Contents Introduction History Definitions Classification Epidemiology Etiology Development of functional disturbances in masticatory system Predisposing factors Initiating

factors Perpetuating factors. Occlusal conditions Parafunctional habits Trauma Emotional stress Deep pain output Signs and symptoms of T DS !unctional disorders of muscles !unctional disorders of T " !unctional disorders of teeth Other signs and symptoms Summary Conclusion #eferences

Introduction$ The masticatory apparatus is speciali%ed unit that performs multiple functions including those of spea&ing' cutting ( grinding food ( s)allo)ing. T " disorder *T D+ are among the most misdiagnosed ( mistreated maladies in medicine. ultifactorial origin

 The term T D are collective term embracing a member of clinical problems that involve the masticatory musculatures' the T " ( associated structure or both This disorders are characteri%ed by !acial pain in the region of the T " ( for the muscle of mastication. ,imitation or deviation in the mandibular range of motion. T " sounds during -a) movements ( function. History$ ./0 1C$ Hippocrates described a condition of T " dislocation. 202/$ Hey had described internal derangement for a locali%ed mechanical fault interfering )ith smooth articular function.

20/3$ Cooper reported on sublu4ation of the T " as a distinct entity. He observed patients )ith snapping -a) ( registered this symptom as an 5 internal derangement of the -a)s6 2007$ Surgical correction )as described by 8nnandale. 2920$ Pringle e4plained clic&ing ( popping of the T " as a sign of anterior displacement of the meniscus. 29./$ Costen )as first to indicate an occlusal etiology in T " pain. He reported association of the bite over closure )ith symptoms li&e ear pain' sinus pain' decreased hearing' tinnitus' di%%iness' burning ( vertigo ( occipital headache. 29/7$ :orgaard used orthographic techni;ues to radiographically demonstrate anterior disc displacement in clic&ing or popping T ". 29<=>?=$ muscular cause not directly related to occlusion )as proposed Sch)art% coined the term Temporomandibular pain syndrome. 297=$ advances in diagnostic imaging have resulted a better understanding of the intracapsular problem associated )ith T D. !arrar ( cCarthy re-uvenated the concept of internal derangement )ith meniscus displacement.

Definition of T D 8cc to Schiffman' Haley' Shapiro *299=+

the T D encompasses many disorders of the masticatory musculature *i.e. myositis' muscle spasm' muscle contracture' ( myofascial pain syndrome+ and T " * internal derangements )ith or )ithout reduction and degenerative -oint disease+ The 88OP * in 299. ( 299?+ refined T D as a collective term embracing a number of clinical problems that involve the masticatory musculature' the temporomandibular -oint and associated structures or both.

@PT > 0 Conditions producing abnormal ' incomplete or impaired function of the temporomandibular -oint. 8 collection of symptoms fre;uently observed in various combinations first described by Costen *29./+ )hich he claimed to be refle4es due to irritation of the auriculotemporal nerve and A or corda tympanic nerve as they emerged from tympanic plate. It is caused by altered anatomic relations and derangements of the T " associated )ith loss of occlusal vertical dimension' loss of posterior tooth support' and A or other malocclusions. The symptoms can include headache about the verte4 and occiput' tannitus' pain about the ear' impaired hearing and pain about the tongue. Classification of diseases of Temporomandibular -oint 1ell in 29?= . subgroups$ Intracapsular conditions Capsular conditions Extracapsular conditions In 2903' < subcategories Masticatory muscle disorder Disk interference disorder Inflammatory disorder Chronic hypomobilities Growth disorders

8cc. to 8merican 8cademy of Orofacial Pain Diagnostic category Cranial bones Diagnosis Congenital & developmental disorders plasia !ypoplasia Dysplasia"#st & $nd brachial arch anomalies% hemifacial microsomia% &ierre syndrome% 'reacher Collin syndrome( Condylar hyperplasia &rognathism% fibrous dysplasia) c*uired disorders +eoplasia ,racture

