Musculature
• All muscles attached to the mandible influence its movement to some
degree. Only the four large muscles that attach to the ramus of the
mandible are considered the muscles of mastication; however, a total
of 12 muscles actually influence mandibular motion, all of which are
bilateral.
• Muscle pairs may function together for symmetrical movements or
unilaterally for asymmetrical movement. For example, contraction of
both lateral pterygoid muscles results in protrusion and depression of
the mandible without deviation, whereas contraction of one of the
lateral pterygoid muscles results in protrusion and opening with
deviation to the opposite side.

Musculature
• Muscles influencing mandibular motion may be divided into two groups by
anatomic position.
1.Attaching primarily to the ramus and condylar neck of the mandible is the
supramandibular muscle group, consisting of the temporalis, masseter,
medial pterygoid, and lateral pterygoid muscles. This group functions
predominantly as the elevators of the mandible. The lateral pterygoid does
have a depressor function.
2.Attaching to the body and symphyseal area of the mandible and to the hyoid
bone is the inframandibular group, which functions as the depressors of the
mandible.
•The suprahyoid muscles (digastric, geniohyoid, mylohyoid, and stylohyoid) .
•The infrahyoid muscles (sternohyoid, omohyoid, sternothyroid, and
thyrohyoid).
•The suprahyoid muscles attach to both the hyoid bone and the mandible and
serve to depress the mandible when the hyoid bone is fixed in place.
•They also elevate the hyoid bone when the mandible is fixed in place.
•The infrahyoid muscles serve Prof.toRehabfixElsharkawy
the hyoid bone during depressive
movements of the mandible.
Blood supply
Branches from Superficial temporal
& Maxillary Artery.
There is a rich plexus of veins in
the posterior aspect of the joint
associated with the retrodiskal
tissues
Nerve supply:
Auriculotemporal & Masseteric
and deep temporal nerve.
Classification of TMJ
Anatomically :
Diarthrodial joint :
Def: Discontinuous articulation of 2 bones permitting freedom of
movement that is dictated by associated muscles and limited by
ligaments.
Synovial joint:
Def: Lined by synovial membrane, which secretes synovial fluid.
• The fluid acts as a joint lubricant and supplies the metabolic and
nutritional needs of the nonvascularized internal joint structures
Functionally:
Compound joint:
• The lower compartment permits hinge motion or rotation.
• The upper compartment permits sliding or translatory movement.
Jaw movements
Excursions: Normal movements of the mandible
during function.
• Lateral excursions (left and right)
• The forward excursion (protrusion).
• The reversal of protrusion is retrusion.

TEMPOROMANDIBULAR JOINT
DISORDERS

TMD
Temporomandibular disorder (TMD) is a collective term
embracing various clinical problems that involve the
masticatory musculature and the temporomandibular
joint
Nonarticular
MPD
Muscle spasm Articular
Myositis

TMD
Articular
Neoplasm Infection
Disk Dislocation
Ankylosis Osteoarthritis
displacement Subluxation
With Degenerative
Intracapsular
reduction joint disease
Without Systemic
Extracapsular
reduction arthritis

Classifications of TMD
I. NON articular:
• MPD
II. Articular:
• Disk displacement disorders
Anterior Disk displacement with reduction.
Anterior Disk displacement without reduction.
• Ankylosis
Intracapsular
Extracapsular
• Chronic recurrent dislocation.
• Degenerative joint disease e.g. osteoarthritis.
• Systemic arthritis.
• Neoplasia
• Infections. Prof. Rehab Elsharkawy
How common are TMDs ?
• Percentage of population with signs 50-75%
• Percentage of population with symptoms 20-25%
• Percentage of population who seek treatment 3-4%
Are TMDs more common in females?

1:1 for the prevalence of symptoms in the population
5:1 more females than males present for treatment

Diagnosis
• History (interview).
• Clinical Examination
• Radiographic evaluation
• Psychological evaluation

Interview
It is the most important part of the evaluation that leads to
clues for the diagnosis.
Age :
Younger: MPDS
Older: degenerative disease
Occupation :
Students Higher class people
Oral habit :
Bruxism Chewing pattern
Nail biting
Pipe smoking violin playing
Medical history :
Rheumatoid arthritis drugs
Extraction tonsilitis
Prof. Rehab Elsharkawy trauma
Chief complaint
• Location: localized , unilateral
• Quality: dull ache or sharp shooting
• Severity
• Timing: Morning or evening
• Setting in which it occurs: stressful situations, after tonsillectomy, or
extraction
• Remission and exacerbation
• Associated manifestations
• Radiating
• Clicking or crepitus sounds
• Change in occlusion or uncomfortable occlusion
• Neck, shoulder, or back pain
• Reduced ability to open or close the mouth
• Previous treatment and Response to this treatment
Chief complaint
• It is a statement of Chronic pain in the muscles of mastication
described as a dull ache, typically unilateral.
• Morning time. (MPD).
• Increasing pain over the course of the day or during function.
(TMJ)
• Pain may radiate to the ear and jaw and is worsened with
chewing.
• Clicking or crepitus sounds.
• Headache.
• Change in occlusion or uncomfortable occlusion.
• Neck, shoulder, and back pain
• Reduced ability to open or close the mouth.
• Previous treatments. Prof. Rehab Elsharkawy
CLINICAL EXAMINATION
 Facial symmetry and muscle hypertrophy.
 Muscles palpation should be done systematically for the
presence of tenderness, spasm, or trigger points.
 TMJ palpation for tenderness.
 TMJ palpation for noise (clicking and crepitus).
 Mandibular range of motion should be determined.
(Normal painless voluntary opening as well as opening
achieved by gentle digital pressure).
 Normal movements observed.
 Dental examination to eliminate dental source of pain, to
look for wear facets or mobility (bruxism) , Missing
posterior teeth and occlusal
Prof. Rehababnormalities
Elsharkawy
Muscle Examination
Tenderness Fasciculations
spasm Trigger points

