Diagnosis of temporomandibular disorders

1. DIAGNOSIS OF
TEMPOROMANDIBULAR
DISORDERS
1
PRESENTED BY:
DR. KELLY NORTON
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2. CONTENTS
• Introduction
• Definition
• Etiology
• Signs and symptoms
• Keys to differential diagnosis
• Classification for diagnosis of TMD
• TMJ disorders
• Conclusion
• References & Cross References
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3. INTRODUCTION
• Masticatory system is the functional unit of body
,primarily responsible for chewing ,speaking
swallowing. This system is made up of bones, joints,
ligaments, teeth and muscles
DIAGNOSIS – GPT -9
• the determination of the nature of a disease
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4. NORMAL ANATOMY OF THE TMJ
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5. MUSCLES OF MASTICATION
5
Masseter muscle Temporalis muscle Medial pterygoid muscle
Inferior and superior lateral pterygoid muscles Digastric muscle.
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6. • TMJ disorder (TMD) are among the most misdiagnosed & mistreated maladies in medicine.
• Multifactorial origin - caused by altered anatomic relations and derangements of the TMJ
associated with loss of occlusal vertical dimension, loss of posterior tooth support, and / or other
malocclusions.
• This disorders are characterized by
1. Facial pain in the region of the TMJ & for the muscle of mastication.
2. Limitation or deviation in the mandibular range of motion.
3. TMJ sounds during jaw movements & function
• The symptoms can include headache about the vertex and occiput, tinnitus, pain about the ear,
impaired hearing and pain about the tongue. 6
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7. History:
• 5th century BC: Hippocrates described a condition of TMJ dislocation.
• 1842: Cooper reported on subluxation of the TMJ as a distinct entity. He observed patients with
snapping jaw & registered this symptom as an “ internal derangement of the jaws”
• 1887: Surgical correction was described by Annandale.
• 1918: Pringle explained clicking & popping of the TMJ as a sign of anterior displacement of the
meniscus.
• 1934: Costen was first to indicate an occlusal etiology in TMJ pain. He reported association of
the bite over closure with symptoms like ear pain, sinus pain, decreased hearing, tinnitus, dizziness,
burning & vertigo & occipital headache. He claimed to be reflexes due to irritation of the
auriculotemporal nerve and / or corda tympanic nerve as they emerged from tympanic plate.
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8. • 1947: Norgaard used orthographic techniques to radiographically demonstrate anterior disc
displacement in clicking or popping TMJ.
• 1950-60: muscular cause not directly related to occlusion was proposed
Schwartz coined the term Temporomandibular pain syndrome.
• 1970: advances in diagnostic imaging have resulted a better understanding of the intracapsular
problem associated with TMD.
Farrar & McCarthy rejuvenated the concept of internal derangement with meniscus displacement.
8
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9. Normal function & Physiologic Tolerance
• Chewing
• Swallowing carried out by the complex neuro muscular control system
• speaking
9
• All 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.
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10. • CLINICAL SIGNS AND SYMPTOMS of TMDs
can be grouped according to the structures affected
• 1) the Muscles.
• 2) the TMJs
• 3) the Dentition
10
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11. Pain
• Pain felt in musculature is called myalgia.
• Often associated with fatigue and tightness.
• Myogenous pain is a type of deep pain and, if itbecomes constant, can produce central excitatory
effects. These 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).
• Another very common symptom associated with masticatory muscle pain is headache.
11
Two major symptoms
• 1) Pain & 2) Dysfunction.
Functional disorders of the muscles
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12. Dysfunction
• When muscle tissues have been compromised by overuse, any contraction or
stretching increases the pain hence decreases the range of mandibular movement.
• Acute malocclusion refers to any sudden change in the occlusal condition that has
been caused by a disorder.
• An acute malocclusion may result from a sudden change in the resting length of a
muscle that controls jaw position. When this occurs, the patient describes a change in
the occlusal contact of the teeth.
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13. Masticatory muscle model
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14. • Local events- acutely alter sensory or
proprioceptive input in the masticatory structures
1. Fracture of tooth
2. Restoration in supra-occlusion
3. Trauma to local tissues e.g. L.A. injections
4. Chewing hard food
5. Chewing for long period
6. Opening mouth too widely e.g. yawning, dental
treatments
1
4
• Systemic events - represent events that
can interrupt normal muscle function.
The entire body and CNS are involved
1. Emotional stress
2. Acute illness.
3. Viral infections
4. Age
5. Gender
6. Diet
7. Genetic predisposition
Events
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15. • The two major symptoms of functional TMJ problems are pain and dysfunction.
PAIN
• Pain in any joint structure (including the TMJs) is called arthralgia .
• Arthralgia from normal healthy structures of the joint is a sharp, sudden, and intense pain
that is closely associated with joint movement. When the joint is rested, the pain resolves
quickly.
• Three periarticular tissues contain nociceptors:
• (1) the discal ligaments, (2) the capsular ligaments, and (3) the retrodiscal tissues.
• Stimulation of the nociceptors creates inhibitory action in the muscles that move the
mandible
15
Functional disorders of the TMJ
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16. • Therefore when pain is suddenly and unexpectedly felt mandibular movement immediately
ceases (i.e., nociceptive reflex).
• When chronic pain is felt, movement becomes limited and very deliberate (i.e., protective co-
contraction). 16
pain in joint
discal ligaments,
capsular ligaments,
retrodiscal tissues
compressed /elongated
pain perceived
originates from nociceptor
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17. DYSFUNCTION
• It presents as a disruption of the normal condyle-disc movement, with the production of joint
sounds .
• The joint sounds may be a single event of short duration, known as a click.
• If this is loud it may be referred to as a pop.
• Crepitation is a multiple, rough, gravel-like sound described as grating and complicated.
• Dysfunction of the TMJ may also present as catching sensations when the patient opens the mouth.
• Sometimes the jaw can actually lock
17
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18. FUNCTIONAL DISORDERS OF DENTITION
1) Mobility
2) Pulpitis
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3) Tooth wear