'emporomandibular -oint Disorders

Deviation in form Disk displacement "with reduction. without reduction( Dislocation Inflammatory conditions "synovitis% capsulitis( rthritides "osteoarthritis% osteoarthrosis polyarthritides( nkylosis "fibrous% bony( +eoplasia Myofascial pain Myositis /pasm &rotective splinting Contracture

Masticatory muscle Disorders

0etween 12 and 324 of people experience some symptoms of 'MD during their lives% and approximately #$4 experience prolonged pain or disability that results in chronic symptoms) 5nly about 2 to 64 have symptoms severe enough to need treatment) 'MD patients are similar to headache and back pain patients with respect to disability% psychosocial profile% and pain intensity% chronicity% and fre*uency) 'he lower prevalence of 'MD signs and symptoms in older age groups supports the probability that most 'MD are self7limiting) 'MD are most prevalent between the ages of $8 and 98 years and predominantly affect women) 'he reason why women make up the ma-ority of patients presenting for treatment is still unclear) In a community7based study% a greater likelihood of developing 'MD was found if oral contraceptives were used and% in women over 98 years of age% if estrogen replacement was used) :hile the prevalence of 'MD is highest in the $87 to 987year age range% signs and symptoms of masticatory7muscle and -oint dysfunction are commonly observed in children) 'he cause may be acute reactive depression% disk displacement% with or without reduction% internal derangement due to previous in-ury)

Development of functional disturbances in the masticatory system

:ormal function event

+ormal fuction Chewing swallowing speaking

C D physiologic tolerance B

T D symptoms

carried out by the complex neuro muscular control system) Events During normal function of the masticatory system% events can occure that may influence function) ;ocal events systemic events)

;ocal events ny change in sensory or proprioceptive input) &lacement of improperly occluding crown or it may be secondary to trauma involving local tissues e)g) post in-ection response of ;) ) trauma due to wide opening "i)e) strain( or unaccustomed use "i)e) bruxisum() systemic events 'he entire body and C+/ are involved) E)g) emotional stress) &hysiologic tolerence ll individuals do not respond in the same manner to the same event) Each patient has the ability to tolerate certain events without any adverse effect this is called physiologic tolerance which can be influenced by both local and systemic factors) ;ocal factors ;ack of occlusal stability7 genetic% developmental% or iatrogenic causes) 'M< instability7 alteration in normal anatomic form e)g)7 disc displacement% arthritic conditions% lack of harmony between stable intercuspal position "IC&( and musculoskeletally stable "M/( position of the -oint) /ystemic factors /ystemic factors which influence the patient=s physiologic tolerance are% genetic% gender% diet% acute and chronic diseases% overall physical condition of the patient) /tructural tolerance and development of symptoms) :hen functional change exceeds a critical level% alteration of tissues begins this level is called structural tolerance level) 'he initial breakdown is seen in the structures with the lowest structural tolerance) 'herefore the breakdown sites varies from individual to individual)

'he etiology of 'MD remains mired in controversy) It is generally agreed that the etiology of symptoms of 'MD is multifactorial) 'hat is several different factors acting alone% or in varying combinations may be responsible)

&redisposing factor > factors that increase the risk of 'MD or orofacial pain developing) Initiating factors > factors that cause the onset of disorder) &erpetuating factors > factors that interfere with healing and complicate management ) &redisposing factors can be subdivided into ? Systematic factors > medical conditions such as rheumatic infections% nutritional and metabolic disorders can influence masticatory system to an extent that 'MD may emerge) Psychologic factors 7 &ersonality% behaviour can affect masticatory system) Structural factors > ll types of occlusal discrepancies% improper dental treatment% postural abnormalities %skeletal deformation% past in-uries etc) Genetic factors) Direct precipitating or initiating component?

