Chapter 10 Diseases Affecting the Temporomandibular Joint Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 1

Chapter 10

Diseases Affecting the Temporomandibular Joint

•Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

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•Outline• Anatomy of the Temporomandibular Joint• Normal Joint Function• Temporomandibular Disorders• Tumors of the Temporomandibular Joint


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Diseases Affecting the Temporomandibular Joint (TMJ)

• Disorders of the TMJ include myofascial pain and dysfunction (MPD), internal derangement syndrome, osteoarthritis, and rheumatoid arthritis

• Benign and malignant tumors can also affect the TMJ


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Anatomy of the Temporomandibular Joint (TMJ)

• The TMJ is an articulation between the condyle of the mandible and the glenoid fossa of the temporal bone


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Anatomy of the Temporomandibular Joint

• Fibrocartilage covers the bony articulating surfaces

• Ginglymoarthrodial movement

• An articular disk divides the space

• Avascular and devoid of nerve fibers

• Synovial fluid provides nourishment and lubrication


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• A synovial membrane lines the joint and produces synovial fluid that nourishes and lubricates avascular surfaces


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• Palpation of the muscles of mastication may be done to determine whether muscle spasm or dysfunctional muscle activity is occurring• Masseter• Temporalis• Medial pterygoid• Lateral pterygoid• Anterior digastric• Mylohyoid


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TMJ: Associated Muscles


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Normal Joint Function

• In the position of maximal occlusal contact, the mandibular condyle rests within the glenoid fossa• The articular disk is situated between the condyle, roof of the glenoid fossa, and the articular eminence

• The first phase of opening is characterized by a rotational (hinge) movement of the condyle followed by an anterior translation (sliding)


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Temporomandibular Disorders

• Pathophysiology of temporomandibular joint disorders

• Patient evaluation• Types of temporomandibular disorders• Treatment of temporomandibular joint disorders


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Temporomandibular Disorders (TMDs)

• TMDs are caused by abnormalities in the function of either the joint itself or associated structures• Majority of patients are female• Between 20 and 40 years of age• Female sex hormones play a role• Depression• Rheumatoid arthritis• Chronic fatigue syndrome• Chronic headache• Fibromyalgia• Sleep disturbances• Irritable bowel syndrome


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• Trauma• Direct (assault)• Indirect (whiplash injury)• Resulting from parafunctional habits such as clenching or bruxism

• Psychosocial factors (stress)

• Dentofacial deformities

• May be associated with disorders in growth and development as in condylar hyperplasia or hypoplasia

Pathophysiology of Temporomandibular Joint Disorders


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Pathophysiology of Temporomandibular Joint Disorders

• Abnormalities are associated with a number of systemic diseases:• Depression• Rheumatoid arthritis and osteoarthritis• Chronic fatigue syndrome• Chronic headache• Fibromyalgia• Sleep disturbances• Irritable bowel syndrome

• Female sex hormones play a role• Iatrogenic cause


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Patient Evaluation

• Dysfunction may be caused by disorders of muscles of mastication or by internal derangements of components of the joints

• Evaluation involves a comprehensive history and thorough clinical examination• Chief complaint• History: Chief complaint, medical, dental• Examination • Imaging


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Patient Evaluation

• Patient management:• Reduced mouth opening• Shorter appointments• Pain control

• Three cardinal features of temporomandibular disorders:• Orofacial pain• Joint noise• Restricted jaw function


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History • Ask questions!• Medical/dental history• Precipitating events• Circumstances that exacerbate or diminish symptoms• Onset and progression of symptoms: Sudden or gradual• Joint symptoms (clicking, popping)• Pain• Problems with mastication• Trismus• Malocclusion• Parafunctional habits (bruxing, clenching)• Extensive dental or orthodontic treatment• History of surgical treatment of the jaws


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Investigate Patient’s History• Orofacial pain: What is causing it?• Referral may be necessary

Differential Diagnosis:

TMDs Pericoronitis

Caries Cracked tooth syndrome

Infection Pulpalgia

Mucosal disorders Burning mouth syndrome

Headache Neuralgia

Fibromyalgia Otitis media

Sinus infection Cervical spine pain

Salivary gland pathology Tumor

Trismus Oral surgery procedures

Local anesthetic Facial bone fractures

Radiation therapy Medications


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Clinical Examination

• Includes examination of the joint, muscles of mastication, oral cavity, and cervical spine

• Auscultation

• Palpitation

• Are joint noises such as clicking, crepitus, or popping related to mandibular movement?