Muscle examination

Muscles examination

Joint Examination
Tenderness
Noise

Joint Examination

• A CLICK indicates an anterior disc
displacement WITH reduction.
• A LOCK indicates anterior disc displacement

WITHOUT reduction.
• Thus, a clicking joint does not lock - a locking

joint does not click - at the same time.

Mandibular range of motion
45 mm
15 mm vertically
protrusive
15 mm
Prof. Rehab Elsharkawy lateral
Limited jaw opening ability

Mandibular range of motion
The range of jaw movement is the only measurable parameter •
which can be objectively recorded in relation to a TMD.
Jaw movement is important as a record of not only the severity •
of the symptoms but also of the rate or degree of improvement.
• Incisal opening - pain free
• Incisal opening - Maximum
• Lateral excursions
• Deviation on pathway of opening
• If the reduction in movement is due to pain this may indicate a

muscular problem.
• If it is due to a physical obstruction then disc displacement is
involved.
Deviation during opening

Mandibular movements observed
(normal should be straight and symmetric)
• Deviation in movement can be due to a variety of
causes. When viewed from the front, jaw movement
could be:
1. In a diagonal straight line from start to end point – in
this case there may be adhesions within the joint.
2. Vertical until almost the maximum range of the
individual’s range of opening is achieved when a
marked lateral movement apparent- if the overall
range of opening is reduced this is usually due to
anterior disc displacement without reduction.
3. Vertical with a lateral movement in the middle of
opening which then returns to the same vertical
plane – this may be associated with disc
displacement with reduction, the condyle having to
move “past the disc” before further opening.
Other investigations
Panoramic radiograph
TMJ arthrography
CT
MRI
Arthroscopy
Lab investigations (e.g.)rheumatoid
arthritis)
Panoramic Radiography
• Screening of odontogenic causes for orofacial pain

• Degenerative bone changes (only in late stages)
• Visualization of both TMJs on the same film, Asymmetries of the
condyle
• Hyperplasia hypoplasia Prof. Rehab Elsharkawy
Trauma Tumors
Computed tomography;
Adv. It provides superior osseous anatomical images

without any superimposition than conventional x-
ray. And in different planes, e.g. Axial, sagittal, coronal
It is good for hard tissues
Disadv. Can’t asses soft tissue components.
MRI
Adv. Doesn’t use ionising radiation.

non invasive
excellent for soft tissues
Disadv. very expensive

patient discomfort
MYOFASCIAL PAIN AND
DYSFUNCTION SYNDROME

Myofascial pain and Dysfunction Syndrome
Def: MPDS is a pain disorder, in which unilateral dull aching
pain is referred from the trigger points in myofascial
structures as a result of abnormal muscular function or
hyperactivity.
Etiology: One of the most commonly accepted causes of MPD
is bruxism secondary to stress and anxiety, with occlusion
being a modifying or aggravating factor.
• MPD is the most common cause of pain and limited
function for which patients seek dental consultation and
treatment.
• It is usually associated with daytime clenching or nocturnal
bruxism. Prof. Rehab Elsharkawy
Activity
Parafunctional Functional
Chewing
Diurnal Nocturnal Speaking Hyperactivity
Swallowing

SYMPTOMS OF MPDS
• Diffuse, poorly localized dull aching facial pain
• The pain may be more severe in the morning (nocturnal bruxism)
• The pain is often more severe during periods of tension and anxiety
• Headaches usually temporal in location (bilateral)
• Tenderness to palpation of muscles of mastication
• Decreased range of mandibular movement
• Deviation of the mandible toward the affected side
• There may be Joint noise and tenderness and maybe not
• Teeth frequently have wear facets.
Radiographs of the TMJs are usually normal
• Some patients have evidence of degenerative changes such as altered
surface contours, erosion, orProf.osteophytes.
Rehab Elsharkawy
INTERNAL DERANGEMENT OF THE
TEMPOROMANDIBULAR JOINT

Internal derangement of the TMJ
• Def: a disruption within the internal aspects of the TMJ in
which there is a displacement of the disc from its normal
functional relationship with the mandibular condyle and
the articular portion of the temporal bone.
• It was estimated that up to 25% of the entire population
has an internal derangement.
• More recently, studies utilizing MRI suggest that the
articular disc is displaced in 35% of asymptomatic
volunteers.
• ID is usually treated with non-surgical methods initially.
• If these methods prove unsuccessful, they are often
followed by surgical methods such as meniscectomy, disc
repositioning procedures and condylotomy.
Internal derangement of TMJ
Aetiology
• Chronic low grade micro trauma e.g. bruxism
• Direct trauma to mandible
• Malocclusion
• Laxity of joint

Internal derangement of TMJ
Types
Anterior disc displacement
.
With Without
reduction reduction

Anterior disk displacement with reduction
• In anterior disk displacement the disk is positioned anterior
and medial to the condyle in the closed position.
• During opening the condyle moves over the posterior band
of the disk and eventually returns to the normal condyle and
disk relationship, resting on the thin intermediate zone.
• During closing the condyle then slips posteriorly and rests on
the retrodiscal tissue, with the disk returning to the anterior,
medially displaced position.
• Examination of the patient usually reveals joint tenderness,
and muscle tenderness may also exist.

