DISORDERS OF

THE TEMPORO-MANDIBULAR JOINT (TMJ)

Dr. Mohamed Shokry
BDS-MSc-PhD
Oral & Maxillofacial Surgery
Faculty of Dentistry- Alexandria

Unique joint, its structure allowing for three different

groups of movements:
1. The up and down, or elevation and depression,
of the jaw.
2. The protraction &retraction of the mandible .
3. Side to side motion, or lateral deviation.
Bony articulation and interposed disc
The condyle is roughly elliptical in cross section with
the medio-lateral dimension equal to about twice its
antero-posterior width.
The articular surfaces are covered with avascular
fibrous tissue.
The primary concave temporal articular surface is
limited anteriorly by the convex articular eminence and
posteriorly by the articular lip.
Interposed between the osseous structures is the
meniscus (disc).It is composed of avascular, aneural,
fibrous connective tissue.

Disc And Its Attachments:

The disc separates the superior and inferior joint cavities.
It is lined with synovial tissues that produce fluid
necessary for lubrication of articular surfaces.
The upper cavity is larger.
The disc composed of three regions:3 mm: Posterior band.
1 mm: Intermediate zone.
2 mm: Anterior band.
It is thinnest centrally (1mm) and somewhat heavier along
its periphery.
The greatest bulk is at the posterior attachment (the
bilaminar zone)
The bilaminar zone consists of two strata of fibers
separated by loose areolar connective tissue
Superior strata is composed mainly of elastic fibers
Inferior strata is made up mainly by fibrous tissue.
The posterior attachment tissues are highly innervated by
the auriculo-temporal nerve.
The superior surface of the disc is concavo-convex,
whereas the undersurface is concave antero-posteriorly.
The meniscus (disc) is attached tightly to the medial and
lateral poles of the condyle.
Posteriorly the attachment is elastic to allow it to translate
forward with the condyle
Anteriorly, the disc is continuous with the capsule and the
lateral pterygoid fascia.

Capsule:
Is a ligamentous structure
It extends from the temporal portion of glenoid fossa ,
fuses with the margins of the disc, reach the neck of
condyle to invest the entire joint.
It is reinforced laterally by the TM ligament.
The temporomandibular ligament:
It is composed of horizontal oblique and deep horizontal
connective tissue fibers.
It reinforces the capsule laterally.
It acts to limit anterior and posterior condylar movements.
It is designed to prevent the mandible from opening too
far on a pure hinge rotation at the uppermost position.
As the jaw opens on a pure hinge movement, the floor of
the mouth is directed back into the airway.To prevent this
the ligament reach its full length at about 15 to 20mm of
the jaw opening.
At this point, the site of attachment of the TML to condyle
becomes a pivot that initiate forward translation of the
rotating condyle.
This requires the mandible to move forward away from
any airway obstruction during full opening.
The temporomandibular ligament: Normal function
The condyle disc interface of the joint is the site of primary
hinge movement.
This is made possible by fixation of the disc to condyle by
the discal ligaments.

Contraction of the inferior lateral pterygoid muscle occurs

during opening movement and result in anterior condylar
translation.
During closure the inferior lateral pterygoid releases
contraction to allow the condyle to be pulled back by the
elevator muscles.
During closure the superior lateral pterygoid activate its
contraction to hold the disc forward, to oppose the pull of
elastic fibers.
The superior lateral pterygoid muscle is essentially
passive; contracting during forced closure, or in the
presence of occlusal interferences.
Centric relation:
The relationship of the mandible to the maxilla when the
properly aligned condyle-disc assembly is in the most
superior position against the eminence, irrespective of
tooth position or vertical dimension.
Centric Occlusion:
The relationship of the mandible to maxilla when the teeth
are in maximum occlusal contact, irrespective of position
or alignment of condyle disc- assembly.

The Temporomandibular Joint Disorders

The
ADA
classification
(developed by Weldon Bell)

of

TMJ

Masticatory muscle disorders :

1. Protective muscle splinting.
2. Myofacial pain dysfunction syndrome.
3. Muscle hyper activity or spasm.
4

disorders

4. Myositis (muscle inflammation)

Intra-articular problems: (internal derangement):
1. Anterior disc displacement with reduction (clicking).
2. Anterior disc displacement without reduction (closed
lock)

Degenerative joint disease

Arthrosis.

Arthritis.

Inflammatory joint disorders:

Rheumatoid arthritis
Infectious arthritis.
Metabolic arthritis.

Functional disorders:
Dislocation & subluxation.
TMJ Ankylosis.

