Temporomandibular Joint DisordersMarch 11, 1998Michael E. Prater, MDByron J. Bailey, MD

IntroductionTMJ Syndrome an outdated conceptShould be able to distinguish between muscular disorders and joint disordersMust rule out joint pathology

Economics$30 Billion lost productivity550 million work days per year

Epidemiology10 million people treated for TMJ at any one time50% of population has Sx1/5 require some treatment1/10 of those treated will need surgery

Epidemiology, ContinuedAvg age onset 18-26Females 5:150% have progressive Sx50% accommodate by functioning within physiologic limits84% not treated improve86% treated improve

AnatomyInnervation via trigeminal nerveOphthalmic (V1), maxillary (V2) and mandibular (V3)Cell bodies in trigeminal gangliaMotor to muscles of masticationSensory to muscles and joint capsule

Anatomy, ContinuedReferred painheadache, sinus pain, otalgia, dental pain and neck painDue to innervation of dura mater, sinuses, TM and EAC, alveolus and trigger points

Anatomy, ContinuedTrigger PointsDefn: hard, painful bands of muscle, tendons or ligamentsActive trigger points alters the areas of painLatent trigger points have only local hypersensitivityLocal anesthetics, saline or acupuncture offer relief of symptoms

Anatomy, ContinuedMuscles of masticationtemporalis, masseter, lateral pterygoids, medial pterygoids are major musclessuprahyoid strap muscles are minor contributorsInnervated by trigeminal nervelateral pterygoid is primary abductor

Anatomy, ContinuedTemporomandibular Jointconsists of mandible suspended from temporal bone via ligaments and muscules, including stylomandibular and sphenomandibular ligamentsa true synovial joint capable of gliding, hinging, sliding and slight rotationmandible and temporal bone separated by meniscus (disc)

Anatomy of TMJ ContinuedCondylar process of mandible articulates with glenoid fossa of temporal boneanterior: anterior eminance of TMJposterior: EAClateral: zygomatic archmedial: styloid process

Anatomy of TMJ, ContinuedCondylar process, continuedlined by fibrous tissues, primarily hyaline cartilagethis is the primary growth center of the mandibledamage leads to facial maldevelopment, including both the mandible and the maxilla

Anatomy of TMJ, ContinuedCoronoid processinsertion for portions of temporalis and masseterincisura mandibularis, or sigmoid notchmasseteric aa

Anatomy of TMJ, ContinuedMeniscus (disc)synovial fluid above and below discshock absorberinternal derangement in 50% of all peopleanteriorly and medially most commonjaw popsheld in place by medial and lateral capsular ligaments and retrodisc pad

Diseases and Disorders of theTMJThe TMJ is susceptible to all conditions that affect other jointsankylosis, arthritis, trauma, dislocations, developmental anomalies and neoplasmsPsychosocial factors are extremely controversialSomatoform disorder, drug seeking, malingering, need for illness

Disorders of TMJ, ContinuedMuscular Disorders (Myofascial Pain Disorders) are the most common cause of TMJ painHigh psychosocial component?many patient with high stress levelpoor habits including gum chewing, bruxism, hard candy chewingpoor dentition

Disorders-Myofascial, ContinuedMPD, continuedunilateral dull, aching painworse with use (gum, candy, bruxism)associated HAs, otalgia, T/HL, burning tongue

Myofascial Pain Disorder, Cont.Six categoriesMyositis acute inflammation with pain, edema and decreased ROM. Usually secondary to overuse, but infection or trauma seenTX: rest, NSAIDs, Abx as needed Muscle Spasmacute contraction from overuse, overstrechingTx: rest, NSAIDs, massage, heat, relaxants

Myofascial Pain Disorder, Cont.Contractureend stage of untreated muscle spasmdue to fibrosis of muscle and connective tissueTx: NSAIDs, massage, vigorous physical therapy, occasional surgical release of scar tissueHysterical trismusdecreased ROM psychosocial etiologymore common in females

Myofascial Pain Disorder, Cont.Fibromyalgiadiffuse, systemic process with firm, painful bands (trigger points)usually seen in weight bearing musclesoften associated sleep disturbancemore common in femalesDiagnostic criteriatrigger pointsknown path of pain for trigger pointsreproducible