19. OTHER SIGNS AND SYMPOMS OF TMD
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Headache
Otologic signs and symptoms
ear pain
fullness in the ear or ear stuffiness
tinnitus (ear ringing)
vertigo.

20. HISTORY TAKING FOR
TEMPOROMANDIBULAR DISORDERS
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21. CLINICAL EXAMINATION
• Cranial nerve examination
• Eye examination
• Ear examination
• Cervical examination
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2
3,4,6 3,4,6
5 5 8
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22. MUSCLE EXAMINATION
• Temporalis muscle and tendon
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Anterior region -above zygomatic
arch and anterior to the TMJ
Middle region - above the TMJ
and superior to the zygomatic arch
Posterior region -above and
behind the ear

23. 23
Masseter muscle
A, Palpation of the masseter muscles at their
superior attachment to the zygomatic arches
B, Palpation of the superficial masseter muscles near
the lower border of the mandible108

24. Sternocleidomastoid muscle
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Posterior cervical muscles
High near the mastoid process (A) and low near the clavicle (B)
A, Palpation of muscular attachments in
the occipital region of the neck.
B, The clinician’s fingers are brought
inferiorly down the cervical area and
the muscles are palpated for pain and
tenderness.

25. FUNTIONAL MANIPULATION
25
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26. DIFFERENTIATING
MUSCLE PAIN FROM
INTRACAPSULAR
DISORDERS
26
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27. Maximal interincisal distance
• Restricted mouth opening –distance less than 40 mm.
• soft end feel suggests muscle-induced restriction, increased opening can be achieved,
• Hard end feels are more likely associated with intracapsular sources (e.g., a disc dislocation)
No increase in opening can be achieved
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28. TMJ EXAMINATION
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Palpation of the TMJ.
A, Lateral aspect of the joint with the mouth closed.
B, Lateral aspect of the joint during opening and closing.
C, With the
patient’s mouth fully open, the clinician moves a finger behind the condyle to palpate the posterior aspect of
the joint.