DIAGNOSIS OF TMJ DISORDERS

Diagnosis of TMJ disease or dysfunction depends upon
thorough
history
and
clinical
examination,
plus
radiographic imaging.
TMJ disease / dysfunction are intimately related to
occlusion.
History Taking
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History of the present complaint (onset & course) is taken

.
Ascertain the effect of function on the symptoms, its
relation to daytime and stresses.
The general past history including medical, surgical,
psychological, occupational, social and family background.

Physical examination
Examination of the joint itself.
The range of opening anteriorly is measured.
Opening, closing, protrusive, and lateral movements are
evaluated.
Direct examination of the condyles both in the
periauricular area and via external auditory meatus
(endaural).
Sounds whether audible to the examiner or heard by the
stethoscope.
Palpation of the muscles of mastication for areas of
tenderness, rigidity, or masses.
Examination of dentition and other hard and soft tissues of
oral cavity.
Radiographic diagnosis
Plain radiography; orthopantomogram (Panoramic x-ray),
oblique lateral transcranial views, and transpharyngeal
views in the open and closed positions.

Tomography; Tomograms offer the best results of plain

radiography because of the elimination of superimposition
found in conventional radiographs.Tomographic section of
TMJ are done with mouth closed and opened.
Arthrography; Arthrograms, where radiographs are
taken after a radio-opaque dye has been injected into the
synovial spaces, can demonstrate the position of soft
tissues within a joint by negative image. It has the
disadvantage of being invasive.
Computed Tomography (CT Scan); It is a non-invasive
technique helpful in diagnosis of abnormalities in hard /
soft tissue components of the joint

Magnetic resonance imaging (MRI); it is an imaging

procedure with vast clinical potential, as it offers detailed
views of internal anatomy without ionizing radiation or
invasion. More helpful in diagnosis of soft tissue ( disk )
diseases.
Arthroscopy; it allows direct visualization .
TMJ is a difficult joint for arthroscopy;
not only being
small in size, but it has two compartments with the line of
entry of the instrument from the lateral side shielded by
the tip of the root of zygoma.
Radiographic diagnosis
Ultrasound (US); the wavelengths available for
diagnostic ultrasound do not permit visualization of soft
tissues in close apposition to bone . Ultrasound in its
present form has no value.

Laboratory examination
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Laboratory examination; such as complete blood cell

count, serum calcium, phosphorous, and alkaline
phosphatase. Also serum uric acid,
serum rheumatoid
factor RF.
The
ADA
classification
(developed by Weldon Bell)

of

TMJ

disorders

Masticatory muscle disorders :

1. Protective muscle splinting.
2. Myofascial pain dysfunction syndrome.
3. Muscle hyper activity or spasm.
4. Myositis (muscle inflammation)

Protective muscle splinting

The lateral pterygoid muscles are capable of holding the
condyles in an advanced position during protrusive
function.
The mechanism that forces this prolonged contraction of
the lateral pterygoid muscles is sensitive protective reflex
system that guards the teeth and their supporting
structures against excessive stress.
This proprioceptive receptors are designed to program the
lateral pterygoid muscle to position the jaw so that the
elevator muscles can close directly into maximum occlusal
contact.
This unique relationship between the lateral pterygoid
muscles and the proprioceptive periodontal receptors is so
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definite that is even override the normal tendency of the

muscle to rest when it becomes fatigued.
The muscles cannot relax the protective bracing
contraction as long as the occlusal interference is present.
The pattern of deviation is reinforced every time the
contact is made, and it is retained in the brains memory
bank (muscle engram) so that muscular closure into the
deviated jaw relationship becomes automatic
One important fact of the proprio-ceptive memory,
however, is that it fades rapidly if continual reinforcement
of the pattern ceases.
Elimination of interfering contacts permits an almost
immediate return to normal muscle function
The fatigue or spasm that occur from prolonged
hyperactivity often produces pain in the muscle.
Sensory nerve endings in the muscles are highly sensitive
to lactic acid buildup and also to ischemia.
When the nerve endings are stimulated, they report such
stimulation as pain.
Ischemia can occur in the muscle because of the tight
spastic contraction around its own blood supply.
Occlusal splints can perform one basic function. They can
prevent the existing occlusion from controlling the jaw to
jaw relationship at maximum intercuspation by providing a
smooth surface, which gives a chance for correcting the
position of the condyle-disk assemblies and relief of any
spasm in the masticatory muscles.
Types of occlusal splints:
Soft Occlusal Splint
Hard Occlusal Splint
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Permissive splint: Designed to unlock the occlusion to

remove the deviating tooth inclines from contact.
Directive splint: Designed to position the mandible in a
specific relation to maxilla.