Myofascial Pain Disorder, Cont.Collagen vascular disordersSLEautoimmune, butterfly rash, fever, rheumatoid arthritisDx with high ESR, positive ANA and a false-positive VDRLSclerodermaautoimmune characterized with gradual muscle and joint pain, tightening of skinlimited jaw expansion with pain may be initial presentation

Myofascial Pain Syndrome, ContSjogrens Syndromeautoimmunexerostomia, xeropthalmia with keratitissometimes see muscle and joint pain , including the TMJdiagnose with minor salivarygland biopsy

Myofascial Pain Syndrome, ContTreatment is divided into four phasesPhase I (four weeks, 50% will improve)educate the patient about muscle fatigueexplain referred painoral hygiene: no gum chewing, candy chewing, jaw clenchingsoft dietNSAIDs (usually ibuprofen)muscle relaxants (benzos)

Myofascial Pain Disorder, Cont.Phase II (four weeks-25% more improve)Continue NSAIDs, benzosadd bite appliance (splint)decrease effects of bruxismsplints the muscles of masticationimproves occlusion while wearing, allowing more natural jaw positionusually worn at night, may be worn during dayonce relief obtained, d/c meds first. If remains asymptomatic, d/c splints.may continue with prn splinting

Myofascial Pain Disorders, Cont.Phase III: (four weeks-15% improved)continue NSAIDs, bite applianceadd either ultrasonic therapy, electrogalvanic stimulation or biofeedbackno one modality superiorPhase IV: TMJ Centermultidisciplinary approach utilizing psychological counseling, medications, trigger point injections and physical therapy

Joint DisordersJoint Disorders are the second most common cause of temporomandibular painInclude internal derangements, degenerative joint disease, developmental anomalies, trauma, arthritis, ankylosis and neoplasms

Joint Disorders, ContinuedCardinal features are jaw popping (clicking) and pain50% of the population has a jaw pop, which usually occurs with opening (between 10-20 mm)may elicit a history of lock jawadvanced disorders may not present with a jaw click, but a history can usually be found

Joint Disorders, ContinuedInternal Derangementthe most common joint disorderinvolves the abnormal repositioning of the discdisc location is usually anteromedialfour types of derangements (see other screen)

Internal Derangement TypesType IApopping over the joint without associated pain (50% of normal subjects)Type IBpopping over the joint with paindue to chronic streching of capsular ligaments and tendons

Internal Derangement Types, ContinuedType IIsimilar to type IB, but a history of lock jaw can be elicitedclosed lock vs open lockType IIIa persistent lock, usually closedNo click on PE!

Tx of Internal DerangementsType I and II similar to myofascial disorders: NSAIDs, anxiolytics/relaxers, oral hygiene and appliances if necessary for four weeksprogression of symptoms may require surgical interventionmain goal is lysis of adhesion and repositioning of discopen vs arthroscopic

Tx of Internal DerangementsType IIIusually requires general anesthesia to mobilize jawagressive medical and physical therapy is initiated, including a bite applianceif no improvement after 3 weeks, surgery is indicated to lyse adhesions and/or reposition disc

Congenital AnomaliesFairly rareImportant to identify absence of growth plates leads to severe deformitiescondylar agenesis, condylar hypoplasia, condylar hyperplasia and hemifacial microsomia most common

Congenital Anomalies, Cont.Condylar agenesisthe absence of all or portions of condylar process, coronoid process, ramus or mandibleother first and second arch anomalies seenearly treatment maximizes condylar growtha costocondral graft may help with facial development

Congenital Anomalies, ContCondylar hypoplasiausually developmental secondary to trauma or infectionmost common facial deformity is shortening of mandiblejaw deviates towards affected sideTx for child: costochondral graftTx for adult: shorten normal side of lengthen involved side

Congenital Anomalies, ContCondylar Hyperplasiaan idiopathic, progressive overgrowth of mandibledeviation of jaw away from affected sidepresents in 2nd decadeTreat by condylectomy