29. Temporomandibular joint dysfunction
• Joint sounds :
• A click is a single sound of short duration.
• If it is relatively loud, it is sometimes referred to as a pop.
• Crepitation is a multiple gravel-like sound described as grating and complicated
• Joint restrictions:
29
Extracapsular Intracapsular
Elevator muscle spasms Disc Derangement
Normal eccentric movements occur ,
Opening movement restricted ( 0-40mm)
Opening movement restricted
to rotation ( 25- 30mm)
Soft end feel Hard end feel
Restricting muscle to joint:
Medial – deflection to ipsilateral side
Lateral- deflection to contralateral side
Restriction in 1 joint and
deflection to ipsilateral side
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30. DENTAL EXAMINATION
• MOBILITY
• Tooth mobility can result from two factors:
• loss of bony support(periodontal disease)
and
• unusually heavy occlusal forces(traumatic
occlusion).
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31. PULPITIS
Heavy occlusal forces
Cracked tooth
Referred muscle pain
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32. TOOTH WEAR
• Functional – functional cusps wear facets
• Para functional – eccentric wear facets
• Chemical – palatal surfaces of maxillary teeth
32
ABFRACTION
• Noncarious lesions or wedge-shaped defects
• facial or buccal cervical areas of the 1st
premolars, followed by the second premolars
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33. OCCLUSAL EXAMINATION
• 1) Centric Relation Contacts – Bilateral manipulation
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34. 2) Leaf gauge method
3) Lucia Jig Method
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35. Eccentric contacts:
1) Protrusive contacts
2) Laterotrusive contacts
3) Mediotrusive contacts – most harmful
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36. Additional Diagnostic Aids:
Radiography:
• Panoramic View
• Lateral Transcranial view
• Trans pharyngeal view
• Trans-orbital
• Conventional tomography
• Computed tomography
• Arthrography
• MRI
• Bone Scanning
• Mandibular Tracking Devices
• Mounted Casts
• Electromyography
• Sonography
• Vibration Analysis
• Thermography
• Analgesic blocking
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37. Keys in making differential diagnosis:
1. History
2. Mandibular Restriction
3. Mandibular Interference
4. Acute Malocclusion
5. Loading Of The Joint
6. Functional Manipulation
7. Diagnostic Anesthetic Blockade 37
The most logical way to simplify any treatment protocol is to first identify what it
is that is being treated, thus first we make a diagnosis.
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38. 1. History
• When joint is traumatized, symptoms begin with trauma and aggravate or worsen from that time
forward.
• When muscle is involved ,symptoms appear to fluctuate and cycle from severe to mild with no
apparent initiating event.
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39. 2.Mandibular restriction
• Restriction of mandibular opening is found in both joint and muscle disorders.
• Checking the ‘ENDFEEL’
• Hard end feel---disc dislocation….. occurs at 25-30mm.
• soft end feel- muscle disorder – occurs anywhere during opening
• Intracapsular restriction (i.e., disc dislocation without reduction)- a contralateral
eccentric movement will be limited but an ipsilateral movement will be normal.
• Muscle disorders- a normal range of eccentric movement exists
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40. 3. Mandibular interference:
• If deviation occurs during opening and jaw returns to midline, before 30-35mm –disc
derangement disorder
• if speed of opening alters the location of the deviation, it is likely to be discal movement
(disc displacement with reduction)
• if speed of opening does not alter the interincisal distance of deviation ,and if location of
the deviation is the same for opening and closing-structural incompatibility
• Deflection of the mandibular opening pathway results when one condyle does not
translate- intracapsular problem such as a disc dislocation without reduction, adhesion
problem or myospasm
40
Watch for deviation from
center when patient slowly
opens and closes mouth108

41. 4.Acute malocclusion:
• If the inferior lateral pterygoid is in spasm and shortens, the
condyle will be brought slightly forward in the fossa on the
involved side. This will result in a disocclusion of the ipsilateral
posterior teeth and heavy contact on the contralateral canines.
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• If the spasms are in the elevator muscles, the patient is likely to report feeling that the teeth
“suddenly don’t fit right,” yet clinically it may be difficult to visualize any change.
• Disk Displacement - increase in the discal space- loss of ipsilateral posterior tooth contact.
• Disc dislocation- collapse of the discal space- heavy posterior contact on the ipsilateral side.

42. 42
5.Loading of joint:
• Positioning condyles in MS position –if loading causes pain- intracapsular problem.
• If no pain – healthy joint.
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43. 6. Functional manipulation:
• Functional manipulation that do not produce pain-rules out
muscles disorders.
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7.Diagnostic anesthetic blockade:
• If 6 keys does not help, then anesthetic blockade is indicated.
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44. Four rules to differentiate primary pain from referred pain:
• 1.local provocation of the site of pain does not increase the pain.
• 2.local provocation at the source of pain not only increases the pain at the source but also the
pain at the site.
• 3. local anesthetic blocking of the site of pain does not decrease the pain.
• 4.local anesthetic blocking of the source of the pain decreases the pain at the source and at the
site.
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45. 3 types-
1.Muscle injection:
• diagnostic. To determine source of pain
• therapeutic. myofascial trigger point pain
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46. Auriculotemporal nerve injection
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2 .Nerve block injections:
Diagnostic purpose – site or source pain
A] Dental blocks
B] Auriculotemporal nerve block
3. Intracapsular injections
Indicated for therapeutic purpose
4. Infraorbital nerve block
To relieve, facial neuropathic pain ..incase of trauma
anesthetic blockade of auriculotemporal nerve –
rules out intracapsular disorder.
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47. 47
Classification Of Diseases Of Temporomandibular Joint
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48. MASTICATORY MUSCLE
DISORDERS
A.protective co-contraction
B.local muscle soreness
C.myofacial pain
D. myospasms
E..centrally mediated myalgia
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48

49. 1. Protective co-contraction:
Is a CNS response to injury or threat of injury. Also known as Muscle
splinting
• Etiology:-
• Altered sensory or proprioceptive input e.g. changes in occlusal condition
• Constant deep pain
• Increased emotional stress
• History:- The key to the history is that the event occurred very recently,
usually within a day or two.
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49