MYOFASCIAL PAIN DYSFUNCTION SYNDROME

It is not a disease entity rather than a set of etiologically
non-related disorders. Normal TMJ / Muscle pain.
This explains why this syndrome is defined on the basis of
the symptoms rather than on the basis or the principle
etiologic factor (cause and effect).
MPDS :Signs and symptoms:
Pain
Tenderness of the masticatory muscles.
Clicking.
Limitation of mandibular movements.
Absence of clinical or radiographic evidence of organic
changes in the TMJ.
Lack of tenderness in TMJ on endaural examination.

The Trigger points are signature mark of MPDS diagnosis.

By spot palpation of all muscles suspected pain is
present.
Painful limits of the range of motion of opening.
Etiology:
Occlusal Disharmony
Psychological Disturbance
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TREATMENT: (it's multidisciplinary)

1- Pharmacological line of treatment :
- NSAIDS (aspirin, ibuprofen)
- Tricyclic anti-depressant drugs in low doses
- Potent muscles relaxant (diazepam, skelaxin )
2- Injection therapy : into trigger points:
a) local analgesic (bupivacaine, lidocaine )
b) Skeletal muscle relaxant ( botulinum toxin BO-TOX )
as it cuts innervation into muscles.
3- Role of Dentist :
-

Breaking up bad habits (bruxism, clinching,

grinding).

- Treatment of occlusal disharmony / occlusal

adjustment.
Occlusal splints :
Occlusal splints can perform one basic function. They
can prevent the existing occlusion from controlling
the
jaw
to
jaw
relationship
at
maximum
intercuspation by providing a smooth surface, which
gives a chance for correcting the position of the
condyle-disk assemblies and relief of any spasm in
the masticatory muscles.

Types of occlusal splints:

1. Soft.
2. Hard
3. Permissive: Designed to unlock the occlusion to
remove the deviating tooth inclines from contact.
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4. Directive: Designed to position the mandible in a

specific relation to maxilla.
4- Improvement of nutrition:
- Soft diet
- Increase of intake of vitamins
5- Psychological line of treatment :
The role of psychiatric specialist will takes place in
elimination of stress.

Intra-articular problems: (internal derangement):

1. Anterior disc displacement with reduction (clicking).
2. Anterior disc displacement without reduction (closed
lock)
Internal derangement
Internal derangement of the TMJ can be defined as a malrelation of the meniscus to the condylar head and articular
eminence.
It is categorized as:
1. Anterior displacement of the disc with reduction
(reciprocal clicking of the joint)
2. Anterior displacement of the disc without reduction
(locked joint).
Anterior disc displacement
(With reduction)
If the normally secure attachment of the meniscus to the
lateral condylar pole is slack or detached.
Or if the bilaminar zone has been
degenerated from trauma or joint disease.
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destroyed

or

As the interincisal opening increases; a spontaneous

reduction of the anteriorly displaced disc occurs producing
the characteristic click.
The origin of the joint click is related to the passage of the
condyle over the thick posterior meniscal band.
On closure, a subsequent resumption of anterior meniscal
displacement occurs, a second click is noted (reciprocal
clicking).
Anterior disc displacement
without reduction
(closed lock)
Closed lock is the result of unreduced, persistent anterior
displacement of the disc.
When the posterior band of the deformed disc is trapped
anterior to the condyle, it forms a mechanical barrier to
normal condylar translation.
Interincisal opening is seldom greater than 25 mm.
Translation is absent.
Clicking phenomenon is lost.
The condition may progress to perforation of the disc
accompanied by osteoarthrosis of the condyle and
articular eminence.
MRI done for diagnosis.
Closed lock.
No translation.
No clicking.
Deformed disc.
Painful joint.

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Acute closed lock

It is the result of trauma in which the condyle is driven
posteriorly with subsequent injury to the posterior
attachment.
The resultant pain/discomfort may be severe, and the
condition is sometimes identified as discitis.
It is an inflammation of the discal attachments rather than
the relatively avascular/aneural disc itself.

Treatment Of Internal Derangement Of TMJ

Conservative treatment
Occlusal therapy:
This line of treatment consists of occlusal splints, occlusal
equilibration (selective grinding of teeth) and dental
reconstruction.
A full occlusal splint harmonized to the most comfortable
joint position may produce acceptable results.
Physiotherapy !!!.
Psychotherapy !!!.
surgical treatment
High condylar shave.
Eminectomy.
Capsular rearrangement.
Menisectomy.
Subcondylar osteotomy.
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Meniscoplasty; transaction and plication of posterior

attachment.
Recently arthrocentesis.
Arthrocentesis
Consists of anesthezing the affected TMJ with local
anaesthetic followed by flushing the joint with a sterile
solution such as Lactate ringers solution antiinflammatory steroids.
Used to lubricate
inflammation.

the

joint

surfaces

and

reduce

Degenerative joint disease

Arthrosis.

