TEMPOROMANDIBULAR

JOINT DISORDERS
- Dr. Haider Iqbal
- Senior Lecturer
- Department of Oral Medicine
and Radiology
 CLASSIFICATION OF TMJ
DISORDERS
• DEVELOPMENTAL
Condylar Hyperplasia
Condylar Hypoplasia
Agenesis of Condyle
Coronoid Hyperplasia
Bifid Condyle
Ankylosis
 • DISC DISPLACEMENT
ADDWR/ Anterior Disk Displacement with
Reduction

ADDWOR/ Anterior Disk Displacement

without Reduction
 • DEGENERATIVE

OSTEOARTHRITIS
 • INFLAMMATORY
RETRODISCITIS
SYNOVITIS
CAPSULITIS
RHEMATOID ARTHRITIS
PSORIATIC ARTHRITIS
SEPTIC ARTHRITIS
ANKYLOSING SPONDYLITIS
GOUT
 • FUNTIONAL
SUBLUXATION
DISLOCATION
 • MYOFUNCTIONAL PAIN IN
MASTICATORY MUSCLES
MPDS
 • TRAUMATIC
SOFT TISSUE INJURY
CONDYLAR FRACTURE
 • NEOPLASTIC
BENIGN
MALIGNANT
 CLASSIFICATION OF TMJ
DEVELOPMENTAL
DISORDERS
DISC DEGENERATIE FUNTIONAL
Condylar Hyperplasia DISPLACEMENT SUBLUXATION
Condylar Hypoplasia ADDWR OSTEOARTHRITIS
DISLOCATION
Agenesis of Condyle ADDWOR
Coronoid Hyperplasia
Bifid Condyle
Ankylosis

MYOFUNCTIONAL PAIN INFLAMMATORY NEOPLASTIC TRAUMATIC

IN MASTICATORY MUSCLES RETRODISCITIS BENIGN SOFT TISSUE INJURY
MPDS SYNOVITIS MALIGNANT CONDYLAR FRACTURE
CAPSULITIS
RHEMATOID ARTHRITIS
PSORIATIC ARTHRITIS
SEPTIC ARTHRITIS
ANKYLOSING SPONDYLITIS
GOUT

D3F MINT
Ankylosis
• Ankylosis is a Greek terminology meaning ‘stiff
joint’.
• Here because of immobility of the joint, the jaw
function gets affected.
• Hypomobility to immobility of the joint can lead
to inability to open the mouth from partial to
complete.
• The most common CAUSES of TMJ
Ankylosis are:
• TRAUMATIC INJURIES and
• RHEUMATOID ARTHRITIS,
although it may also result from
• CONGENITAL ABNORMALITIES,
• INFECTION, or
• NEOPLASIA.
 Classification of Ankylosis

1. FALSE ANKYLOSIS or TRUE ANKYLOSIS.

2. EXTRA-ARTICULAR or INTRA-ARTICULAR.
3. FIBROUS or BONY.
4. UNILATERAL or BILATERAL.
5. PARTIAL or COMPLETE.
• EXTRA-ARTICULAR AND INTRA-
ARTICULAR TYPES of TMJ Ankylosis have
been described depending mainly on the
anatomic site of the FUSION OR UNION. Intra-
articular Ankylosis indicates union between the
articular surfaces of the TMJ, while extra-articular
Ankylosis results from lesions involving extra-
articular structures.
• It is important to distinguish between TRUE
ANKYLOSIS, which involves the joint, and
FALSE ANKYLOSIS, which involves Extra
Articular Conditions such as:

• ENLARGEMENT OF THE CORONOID

PROCESS,
• DEPRESSED FRACTURES OF THE
ZYGOMATIC ARCH, or
• SCARRING FROM SURGERY OR
IRRADIATION.
 PATHOGENESIS
• Trauma will bring about extravasation of blood into the joint
space called HAEMARTHROSIS.

• This predisposes to CALCIFICATION AND

OBLITERATION of a joint space, where immobility of the
joint is maintained over a prolonged period.