Diagnosis:
• Joint tenderness
• May be muscle tenderness and temporal headache
• Maximal opening can be normal or slightly limited
• Transient locking
• Clicking:
•Opening click corresponds to the disk reducing to a
more normal position
•Closing click (i.e., reciprocal click) corresponds to the
disk failing to maintain its normal position between the
condylar head and the articular eminence and slipping
forward to the anteriorly displaced position
Radiographic evaluation:
• Plain TMJ radiography: normal
• MRI images usually demonstrate anterior displacement of
the disk during closing position

Magnetic resonance imaging
MRI

Anterior disk displacement without
reduction
Aetiology: The disk displacement cannot be reduced, and
thus the condyle is unable to translate to its full anterior
extent.
Some evidence suggests that the limitation of motion may
be due to the adherence of the disk to the fossa, causing
a restriction of the sliding function of the joint.

Anterior disk displacement without reduction
Diagnosis:
• No clicking occurs, because they are unable to translate
the condyle over the posterior aspect of the disk.
• Restricted opening
• Deviation to the affected side.
• Decreased lateral excursions to the contralateral side.
Radiographic evaluation:
Plain TMJ radiography may appear normal,
MRI generally demonstrate anteromedial disk displacement
in the close position.
MRI Images taken in the maximal open position continue to
show anterior disk displacement within the open position.
Degenerative Joint Disease (osteoarthritis)
DJD anatomic findings
• Irregular, perforated, or severely damaged disks
• Articular surface abnormalities such as flattening, erosions,
or osteophyte formation
Etiology: The mechanisms of TMJ degenerative diseases are
not clearly understood but are thought to be multifactorial
1) Direct mechanical trauma
2) Hypoxia reperfusion injury
3) Neurogenic inflammation.
Degenerative Joint Disease
Clinical picture:
• Pain
• Stiffness
• Clicking or crepitus
• Limitation of opening.
• Usually in people above 50 years

Degenerative Joint Disease
Radiographic picture:
• Decreased joint space
• Surface erosions
• Osteophytes
• Flattening of the condylar
head
• Irregularities in the articular
fossa and eminence
• Irregular perforated disk

Wilkes Staging Classification for Internal
Derangement of the TMJ
1. Early Stage
a. Clinical: no significant mechanical symptoms,
other than soft, reciprocal clicking; no pain or
limitation of motion
b. Radiologic: slight forward displacement; good
anatomic contour of the disk; normal computed
tomography (CT) scan

2. Early/Intermediate Stage
a. Clinical: first few episodes of pain, occasional
joint tenderness and related temporal headaches,
beginning major mechanical problems, increase in
intensity of clicking
b. Radiologic: slight forward displacement, slight
thickening of the posterior edge or beginning
anatomical deformity of disk, and normal CT scan

3. Intermediate Stage
a. Clinical: multiple episodes of pain, joint
tenderness, temporal headaches, major mechanical
symptoms—intermittent catching or locking and
sustained locking, restriction of motion and pain with
function
b. Radiologic: anterior displacement with significant
deformity of the disk (moderate to marked
thickening of posterior edge) and normal CT scan

4. Intermediate/Late Stage
a. Clinical: chronic pain with variable and episodic
acute pain, headaches, variable restriction of motion,
and undulating course
b. Radiologic: increase in severity over intermediate
stage, abnormal CT scan, and early to moderate
degenerative remodeling hard-tissue changes

5. Late Stage
a. Clinical: characterized by crepitus, grinding
symptoms, variable and episodic pain, chronic
restriction of motion, and difficulty with function
b. Radiologic: anterior displacement, perforation
with simultaneous filling of upper and lower joint
space, filling defects, gross anatomic deformity of
disk and hard tissue, abnormal CT scan as described,
and degenerative arthritic changes
Systemic Arthritic Conditions
• The most common is Rheumatoid arthritis.
• Rheumatoid arthritis: is an inflammatory condition that can
cause pain and aching in the TMJ.
• Symptoms of arthritis are usually present in other areas of
the body. Not necessary old age
• Symptoms usually affects the TMJs bilaterally.
• An inflammatory process results in abnormal proliferation of
synovial tissue (pannus).
• Pannus :a sheet of inflammatory granulation tissue that
spreads from the synovial membrane and invades the joint
ultimately leading to fibrous ankylosis .
• If RA is left untreated, it may deform both the head of the
condyle and the Glenoid fossa
Rheumatoid arthritis
Radiographic findings;
• TMJ initially show erosive changes in
the anterior and posterior aspects of
the condylar heads.
• Progress to large eroded areas that
leave the appearance of a small,
pointed condyle in a large fossa
• Eventually the entire condyle and
condylar neck may be destroyed
• Shortening of ramus and anterior
open bite

Rheumatoid arthritis.
Laboratory tests: may be helpful in confirming the
diagnosis of rheumatoid arthritis.
• Rheumatoid factor
• Erythrocyte sedimentation rate

