This presentation prepared and showed by doctor of Oral Medicine Shaimaa Hamid in Anbar University Faculty of Dentistry all rights are save

2. Temporomandibular Disorders

3. the masticatory muscles,
the temporomandibular
joints (TMJs) and associated
structures, or both.

4. (1) facial pain in the region of
theTMJs and/or muscles of
mastication,
(2) limitation or deviation in
mandibular movements,
(3)TMJ sounds during jaw
movement and function.

5. Functional Anatomy
hinge-type movements
gliding movements.

6. the
mandibular condyle,
which forms the lower
part of the bony joint
hollow in
the temporal bone (the
mandibular or glenoid
fossa) which form the
upper part of the bony
joint.

7. During wide mouth opening, the condyle rotates around
a hinge axis and glides, causing it to move beyond the
anterior border of the fossa, identified as the articular
eminence.
Rotation of the condyle contributes more to normal
mouth opening than translation.

10. The bony components are enclosed and
connected by a fibrous capsule
The capsule is lined with synovium and the
joint cavity is filled with synovial fluid.
The synovium is a vascular connective tissue
lining the fibrous joint capsule and
extending to the boundaries of the
articulating surfaces.
Synovial fluid is a filtrate of plasma with
added mucins and proteins. Fluid forms on
the articulating surfaces and decreases
friction during joint compression and
motion.

11. Articular Disc
A fibrocartilage made up primarily of dense
collagen of variable thickness and referred to
as a disc occupies the space between the
condyle and mandibular fossa.
The disc is attached by ligaments to the
lateral and medial poles of the condyle.
These ligaments permit rotational
movement of the disc on the condyle during
mouth opening and closing.

12. The disc is thinnest in its center and thickens to
form anterior and posterior bands.
This arrangement is considered to help stabilize
the condyle in the glenoid fossa.
The disc is primarily avascular and has little
sensory nerve penetration.
The disc provides an interface for the condyle
as it glides across the temporal bone.

14. The disc and its attachments divide
the joint into upper and lower
compartments that normally do not
communicate.
The roof of the superior compartment
is the mandibular fossa, whereas
the floor is the superior surface of the
disc.
The roof of the inferior compartment
is the inferior surface of the disc and
the floor is the articulating surface of
the mandibular condyle.

15. RetrodiscalTissue
A mass of soft tissue occupies the
space behind the disc and
condyle. It is often referred to as
the posterior attachment.
two lamina of dense connective
tissue (superior and inferior
lamina).

17. Temporomandibular Ligaments

18. Capsular Ligament
superiorly
inferiorly,
It acts to resist any medial, lateral or
inferior forces that tend to separate or
dislocate the articular surface.
to encompass the joint,
thus retaining the synovial fluid.

20. LateralTemporomandibular Ligament
lateral
to the capsule but not easily separated
from it by dissection.
It is composed of two parts,
an outer oblique portion
an inner horizontal portion.
The oblique portion of the ligament
resists excessive dropping of the
condyle and therefore acts to limit the
extent of mouth opening.

22. Accessory Ligaments
The sphenomandibular ligament arises
from the sphenoid bone and inserts on
the medial aspect of the mandible at the
lingula. It is not considered to limit or
affect mandibular movement.
The stylomandibular ligament extends
from the styloid process to the deep
fascia of the medial pterygoid muscle.
contribute to limiting
protrusive movement.