50. • Clinical characteristics:-
• Structural dysfunction: decrease in range of mandibular
movement
• No pain at rest
• Increased pain with function
• Feeling of muscle weakness
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50
Erupting 3rd molar and chronic cheek biting

51. 2. Local muscle soreness (Non-inflammatory myalgia):
First response of the muscle tissue to continued protective co-contraction.
• Etiology:-
• Protracted co-contraction
• Trauma – Local tissue injury or unaccustomed use
• Increased emotional stress
• Idiopathic myogenous pain
• History:- Pain complaint began several hours or days following an event
associated with one of the etiologic factors.
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51

52. • Clinical Characteristics:-
• Structural dysfunction
• Minimum pain at rest
• Increased pain to function
• Actual muscle weakness
• Local muscle tenderness
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52

53. 3) Myospasm (Tonic contraction myalgias):
An involuntary CNS- induced tonic muscle contraction.
• Etiology:-
• Local muscle soreness
• Muscle fatigue
• Systemic conditions
• Deep pain input
• History:- Sudden onset of pain, tightness, and often a change in jaw position.
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53

54. • Clinical Characteristics:-
• Structural dysfunction
• Restriction in range of mandibular movement
• Acute malocclusion
• Pain at rest
• Increased pain with function
• Local muscle tenderness
• Muscle tightness
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Spasm of right inferior lateral pterygoid muscle

55. 4) Myofascial Pain
(Trigger point myalgia/ Myofacial trigger point pain):
• characterized by local areas of firm, hypersensitive bands of muscle tissue known as
trigger points.
• A trigger point is a circumscribed region in which just a relatively few motor units
are contracting. If all the motor units of a muscle contract, the muscle will of course
shorten in length. This condition, called myospasm. Because a trigger point has only a
select group of motor units contracting, no overall shortening of the muscle will
occur as with myospasm.
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55

56. • Etiology:-
• Protracted local muscle soreness
• Constant deep pain
• Increased emotional stress
• Sleep disturbances
• Local factors – Habits, posture etc.
• Systemic factors - poor physical conditioning, fatigue, and viral infections
• Idiopathic trigger pain mechanism
• History:- c/o heterotrophic pain and not the actual source of pain
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57. • Clinical characteristics:-
• Structural dysfunction
• Pain at rest (referred pain)
• Increased pain with function
• Presence of trigger points
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57
A trigger point (X) in the
semispinalis capitis muscle will
refer pain to the preauricular (TMJ)
area and anterior temporal region.

58. 5) Centrally Mediated Myalgia: (Chronic Myositis)
• Is a chronic, regional, continuous muscle pain disorder originating from CNS effects
that are felt peripherally in the muscle tissues.
• Etiology:
• Has its etiology more in the CNS than the muscle tissue itself.
• It is the result of central sensitization to the central neurons in the brain and brainstem.
• History:- Pain duration - 4 weeks to several months
• Constant pain
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58

59. • Clinical Characteristics:-
• Structural dysfunction
• Pain at rest
• Increased pain with function
• Local muscle tenderness
• Feeling of muscle tightness
• Often associated with allodynia
• Muscle contracture
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60. 6) Fibromyalgia (Fibrositis):
• is a chronic, global musculoskeletal pain disorder.
• Etiology:- Not well documented
• History:-
• Pain in numerous sites of the body
• Poor quality of sleep
• Sedentary lifestyle accompanied by some degree of depression.
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61. • Clinical Characteristics:-
• Structural dysfunction
• Pain at rest
• Increased pain with function
• Weakness and fatigue
• Presence of tender points
• Sedentary physical condition
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61

62. FUNCTIONAL DISORDERS OF THE TEMPOROMANDIBULAR
JOINTS
62They generally fall into three broad categories:
(1) derangements of the condyle-disc complex,
(2) structural incompatibility of the articular surfaces, and
(3) inflammatory joint disorders
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63. 1. Derangements of the Condyle-Disc Complex
63
DISC DISPLACEMENT
DISC DISLOCATION
WITH REDUCTION
DISC DISLOCATION
WITHOUT REDUCTION
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Factors That Predispose To Disc Derangement Disorders
• Steepness of the articular eminence: As the steepness increases, more
rotational movement is required between the disc and condyle during forward
translation of the condyle. Therefore patients with steep eminences are more likely
to demonstrate greater condyle-disc movement during function.
• Morphology of the condyle and fossa: Flat condyles that articulate against
inverted V-shaped temporal components seem to have an increased incidence of
disc derangement disorders and degenerative joint disease. It would appear that
flatter, broader condyles distribute forces better, leading to fewer loading problems.