Infections
• Infections in the TMJ area are extremely rare.
Etiology: It may result from direct extension of adjacent
infection or hematogenous spread of bloodborne organisms.
Diagnosis:
• Pain, hotness, and limitation of motion.
• X-ray results are negative in the early stages but may show
bone destruction later.
• If suppurative arthritis is suspected, the joint is aspirated to
confirm the diagnosis and to identify the causative organism.
Treatment includes antibiotics, proper hydration, pain control,
and motion restriction (till infection subsides) then jaw
opening exercises to prevent limitation of motion.
TREATMENT

Treatment
Goals of treatment:
• Decrease joint overload
• Decrease pain
• Reduce inflammation
• Improvement in the range of motion
• Restore function
• Identify and control the Causative factors

NONSURGICAL MANAGEMENT OF
TMD

Treatment
Nonsurgical options include:
• Patient education
• Soft diet
• Occlusal appliance/orthotic devices
• Parafunctional habit awareness
• Biofeedback
• Nonsteroidal anti-infammatory medication
• Muscle relaxants
• Botulinum toxin
• Physical therapy
Patient education
1.Patients awareness of the factors associated with their pain
and dysfunction can participate in their own improvement.
• MPD often results from parafunctional habits or muscular
hyperactivity secondary to stress and anxiety.
• Patients who are aware of these factors are often able to
control their activity and thereby reduce discomfort and
improve function, reducing exposure to stressful situations,
and psychological counselling.

Patient education
2. Modification of diet : The less hard diet prevents

overloading of the TMJ and decreases muscle activity that
may be hyperactive.
• Alteration of the diet : cut food into small pieces, avoid
eating chewy, crunchy foods or ice crushing, avoid gum
chewing for certain treatmenttime may result in a
significant reduction in symptoms.
• A gradual progression to a more normal diet over a period
of 6 weeks may be sufficient to reduce joint or muscle
symptoms.

Physiotherapy
• 3. Physiotherapy: Physical therapy can be useful in the management of
patients with TMJ pain and dysfunction. A variety of techniques have
been used successfully as adjunctive therapy The most common
modalities used include range of motion exercises, relaxation training,
ultrasound, spray and stretch, and pressure massage
• Although the patient is generally encouraged to reduce the functional
load placed on the joint and muscles, it is important to remember
that maximizing range of motion is also an important aspect of
treatment of all TMDs.
• Limited mandibular range of motion may lead to problems in the TMJ
and muscles of mastication. The lack of mobility may limit the
lubrication of the joint via changes in the synovial membrane and
contribute to degenerative changes of the articular surfaces. Limited
muscular movement can result in fibrosis, further restriction of
motion, and an increase in pain.
Physiotherapy
• 3. Physiotherapy:
• Passive jaw exercise Passive jaw exercise allows the patient to
manually, or with a device progressively increase inter-incisal
opening.
• Gentle stretching exercises done to pain tolerance through
passive opening. Simple methods for passive therapy include
stretching by exerting a scissor effect with the thumb and
forefinger or interval increases in tongue blades placed between
the upper and lower teeth, In some cases patients can obtain
simple appliances that provide easy and efficient methods for
improving jaw mobility (Therabite.)
• It is effective for patients experiencing MPD, but may be
contraindicated in patients with severely displaced disks, due to
the possibility of damage to the disk or retrodiskal tissues.
• Passive jaw exercise is also very effective for patients who
experience muscular-associated trismus and myofascial pain and
dysfunction (MPD).
Physiotherapy
3. Physiotherapy:
• Heat therapy has been reported to reduce muscle pain by causing local
vasodilation and increased blood flow, thereby clearing out local
inflammatory mediators.
• Cryotherapy (cold) is often used by physical therapists as an aid in muscle
stretching exercises in an attempt to increase jaw opening that is limited
by muscular pain.
• Ultrasound is an effective way to produce tissue heating with ultrasonic
waves, which alter blood flow and metabolic activity at a deeper level
than that provided by simple surface moist-heat applications. The effect
of ultrasonic tissue heating is theoretically related to increase in tissue
temperature, increase in circulation, increase in uptake of painful
metabolic byproducts, and disruption of collagen cross-linking, which may
affect adhesion formation. All of these effects may result in a more
comfortable manipulation of muscles and a wider range of motion. intra-
articular inflammation may also be reduced with ultrasonic applications.
Therapeutic exercises
• Reduce pain
• Improve coordination of masticatory muscles
• Reduce muscle spasm and hyperactivity
• Restore the original muscle length
• Strengthen the muscles involved
• Promote tissue repair and regeneration.