 'rauma from hyperextension "e)g) dental procedure% oral intubation for G) )% yawning% hyperextension associated with cervical trauma( Micro & macro trauma dverse or overloading of -oint structures &arafunctional habits "nocturnal bruxing% tooth clenching% lip or cheek biting( &erpetuating factors or sustaining factors? Mechanical & muscular stress Metabolic problems Mainly behavioral% social & emotional difficulties ,ive ma-or factors associated with 'MD #( 5cclusal condition $( 'rauma @( Emotional stress 9( Deep pain input 2( &arafunctional activities)

occlusal condition) &ullinger et al) "- prosthet dent $888%3@?11762(% studied ## possible occlusal factors) Concluded that% +o single occlusal factor was able to differentiate patient from healthy sub-ects) ,our factors% however occurred mainly in 'MD patients and were rare in normal sub-ects #( 'he presence of a skeletal anterior open bite) $( Aetruded contact position "AC&( and IC& slides of greater than $mm) @( 5ver-ets of greater than 9mm) 9( ,ive or more missing and unreplaced posterior teeth)

Dynamic relationship between occlusion and 'MD 5cclusal conditions affects 'MD by one of the two ways #( 5cclusal conditions affects the orthopedic stability of the mandible) $( cute changes in occlusion )

Occlusion and orthopedic stability

5cclusion and orthopedic stability

 Degree of orthopedic instability7 discrepancy more than #7$ mm mount of loading7 bruxers are affected more than non7 bruxers cute changes in occlusion and 'MD Mainly affects the activities of masticatory muscles) Muscle activities are basically divided in to #( ,unctional "chewing% speaking% swallowing( $( &arafunctional "clinching and bruxism(

5cclusal contacts and muscle hyperactivity &recise effect of the occlusal condition on muscle hyperactivity has not been clearly established) :illiamson and ;and*uist demonstrated that certain posterior contacts can increase activity of the elevator muscles) 0ut Augh et al) /hown that premature occlusal contacts do not increase bruxing activity "no correlation between occlusal contacts and muscle activities() 'he difference between first and second study?7 first study assesed the effects of occlusal contacts on conscious and controlled% voluntary mandibular movements "controlled by peripheral nervous system( while the second study assessed subconscious and uncontrolled% involuntary muscle activity "bruxisum( "controlled by C+/() 'hus sudden changes that disrupts the IC& can lead to a protective response of the elevator muscles "i)e) protective co7contraction( in conscious state which may lead to pain) 0ut this increased tonus or change in IC& do not cause any increase in bruxing activity which is controlled by C+/) Chronic occlusal interferences #( Most common way is to alter muscle engrams so as to avoid the potentially damaging contacts and get on with the task of function) $( 'ooth movement to accommodate heavy loading) 0ruxism never occurs or accentuates because of occlusal problems)

 &roblems with bringing the teeth into occlusion are answered by muscles) !owever% once the teeth are in occlusion% problem with loading the masticatory structures are answered in the -oints) 'herefore if one of these conditions exists% dental therapy is likely indicated) 'rauma 'rauma seems to have greater influence on intracapsular disorders than muscular disorders) 'wo types #( Macrotrauma7 any sudden force that can result in structural alteration e)g) blow on the face) $( Microtrauma?7 any small force that is repeatedly applied to the structures over a long period of time e)g) bruxism% clinching) Macro trauma /udden force on the condyle) It can be direct or indirect) 'he direct macro trauma can be open mouth trauma or closed mouth trauma)

5pen mouth direct macro trauma 0low to the chin% when the teeth are separated "i)e)% open7mouth trauma(7 the condyle can be suddenly displaced from the fossa 7 ligaments resist this sudden displacement) If the force is great% the ligaments can become elongated 7 resulting increased looseness can lead to discal displacement and to the symptoms of clicking and catching)

 Bnexpected macrotrauma to the -aw "as might be sustained during a fall or in a motor vehicle accident( may lead to discal displacement% dislocation% or both) Closed mouth direct macro trauma Macrotrauma can also occur when the teeth are together "i)e)% closed7 mouth trauma( 7 the intercuspation of the teeth maintains the -aw position% resisting -oint displacement) Closed7mouth trauma is therefore less in-urious to the condyle7disc complex) thletes who wear soft% protective mouth appliances have significantly fewer -aw7related in-uries than those who do not) lthough ligaments may not be elongated% articular surfaces can certainly receive sudden traumatic loading) 'his type of impact loading may disrupt the articular surface of the condyle% fossa or disc% which may lead to alterations in the smooth sliding surfaces of the -oint% causing roughness and even sticking during movement) 'herefore this type of trauma may result in adhesions)