65. 65
Joint laxity: Some joints will show slightly more freedom or laxity
than others. Some generalized laxity may be caused by increased
levels of estrogen. For example, women's joints are generally more
flexible and lax than men's.
Attachment of the superior lateral pterygoid muscle: it would be
reasonable to assume that if the attachment of the muscle is greater
to the neck of the condyle (and less to the disc), muscle function will
have), correspondingly less influence on disc position. Conversely, if
the attachment is greater on the disc (and less to the condyler neck),
muscle function will correspondingly influence disc position more
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66. If the inferior retrodiscal lamina and the discal collateral ligament become
elongated

Disc positioned anteriorly by pull of superior lateral pterygoid

Thinning of the posterior border of disc

Displacement of disc in more anterior position

Abnormal translatory shift of condyle over the disc can occur during opening

functional disc displacement.

Click: opening click only or opening and closing (reciprocal) click
66
Mechanism
DISC DISPLACEMENT
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67
A, Normal condyle-disc relationship in
the resting closed joint.
B, Anterior functional displacement of
the disc. The posterior discal border
has been thinned, and the discal and
inferior retrodiscal laminae are
sufficiently elongated to allow the disc
to be displaced anteromedially.

68. HISTORY
• TRAUMA
• PAIN(+/-)
• SOUND ON OPENING
CLINICALLY
• SINGLE CLICK
• RECIPROCAL CLICK
• NORMAL JAW MOVEMENTS
• PAIN(+/-) 68
MACROTRAUMA
• Direct
• Indirect
(Whiplash Injury)
MICROTRAUMA
• Bruxism
• Clenching
CAUSES (TRAUMA)
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69. DISC DISLOCATION WITH REDUCTION
69
HISTORY
• Long Clicking
• Recent Catching
• Self Reduction
• Pain(+/-)
CLINICALLY
• Limited Jaw Opening
• Protruded Position Of Mouth Eliminate Catching
Sensation
• Two click108
If the inferior retrodiscal lamina and discal collateral ligaments become further
elongated and the posterior border of the disc becomes sufficiently thinned, the
disc can slip or be forced completely through the discal space.
Since the disc and condyle no longer articulate, this condition is referred to as a
disc dislocation.
If the patient can so manipulate the jaw as to reposition the condyle onto the
posterior border of the disc, the disc is said to be reduced.

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70
A, Resting closed joint position.
B, During the early stages of translation, the
condyle moves up onto the posterior border of the
disc. This can be accompanied by a clicking sound.
C, During the remainder of opening, the condyle
assumes a more normal position on the intermediate
zone of the disc as the disc rotates posteriorly on the
condyle. During closure, the exact opposite occurs. In
the final closure, the disc is again functionally
dislocated anteromedially. Sometimes this is
accompanied by a second (reciprocal) click.

71. 71
Characteristics of reciprocal click
108
Opening click
occur anywhere during the opening
movement depending upon the
• amount of disc displacement,
• the anatomy of the disc, and
• the speed of movement
Closing click
occurs very near the intercuspal position
when the influencing factor, the superior
lateral pterygoid muscle, encourages the
disc to once again be displaced.

72. • Congenital and developmental muscle
disorders
• 1.Hypotrophy
• 2.Hypertrophy
• 3.Neoplasia
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73. • As the ligament becomes more elongated and the elasticity of the superior retrodiscal lamina is lost,
recapturing of the disc becomes more difficult.
• When the disc is not reduced, the forward translation of the condyle merely forces the disc in front of
the condyle. The dislocation without reduction has also been termed a closed lock.
73
DISC DISLOCATION WITHOUT REDUCTION
108
HISTORY
• Biting On A Hard object Or Waking Up with The Condition
• person usually is aware of which joint is involved and
• Person can remember the occasion that led to the locked feeling.
• Locked Jaw
• Pain(+/-)
• Clicking Before The Dislocation
CLINICALLY
• 25-30mm Opening
• Mandibular deflection to involved side
• Hard End Feel
• Pain On Loading the joints.

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74
A, Resting closed-joint position.
B, During the early stages of translation,
the condyle does not move onto the disc
but instead pushes the disc forward.
C, The disc becomes jammed forward in
the joint, preventing the normal range of
condylar translatory movement. This
condition is referred to clinically as a
closed lock.