4. Medication
a. NSAIDs : e.g. Propionic acids (ibuprofen) , salicylic
acids (aspirin).
• Effective in reducing inflammation in both muscles and
joints and provide satisfactory pain relief.
• It is important to remember that these medications
work best when administered on a timetable rather
than on a pain-dependent schedule.
• Patients should be instructed to take the medicine on
a regular basis, obtaining an adequate blood level that
should then be maintained for a minimum of 7 to 10
days.
• The COX-2 inhibitors such as (Celebrex) and (Vioxx)
have gained popularity in the treatment of
inflammation and pain. These drugs have been
associated with significant Prof.side effects, including
Rehab Elsharkawy
vascular and cardiac complications.
Medication
b.Analgesic medicines may be used in addition to the
antiinflammatory medications in some cases
• The may range from acetaminophen to potent narcotics.
• Acetaminophen (Paracetamol, Panadol, Tylenol) used for
10 days to 2 weeks should be sufficient.
• Narcotics: Because of their sedative and depressive effects
and their potential for addiction, these medications are
usually restricted to short-term use in patients with severe,
acute pain

Medication
c.Muscle relaxants: these are drugs which affect skeletal
muscle function and decrease the muscle tone. It may be
used to alleviate symptoms such as muscle spasms and
pain. They provide significant improvement in jaw
function and relief of masticatory pain.
• However, muscle relaxants have a significant potential for
depression and sedation and can produce long-term
addiction.
• In many patients with acute pain or exacerbation of
muscular hyperactivity, muscle relaxants can be
considered for short periods, such as 10 days to 2 weeks.
e.g. Methocarbamol, Diazepam.
Medication
d. Tricyclic antidepressants: (TCAs) are group of chemical
compounds which are used primarily for their ability to
relieve depressive symptoms. They are named after their
chemical structure, which contains three rings of atoms.
• TCAs when used in low doses appear to be useful in the
management of patients with chronic pain as they prevent
the reuptake of amine neurotransmitters, such as serotonin
and norepinephrine, causing an inhibition of pain
transmission.
• It is effective in decreasing nocturnal bruxism.

Medication
e.Botulinum Toxin A: has shown promise in decreasing
masticatory muscle hyperactivity.
• Botulinum Toxin (Botox) is a neurotoxin produced by the
bacterium Clostridium botulinum.
• This neurotoxin produces a paralytic effect on muscles by
inhibiting the release of acetylcholine at the neuromuscular
junction.
• In very low doses, Botox can be safely administered by
injection directly into the affected muscle area, decreasing
muscle contraction activity and the associated pain.
• The effect of Botox is temporary, lasting from a few weeks to
several months. In many cases injection of Botox must be
repeated to obtain long-term pain relief.
Injection of LA
f. Local anesthetics can be used as diagnostic blocks intra-articularly and/or
intramuscularly to alleviate pain and increase range of motion.
• Injection of LA and steroids into the temporalis tendon has been shown to be an
effective way to decrease pain and inflammation. Tendinitis in such areas as the
insertion of the temporalis tendon along the ascending ramus and coronoid process
often responds favorably to trigger point injection.
• Local anesthetic provides temporary relief of pain, and steroids exert their effect
through the inhibition of proinflammatory cytokines.
• Some debate is ongoing about the long-term effect of steroids in the joint and the
possibility that further degeneration may be associated with steroid injection
• A local anesthetic without vasoconstrictor should be used, because the decrease in
blood flow may exacerbate muscular pain

SPLINT THERAPY
There is strong evidence that occlusal splint therapy is successful in the
treatment of TMD but there is no consensus of opinion on how splints
work.

PERMANENT OCCLUSION MODIFICATION
• After completion of a course of reversible treatment,
some patients may be candidates for permanent
modification of the occlusion.
• It may include:
 occlusal equilibration,
 prosthetic restoration,
 orthodontics,
 orthognathic surgery.

TEMPOROMADIBULAR JOINT
SURGERY

Arthrocentesis
• Arthrocentesis is a minimally invasive technique that involves placing ports (needles or
small cannulas) into the TMJ to lavage the joint and to break up fine adhesions.
• Most patients undergoing arthrocentesis do so with intravenous sedation and an
auriculotemporal nerve block.
• The most common method of arthrocentesis is placing one needle into the superior
joint space. A small amount of lactated Ringer solution is injected to distend the joint
space and release fine adhesions that may be limiting disk mobility. With the joint
insufflated, a second needle is placed into the superior joint space, allowing thorough
lavage with large amounts of fluid (approximately 200 mL).
• The most common use is in patients with anterior disk displacement without reduction.
• Why?
1. When disk displacement occurs, negative pressure may develop within the joint,
causing a "suction cup" effect between the disk and fossa. Distending the joint
eliminates this negative pressure.
2. In some cases of more chronic disk displacement, some adhesion may develop
between the disk and fossa. With arthrocentesis the distension under pressure can
release these adhesions.
3. Capsular constriction may occur as a result of joint hypomobility and can be stretched
with pressure distention.
4.The simple flushing action in the joint may eliminate biochemical factors contributing to
inflammation and pain. Prof. Rehab Elsharkawy
Arthroscopy
• Arthroscopic surgery has become one of the most popular
and effective methods of diagnosing and treating TMJ
disorders.
Indications: It has been advocated for treatment of a variety
of TMJ disorders, including internal derangements,
hypomobility as a result of fibrosis or adhesions, and
hypermobility.
Advantages: The efficacy of arthroscopic treatment appears
to be very similar to that of open joint procedures, with the
advantage of less surgical morbidity and fewer and less
severe complications