Indirect macro trauma Indirect trauma refers to in-ury that may occur to the 'M< secondary to a sudden force% but not one that occurs directly to the mandible) 'he most common type of indirect trauma reported is associated with a cervical flexion7extension in-ury "i)e)% whiplash in-ury()

Microtrauma Microtrauma refers to any small force that is repeatedly applied to the -oint structures over a long period of time loading exceeds the functional limit of the tissue% irreversible changes or damage can result) :hen the functional limitation has been exceeded% the collagen fibrils fragmented% resulting in a decrease i ness of the collagen network) 'his allows proteoglycan7water gel to swell and flow out the -oint space% leading to a softening of articular surface) 'his softening is called chondromalacia. Aegions of fibrillation can begin to develop% resulting in focal roughening of the articular surfaces) 'his alters the frictional characteristics of the surface and may lead to sticking of the articular surfaces% causing changes in the mechanics of condyle7disc movement) Continued sticking% roughening% or both leads to strains on the discal ligaments during movements and eventually to disc displacements) nother way in which micro trauma affects is the hypoxia7reperfusion theory)

nother type of microtrauma results from mandibular orthopedic instability) s previously described% orthopedic stability exists when the stable IC& of the teeth is in harmony with the musculoskeletally stable "M/( position of the condyles 0ruxing patients with orthopedic instability are more likely to create problems than nonbruxers with the same occlusion) Emotional stress 'he emotional centers of the brain have an influence on muscle function /tress 7 activates hypothalamus 7 increase the activity of the gamma efferents 7 the intrafusal fibers of the muscle spindles contract) /tress releasing mechanisms?7 external and internal Deep pain input Deep pain input7 centrally excites the brain stem7 produces muscle response "protective co7contraction( It is normal body response to pain) Intraoral pains like tooth pain% sinus pain% ear pain or even remote facial pains like cervical pain input may restrict the mouth opening) &arafunctional activities 'wo types #( Diurnal7 occurs during day)

 $( +octurnal 7 occures during night) DIBA+ ; C'ICI'IE/ 7 clinching and grinding% cheek and tongue biting% finger and thumb sucking% unusual postural habits% occupation related habits e)g) holding nails% pen in mouth% holding ob-ects like telephone% violin under the chin) +octurnal activities Clinching "single episode of muscular contraction( 0ruxing "rhythmic contractions( causes of bruxing activities emotional stress% certain medications% genetic predisposition% C+/ disturbances% occlusal interferences DDD Etiological concepts ? Mechanical displacement theory? +euromuscular theory? Muscle theory? &sycophysiological theory? &sychological theory?

sign is an ob-ective clinical finding that the clinician uncovers during a clinical examination) symptom is a description or complaint reported by the patient patients are acutely aware of their symptoms yet may not be aware of their clinical signs) Clinical signs and symptoms of 'MDs can be grouped according to the structures affected #( the Muscles) $( the 'M<s @( the Dentition

,unctional disorders of the muscles 'wo ma-or symptoms #( &ain $( Dysfunction) &ain &ain felt in musculature is called myalgia) 5ften associated with fatigue and tightness) It is related to vasoconstriction of the relevant nutrient arteries and accumulation of metabolic waste products) :ithin the ischemic area of the muscle% certain algogenic substances "e)g) bradykinin% prostaglandins( are released% causing muscle pain 'he severity of muscle pain is directly related to the functional activity of the muscle involved) 'herefore patients often report that the pain affects their functional activity) :hen a patient reports pain during chewing or speaking% these functional activities are not usually the cause of the disorder) Myogenous pain is a type of deep pain and% if it becomes constant% can produce central excitatory effects) 'hese effects may present as sensory effects "i)e) referred pain or secondary hyperalgesia( or efferent effects "i)e) muscle effects(% or they may even present as autonomic effects) Muscle pain can reinitiate more muscle pain "i)e)% the cyclic effect() nother very common symptom associated with masticatory muscle pain is headache) Dysfunction decrease in the range of mandibular movement) :hen muscle tissues have been compromised by overuse% any contraction or stretching increases the pain) 'herefore to maintain comfort% the patient restricts movement within a range that does not increase pain levels) Clinically this is seen as an inability to open widely)