• Many times INITIAL FIBROUS BANDS lead toward bony

consolidation to ossification.
• Many times bony fusion may extend well beyond
the joint space to involve the CRANIAL BASE
and even the SIGMOID NOTCH, ZYGOMATIC
ARCH, CORONOID PROCESS.
• In the severest form, it may include the LATERAL
PTERYGOID PLATE and even the SPINE OF
THE SPHENOID BONE.
 Unilateral Ankylosis
Seen in a child or in a person where the onset was usually
in the childhood.
1. Obvious facial asymmetry.
2. Deviation of the mandible and chin on the affected side.
3. The chin is receded with hypoplastic mandible on the
affected side.
4. Roundness and fullness of the face on the affected side.
5. The appearance of the flatness and elongation on the
unaffected side.
6. In unilateral Ankylosis some amount of oral opening
may be possible. Interincisal opening will vary depending
on whether it is fibrous or bony Ankylosis.
7. Cross bite may be seen.
8. Class II angles malocclusion on the affected side plus
unilateral posterior cross bite on the ipsilateral side seen.
 Bilateral Ankylosis
1. Inability to open the mouth progresses by gradual decrease in
Interincisal opening. The mandible is symmetrical but micro gnathic.
The patient develops typical ‘BIRD FACE’ DEFORMITY with receding
chin.
2. The neck chin angle may be reduced or almost completely absent.
3. Antegonial notch is well-defined bilaterally.
4. Class II malocclusion can be noticed.
5. Upper incisors are often protrusive with anterior open bite. Maxilla
may be narrow.
6. Oral opening will be less than 5 mm or many times there is nil oral
opening.
7. Multiple carious teeth with bad periodontal health can be seen.
8. Severe malocclusion, crowding can be seen and many impacted teeth
may be found on the X-rays.
 DIAGNOSIS
Diagnosis is based on the following:

1. HISTORY OF TRAUMA, INFECTION, etc.

2. CLINICAL FINDINGS.
3. RADIOGRAPHIC FINDINGS—are important in arriving at a
final diagnosis:

A. ORTHOPANTOMOGRAPH—will show both the joints picture which

can be compared in unilateral cases. Presence of antegonial notch can be
appreciated which develops secondary to the contraction of the depressor
muscles and their action against elevator group of muscles.
The antegonial notch becomes more pronounced in severe cases.
B. LATERAL OBLIQUE VIEW—will give anteroposterior dimension of the
condylar mass. Elongation of coronoid process can be seen.
C. CEPHALOMETRIC RADIOGRAPH—is taken to evaluate the associated
skeletal deformities.
D. POSTEROANTERIOR RADIOGRAPH—will reveal the mediolateral
extent of the bony mass. It will also highlight the symmetry in unilateral
cases.
E. CT SCAN—very helpful guide for surgery. Relation to the medial cranial
fossa, the anteroposterior width, mediolateral depth can be assessed. Any
presence of fractured condylar head on the medial aspect of ramus can be
located. In cases of reankylosis, the bony fusion can be seen. 3-D CT scan
will give life-size picture of all aspects of the deformity
 MANAGEMENT
Management of Ankylosis is ALWAYS SURGICAL
AIMS AND OBJECTIVES OF SURGERY
1. Release of ankylosed mass and creation of a gap to mobilize the
joint.
2. Creation of a functional joint.
a. To improve patient’s nutrition.
b. To improve patient’s oral hygiene.
c. To carry out necessary dental treatment.

3. To reconstruct the joint and restore the vertical height of the ramus.
4. To prevent recurrence.
5. To restore normal facial growth pattern (based on functional matrix
theory).
6. To improve esthetics and rehabilitate the patient (cosmetic surgery
may be carried out at a later date or at second phase).
 Surgical Techniques

Number of techniques have been advocated

by
different surgeons. Critical analysis of all,
filters only to three basic methods.
I : Condylectomy
II : Gap Arthroplasty
III : Interpositional Arthroplasty
 INTERNAL
DERANGEMENT
anterior disc displacement with reduction (addwr)
anterior disk displacement without reduction (addwor)
 PHYSIOLOGY OF DISC-
CONDYLE RELATIONSHIP
IN BRIEF
NORMAL RELATIONSHIP BETWEEN THE DISK AND
CONDYLE AT CLOSE MOUTH POSITION
Posterior Band of The Disc Slides over the
Disc at 12 o’ clock Condyle on Mouth
position Opening

NORMAL
Disc not placed at 12 o’clock The Disc Slides over the
position but is slightly Condyle on Mouth
Anteriorly Displaced Opening

ANTERIOR DISC DISPLACEMENT WITH REDUCTION

Clinical Signs of Anterior Disk Displacement WITH
Reduction were
seen in a Patient:-
 PAIN is precipitated by joint movement.

 DEVIATION during movement coinciding with a click.