Tech:
Arthroscopy
• The technique involves placement of a small cannula into the
superior joint space, followed by insertion of an arthroscope to allow
direct visualization of all aspects of the glenoid fossa, superior joint
space, and superior aspect of the disk.
• Arthroscopic evaluation enables the surgeon to visualize the joint
and, therefore, contributes to the diagnosis of the internal pathologic
condition of the joint. Lysis of adhesions and lavage of the joint are
also completed.
• More sophisticated arthroscopic operative techniques have been
developed, increasing the ability of the surgeon to correct a variety of
intracapsular disorders. 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.
Tech:
Arthroscopy
• Instrumentation used through the working cannula includes forceps,
scissors, sutures, medication needles, cautery probes, and motorized
instrumentation such as burs and shavers.
• Laser fibers can also be used to eliminate adhesions and inflamed
tissue and incise tissue within the joint.
• Disk manipulation, disk attachment release, posterior band cautery,
and suture techniques have been developed in an attempt to
reposition or stabilize displaced disks.
• At the end of the arthroscopic or arthrocentesis procedures, the
surgeon has the option of injecting medications including steroid,
hyaluronic acid (HA), and platelet-rich plasma (PRP). Hyaluronic acid
is a material naturally found in synovial fluid. It plays an important
role in joint function and nutrition. HA is the main contributor to the
viscosity of synovial fuid and provides protection under joint loading.
Surgical Approaches to the TMJ
Preauricular incision Endaural Approach
Postauricular incision

Disk-Repositioning Surgery
• Open joint procedures could be performed to correct disk
displacement that has not responded to nonsurgical treatment with
persistent painful clicking joints or closed locking.
• The goal of disc-repositioning procedures is to relocate the disc to the

normal condyle-disc-fossa relationship.
Indications for disc-repositioning procedures:

1. Patients with painful anterior disc displacement with reduction that
has not responded to nonsurgical and minimally invasive procedures
2. Patients with anterior disc displacement without reduction with
persistent pain and limited mouth opening that has not responded to
nonsurgical and minimally invasive procedures
Disc-Repositioning Surgery
• In this operation, the displaced disk is identified and
repositioned into a more normal position using one
of the following techniques:
1.Partial Disc plication: A partial-thickness excision in
which only the superior lamina of the retrodiscal
tissues are removed, without violation of the inferior
joint space, and the rest of retrodical tissues are folded
over each other, reapproximated and sutured.
2. Complete Disc plication: Full-thickness wedge-
shaped portion of the posterior attachment is removed
, the disc is pulled posteriorly and the reaining
retrodiscal tissues are sutured to the posterior and
lateral margins.
• 50 Unfortunately, this surgery does not produce improvement
in all patients, with 10% to 15% of patients describing no
improvement or a worsening of the condition
Disk Repair
• 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.
• Perforations rarely occur within the disc
proper but rather within the lateral third of
the posterior attachment.
A. Small perforations (1-3mm) can be treated
with primary closure (suturing).
B. If the disc has a large perforation, the edges
of the perforation are excised and a graft
material is laid over the perforation. Grafts may
be abdominal dermal tissues, auricular
cartilage, or temporalis fascia.
Disc Removal (Discectomy)
• Discectomy is the procedure in which the entire
disc is removed.
• It is indicated when the disc is irreparable due to
deformation or severe degeneration.
• It could be either:
A. Disc removal without replacement. Degenerative
changes may occur in the joint and crepitus is a
common finding after this procedure.
B. Disc removal with replacement using Autogenous
(dermis, auricular cartilage or temporalis
fascial),allogenic or alloplastic(silicon) material to
prevent intra-articular adhesions, osseous
remodeling, and recurrent pain.
Total joint replacement
• In some cases, a pathologic condition of the joint results in
destruction of joint structures and in loss of vertical dimension
of the condyle and posterior ramus, malocclusion, limited
opening, and severe pain.
• One method of joint reconstruction involves grafting
autogenous tissue using a costochondral bone graft.
• These grafts are most frequently used in growing individuals but
also can be used effectively in the treatment of a variety of adult
disorders.
• In this situation, the graft replaces only the condylar portion of
the joint and does not address significant abnormalities of the
fossa.
• Problems with costochondral grafting include recurrent
ankylosis, degenerative changes of the graft, and (in some
cases) excess and asymmetric growth of the graft.
Total Joint Replacement
• Total joint replacement could be done using Alloplastic
joint prostheses where it is the only viable surgical option
for patients with:
1. Significant TMJ structures destruction
2. Cases who have had poor results from previous surgical
treatments that has resulted in severe pain, limited
mouth opening or ankylosis, and malocclusion
• In the past, several types of prosthetic joint replacement
have been available. Unfortunately, long-term results
have been disappointing because of a variety of
engineering and biologic problems. The excessive scar
tissue associated with multiple previous open joint
surgeries, mechanical failure, and foreign body reaction
from wear debris.
Total Joint Replacement
• However, current prosthetic joints have been shown to be a safe, effective,
and reliable treatment modality for those with advanced disease.
• Newer-generation joint prostheses have improved engineering, better
biocompatibility, and materials with greater wear resistance. These recent
advantages have provided significant improvement in the outcome after total
joint replacement
• Total joint replacement can be completed with standard preformed fossa and
condyle parts or with custom fabrication of joint components.
• Prefabricated fossas are sized based on the available bone for fixation along
the zygomatic arch while the condylar component is sized based on the
height of the native condyleramus unit.
• Custom joints are generated from a wax template created on a stereolithic
model based on three-dimensional CT scan imaging of the articular fossa and
mandibular anatomy

