TMJ and Temporomandibular Joint Disorder Dr. Soukaina Ryalat.

TMJ and TMJ and TemporomandibulaTemporomandibula

r r Joint Disorder Joint Disorder Dr. Soukaina RyalatDr. Soukaina Ryalat

Basic Anatomy Basic Anatomy

Mandibular Mandibular condylecondyle

Temporal boneTemporal bone

MeniscusMeniscus

Coronoid procesCoronoid proces

Basic Structure

TMJ Anatomy continuedTMJ Anatomy continued

Primary articulation is formed by the Primary articulation is formed by the mandibular condyle and the mandibular condyle and the mandibular fossamandibular fossa

It is considered a “sliding” hinge It is considered a “sliding” hinge joint and allows movement in only joint and allows movement in only one plane, forward and backward one plane, forward and backward movementmovement

TMJ Articular Disc TMJ Articular Disc FunctionFunction

Transmits forces, Transmits forces, protects, lubricates the protects, lubricates the articulating surfacesarticulating surfaces

Divided into 3 portions, Divided into 3 portions, anterior, intermediate anterior, intermediate and posteriorand posterior

Movement is mediated Movement is mediated by lateral pterygoid by lateral pterygoid attachment on the attachment on the anterior disc, anterior disc, retrodiscal tissue on retrodiscal tissue on the posterior disc and the posterior disc and the amount of synovial the amount of synovial fluid in the joint capsulefluid in the joint capsule

Anterior

TMJ Disc FactsTMJ Disc Facts

The intermediate portion is the thinnest and The intermediate portion is the thinnest and has very little or no innervation or has very little or no innervation or vascularity. Its nutrition comes from the vascularity. Its nutrition comes from the synovial fluid pressed into it by the properly synovial fluid pressed into it by the properly aligned condyle and fossa during closurealigned condyle and fossa during closure

The anterior and posterior portion is highly The anterior and posterior portion is highly vascularized and innervated and also vascularized and innervated and also receives some nutrition from synovial fluidreceives some nutrition from synovial fluid

Facts on TMJFacts on TMJ Most soft clicking noise are not an Most soft clicking noise are not an

indicator of joint dysfunction and are of indicator of joint dysfunction and are of no clinical significanceno clinical significance

Loud clicking while opening, with Loud clicking while opening, with deviation present on opposite side, deviation present on opposite side, clinically significant of possible anterior clinically significant of possible anterior condyle displacement.condyle displacement.

Loud clicking while closing, with deviation Loud clicking while closing, with deviation present on opposite side, clinically present on opposite side, clinically significant of possible posterior condyle significant of possible posterior condyle displacement. Signs/Symptoms of TMDdisplacement. Signs/Symptoms of TMD

More TMJ FactsMore TMJ Facts

40% of population have some type of 40% of population have some type of joint noise, indicating the existence joint noise, indicating the existence of possible disc problemsof possible disc problems

24% have some head, neck and/or 24% have some head, neck and/or face painface pain

12% report pain when opening12% report pain when opening

TMJ DisordersTMJ Disorders Temporomandibular joint and muscle Temporomandibular joint and muscle

disorders, commonly called “TMJ” or disorders, commonly called “TMJ” or TMD are a group of conditions that TMD are a group of conditions that cause pain and dysfunction in the cause pain and dysfunction in the jaw joint and the muscles that jaw joint and the muscles that control jaw movement. control jaw movement.

TMJ DisorderTMJ Disorder

dysfunctional conditions involving dysfunctional conditions involving the masticatory systemthe masticatory system

““TMJ syndrome” previous TMJ syndrome” previous teminologyteminology

TMJ DisordersTMJ Disorders For most people, pain in the area of the For most people, pain in the area of the

jaw joint or muscles does not signal a jaw joint or muscles does not signal a serious problem. Generally, discomfort serious problem. Generally, discomfort from these conditions is occasional and from these conditions is occasional and temporary, often occurring in cycles. temporary, often occurring in cycles. The pain eventually goes away with The pain eventually goes away with little or no treatment. Some people, little or no treatment. Some people, however, develop significant, long term however, develop significant, long term symptoms. symptoms.

