Temporomandibular

Disorders
Dr Teo Ying Yi
• Articulation between jaw and head,
bilaterally.
• Bony components enclosed by fibrous
capsule, filled with synovial fluid.
• Sustain various functions-speech, chewing,
sucking etc.

Anatomy of TMJ
• Modified hinge joint.
• Fibrocartilage – articular disc.
• Capable of hinge movement and gliding movement.
• Mouth opens-1st rotation, 2nd translation.
• What is TMD?
 A group of musculoskeletal disorders that cause pain and
dysfunction in the jaw joint and the muscles that control jaw
movement.
 Most important feature is PAIN, followed by restricted
movement and noises from the joints during jaw movement.

Temporomandibular disorders
• Exact etiology unknown.
• Thought to be caused by multiple, poorly understood factors:
 Parafunctional habits (noctural bruxing, tooth clenching).
 Emotional distress.
 Acute trauma to jaw.
 Trauma from hyperextension (dental procedure, yawning,
oral intubations for GA).
 Laxity of joint.
 Comorbidity of other rheumatic or musculoskeletal
disorders.
 Poor general health and unhealthy lifestyle.

Etiology
 TMD

Intracapsular Extracapsular

Disc displacement Articular bone Muscles

Disc displacement w/ reduction Arthralgia Myofascial pain

Disc displacement w/o Osteoarthritis of Myofascial pain w/

reduction, w/ limited opening TMJ limited opening

Disc displacement w/o

reduction, w/o limited opening Osteoarthrosis of TMJ

Classification
• Pain in the face, jaw or ear area.
• Headaches (often mimicking migraines), earaches, and pain and
pressure behind the eyes.
• A clicking or popping sound when opening or closing the
mouth.
• Jaw that "gets stuck," locked or goes out of place.
• Tenderness of the jaw muscles.
• Trouble chewing or biting.
• Swelling of the face.
• A sudden change in the person’s dental occlusion (the way the
upper and lower teeth fit together).

Symptoms
• Present examination methods do not have the ability to
accurately differentiate individuals with TMD from those
without.
• Most valuable diagnostic assessment are a thorough history and
physical examination.
• Diagnostic imaging is of value in selected conditions but not as
a routine part of standard assessment.
1. History
2. Physical examination
3. Diagnostic imaging
 Tomography, CT-osteodegenerative joint disease.
 MRI-assess disc form and position.
 Radioisotope scanning-condylar hyperplasia.

Assessment & Diagnosis

• Treatment goal:
 Control pain.
 Improve mandibular motion.
 Restore function as close to normal as possible.
• Symptoms of TMD tend to be intermittent, fluctuate over
time, often self-limiting.
• The need for treatment largely based on the level of pain and
dysfunction and the progression of symptoms.
• Broadly classified into:
1. Conservative/non-surgical management.
2. Surgical management.

Management
 1. Education:
 Explanation of diagnosis and treatment.
 Reassurance-anxiety can lead to greater disability.
2. Self-care and habit reversal:
 Attention to oral habits (tooth clenching, nail biting, leaning on
jaw) – hyperactivity.
 Habit control  reduce pain.
 Maintain good posture.
 Moist heat application 15-20 mins x2 daily.
 Acute flare-cold application for pain control.
 Modify diet-soft food, cut food into smaller pieces.
 Support jaw while yawning.

Conservative Approach
3. Physiotherapy:
 Posture therapy-avoid forward head posture.
 Range of motion exercises.
 Passive stretching.
 Ultrasound, Laser.
4. Intraoral appliances:
 Stabilization appliance / muscle relaxation splint.
 Clear the occlusion, relax the muscles, provide joint stabilization,
reduce joint loading by decrease muscle activity, protect the teeth,
flat and large surface to redistribute biting forces.
 Should not alter the occlusion.
5. Pharmacotherapy:
 Mild analgesics (acetaminophen), NSAIDs, muscle relaxants,
antianxiety, tricyclic antidepressants.
6. Behavioral therapy and relaxation techniques:
 Meditation.
 Hypnosis.
 Biofeedback.
 Cognitive-behavioral therapy.
1. Arthrocentesis
 Least invasive procedure.
 Treatment for closed lock, when pt refractory to conservative approach.
 Flushed with a sterile saline solution or a lactated Ringers solution.
 At the end of the procedure, some surgeons inject a steroid into the joint.
 To improve disc mobility, eliminate pain & joint inflammation, remove
resistance to condylar translation.

Surgical Approach
2. Arthroscopy
 More invasive than arthrocentesis.
 Insertion of a specially designed fiberoptic endoscope into the joint
compartment for observation (diagnostic) and therapeutic purpose.
 Under GA.
 During arthroscopic surgery, surgeon may:
Remove scar tissue and thickened cartilage.
Reshape parts of the jawbone.
Reposition the disc.
Tighten the joint to limit movement.
Flush (lavage) the joint.
Insert an anti-inflammatory medicine.

Surgical Approach
2. Arthrotomy
 Developmental disturbances (condylar hypo-, hyperplasia of the
mandible, tumours, ankylosis etc.).
 Recognised as the only treatment method of fibrous or osseous ankylosis.
 Eg: eminectomy, high condylectomy, gap arthroplasty etc.

Surgical Approach