75. 75
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76. 2) Structural Incompatibilities of the Articular Surfaces
i) Deviation in form:
• Etiology:-
• Changes in the shape of articular surface
• Flattening of condyle or fossa
• Bony protruberance on the condyle
• Thinning of the borders and perforations
• History:-
• Long term dysfunction
• No pain
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76

77. • Clinical Characteristics:-
• Dysfunction at a particular point of
movement, which is repeatable
during opening and closing
• Speed and force of opening do not
alter the point of dysfunction unlike
displaced disc
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77

78. • ii) Adherences and Adhesions:
• Etiology:
• Prolonged static loading of the joint structures
• Loss of effective lubrication
• Secondary to hemarthrosis or inflammation (adhesion)
History:-
• Clicking of joint after a period of static loading
• Morning stiffness of joint
• If permanent adhesions develop   opening
• Pain may or may not
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A, Adherence in the superior joint space. B, The presence of the adherence limits the joint
to only rotation. C, If the adherence is freed, normal translation can occur.
A, Permanent adhesion between the disc and fossa. B, Continued movement of the
condyle causes elongation of the discal and anterior capsular ligaments, permitting the
condyle to move onto the anterior border of the disc. C, Eventually the condyle passes
over the anterior border of the disc, causing a posterior dislocation of the disc.

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80
A, Adherence in the inferior joint space.
B, As the mouth opens, translation between the disc and fossa can occur but rotation
between the disc and condyle is inhibited. This can lead to a sensation of tightness and
irregular movement.
C, If the adherence is freed, normal disc movement returns.

81. Clinical characteristics
• Superior joint space adhesion
• mandibular opening of only 25 to 30 mm
• No pain on loading the joints
• Chronic fixed disc
• normal opening movement with little or no restriction
• During closure the patient senses an inability to get the teeth back
into occlusion
• Inferior joint space adhesion
• stiffness or catching on the way to maximal opening
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81

82. iii) Subluxation (Hypermobility):
• Sudden forward movement of the condyle beyond the crest of the articular
eminence during the latter phase of mouth opening.
• Etiology:- No pathologic condition
• The TMJ whose articular eminence has a steep, short posterior slope
followed by longer anterior slope that is often more superior than the crest
tends to subluxate.
82
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83. • History:- Jaw “Goes Out” with a thud sound on wide opening.
• Clinical Characteristics:-
• Observed by requesting the patient to open wide, the condyle jumps
forward leaving a small void or depression on the face behind the condyle.
• Repeatable
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84. iv) Spontaneous Dislocation (Open Lock):
• Etiology:-
• Represents a hyperextension of the TMJ resulting in a
condition that fixes the joint in the open position
preventing any translation
• History:-
• Associated with procedures requiring wide open
mouth( dental appointment/extended yawning)
• Inability to close mouth
• Pain associated with dislocation
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85
Clinical Characteristics:-
Spontaneous dislocation is sudden and the patient is locked in the
wide open mouth position
Anterior teeth are usually separated, with posterior teeth closed

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86
A, Normal condyle-disc relationship in the resting closed-joint position.
B, In the maximally translated position. Here the disc has rotated
posteriorly on the condyle as far as permitted by the anterior capsular
ligament.
C, If the mouth is forced open wider, the disc is pulled forward by the
anterior capsular ligament through the disc space. As the condyle moves
superiorly, the disc space collapses, trapping the disc forward.
Spontaneous dislocation
(with the disc anteriorly dislocated).

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87
A, Normal condyle-disc relationship in the resting closed-joint position.
B, In the maximally translated position. Here the disc has rotated
posteriorly on the condyle as far as permitted by the anterior capsular
ligament.
C, If the mouth is forced open wider, the condyle is forced over the disc,
dislocating it posterior to the condyle. As the condyle moves superiorly,
the disc space collapses, trapping the disc posteriorly.
Spontaneous dislocation
(with the disc posteriorly dislocated).

88. 3. Inflammatory Joint Disorders (Arthralgia)
88
The four categories are:
Synovitis.
Capsulitis.
Retro discitis.
Arthritis.
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Inflammatory disorders of the TMJ are characterized by continuous deep pain
accentuated by function, referred pain, excessive sensitivity to touch (allodynia),
and/or increased protective co-contraction.

