Temporo-Mandibular Joint Disorders (TMD)

Part I I

Dr. Gaurav Sharma P.G. Part III

Contents

1. Myofascial Pain Dysfunction Syndrome( MPDS )

2. Internal Derangement

Myofascial Pain Dysfunction Syndrome ( MPDS )

Introduction

• Most common type of TMD.• Characterised by :• Regional Dull Aching pain.• Localised Tenderness in one / more masticatory

muscle

History• Costen 1934.• Schwartz 1956.• Laskin 1969.

Definition of Important Terms

• Active trigger point

• Latent trigger point

• Referred pain

• Taut band

• Jump sign

• Twitch response

Etiology

• Muscular Hyperfunction.• Parafunctional Habits.• Mal Nutrional .• Physcological Stress.• Sleep Disturbances.• Improper prosthesis.• Internal Derangements.• Degenerative joint disorders.

Clinical Features

1> Pain : Unilateral dull, aching pain, which increases with muscular activity, and progressively worsens towards the end of the day.

Clinical Features

2>Increased stress levels :Results in habits, like :

• Bruxism. • Clenching of teeth.

Leading to :• Muscular overuse• Fatigue • Spasm.

3> Limitation in opening of mouth :

Clinical Features4> Tenderness on Palpation :

5> Headache:

• Headache becomes worse while jaw movements .

6> Ear pain:

• Patient notice ear pain but there are no signs of infection.

• The ear pain is usually described as being in front of or below the ear.

Clinical Features

7> Sounds:

• Clicking or popping sounds, termed as crepitus, are common in patients with a TMJ disorder.

8> Dizziness:

• Majority of patients report a vague dizziness or vertigo.

Clinical Features

9> Fullness of the ear:

Patients describes muffled, clogged, or full ears.

10> Tinnitus :

Clinical Examination

1> TMJ :• Extent of mouth opening and lateral

excursions.• Palpation for Tenderness.• Evaluation of TMJ Sounds.

Clinical Examination

2> Muscular Examination :

• Pt. examined for Active trigger point, Latent trigger

point, Taut band, Jump sign and Twitch response .

Clinical Examination

3> Dental Evaluation :Occlusal Discrepancies.Attrition.Interferrence in occlusal due to prosthesis.

Clinical Examination

4> Cervical Examination :• Neck muscles are palpated and range of neck

movements are examined.• Movement of Cervical Spine.

Diagnostic Criteria

1. Primary Findings :Pt. complains of pain in one or more masticatory

muscle.Tenderness on palpation over the muscle.Presence of Trigger points.Pain aggrevated due to movement of mandible.

Diagnostic Criteria

2. Secondary Findings :Restricted range of movement of mandible.Maximum assisted opening > Maximum unassisted

opening > Pain free opening.Range of movement increased by use of Alkane

vapocoolant.Clinical or behavioral indications of Hyperfunction

or parafunctions.Malocclusion.

Diagnostic Criteria

3. Possible findings :TMJ pain.Joint Sounds.Inflammation.

Management

• The aim of management should be:

1.Control of factors that worsen MPDS.2.Reduction of harmful “loading” on the joints.3.Restoration of jaw function.4.Resumption of regular daily activities.5.Pain reduction.

Management

• Management is divided into four phases:

Phase I :

Initiated upon diagnosis, and consists of :

• Patient education.• Avoidance of clenching and grinding .

• Soft diet.

Management• NSAIDs , with or without a muscle relaxant.

• The most commonly used agents are :

• Diazepam (2-5 mg twice a day)• Ibuprofen (400 mg thrice a day). • Naproxen (500 mg twice daily) .

• Moist Heat therapy +Vapocoolant Spray and stretch massage .

50% of patients will obtain significant relief in 2-4 weeks.

Management

Phase II : To be initiated if Phase one treatment fails.

• Medications are continued.• Custom made oral orthopaedic acrylic

appliance (splint) is added. • These include occlusal splints, bite guards and

night guards.

Management

Phase III :

Physiotherapy of the muscle groups, including Ultrasonic therapy, Electro galvanic stimulation, Transcutaneous Electrical Nerve Stimulation (TENS).

Management

Phase IV :

• Psychological counseling .• Biofeedback.

Internal Derangements

Introduction

• It is an Orthopedic term defined as “A localised mechanical fault interfering with smooth jaw movement.”. Adams J. C.“An abnormal relationship of the articular disc to the mandibular condyle, fossa, and articular eminence.” Lambert G. M.

Normal TMJ Movement

Rotation of condyles occurs in the lower joint space

Translation of condyles in upper joint space

Disc moves passively with condyle

Unfolding and strectching the superior laminae of retrodiscal tissue

Rotating disc in to posteroir direction relative to condyle.

During mouth opening :

Normal TMJ Movement

During Closure :

• Inferior laminae passively limits forward rotation of the disc on the condyle.

• Anterior disc displacement can only occur when there is presence of an overstreched inferior laminae of the retrodiscal tissue.

• Diagram 8 – 2 b pg 127 laskin

Classification

1. Incoordination Phase.2. Anterior disk displacement with reduction.

3. Anterior disk displacement without reduction.

4. Adhesion of Intra Articular Disc.

Incoordination Phase:• First stage in progression of disease.• Patient is unaware and aymptomatic.

Anterior disk displacement with reduction:

Intra Articular disc is slipped anteriorly and mouth opening is accompained by clicking.

• Anterior disk displacement without reduction/ Closed Lock:

The intra articular disc is located even further forward and condyle is unable to pass over the posterior band on attempted mouth opening accompanied by locking.

Adhesion of Intra Articular Disc:

Disc is in normal position but there is adhesion of the disc to the articular eminence so that only condylar rotation can occur.Diagram 16 – 3 pg 251 laskin.

Etiology

• Trauma to the Articular Disc.• Laxity of Loint Ligaments.• Bruxism.• Changes in Synovial Fluid and Joint

Lubrication.

Clinical Features

• Severe pain on wide opening of mouth / yawning

• History of trauma

• Clicking sound on opening the mouth [ opening click ]

• Clicking sound on closing the mouth [ reciprocal click ]

• Joint pain and tendeness during function.

• Deviation of jaw to the affected side.

• Crepitus.

• Restricted mouth opening : Inter-incisal distance 20-25mm.

Management

Conservative management :

1.NSAIDs, muscle relaxants,2.Occlusal splints3. Intra – articular injection of corticosteroids for

acute pain and tenderness

• When all the conservative measures fail surgical management is the last resort.

Management

• Surgical management consists of:

1.Arthrocentesis & lavage 2.Arthroscopy3.Disc repositioning / disc removal4.Meniscal plication5.Eminectomy6.Condylectomy