TMJ MusclesTMJ Muscles

Temporalis - Temporalis - closes jaw and retracts closes jaw and retracts mandiblemandible

Masseter – closes jawMasseter – closes jaw Internal or medial Pterygoid – closes Internal or medial Pterygoid – closes

jawjaw External or lateral Pterygoid – opens External or lateral Pterygoid – opens

jaw, moves jaw side to side and jaw, moves jaw side to side and protrudes mandibleprotrudes mandible

TMJ Disorder

• dysfunctional conditions involving the masticatory system

• “TMJ syndrome” previous teminology

TMD reflects possibilities of TMD reflects possibilities of involvement of other factors, not just involvement of other factors, not just the joint capsulethe joint capsule

Occlusal factorsOcclusal factors Intrajoint dysfunctionIntrajoint dysfunction Psychological factorsPsychological factors Biochemical factorsBiochemical factors Skeletal misalignmentsSkeletal misalignments

What are TMJ What are TMJ Disorders? Disorders?

TMJ disorders fall into three main categories:  TMJ disorders fall into three main categories:  

Myofascial painMyofascial pain, the most common temporo- , the most common temporo- mandibular disorder, involves dis comfort or mandibular disorder, involves dis comfort or pain in the muscles that control jaw function. pain in the muscles that control jaw function.

   Internal derangementInternal derangement of the joint involves a of the joint involves a

displaced disc, dislocated jaw, or injury to the displaced disc, dislocated jaw, or injury to the condyle. condyle.

ArthritisArthritis refers to a group of degenerative or refers to a group of degenerative or inflammatory joint disorders that can affect the inflammatory joint disorders that can affect the temporomandibular jointtemporomandibular joint

The most common type of TMJ The most common type of TMJ disorder is myofascial pain and disorder is myofascial pain and dysfunction, usually as a result of dysfunction, usually as a result of bruxism and jaw clenchingbruxism and jaw clenching

Related to stress, anxiety, Related to stress, anxiety, depression or chronic paindepression or chronic pain

3 cardinal features of TMJ are 3 cardinal features of TMJ are orofacial pain, restricted jaw orofacial pain, restricted jaw function and noise in the jawfunction and noise in the jaw

TMD is characterized by many symptomsTMD is characterized by many symptoms

HeadacheHeadache Burning or tingling sensationBurning or tingling sensation Tenderness and swellingTenderness and swelling Clicking or popping Clicking or popping Reduced ROMReduced ROM Ear pain w/o infectionsEar pain w/o infections Neck and or facial painNeck and or facial pain

Grinding teeth at night Pain that worsens with stress Pain with opening of your mouth Teeth that meet differently from

time to time Pain while chewing

Summary of Symptoms:Summary of Symptoms:• History of trauma, blow to jaw, MVA ( motor vehicle accident), dental malocclusions• Pain and tenderness of the TMJ• Head and/or ear pain• Sore and stiff jaw muscles• Locking of the jaw in a shut or open position• Frequent headaches and/or neck aches• Pain that worsens when teeth are clenched•

Assessment of TMJAssessment of TMJ

Intercuspid alignmentIntercuspid alignment Mandibular gait patternMandibular gait pattern Screening (3 finger test)Screening (3 finger test) Palpate joint and soft tissuesPalpate joint and soft tissues Adjustive procedureAdjustive procedure

Distraction techniqueDistraction technique Translation techniqueTranslation technique

TMJ Examination:TMJ Examination:

History: History:

Bare the areaBare the area

Bilateral observationBilateral observation

Bilateral palpationBilateral palpation

Active ROMActive ROM

Passive ROMPassive ROM

Ortho/neuroOrtho/neuro

X-ray ?X-ray ?

Normal opening should be enough to fit 3 fingers into mouth. Have the patient use their own fingers.

Normal

Watch for deviation from center when patient slowly opens and closes mouth

C and S Curve Examination

While having the patient

slowly open the mouth feel for the movement

of thecondyles

Alternate Procedure:Alternate Procedure:Inferior MisalignmentInferior Misalignment

How are TMJ Disorders How are TMJ Disorders Treated?Treated?