89. Synovitis and capsulitis:
These both can be distinguished only by visualizing the tissues through
arthroscopy.
• Etiology:
• Trauma - blow to the chin or slow impingement on these tissues by an
anterior displacement of the disc
• Infection from adjacent structures.
• History:
Trauma or abuse
Continuous joint pain
89
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90. Clinical features
• pain on palpation which is reported to be directly in front of the ear.
• Limited mouth opening, with soft end feel
• If edema present then, disocclusion of ipsilateral posterior teeth.
90
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91. Retrodiscitis
• It is a inflammatory condition of retrodiscal tissues.
• Etiology
• Trauma -blow to the chin or progressive phases of disc displacement and
dislocation.
• the condyle gradually encroaches on the inferior retrodiscal lamina and retrodiscal
tissues which gradually insults these tissues, leading to retrodiscitis
• History:
• incident of trauma to jaw or a progressive disc derangement disorder
• Clenching of teeth increases pain,but clenching on ipsilateral blade decreases pain.
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92. Clinical characteristics:
– Soft end feel
– Constant periauricular pain that is accentuated with jaw movement.
– If the tissues swell a loss of posterior occlusal contact can occur on the
ipsilateral side, and heavy contact on contralateral anterior teeth.
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93. • As the disc is thinned and the ligaments become elongated, the
condyle begins to encroach on the retrodiscal tissues. The first area
of breakdown is the inferior retro discal lamina,which allows
even more discal displacement. With continued breakdown, disc
dislocation occurs and forces the entire condyle to articulate on the
retrodiscal tissues.
• If the loading is too great for the retrodiscal tissue, breakdown
continues and perforation can occur. With perforation of the
retrodiscal tissues, the condyle may eventually move through these
tissues and articulate with the fossa.
93
DEGENERATIVE JOINT DISEASE/ Arthrides
• Arthritis: Arthritis means inflammation of the articular surfaces of the joint.
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94. • Etiology:
• most common types of TMJ arthritides represents a
destructive process by which the bony articular surfaces
of the condyle and fossa become altered.
• It is generally considered to be the body's response to
increased loading of a joints.
• surface becomes softened (i.e., chondromalacia) and the
subarticular bone begins to resorb.
• Progressive degeneration eventually results in loss of the
subchonondral cortical layer, bone erosion, and
subsequent radiographic evidence of osteoarthritis.
• Previous Disc dislocation without reduction or
perforation
94
Osteoarthritis:
108

95. • Clinical characteristics:
– Limited mandibular opening - because of joint pain.
– Soft end feel
– Crepitation typically felt.
• Lateral palpation of the condyle increases the pain .
• Osteoarthritis is often painful, and jaw movement accentuates the
symptoms.
• Diagnosis confirmed by TMJ radiographs.( flattening, erosions,
osteophytes)
95
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History:
Report of unilateral joint pain that is aggravated by
mandibular movement.
The pain is usually constant but often worsens in the
late afternoon or evening.

96. Osteoarthrosis
96
• Often once loading is decreased, the arthritic condition can become adaptive.
• The adaptive stage has been referred to as osteoarthrosis
• When structural changes seen on radiographs. But no pain---osteoarthrosis
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97. Inflammatory disorders of associated structures
• A) Temporalis tendinitis:
• Etiology: Constant and prolonged activity of the temporalis . This muscle hyperactivity may be
secondary to bruxism, increased emotional stress, or a constant deep pain, such as
intracapsular pain.
• History: constant unilateral pain felt in the temple region and/or behind the eye which is
aggravated by jaw function
• Clinical characteristics: pain on mandibular elevation, restricted jaw opening is noted with a
soft end feel
• Intraoral palpation of the temporal tendon will produce extreme pain
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97
• B) Inflammation of the stylomandibular ligament
• Pain felt at the angle of the mandible and even radiating
superiorly to the eye and temple.
• Identified by placing the finger at the angle of the mandible and
attempting to move inward onto the medial aspect of the
mandible, where the stylomandibular ligament is attached

98. A. Ankylosis - Adhesions of intracapsular surfaces of joint.. 98
Types
•Fibrous / Bony
•Unilateral / Bilateral
Etiology
• HISTORY - previous history injury/capsulitis
• TRAUMA - macro trauma /secondary inflammation / haemarthrosis/bleeding / TMJ surgery
• INFECTION - Otitis media / Osteomyelitis of the jaw/Haematogenous
Clinical Features: Restricted movement. If unilateral, midline pathway deflection to affected side
on opening
CHRONIC MANDIBULAR HYPOMOBILITY
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99. B. Muscle contracture:
• Bell has described 2 types of muscle contracture
• 1. Myostatic : results when a muscle is kept from fully stretching for a
prolonged time.
• H/o Long term restricted jaw movement.
• Characterized by painless limitation of mouth opening.
• 2. Myofibrotic:
• Results as a result of tissue adhesions within the muscle or its sheath
following an inflammatory condition in muscle tissue or trauma to the
muscle.
• Characterized by painless limitation of mouth opening and normal lateral
condylar movement. 99
108

100. C. Coronoid impedance
• Cause :extremely long coronoid or fibrosis in the area between zygomatic
process and the posterior lateral surface of the maxilla.
• Chronic activity of the temporalis muscle
• History: long term painless restriction of opening
• H/o trauma/infection
• H/o long standing anterior disc dislocation without reduction
• Clinical features:
• limitation in all movements.
• If the problem is unilateral, opening will deflect the mandible to the same
side
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101. Growth disoders:
• Etiology: developmental issues that may be associated with trauma or genetic factors.
• History: clinical symptoms reported by the patient are directly related to the associated
structural changes. No pain is not common and the patient develops functional changes that
accommodate the altered growth.
• Clinical characteristics:
• Any alteration of function or the presence of pain is secondary to structural changes.
• Clinical asymmetry may be noticed that is associated with and indicative of a growth or
developmental interruption
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102. CONTINUUM OF FUNCTIONAL DISORDERS OF
THE TMJ
• Disorders of the TMJs may follow a path of progressive events, a continuum, from the
initial signs of dysfunction to osteoarthritis
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108
Various states of internal derangement
of the TMJ.
A, Normal joint.
B, Functional displacement of the disc.
C, Functional dislocation of the disc.
D, Impingement of retrodiscal tissues.
E, Retrodiscitis and tissue breakdown.
F, Osteoarthritis