• Evaluate movement of mandible in a normal rotation and translatory cycle

• Measure interincisal opening and note any obvious deflection to the right or left side

• Note lateral excursions, protrusions, deviations, and deflection

• Evaluate occlusion


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Imaging• Panoramic• Transcranial• Tomography

• Computed tomography• Magnetic resonance imaging

• Arthrography


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Imaging


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MRI Imaging


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Types of Temporomandibular Disorders

• Myofascial pain and dysfunction• Internal derangements• Arthritis


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Myofascial Pain and Dysfunction

• A dysfunctional muscle hyperactivity with regional pain, tenderness in affected muscles, and variable amounts of reduced opening and complaints of malocclusion

• Comprises at least 50% of all TMDs


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Internal Derangements

• An abnormal positional relationship of the disk relative to the mandibular condyle and the articular eminence

• Continuous pain exacerbated by jaw movement


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Disk Displacement• With reduction

• It may be displaced anteriorly and returns to normal position when the mouth is opened or movement is away from the affected side

• Without reduction• It may act as an obstacle to the sliding condyle

• Patients may complain of problems such as intermittent locking of the jaw; a sudden onset of limited mouth opening, usually associated with cessation of joint sounds; deflection of the mandible, with a midline correction on opening; and restricted lateral excursive movements away from the affected side


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Arthritis• Inflammation of the joint• Osteoarthritis

• Characterized by degenerative changes of the cartilage• Pain symptoms that are worse in the evening• Limited opening• Muscle splinting• Crepitus

• Rheumatoid arthritis• An inflammatory, immunologic disorder of the joints• Symptoms that are worse in the morning• Limited opening• Occlusal changes• Preauricular edema • Tenderness


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Hypermobility Disorders

• Dislocation• When one or both of the condyles translates anterior to the articular eminence, leading to an open lock the patient cannot reduce

• Subluxation• Hypermobility in which the patient can relocate the mandible back into the glenoid fossa


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Ankylosis• Immobility of the condyle caused by fibrous or bony union between articulating surfaces• Joint infection after trauma accounts for 50% of all cases

• 30% result from trauma without infection

• Classified by:• Tissue type (fibrous, bony)• Location (intraarticular, extraarticular)• Extent of fusion (complete, incomplete)


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Tumors of the Temporomandibular Joint

• Osteochondroma• Osteoblastoma• Chondroblastoma• Osteoma• Synovial chondromatosis: Most common benign neoplasm of the synovium

• Osteogenic sarcoma: Commonly occurring malignant bone tumor


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Treatment of Temporomandibular Joint Disorders

• Nonsurgical treatment• Surgical treatment• Multidisciplinary treatment


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Nonsurgical Treatment

• Goals involve improving function and reducing pain

• Pharmacologic therapy: Pain medication, muscle relaxants, and antianxiety agents

• Moist heat• Physical therapy• Soft mechanical diet• Jaw stretching• Coordination exercises• Occlusal adjustments


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Nonsurgical Treatment

• The second phase involves the use of occlusal appliances• These may relax muscles, protect dentition, stabilize and protect the joint, and provide biofeedback by making patients aware of their bruxing habits or by relieving the load on the disk


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Surgical Treatment• Arthrocentesis

Lavaging the joint through a needle

• Arthroscopy Allows direct visualization and manipulation

of the joint

• Open joint surgery• Used to perform disk reconstruction with a prosthetic device or autogenous graft

• Eminectomy• Removal of the articular eminence of the temporal bone


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Multidisciplinary Management

• Patients may require referral to specialists such as a neurologist or an otolaryngologist


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Discussion Questions

• How is normal joint function defined?• What are some of the symptoms of temporomandibular disorders?

• What are some nonsurgical treatment methods for temporomandibular joint disorders? Surgical methods?

Documents

Chapter 10 Diseases Affecting the Temporomandibular Joint Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. 1