 REPRODUCIBLE JOINT NOISE, usually at variable

positions during opening and closing of mandible.

 NO RESTRICTION IN MANDIBULAR MOVEMENT

(episodic and momentary catching of smooth jaw
movements during mouth opening [< 35 mm] that self-
reduces with voluntary mandibular repositioning).
Disc not placed at 12 o’clock Disc does not slide back on top of the
position but is slightly Condyle and thus remains in the Anterior
Anteriorly Displaced Displaced Position

ANTERIOR DISC DISPLACEMENT WITHOUT REDUCTION

 Clinical Signs of Anterior Disk Displacement
WITHOUT Reduction were seen in a Patient:-

 Pain precipitated by function.

 Marked limited mandibular opening.

 HISTORY of clicking that ceases with the locking.

 Pain with palpation of the affected joint; ipsilateral

hyperocclusion
 TREATMENT
• Most symptoms associated with ADD RESOLVE OVER TIME either with NO TREATMENT or with
minimal conservative therapy.

• Since symptoms associated with anterior disk displacement with and without reduction tend to
decrease with time, the clinician should not treat patients on the assumption that asymptomatic
clicking will inevitably progress to painful clicking or locking.

• PAINFUL CLICKING OR LOCKING should initially be treated with conservative therapy.

• RECOMMENDED TREATMENTS for symptomatic ADD include : SPLINT THERAPY, MANUAL

MANIPULATION and
OTHER FORMS OF PHYSICAL THERAPY,
ANTI-INFLAMMATORY DRUGS,
ARTHROCENTESIS, ARTHROSCOPIC LYSIS and LAVAGE, and other SURGICAL PROCEDURES
like ARTHROPLASTY.
– FUNTIONAL

SUBLUXATION

DISLOCATION
 DISLOCATION &
SUBLUXATION
• In DISLOCATION OF THE MANDIBLE, the condyle is positioned

ANTERIOR TO THE ARTICULAR EMINENCE and CANNOT RETURN

to its NORMAL POSITION without assistance.

• This disorder contrasts with SUBLUXATION, in which the condyle

moves ANTERIOR TO THE EMINENCE during wide opening but is able to

return to the resting position without manipulation.

• DISLOCATIONS of the mandible usually result
from:
- MUSCULAR INCOORDINATION in wide
opening during EATING or YAWNING,
- LESS COMMONLY FROM TRAUMA;

• May be UNILATERAL or BILATERAL.

• The typical complaints of the patient with dislocation are an
INABILITY TO CLOSE THE JAWS and PAIN RELATED
TO MUSCLE SPASM.

• On clinical examination,
a DEEP DEPRESSION may be observed in the
PRETRAGUS REGION corresponding to the condyle
being positioned anterior to the eminence.
• The condyle can usually be repositioned
without the use of muscle relaxants or
general anesthetics.

• If muscle spasms are severe and reduction

is difficult, the use of INTRAVENOUS
DIAZEPAM (APPROXIMATELY 10 mg)
can be beneficial.
 PRACTITIONER SHOULD STAND IN FRONT OF THE SEATED PATIENT

PLACE THUMBS
LATERAL TO THE
MANDIBULAR MOLARS
ON THE BUCCAL SHELF OF
BONE

CONDYLE is
repositioned by a
DOWNWARD FIRST
and BACKWARD
MOVEMENT
REMAINING FINGERS OF achieved by
EACH HAND SHOULD BE
PLACED UNDER
SIMULTANEOUSLY
THE CHIN PRESSING DOWN
on the posterior part of
the mandible while
RAISING THE CHIN.
AS THE CONDYLE REACHES THE HEIGHT OF THE EMINENCE,
IT CAN USUALLY BE GUIDED POSTERIORLY TO ITS NORMAL POSITION.
 POST REDUCTION RECOMMENDATIONS consist
of:

• DECREASE in MANDIBULAR MOVEMENT and

• the use of ASPIRIN OR NONSTEROIDAL ANTI-INFLAMMATORY
MEDICATIONS to lessen inflammation.
• The patient should be cautioned not to open wide when EATING or
YAWNING because recurrence is common, especially during the period
initially after repositioning.
• Long periods of immobilization are not advised due to the risk of FIBROUS
ANKYLOSIS.
• Chronic recurring dislocations have been treated with surgical and nonsurgica
approaches.
• Various SURGICAL PROCEDURES have been advocated for treating
recurrent DISLOCATIONS.