103. A Study to Determine the Prevalence of Temporomandibular Disorders in
a Young Adult Population and its Association with Psychological and
Functional Occlusal Parameters
• Aim: To determine the prevalence of temporomandibular disorders (TMD) in medical university
students and to analyze the relationship of TMD with psychological and functional occlusal
parameters
• 200 students (mean age 21.81 ± 1.99) were screened for TMD with the TMD Pain Screener
• 3 groups: group 1- non-TMD, group 2- pain related TMD and headaches, and group 3- intra-
articular joint disorders.
• Emotional distress was evaluated
• Occlusion time, left lateral disclusion time, right lateral disclusion time, and protrusion
disclusion time were measured with T-Scan III.
• Conclusion: This study found that the prevalence of TMD in this university student population
was 17%. There were significant associations of TMD with psychological parameters and
functional occlusal parameters
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103

104. The evaluation of lateral pterygoid muscle pathologic changes and
insertion patterns in temporomandibular joints with or without disc
displacement using magnetic resonance imaging
• Aim: To investigate LPM attachments and their relationships with disc displacement and
subsequent pathologic changes.
• 26 patients with clinical temporomandibular disorders (TMDs) and a control group of 14
unaffected individuals were studied.
• Magnetic resonance images (MRIs) were taken to evaluate LPM insertion patterns, superior LPM
head pathologic changes, and relative disc to condyle
• Conclusion: The most common variation was shown to be the superior head with two
bundles, one attached to the disc and another to the condyle. No significant relationship
between LPM insertion type and disc displacement or pathologic changes of the muscle was
found. However, a link between disc displacement and muscle pathologic changes was
established
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104

105. Differences between centric relation and maximum intercuspation as
possible cause for development of temporomandibular disorder analyzed
with T-scan III
• Aim: To compare subjects from the group with fixed dentures, the group who present
temporomandibular disorders (TMDs) and a control group considering centric relation (CR) and
maximum intercuspation (MIC)/habitual occlusion (Hab. Occl.) and to analyze the related
variables also compared and analyzed with electronic system T-scan III.
• 54 subjects were divided into three groups; 17 subjects with fixed dentures, 14 with TMD and
23 controls
• Occlusal force, presented by percentage (automatically by the T-scan electronic system) was
analyzed in CR and in MIC.
• Conclusion: there are not statistically significant differences between CR and MIC in the group
of individuals without any symptom or sign of TMD although there are noticed in the group with
TMD and fixed dentures disharmonic relation between the arches with overload of the occlusal
force on the one side.
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105

106. Conclusion
106
• Several decisions must be made concerning the complex area of TMJ, before starting the
management
• Satisfactorily restoring a patient to a state of physiologic health is a challenge that requires the
clinician not only to be an acute diagnostician but also a master of a wide range of treatment
modalities.
• Making a proper and correct diagnosis becomes an extremely important part of management
temporomandibular disorders.
108

107. REFERENCES
 Management of TMDs and Occlusion. Jeffrey Okeson 6th edt.
 Functional occlusion from TMJ to smile design. Dawson- 3rd ed.
 Color atlas of TMJ surgeries. Peter Quinn.
 DCNA 2007, Jan, vol 51, no. 1 -TMDs and orofacial pain
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108. • Jivnani HM, Tripathi S, Shanker R, Singh BP, Agrawal KK, Singhal R. A
Study to Determine the Prevalence of Temporomandibular Disorders in a
Young Adult Population and its Association with Psychological and
Functional Occlusal Parameters. Journal of Prosthodontics. 2017 Nov 14.
• Imanimoghaddam M, Madani AS, Hashemi EM. The evaluation of lateral
pterygoid muscle pathologic changes and insertion patterns in
temporomandibular joints with or without disc displacement using
magnetic resonance imaging. International journal of oral and
maxillofacial surgery. 2013 Sep 30;42(9):1116-20.
• Lila-Krasniqi ZD, Shala KS, Pustina-Krasniqi T, Bicaj T, Dula LJ,
Guguvčevski L. Differences between centric relation and maximum
intercuspation as possible cause for development of temporomandibular
disorder analyzed with T-scan III. European journal of dentistry. 2015
Oct;9(4):573.
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