24. Muscles of mastication

25. Masseter
It is the most powerful muscle of mastication.
It is quadrangular in shape, and can be split into
two parts; deep and superficial.
Attachments:The superficial part originates
from maxillary process of the zygomatic bone.
The deep part originates from the zygomatic
arch of the temporal bone. Both parts attach to
the ramus of the mandible.
Actions:
Innervation:

27. Temporalis
Attachments:
Actions:
Innervation:

28. Medial Pterygoid
It has a quadrangular shape, with two heads; deep
and superficial. It is located inferiorly to the lateral
pterygoid.
Attachments:The superficial head originates from
the maxilla.The deep head originates from the
lateral pterygoid plate of the sphenoid bone.
Actions:
Innervation:

29. Lateral Pterygoid
Attachments:
Actions:
Innervation:

31. Etiological factors inTemporomandibular Joint
Disorders (TMDs)
1. Parafunctional habits
2. Emotional distress
3. Acute trauma to the jaw
4.Trauma from hyperextension
5. Instability of maxillomandibular relationships
6. Laxity of the joint
7. Comorbidity of other rheumatic or musculoskeletal disorders
8. Poor general health and an unhealthy lifestyle

32. Diagnosis of temporomadibular joint
disorders:
1. History taking
*past history of the diseases
*social and family history
*past dental and medical history and
hospitalization.

33. 2. Clinical examination
*Extra oral examination

37. *Intra oral examination

38. 3. Radiographic examination

40. 4. Magnetic Resonance Imaging
On opening the condyle and disc translate down and
forward beneath the articular eminence.NormalTMJ

41. 5. Arthroscope
-The diagnosis
-The treatment

42. 6. Electromyograph

43. Myofascial Pain of the Masticatory Muscles
muscle
pain produced on palpation
muscle pain that also radiates
or is referred when the muscle is stimulated
during palpation examination.

44. Clinical Features
• Age and sex distribution middle age group
women.
• Onset
Usually episodes are
seen during increased emotional tension, resulting in increased
intra-articular pressure in the joint.
• Symptoms Pain is localized to preauricular area but can be
radiated to temporal, frontal, and occipital region.There is
difficulty in chewing and restriction of mandibular excursion.
Patient also complaint of noise on rubbing, grinding, clicking,
and popping snapping sounds on mandibular movement.

45. •Tinnitus tinnitus (ringing in
ear) otalgia (pain in ear)
• Hearing loss

46. • Signs—restriction of opening and protrusion may be
accompanied by deflection of the mandibular incisal
pathway.
• Other features
indentation on lateral borders of the
tongue, ridging of the buccal mucosa extensive
attrition of teeth.

47. InitialTreatment of Myofascial Pain
●Education

48. ●Self-care

49. ●Physical therapy
Cold laser forTMD

50. TENS unit electronically massages and stimulates the muscles with low
frequency pulses to help the muscle find its most relaxed state.

52. ●Intraoral appliance therapy

53. ●Pharmacotherapy
●Behavioral/relaxation techniques

54. Articular Disc Disorders of theTMJ
abnormal relationship between
the disc, the mandibular condyle, and the
articular eminence,
elongation or tearing of the attachment of the
disc to the condyle and glenoid fossa.
joint sounds,
limitation and deviation of mandibular
motion, and pain.

57. cases result from direct trauma to the joint from a blow to the
mandible.
chronic low-grade microtrauma
ong-term bruxism or clenching of the teeth

58. Clinical Manifestations
Disc displacement is divided into stages
A simple classification system dividesADD into:
Anterior Disc Displacement with Reduction.
. Anterior Disc Displacement without Reduction (Closed Lock).
Posterior Disc Displacement.

59. Anterior Disc Displacement with Reduction.
articular disc that has been
displaced from its position on top of the condyle due to
elongation or tearing of the restraining ligaments.
*An alteration in the form of the disc has also been proposed as
a possible factor.
common in the general
population
pain, loss of function,
and/or intermittent locking.

60. Palpation and auscultation of theTMJ will reveal a clicking or popping
sound during both opening and closing mandibular movements
(reciprocal click).
click that may occur on opening in the
early, middle, or late movement in the closing movement just
before the teeth come in contact.

62. ADDR, the disc (black arrows) lies anterior to the condyle (C) in closed
mouth position (1). On mouth opening the disc moves posteriorly over
the head of the condyle (2) and finally rests over the condylar head in
maximal open mouth position(3). Thus, the disc which was anteriorly
positioned, is now reduced back to its normal position on mouth
opening.