n acute malocclusion may result from a sudden change in the resting length of a muscle that controls -aw position) :hen this occurs the patient describes a change in the occlusal contact of the teeth) 'he mandibular position and resultant alteration in occlusal relationships depend on the muscles involved) ,or example% slight functional shortening of the inferior lateral pterygoid will cause disocclusion of the posterior teeth on

the ipsilateral side and premature contact of the anterior teeth "especially the canines( on the contralateral side) :ith functional shortening of the elevator muscles "clinically a less detectable acute malocclusion(% the patient will generally complain of an inability to occlude normally) It is important to remember that an acute malocclusion is the result of the muscle disorder and not the cause

Events Carious types of events can interrupt normal muscle function) 'hese events can arise from either local or systemic factors Local events that acutely alter sensory or pro7prioceptive input in the masticatory structures ) /ystemic factors may also represent events that can interrupt normal muscle function) ;ocal events #( ,racture of tooth $( Aestoration in supraocclusion @( 'rauma to local tissues e)g) ;) ) in9( Chewing hard food 2( Chewing for long period 1( 5pening mouth too widely e)g) yawning% dental treatments

/ystemic events

#( $( @( 9( 2( 1( 6(

Emotional stress cute illness) Ciral infections ge Gender Diet Genetic predisposition

&rotective co7contraction &rotective co7contraction is a C+/ response to in-ury or threat of in-ury) 'his response has also been called protective muscle splinting. In the presence of an in-ury or threat of in-ury% normal se*uencing of muscle activity seems to be altered to protect the threatened part from further in-ury) 'his coactivation of antagonistic muscles is thought to be a normal protective or guarding mechanism ) If protective co7contraction continues for several hours or days% the muscle tissue can become compromised and a local muscle problem may develop) ;ocal muscle soreness ;ocal muscle soreness is a primary% noninflammatory% myogenous pain disorder "i)e)% noninflammatory myalgia() It is often the first response of the muscle tissue to prolonged co7contraction) lthough co7contraction represents a C+/7induced muscle response% local muscle soreness represents a condition characteriEed by changes in the local environment of the muscle tissues) 'hese changes are characteriEed by the release of certain algogenic sub7 stances "i)e)% bradykinin% substance &% and even histamine( that produce pain) long with protracted co7contraction% other causes of local muscle soreness are local trauma or excessive use of the muscle) :hen excessive use is the cause% a delay in the onset of muscle soreness can occur ;ocal muscle soreness presents clinically with muscles that are tender to palpation and reveal increased pain with function) /tructural dysfunction is common% and limited mouth opening results when the elevator muscles are involved) C+/ E,,EC'/ 5+ MB/C;E & I+ ctivities within C+/ either influence or originates muscle pains 'he C+/ responds in this manner secondary to one of three factors? "#( the presence of ongoing deep pain input%

"$( increased levels of emotional stress "i)e)% up7regulation of the autonomic nervous system(% or "@( changes in the descending inhibitory system that lead to a decrease in the ability to counter the afferent input) #( $( @( 9( C+/ induced muscle pain disorders are Myospasm Myofacial pain "trigger point myalgia( Centrally mediated myaligia "chronic myocitis( Chronic systemic myalgic disorders "fibromyalgia(

&erpetuating factors in myalgia #( $( @( #( $( @( 9( 2( ;ocal perpetuating factors &rotracted cause Aecurrent cause 'herapeutic mismanagement) /ystemic perpetuating factors Continued emotional stress /leep disturbances ;earned behavior /econdary gain Depression

(1) *3+ (3) (1) *3+ (3)