HYPOMOBILITY AND HYPERMOBILITY

ANKYLOSIS

Extracapsular ankylosis
• Etiology:
1. Coronoid process hyperplasia.
2. Depressed zygomatic arch fracture.
3. Infection or fibrosis of the temporalis muscle
4. High-dose radiation involving the muscles of mastication.
5. Scar contracture following thermal injury
6. Tumor of the condyle or coronoid process
7. Trismus due to Infection (pterygomandibular space ), Neurologic
(tetanus toxins), Post surgical.
•Patients initially have limitation of opening and deviation to the

affected side.
•limited lateral and protrusive movements can usually be performed
indicating no intracapsular ankylosis.
Intracapsular ankylosis
Def: Intracapsular ankylosis results from a
fusion of the condyle, disc, and fossa
complex, as a result of the formation of
fibrous tissue but more commonly bone
fusion or a combination of the two.
• It leads to reduced mandibular opening that
ranges from partial reduction in function to
complete immobility of the jaw.
• It may arrest the mandibular growth if
occurred during the first 2 decades of life due
to the loss of the condylar growth center and
the loss of the continuous functional
stimulation. Prof. Rehab Elsharkawy
Etiology:
1. Trauma, usually to the chin that leads to intracapsular
condylar fractures. Which will lead to haemarthrosis,
fibrosis, and finally calcification with bony union.
2. In very rare cases, infections (Otitis media).
3. Obstetric trauma.
4. Inflammation: rheumatoid arthritis.
5. Previous surgical treatment that resulted in scarring:
postoperative complications of TMJ or orthognathic surgery

Diagnosis: Clinical picture
1. Severe restriction of mouth opening.
2. Deviation to the affected side when opening. (Unilateral)
3. Decreased lateral excursions to the contralateral side.
4. Palpation of bony protuberance infront of the ear.
5. Facial deformation that depends on the age at which it
occurred. Underdevelopment of the lower jaw which may
lead to facial asymmetry (if unilateral) or micrognathia (if
bilateral) giving the look of a birds face.
6. Chin scar is common.
7. Caries, periodontal disease and impactions with
malocclusion.

Diagnosis: Radiographic evaluation:
1.Lack of the condyle and fossa,
with varying degrees of calcified
connection between these surfaces.
2. Acute antigonial notch.
3. Shortening of the ramus and body of the
mandible.
4. The anterior teeth are protruded.

Intracapsular Ankylosis
Treatment: Surgery is the mainstay of treatment.
Aim of the surgery:
1. To free the affected joint and restore normal mouth

opening.
2. To correct the facial contour.
3. To correct the occlusion
4. To relief any respiratory obstruction.

Intracapsular Ankylosis
Treatment
1. Codylectomy: When the anatomy of the condyle is not
totally disrupted surgery is done to cut off the codyle to free
the mandible.
2. Gap arthroplasty: When the joint is massively fused with
the glenoid fossa where no anatomic details are present, 2
osteotomy lines are created below the mass ,1cm wide, the
section of bone between these 2 osteotomy lines is
removed to free the mandible and create a new ‘joint
cavity’.
3.Interpositional grafts: sometimes after separating the
mandible from the ankylotic mass and creating new joint a
graft material is placed in this gap to prevent re-ankylosis.
Silastic, cartilage, temporalis muscle and fascia have all
been used. Prof. Rehab Elsharkawy
Ankylosis
Treatment
4. Prosthetic joint replacement : Ankylosis results in destruction of joint
structures so that reconstruction or replacement of components of the
TMJ is necessary. Several prosthetic TMJ systems are available whether
ready made or custommade.
5. Costochondral grafts:
In childhood ankylosis, a functional, growth permitting replacement for the
mandibular condyle can be fashioned from a costochondral graft (fifth and
seventh).
Advantages:
a. Costochondral graft has a growth potential
b. It has a biological compatibility.
c. It can remodel to form a new condyle
Problems:
a. Donor site morbidity
b. Resorption
c. Excessive growth on the treated side may occur
d. Inability to catch up with the speed of growth on the normal side
Treatment
Ankylosis
6. Distraction osteogenesis.
•The loss of vertical ramus height is a consequence of a condylar
pathologic condition and may result in asymmetry and malocclusion,
as well as dysfunction and pain.
•Until recently, skeletally immature patients were treated primarily
with costochondral grafts.
•The need for donor site surgery and unpredictable results yielded less
than ideal results in many patients.
•More recently, distraction osteogenesis has been used successfully to
elongate mandibular ramus and body
Distraction osteogenesis
• One new approach to correction of deficiencies in the mandible
and the maxilla involves the use of distraction osteogenesis (DO).
• When correcting bone deficiencies caused by the early childhood
ankylosis and trying to elongate the body and the ramus, the
conventional osteotomy techniques have several potential
limitations.
• When large skeletal movements are required, the associated soft
tissue often cannot adapt to the acute changes and stretching that
result from the surgical repositioning of bone segments. This
failure of tissue adaptation results in several problems, including
surgical relapse, and increased severity of neurosensory loss as a
result of stretching of nerves.
• In some cases, the amount of movement is so large that the gaps
created require bone grafts harvested from secondary surgical
sites such as the iliac crest.

Distraction osteogenesis
• DO involves cutting an osteotomy to separate segments of bone and the
application of an appliance (distractor) that will facilitate the gradual and
incremental separation of bone segments.
• The gradual tension placed on the distracting bone interface produces
continuous bone formation.
• Additionally, surrounding tissue appears to adapt to this gradual tension,
producing adaptive changes in all surrounding tissues, including muscles and
tendons, nerves, cartilage, blood vessels, and skin.
• Advantages:
1. Ability to produce larger skeletal movements
2. Ilimination of the need for bone grafts and the associated secondary
surgical site
3. Better long term stability
4. Decreased neurosensory loss.