Traumatic InjuriesFractures of the condyle and subcondyle are commonunilateral fracture involves deviation of jaw towards affected side with or without open biteTx: MMF with early mobilization bilateral fracture usually has anterior open biteoften requires ORIF of one side with MMF

Dislocation of the TMJAcute dislocationnew onset Type III derangement, surgery of the mouthtreatment is reduction under anesthesiaChronic dislocationusually secondary to abnormally lax tendonsTx: sclerosing agents, capsulorraphy, myotomy of lateral pterygoid

Ankylosis of the TMJDefn: the obliteration of the joint space with abnormal bony morphologyetiologies include prolonged MMF, infection, trauma, DJDFalse ankylosis: an extracapsular condition from an abnormally large coronoid process, zygomatic arch or scar tissue

Ankylosis of the TMJ, ContinuedTreatmentChild: a costochondral graft to help establish a growth plateAdult: prosthetic replacementthe new joint should be established at highest point on ramus for maximal mandibular heightan interpositional material is needed to prevent fusionPT must be aggressive and long term

Arthritis of the TMJThe most frequent pathologic change of the TMJMost are asymptomaticRheumatoid arthritisusually seen in other joints prior to TMJwhen present, both joints usually affectedearly radiographic changes include joint space narrowing without bony changes

Arthritis of the TMJ, ContinuedRheumatoid Arthritis, Continuedlate radiographic changes may involve complete obliteration of space with bony involvement and even ankylosisend stage disease results in anterior open biteJuvenile RA may progress to destruction of the growth plate, requiring costochondral graft

Arthritis of the TMJ, ContinuedRheumatoid Arthritis, continuedTreatmentNSAIDs, penicillamine, goldSurgery limited to severe JRA and ankylosisDegenerative Arthritiswear and tear of the jointsmost asymptomatic

Arthritis of the TMJ, ContinuedDegenerative Arthritis, ContinuedPrimary Degenerative arthritiswear and tear - usually in older peopleasymptomatic or mild symptomsSecondary Degenerative arthritisdue to trauma, infection and bruxismsymptoms severeradiographic findings include osteophytes an derosion of the condylar surface

Arthritis of the TMJ, ContinuedDejenerative Arthritis, continuedTreatment is initially similar to myofascial disorders, including NSAIDs, benzos and oral hygiene. Bite appliance may be necessaryAfter 3-6 months, surgery is consideredlysis of adhesions, osteophyte removalcondylar shave. Resorption of the condyle is a known complication

Neoplasms of the TMJUncommonUsually benignchondromas, osteomas, osteochondromasfibrous dysplasia, giant cell reparative granuloma and chondroblastoma rareMalignant tumors such as fibrosarcoma and chondrosarcoma very rareRadioresistant

Surgery of the TMJLess than 1% of people with TMJ symptoms will require surgeryFive requirements for surgery:joint pathologypathology causes symptomssymptoms prevent normal functionmedical management has failedcontributory factors are controlled

Surgery of the TMJ, ContinuedDisc Repairrecommended for minimal pathologydisc is usually repositioned posteriorlyarticular eminance may need to be shaved90% of patients have improvementarthroscopic versus open

Surgery of the TMJ, ContinuedMenisectomyrecommended when severe changes in disc occura temporary implant may be usedscar tissue forms new disc85% improvementbony changes of disc space a known complication

Surgery of TMJ, ContinuedMenisectomy with implantationdisc removal with permanent interpositional implantsilastic most commonproplast also usedtemporalis fascial graft and auricular cartilage can be usedanimal models show FB reaction

Surgery of the TMJ, ContinuedBone Reductionpreserve the disc through high condylotomy or condylectomypreserve disc spacewiden disc by decompression

Surgery of TMJ, ContinuedArthroscopydiagnostic as well as therapeuticadhesions and loose bodies the most common indicationmay be used for minor disc procedures

Complications of TMJ SurgeryBleeding, infection, adhesions, pain, degenerative disease, infectionDepressionemphasizes the psychosocial component

RadiologyMRI is best technique for joint space pathologyCT is best technique for bony pathologyPlain films with arthrography sometimes useful, although largely replaced by MRI and CT Arthroscopy is also diagnostic