They generally fall into three broad categories$ derangements of the condyle-disc complex, structural incompatibility of the articular surfaces, and inflammatory joint disorders They generally fall into three broad categories$ derangements of the condyle-disc complex, structural incompatibility of the articular surfaces, and inflammatory joint disorders

 Stimulation of the nociceptors creates inhibitory action in the muscles that move the mandible. Therefore )hen pain is suddenly and une4pectedly felt mandibular movement immediately ceases *i.e.' nociceptive refle4+. Ehen chronic pain is felt' movement becomes limited and very deliberate *i.e.' protective co>contraction+. 8rthralgia from normal healthy structures of the -oint is a sharp' sudden' and intense pain that is closely associated )ith -oint movement. Ehen the -oint is rested' the pain resolves ;uic&ly. DFS!G:CTIO: It presents as a disruption of the normal condyle>disc movement' )ith the production of -oint sounds . The -oint sounds may be a single event of short duration' &no)n as a click. If this is loud it may be referred to as a pop. Crepitation is a multiple' rough' gravel>li&e sound described as grating and complicated. Dysfunction of the T " may also present as catching sensations )hen the patient opens the mouth. Sometimes the -a) can actually loc&.

CO:TI:GG

O! !G:CTIO:8, DISO#DE#S O! THE T "

 Disorders of the T "s may follo) a path of progressive events' a continuum' from the initial signs of dysfunction to osteoarthritis 2. :ormal healthy -oint 3. ,oss of normal condyle>disc function the result of either$ a. acrotrauma that resulted in elongation of the discal ligaments b. icrotrauma that created changes in the articular surface' reducing the frictionless movement bet)een the articular surfaces .. Significant translatory movement begins bet)een disc and condyle *resulting in displacement of disc+ /. Posterior border of disc becomes thinned <. !urther elongation of discal and inferior retrodiscal ligaments Disc becomes functionally displaced Single clic& #eciprocal clic& 7. Disc becomes functionally dislocation a. Dislocation )ith reduction *i.e. catching+ b. Dislocation )ithout reduction *i.e. closed loc&+ 0. #etrodiscitis 9. Osteoarthritis a. b. ?.

Derangements of the Condyle-Disc Complex

 If the morphology of the disc is altered and the discal ligaments become elongated' the disc is then permitted to slide *i.e.' translate+ across the articular surface of the condyle. 8lteration in the morphology of the disc accompanied by elongation of the discal ligaments can change this normal functioning relationship. In the resting closed -oint position the interarticular pressure is very lo). If the discal ligaments become elongated' the disc is free to move on the articular surface of the condyle. 1ecause in the closed -oint position the superior retrodiscal lamina does not provide much influence on disc position' tonicity of the superior lateral pterygoid muscle )ill encourage the disc to assume a more for)ard position on the condyle. The length of the discal ligaments and the thic&ness of the posterior border of the disc )ill limit for)ard movement of the disc. If the pull of this muscle is protracted' over time the posterior border of the disc can become more thinned This is called as functional disc displacement.

Characteristics of reciprocal click 2+During mandibular opening a sound is heard that represents the condyle moving across the posterior border of the disc to its normal position on the intermediate %one. The normal disc>condyle relationship is maintained through the remaining opening movement. 3+During closing the normal disc position is maintained until the condyle returns to very near the closed -oint position. .+8s the closed -oint position is approached' the posterior pull of the superior retrodiscal lamina is decreased. /+The combination of disc morphology and pull of the superior lateral pterygoid allo)s the disc to slip bac& into the more anterior position' )here movement began. This final movement of the condyle across the posterior border of the disc creates a second clic&ing sound and thus the reciprocal clic&.