63. Anterior Disc Displacement without Reduction (Closed Lock):
Closed lock may be the first sign ofTMD occurring after trauma or
severe long-term nocturnal bruxism.
due to disc interference with
the normal translation of the condyle.

65. ADDWR,the disc (black arrows) remains persistently
anterior to the condyle (C) as the condyle translates
from closed mouth position (1) to maximal open mouth
position (3).

67. away from

69. Posterior Disc Displacement:
condyle slipping over the
anterior rim of the disc during opening
with the disc being caught and brought
backward in an abnormal relationship to the
condyle when the mouth is closed.

70. The clinical features are
(1) a sudden inability to bring the upper and lower teeth
together in maximal occlusion,
(2) pain in the affected joint when trying to bring the teeth
firmly together,
(3) displacement forward of the mandible on the affected side,
(4) restricted lateral movement to the affected side, and
(5) no restriction of mouth opening.

71. Management
these nonsurgical and surgical techniques are effective in
decreasing pain increasing the range of mandibular motion

72. Temporomandibular Joint Arthritis
Osteoarthritis (Degenerative Joint
Disease)
is primarily a disorder of articular
cartilage and subchondral bone, with
secondary inflammation of the synovial
membrane.
It is a localized joint disease without
systemic manifestations.

73. DJD may be categorized as
Primary DJD u g
a
a
Secondary DJD

74. Clinical Manifestations:
increases with age
symptomatic DJD pain
directly over the affected condyle, limitation of mandibular
opening, crepitus, and a feeling of stiffness after a period of
inactivity.
tenderness crepitus
Deviation painful side

75. Radiographic findings in DJD may include
*
*
*
*
*
*

76. Cone-beam computed tomography images ofTMJ showing morphological variation of the mandibular condyle.
A- Normal (coronal view)
B- Flattening (coronal view)
C- Erosion (coronal view)
D- Osteophyte (sagittal view)

77. Rheumatoid Arthritis (RA)
an inflammatory disease affecting
periarticular tissue and secondarily bone.
Degenerative changes in rheumatoid arthritis-
attenuation of the condyle.

78. Clinical Manifestations:
bilaterally
Pain early acute phase
not a common complaint in later stages
morning stiffness, joint sounds,
and tenderness and swelling over the joint area.
Micrognathia and an anterior open bite
Radiographic changes

79. Treatment:
placed on a soft diet
Use of a flat-plane occlusal appliance
exercise program
Intra-articular steroids

80. placement of
prosthetic joints, is indicated in patients who have severe
functional impairment intractable pain not successfully
managed by other means.
correction of facial deformity resulting from arthritis
during growth.

81. Developmental Defects
size shape
Hyperplasia, hypoplasia, agenesis, and the formation of a bifid
condyle
Local factors trauma or infection
Facial asymmetry
site for compensatory growth
and adaptive remodeling.

82. Fractures
blow to the chin.
pain and edema
over the joint area and limitation and
deviation of the mandible to the injured
side on opening.
Bilateral condylar fractures may result in
an anterior open bite.

83. Dislocation
condyle is positioned anterior to the
articular eminence and cannot
return to its normal position without
assistance.

84. muscular incoordination in wide opening during
eating or yawning less commonly from trauma;
unilateral or bilateral
inability
to close the jaws and pain related to muscle spasm.

85. The condyle can usually be repositioned without the use
of muscle relaxants or general anesthetics.
If muscle spasms are severe and reduction is difficult, the
use of intravenous diazepam (approximately 10 mg) can
be beneficial.

86. stand in front of the seated
patient place his or her thumbs lateral to
the mandibular molars on the buccal shelf of
bone; the remaining fingers of each hand
should be placed under the chin.

88. Ankylosis
fusion of the head of the
condyle to the temporal bone.
Trauma
infections
prolonged immobilization following
condylar fracture.

91. Bruxism