CC OS - TMJ

• Synarthrodial joints


  Immovable joints
• Amphiarthrodial joints


  Slightly movable joints
• Diarthrodial joints


  Freely movable joints
• Arthrodial joints


  Gliding movement
• Gynglymoidal joints


  Hinge movement
• Ball and socket joints


  Allow the greatest flexibility of movement
• Saddle joint


  Atlantoaxial bone of the vertebra
• Temporomandibular joint (TMJ)


  Articulation between the mandible and the temporal bone of the cranium
• Temporomandibular joint (TMJ)


  • Paired articulation
  • Diarthrodial joint (freely movable)
  • Has a rigid point of closure
  • Gynglymoarthrodial (first 20 mm of opening is hinge movement, then sliding movement occurs as opening exceeds 20mm)
  • Compound joint - articulation between 3 bones (temporal bone, mandible, articulating disc)
• TMJ Evaluation


  1. History taking (chief complaint, initial symptoms, duration of symptoms, history of noise or limited mouth opening, clenching/grinding, previous treatment)

  2. Patient self-assessment (location of pain, pain level on forced mouth opening, amount of dysfunction)

  3. Clinical examination (range of motion, palpation, resistive test, presence of noise)
• Range of motion


  • Refers to the full potential movement of a joint
  • Maximum opening is 40-50 mm inter-incisal distance
  • Maximum lateral excursion is approximately 12 mm
• Deviation of opening


  • Mandible often deviates towards the affected side during opening
  • Due to muscle spasm or mechanical locking by a displaced meniscus
• Palpation of lateral aspect of TMJ


  • Palpate anterior to the tragus over the joint while the patient opens mouth
  • Condyle will move posteriorly against your finger when patient closes mouth slowly
• Laboratory tests


  • Complete blood count
  • Erythrocyte sedimentation rate
  • Rheumatoid factor
  • Antinuclear antibody
  • Serum uric acid
• Palpation of muscles of mastication

  Attempt to identify the involved muscle causing the pain (masseter, temporalis, lateral pterygoid, medial pterygoid)
• Resistive muscle test


  Test performed to evaluate muscle strength (opening, lateral movement, protrusive)
• Diagnostic imaging


  • Panoramic
  • Transcranial
  • Tomograph
  • Arthrograph
  • CT scan
  • Magnetic resonance imaging
• CT scan


  Requires contrast, high dose radiation
• MRI


  Only imaging that shows the disc
• TMJ disorders


  • Mandibular dislocation
  • Myofascial pain
  • Internal derangement of the joint
  • Arthritis
• Mechanism of mandibular dislocation


  Condyle moves anteriorly, muscles of mastication contract in spasm, inability to return to glenoid fossa
• TMJ myofascial pain dysfunction


  • Typically occurs after a muscle has been contracted repetitively (bruxism, clenching)
  • Persistent and progressive
  • Interferes with daily activities
• Signs and symptoms of TMJ myofascial pain

  • Deep, aching pain in a muscle
  • Pain that persists or worsens
  • Tenderness of a muscle to palpation
  • Difficulty sleeping due to pain
  • May progress to myofibromyalgia (chronic widespread pain)
• Diagnosis of TMJ myofascial pain

  • Pain is the presenting complaint
  • No visible signs
  • Functional tests (limitation of opening, pain on forced opening, muscle weakness)
  • Tenderness during muscle palpation
• Most common causes of TMJ myofascial pain dysfunction

  Overuse, abuse and misuse of the muscles of mastication (clenching, bruxism, biting nails, holding items clenched between teeth, constant chewing)
• Treatment for TMJ myofascial pain dysfunction

  1. Home care method (soft diet, ice packs, avoiding extreme jaw movements, gentle jaw stretching and exercises, stress management)

  2. Short term medication (NSAIDs, sedatives, antidepressants)

  3. Physical therapy (maintain joint lubrication and motion, range of motion exercises, thermal packs, therapy devices)

  4. Splint therapy

  5. Injections (local anesthesia, Botox)

  6. Transcutaneous electrical nerve stimulation (TENS)
• Splint therapy


  • Interocclusal devices alleviate or prevent degenerative forces on TMJ, muscles and dentition
  • Use should be short term
  • Occlusal surface should be flat
  • Periodic adjustments performed
  • Treatment should be reversible
• Injections

  • Local anesthesia (for diagnosis and pain alleviation)
  • Clostridium Botulinum (Botox) (to eliminate muscle spasm, reduce strength of contraction, maintain voluntary muscle movement)
• Transcutaneous electric nerve stimulation (TENS)


  Provides symptomatic pain relief by exciting sensory nerves and stimulating the pain gate mechanism and/or the opioid system
• TMJ internal derangement


  Disruption within TMJ in which there is a displacement of the disc from its normal functional relationship with the mandibular condyle and temporal bone
• Classifications of TMJ internal derangement

  • Disc displacement with reduction (anterior, medial, lateral)
  • Disc displacement with reduction with intermittent locking
  • Disc displacement without reduction (without limited opening, with limited opening)
• Disc displacement with reduction

  • Most common type
  • Posterior part of disc lies anterior to condyle, assumes normal position over condyle when mouth opens
  • Generally not associated with pain or dysfunction
• Management of disc displacement with reduction

  1. Monitoring is required

  2. Symptomatic cases should be addressed with management directed at pain and dysfunction

  3. Anterior repositioning appliances are sometimes worn
• Guidelines for anterior repositioning appliance

  • Mandible is guided forward until the disc is reduced
  • This position is indexed on to the appliance
  • Maintain a reduced disc prevents pinching of the retrodiscal tissue
  • Worn all day for 5-7 days, then reduced to night time use to minimize occlusal changes
• Disc displacement with reduction with intermittent locking


  • Identical to disc displacement with reduction, but with occasional limited mandibular opening
  • If frequent enough to be bothersome, attempt to increase lubrication and perform full range of motion exercises
• Anterior disc displacement without reduction


  • Disc consistently remains positioned anterior to the condyle regardless of mouth being open or not
  • May or may not involve pain, but dysfunction is present
  • Requires management because of dysfunction
• Management of anterior disc displacement without reduction

  1. In acute stage, disc mobility may be restored by manual manipulation

  2. Exercises focused on range of motion can reduce risk of joint damage
• Joint manipulation


  • Unafffected side stabilized, affected side pressed inferiorly to clear disc height, then brought anteriorly to seat condyle on disc
  • Mandible slid anteriorly and posteriorly to lubricate disc
• Arthrocentesis


  • Lavage of the upper joint space, hydraulic pressure and manipulation to release adhesions
  • Main objectives: wash out inflammatory mediators, release the disc, break up adhesions, eliminate pain, improve joint mobility
• Arthroscopy


  Form of surgery using a thin surgical telescope placed into the upper TMJ space through a small incision