 8s the disc becomes more flat' it further loses its ability to self>position on the condyle' allo)ing more translatory movement bet)een condyle and disc. The more freedom of the disc to move' the more positional influence from the attachment of the superior lateral pterygoid muscle. Eventually the disc can be forced through the discal space' collapsing the -oint space behind. Ehen this occurs' interarticular pressure )ill collapse the discal space' trapping the disc in the for)ard position. Then the ne4t full translation of the condyle is inhibited by the anterior and edial position of the disc. The person feels the -oint being loc&ed in a limited closed position because the articular surfaces have actually been separated' this condition is referred to as a functional dislocation of the disc

,unctional dislocation Cs functional displacement 8s previously described' a functionally displaced disc can create -oint sounds as the condyle s&ids across the disc during normal translation of the mandible .If the disc becomes functionally dislocated' the -oint sounds are eliminated because no s&idding can occur. Some persons )ith a functional dislocation of the disc are able to move the mandible in various lateral or protrusive directions to accommodate the movement of the condyle over the posterior border of the disc' and the loc&ed condition is resolved. If the loc& occurs only occasionally and the person can resolve it )ith no assistance' it is referred to as a functional dislocation ith reduction. The patient )ill often report that the -a) HcatchesH )hen opening )ide.

 )hen person is unable to return the dislocated disc to its normal position on the condyle. The mouth cannot be opened ma4imally because the position of the disc does not allo) full translation of the condyle .

 Typically the initial opening )ill be only 3< to .= mm interincisally' )hich represents the ma4imum rotation of the -oint. The person usually is a)are of )hich -oint is involved and can remember the occasion that led to the loc&ed feeling. 1ecause only one -oint usually becomes loc&ed' a distinct pattern of mandibular movement is observed clinically.

The -oint )ith the functionally dislocated disc )ithout reduction does not allo) complete translation of its condyle' )hereas the other -oint functions normally. Therefore )hen the patient opens )ide' the midline of the mandible is deflected to the affected side. The dislocation )ithout reduction has also been termed a closed lock.

!tructural "ncompatibility of the #rticular !urfaces

 Smooth articulation of the T " is ensured by t)o mechanisms$ *2+ boundary lubrication and *3+ )eeping lubrication. If static loading continues for a prolonged time' ho)ever' )eeping lubrication can become e4hausted and stic&ing of the articular surfaces can result. Ehen the static loading is finally discontinued and movement begins' a sense of stiffness is felt in the -oint until enough energy is e4erted to brea& apart the adhering surfaces. This brea&ing apart of adherences can be felt as a clic&' and it denotes the instant return to normal range of mandibular movement

If ho)ever' the adherence remains for a significant period of time' fibrous tissue can develop bet)een the articular structures ,and a true adhesion can develop. This condition represents a mechanical connection that limits normal condyle> disc>fossa function. 8nother cause of adhesions is hemarthrosis *i.e.' bleeding )ithin the -oint+. The presence of blood by>products seems to provide a matri4 for the fibrous unions found )ithin adhesions. Hemarthrosis can occur )hen the retrodiscal tissues are disrupted by either e4ternal -a) trauma or surgical intervention. The morphologic characteristics of the surfaces usually conform to each other closely. If the morphology of the disc' condyle' or fossa is altered' -oint function can be impaired. !or e4ample' a bony protuberance on the condyle or fossa may catch the disc at certain degrees of opening' causing alterations in function. The disc itself may become thinned *as )ith disc displacement+ or even perforated' causing significant changes in function.

 These alterations in form can create clic&ing and catching of the -a) similar to that seen )ith functional disc displacements.

Sublu4ation *hypermobility+ Some -oint reveal that as the mouth opens to its fullest e4tent' a momentary pause occurs' follo)ed by a sudden -ump or leap to the ma4imally open position. This -ump does not produce a clic&ing sound but instead is accompanied by more of a $%&'. The e4aminer can readily see it by )atching the side of the patientIs face. During ma4imum opening the lateral poles of the condyles -ump for)ard *i.e.' sublu4ation+' causing a noticeable preauricular depression. The cause of sublu4ation is usually not pathologic. Sublu4ation is more li&ely to occur in a T " )ith an articular eminence that has a short' steep posterior slope follo)ed by a longer' flatter anterior slope. The anterior slope is often more superior than the crest of the eminence /pontaneous dislocation)

 On occasion the mouth is opened beyond its normal limit and the mandible loc&s. This is called spontaneous dislocation or an open lock Eith spontaneous dislocation the patient cannot close the mouth. Eide opening *e.g.' from an e4tended ya)n or a long dental procedure+ almost al)ays produces this condition. Spontaneous dislocation typically occurs in a patient )ho has the fossa anatomy that permits sublu4ation.

