DIAGNOSIS &

TEMPOROMANDIBULAR
JOINT DISORDER
MUH. RUSLIN

P3KGB Bedah Mulut Modul A PABMI

Pengwil Sulawesi

INTRODUCTION

ANATOMI
Condyle part of TMJ, who
move freely in both
rotation & translation
Condylar head & glenoid
fossa are covered by
dense fibrocartilage.
Between condylar head &
glenoid fossa spaces
separated by the discus
articularis.
The discus articularis is a
biconcave disk composed
of dense fibrous tissue.

TMJ disorder : 33% from population

Internal derangement : 4-28%
Man > women = 10:1
Therapy : most of case with
conservative, 5% with surgical
treatment

TMJ DISORDERS

Myofascial pain
Disc displacement disorder (internal
derangment)
Degenerative joint disease (arthrosis,
osteoarthritis)
Systemic arthritic conditions
Chronic recurrent dislocation
Ankylosis
Neoplasia
Infections

Symptom:
pain, clicking, joint
dysfunction

The neural structure:

Sensory auriculotemporal nerve, branch of
trigeminal nerve.

NORMAL MOVEMENT OF TMJ

Rotation &
Translation

INTERNAL DERANGEMENT

Mechanical joint disorders that

associated to movement
Occurred disc displacement to
anteriorly
Discus in front of the condyle cause
disorders movement
Clicking
With or without pain

INTERNAL DERANGEMENT

NORMAL

INTERNAL DERANGEMENT

CLASSIFICATION OF
INTERNAL DERANGEMENT

WITH REDUCTION

WITHOUT REDUCTION

INTERNAL DERANGEMENT WITH REDUCTION

Discus placed anteriorly from condyle

Discus passed the posterior band
through to Intermediate Zone to reach
normal relationship
There are clicking in opening-closing

INTERNAL DERANGEMENT
WITHOUT REDUCTION

Closed lock
Discus failure to reduction, condyle cannot
passed the PB
Condyle cannot sliding anteriorly
Limited opening
No clicking

ETIOLOGY

Occlusion factors
Macrotrauma
Microtrauma
Arthritis desease

CLINICAL FEATURE
Internal derangement with
reduction :
Clicking opening & closing
(reciprocal clicking)
Normal mouth opening & painless
Midline mandibular deviation
Internal derangement without
reduction :
No clicking
Limited opening
Pain
Mandibular deflection

RADIOGRAPHIC EXAMINATION

MRI, CT Scan,
Arthrography
Showing the
discus placed
anteriorly from
the condyle

TREATMENT
CONSERVATIVE

90%

SURGICAL

5-10%

CONSERVATIVE

MEDICATION: NSAID,
STRONG ANALGESIC,
MUSCLE RELAXSAN, ANTI
DEPRESSANT
PHYSICAL THERAPY: EMG
BIO FEEDBACK,
RELAXSATION TRAINING,
ULTRA SOUND,
EMPRESSURE MASSAGE
SPLINT: OCLUSSAL
ADJUSTMENT

SURGICAL TREATMENT
For ID and arthritis with severe to moderate
pain/ dysfunction and no responses to
conservative procedure accompanied with :
Earache, headaches, masticatory or cervical
myalgias
Clicking or popping of the joint
Locking of the joint
Restricted masticatory function
Restricted range of jaw motion
Imaging & arthroscopic evidence of ID

The goal of surgical treatment of ID, to reach :

Relief from pain in the joint
Relief from Earache, headaches, masticatory
or cervical myalgias
Improvement in range of jaw motion/
function
Reduction of the noise of the joint

SURGICAL APPROUCH

PREAURICULAR

ENDAURAL

DISCECTOMY

Total removal of the disc &

accompanying with soft tissue
attachment
Discus may not be replaced
allowing the condyle to function
directly with glenoid fossa
To increase functions, after
discectomy can replaced the
discus with autogenous or
allogenic graft
Autogenous : dermal, cartilage,
temporalis muscle/fascia
Allogenic : silikon, proplastteflon, metal

DISCUS REPOSITION

Repositioned to more normal position by

removing a wedge of tissue from the
posterior attachment & suturing back to
anatomical position
90% painless and improved the jaw
function
10% : no improvement/ worsening
conditions

DISCUS REPOSITION

DISCUS REPOSITION

CONDYLOTOMY

Modification of vertical ramus osteotomy

To reposition of the condyle to
anteroinferior to reach more normal
position

ARTHROCENTESIS

Puncture into joint

space, associated
with fluid irrigated
Placement 2
needle or 1 needle
Y-shape within
joint space
Easy & low risk

ARTHROSCOPY

Place 2 cannula into anterior & posterior

regions of the superior joint using trocars
Cannula become the portal for placement
of the arthroscope, insertion instrument
and fluid flow
Lysis-lavage-manipulation, ant disc
releasing, disc stabilization, surgical
debridement, laser surgical

ARTHROSCOPY

CONCLUTION

Internal Derangment : joint mechanical disorders

that relationship with smooth movement, the disc
placed anteriorly
Therapy of Internal Derangment divided in 2
ways : conservative & surgical : arthrocintesis,
arthroscopy, discectomy, reposition &
condylotomy
Comprehensive therapy: systemic therapy, local
therapy (filling, extraction, prothesa, orthodontic)