Because more studies are needed on the Because more studies are needed on the safety and effectiveness of most treatments safety and effectiveness of most treatments for jaw joint and muscle disorders, experts for jaw joint and muscle disorders, experts recommend using the most conser vative and recommend using the most conser vative and reversible treatments when possible. reversible treatments when possible.

Reversible treatments do not cause Reversible treatments do not cause permanent changes in the structure or posi permanent changes in the structure or posi tion of the jaw or teeth. Even when TMJ dis tion of the jaw or teeth. Even when TMJ dis orders have become persistent, most orders have become persistent, most patients still do not need aggressive types of patients still do not need aggressive types of treatment. treatment.

How are TMJ Disorders How are TMJ Disorders Treated?Treated?

Treatment by a Prosthodontist may be Treatment by a Prosthodontist may be needed for other reasons such as to needed for other reasons such as to restore severely worn, damaged, or restore severely worn, damaged, or diseased teeth or to replace teeth for the diseased teeth or to replace teeth for the purpose of improving chewing, providing purpose of improving chewing, providing enhanced support for your lips or cheeks, enhanced support for your lips or cheeks, or improving the appearance of your smile. or improving the appearance of your smile.

Extensive prosthodontic treatment should Extensive prosthodontic treatment should only be provided only be provided afterafter the TMJ disorder the TMJ disorder has been adequately diagnosed and its has been adequately diagnosed and its pain successfully managed.pain successfully managed.

Conservative TreatmentsConservative TreatmentsMost jaw joint and muscle problems Most jaw joint and muscle problems are temporary and do not get worse. are temporary and do not get worse. Treatment is based on a proper Treatment is based on a proper diagnosis which should be diagnosis which should be conservative and reversible.conservative and reversible. Self-Care PracticesSelf-Care PracticesPain MedicationsPain MedicationsStabilization SplintsStabilization SplintsProsthodontic TreatmentProsthodontic Treatment

Self-Care PracticesSelf-Care Practices Your Prosthodontist may Your Prosthodontist may

recommend steps that you can recommend steps that you can take that may be helpful in easing take that may be helpful in easing symptoms, such as: symptoms, such as:

• eating soft foods, • applying ice packs to recommended areas, • avoiding extreme jaw movements (such as wide yawning, loud singing, and gum chewing), • learning techniques for reducing stress, • practicing gentle jaw stretching and relax ing exercises that may help increase jaw movement.

Pain MedicationsPain Medications For many people with TMJ For many people with TMJ

disorders, short -term use of disorders, short -term use of over- the- counter pain medicines over- the- counter pain medicines or nonsteroidal anti- or nonsteroidal anti- inflammatory drugs (NSAIDS), inflammatory drugs (NSAIDS), such as ibuprofen, may provide such as ibuprofen, may provide temporary relief from jaw temporary relief from jaw discomfort. discomfort.

When necessary, your dentist or When necessary, your dentist or doctor can prescribe stronger doctor can prescribe stronger pain or anti inflammatory pain or anti inflammatory medications, muscle relaxants, medications, muscle relaxants, or anti depressants to help ease or anti depressants to help ease symptoms. symptoms.

Stabilization SplintsStabilization Splints Your Prosthodontist may Your Prosthodontist may

recommend an oral appliance, recommend an oral appliance, also called a stabilization splint also called a stabilization splint or bite guard, which is a plastic or bite guard, which is a plastic guard that fits over the upper guard that fits over the upper or lower teeth. Stabilization or lower teeth. Stabilization splints are the most widely used splints are the most widely used treatments for TMJ disorders.treatments for TMJ disorders.

If a stabilization splint is If a stabilization splint is recommended, it should be recommended, it should be used only for a short time and used only for a short time and should not cause permanent should not cause permanent changes in the way your teeth changes in the way your teeth bite together when the splint is bite together when the splint is removed from your mouth. removed from your mouth.

Prosthodontic TreatmentProsthodontic Treatment Occlusal splints may Occlusal splints may

also be used to also be used to reestablish the bite reestablish the bite prior to prior to prosthodontic prosthodontic treatment. treatment.

It is used when the It is used when the bite is not contacting bite is not contacting evenly due to missing evenly due to missing or worn teeth and or worn teeth and may relax the may relax the muscles.muscles.