Ankylosis
6. Distraction osteogenesis.
a. The initial surgical procedure involves performing an osteotomy in
the bone and placement of the distraction appliance.
b. Leaving bone to start healing for 5-7 days (the latency period)
c. Following the latency period the distraction appliance is activated in
a rate and rhythm of 1 mm per day (0.5 mm twice each day). This
moves the bony segment for 1mm each. (distraction phase)
d. Once this distraction is complete, the appliance is left in place for
the consolidation phase, which is usually 2 or 3 times the amount of
time required for the distraction phase.(consolidation phase)
e. A second intervention is required to remove the distractor, and a
stabilizing bone plate can be placed over the regenerate gap.
•Finalizing the occlusion often requires orthodontic detailing or
equilibration to aid in providing a stable, balanced interdigitation.
Dislocation
• Mandibular Dislocation is a situation
characterized by a condylar position anterior
and superior to the articular eminence
that is not self-reducing.
• Dislocation may be unilateral or bilateral
• It is associated with Pain and severe muscular spasms
• May occur spontaneously after opening the mouth widely,
such as when yawning, eating, or during a dental
procedure.
• Dislocation of the mandibular condyle that persists for
more than a few seconds generally becomes painful and is
often associated with severe muscular spasms.
Dislocation
Etiology:
1. Extrinsic trauma, especially that sustained while the mouth is
open
2. Iatrogenic: Medical and dental procedures which require wide
mouth opening for prolonged time: Intubation procedures,
gastrointestinal endoscopy, laryngoscopy/bronchoscopy
3. Spontaneous: Laughing, Yawning, Biting, Epileptic seizures
4. Anatomical aberrations: Small condyle, shallow/steep articular
eminence, laxity of ligaments and capsule.
5. Systemic disorders: Parkinson disease
6. Medications: Antipsychiatric, Antiemetic
7. Occlusal conditions: Edentulous posterior region
Dislocation
Clinical Features:
1. Pain in the preauricular and surrounding region
2. Preauricular depression/hollowing
3. Protruding chin
4. Inability to close mouth
5. Drooling of saliva
6. Inability to speak, swallow, or masticate
7. Tense masticatory muscles
Unilateral dislocation is associated with deviation of

chin towards contralateral side
Dislocation
• Usually reduction is not difficult. However,
muscular spasms may prevent simple
reduction, particularly when the dislocation
cannot be reduced immediately.
• In these cases, anesthesia of the auricular
temporal nerve and the muscles of
mastication may be necessary.
• Sedation to reduce patient anxiety and
provide muscular relaxation may also be
required.
• After reduction the patient should be
instructed to restrict mandibular opening
for 3 to 6 weeks.
• Ice Moist heat
• NSAIDs are also helpful in controlling pain
and inflammation. Prof. Rehab Elsharkawy
Subluxation
• Def: Mandibular subluxation occurs when there is a
momentary inability to close the mouth from a maximally
open position.
• It is defined as a self-reducing partial dislocation of the
TMJ, during which the condyle passes anterior to the
articular eminence.
Aetiology:
• Acute trauma.
• Following a seizure
• Associated with systemic diseases such as parkinson’s
disease.
• In the elderly drug induced dystonias may be implicated.
• Most cases are idiopathic.
Subluxation
Treatment:
 In the absence of pain, subluxation requires no specific
treatment since it is self-reduced by the patient.
 When associated with wide mouth opening, conscious
efforts to avoid it.
 Patients are advised to modify their diets.
 Dental treatment is done over multiple shorter
appointments and the use of biteblocks during procedures
can also be helpful.

Subluxation Treatment
A.Non-surgical treatment
1.Revision of the etiology or the drug treatment.
2.Sclerotherapy and Prolotherapy: (Proliferative Injection
Therapy) involves injecting irritant solution into the ligaments
in order to strengthen weakened connective tissue.
3. Injection of botulinum toxin into the lateral pterygoid
muscles.
B. Surgical treatment
1. Eminectomy. reduction of the bony eminence.
2. Downward fracture of a segment of the zygomatic arch
3.Bone grafts: Augmentation of the articular eminence to
prevent dislocation.
4. Capsular plication : The lateral capsule is incised and sutured
back on itself to tighten and limit capsular laxity.
THANK YOU
Good Luck

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Temporomandibular Joint

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Inferior retrodiskal lamina:

Prof. Rehab Elsharkawy

Omohyoid Sternohyoid Sternothyroid Thyrohyoid

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Are TMDs more common in females?

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

spasm Trigger points

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

• A LOCK indicates anterior disc displacement

• Thus, a clicking joint does not lock - a locking

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

• If the reduction in movement is due to pain this may indicate a

Prof. Rehab Elsharkawy

• Screening of odontogenic causes for orofacial pain

Adv. It provides superior osseous anatomical images

Adv. Doesn’t use ionising radiation.

Disadv. very expensive

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

• Chronic low grade micro trauma e.g. bruxism

• Direct trauma to mandible

Prof. Rehab Elsharkawy

Anterior disc displacement

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

1) Direct mechanical trauma

2) Hypoxia reperfusion injury

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

Prof. Rehab Elsharkawy

2. Modification of diet : The less hard diet prevents

Prof. Rehab Elsharkawy