Arthritis.

Inflammatory joint disorders:

Rheumatoid arthritis
Infectious arthritis.
Metabolic arthritis.
Degenerative (osteoarthritis).
Traumatic.
It is an inflammatory systemic disease that produces
destructive changes, in more than a single joint.
Clinically, there is pain, joint noise, and limitation of
motion.
Obvious distortion of occlusion may be seen
Rheumatoid arthritis
15

In cases of juvenile rheumatoid arthritis (JRA) there is such

an extensive damage to the condyle that the growth of
the jaw may be seriously impaired by the development of
ankylosis.
Diagnosis is established
radiographic studies

by

both

laboratory

and

A positive rheumatoid factor RF, particularly in the

presence of multiple joint involvement is fairly decisive in
establishing the diagnosis.
The condyles are eroded, and flattened.
There is narrowing of the joint space .
Arthritis urica (Gout)
Is a metabolic disease of unknown etiology.
The joint tissue may be inflamed owing to deposition of
micro crystals of sodium urate.
The acute onset is very characteristic.
The affected joint is reddened, warm,swollen, and very
tender.
The pt. Feels ill and fever.
Degenerative
(osteoarthritis)

arthritis

It can occur as the result of prolonged functional abuse

(closed lock).
Diagnosis of Osteoarthritis is made on the basis of clinical
& radiographic evidences
Sclerosis of the interposed deformed disc
Facet on antero-superior surface of condyle with loss of
corex.

16

Sclerosis of cortex at summit and inferior surface of

condyle.
Cyst like destruction posteriorly
Flattened eminence
Small osteophyte on superior surface of the condyle.
Sclerosing of the condyle.
The intermediate zone and posterior band of the TMJ disc
are ill defined.
Infectious arthritis
Bacterial or fungal disease of the joint.
It may be due to local extension of infections from the
middle ear, mastoid process, parotid gland and mandible.
Eventually, fibrous or even bony ankylosis can occur.
Traumatic arthritis
It the result of acute direct trauma and not micro-trauma
caused by repeated dental function and mechanical
stress.
Hemarthrosis or traumatic svnovitis may be the major
direct effects of trauma to the joints.

Dislocation and subluxation

Dislocation i.e., luxation, is the displacement of condylar
head completely out of glenoid fossa anterior & superior
to the summit of articular eminence.
It occurs when capsule (collateral ligaments)
temporomandibular ligament are compromised.
it cannot be reduced by the patient.

17

and

It may assume a chronic, recurrent form in which patients

suffer numerous episodes with resultant abnormal laxity of
the
supporting
capsule
and
ligaments
(chronic
subluxation). Reduced by the patient.
Etiology:
Most dislocations occur spontaneously on opening the
mouth widely for yawning, dental work, during seizure.
Trauma may also produce dislocation.
Clinical findings
Uncomfortable but not severely painful.
Inability to close the mouth.
Dislocations may be unilateral or bilateral
Prognathic appearance to jaw when both are dislocated.
Deviation of the mandible to the opposite side in unilateral
dislocation.
Reduction of TMJ dislocation
Reduction occurs through downward pressure with the
thumbs on the external oblique ridges, and upward
pressure with the fingers.
Treatment of dislocation
1- Eminectomy
2- Dautery operation
Preauricular incision.
The anterior part of the eminence which is attached to the
zygomatic arch is exposed.
This anterior portion of the eminence is down-fractured.

18

Because of the increase in eminence height, the condyle is

unable to dislocate.
Other methods of eminence augmentation have been
described, for example bone graft augmentation.

TMJ ankylosis
Ankylosis is a chronic hypomobility or immobility of
movable articulation.
It is considered as one of the most common sequelae
following infection or trauma.
TMJ ankylosis
It has been classified into:
*

Unilateral or bilateral

True (intra-articular)

False (extra-articular).

Fibrous or bony.

Partial or complete.

CLINICAL FEATURES

Inability to open the jaws.

In unilateral ankylosis, the lower jaws shifts towards
the affected side on opening of the mouth.

In severe cases, there is complete immobilization.

Facial deformity (Bird Face).

19

Other bones
associated.

and

joints

deformities

may

be

TREATMENT:
1- Condylectomy
Pre-auricular incision.
Horizontal cut carried is out at the level of the condylar
neck
The head (condyle) should be separated from the
superior attachment
3- Gap Arthroplasty.
2- TMJ
Interpositional Arthroplasty
arthroplasty using buccal pad of fat
4- Total Joint Replacement.

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: Interpositional