factors that Predispose to Disc Derangement Disorders /teepness of the articular eminence? 8s the steepness increases' more rotational movement is re;uired bet)een the disc and condyle during for)ard translation of the condyle. Therefore patients )ith steep eminences are more li&ely to demonstrate greater condyle>disc movement during function. Morphology of the condyle and fossa? !lat or gable li&e condyles that articulate against inverted J>shaped temporal components seem to have an increased incidence of disc derangement disorders and degenerative -oint disease. It )ould appear that flatter' broader condyles distribute forces better' leading to fe)er loading problems.

 <oint? Some -oints )ill sho) slightly more freedom or la4ity than others. Some generali%ed la4ity may be caused by increased levels of estrogen. !or e4ample' )omenIs -oints are generally more fle4ible and la4 than menIs. ttachment of the superior lateral pterygoid muscle? it )ould be reasonable to assume that if the attachment of the muscle is greater to the nec& of the condyle *and less to the disc+' muscle function )ill have+' correspondingly less influence on disc position. Conversely' if the attachment is greater on the disc *and less to the condyler nec&+' muscle function )ill correspondingly influence disc position more.

Synovitis Synovial tissues that lines the recess area of the -oint become inflamed. Characterised by constant intracapsular pain that enhances )ith -oint movements. Capsulities Capsular ligament becomes inflamed. Tenderness )hen the lateral pole of the condyle is palpated. Pain even in static position but -oint movement generally increase the pain. #etrodiscities Inflammation of retrodiscal tissues. Constant dull aching pain that often increased by clinching. s)elling may occur and force the condyle slightly for)ard' do)n the Posterior slope of the articular eminence. This sum can cause an acute malocclusion. Clinically such an acute malocclusion is seen as disengagement of the ipsilateral posterior teeth and heavy contact of the contralateral canines 8s the disc is thinned and the ligaments become elongated' the condyle begins to encroach on the retrodiscal tissues. The first area of brea&do)n is the inferior retrodiscal lamina' )hich allo)s even more discal displacement. Eith continued

brea&do)n' disc dislocation occurs and forces the entire condyle to articulate on the retrodiscal tissues. If the loading is too great for the retrodiscal tissue' brea&do)n continues and perforation can occur. Eith perforation of the retrodiscal tissues' the condyle may eventually move through these tissues and articulate )ith the fossa. rthritides) "oint arthritides represent a group of disorders in )hich destructive bony changes are seen. Osteoarthritis$ most common types of T " arthritides represents a destructive process by )hich the bony articular surfaces of the condyle and fossa become altered. It is generally considered to be the bodyIs response to increased loading of a -oints. surface becomes softened *i.e.' chondromalacia+ and the subarticular bone begins to resorb. Progressive degeneration eventually results in loss of the subchondral cortical layer' bone erosion' and subse;uent radiographic evidence of osteoarthritis. Osteoarthritis is often painful' and -a) movement accentuates the symptoms. Crepitation *i.e.' grating -oint sounds+ is a common finding )ith this disorder. Osteoarthritis can occur any time the -oint is overloaded' but it is most commonly associated )ith disc dislocation or perforation 8lthough osteoarthritis is in the category of inflammatory disorders' it is not a true inflammatory condition. Often once loading is decreased' the arthritic condition can become adaptive. The adaptive stage has been referred to as osteoarthrosis

Headache Otologic signs and symptoms ear pain fullness in the ear or ear stuffiness tinnitus *ear ringing+ vertigo *di%%iness+

anagement of T Ds and Occlusion. "effrey O&eson <th edt. !unctional occlusion from T " to smile design. Da)son> .rd ed. Color atlas of T " surgeries. Peter Kuinn. DC:8 3==7' "an' vol <2' no. 2 >T Ds and orofacial pain Temperomandibular disorders L Eeldon 1ell T Ds an evidence based approach to diagnosis and treatment L Danial ,as&in