TEMPOROMANDIBULAR DISORDER/ TMD

Question 1

1. What is the first choice of TMJ diagnostic imaging? Give a Reason (2)

Answer 1

 MR imaging has been confirmed as the imaging technique of choice in the study of TMJ dysfunction.
 Precise localization of the disk is very important in the diagnosis of TMJ internal derangement and can
easily be achieved with MR imaging.

Question 2

32 y.o. female, busy bank clerk, complained of left TMJ pain, patient mentioned about occasional clicking. pain on palpation of MOM, trismus, jaw deviation to the left upon opening.
Radiograph shows articulating disc of left TMJ is displaced anteriorly when the mouth is closed, but is in normal position when the mouth is opened

a. What is the diagnosis for the patient? (1)

Answer 2

 Anterior disc displacement with reduction

Question 3

32 y.o. female, busy bank clerk, complained of left TMJ pain, patient mentioned about occasional clicking. pain on palpation of MOM, trismus, jaw deviation to the left upon opening.
Radiograph shows articulating disc of left TMJ is displaced anteriorly when the mouth is closed, but is in normal position when the mouth is opened

b. Is clicking an abnormal condition? (1)

Answer 3

 Yes. Disc is considered displaced when the inferior intermediate zone of articular disk is separated more than 2 mm from the anterior aspect of condyle
 As translation commence, head of condyle encounter the disc in an unexpected and displaced position, bilaminar zone is stretched, friction is built up and when the tension exceed pressure exerted by condyle, the disc move backward suddenly to release energy
 Sudden distraction of the opposing wet surface produce click

Question 4

32 y.o. female, busy bank clerk, complained of left TMJ pain, patient mentioned about occasional clicking. pain on palpation of MOM, trismus, jaw deviation to the left upon opening.
Radiograph shows articulating disc of left TMJ is displaced anteriorly when the mouth is closed, but is in normal position when the mouth is opened

c. What is the normal range of maximum mouth opening? (1)

Answer 4

 Assisted range of motion: male > 40 mm, female > 35 mm (including overlap)
 Lateral 8 mm, protrusion 6 - 8 mm
 ***Book’s word is “Minimal / lower limit” opening

Question 5

32 y.o. female, busy bank clerk, complained of left TMJ pain, patient mentioned about occasional clicking. pain on palpation of MOM, trismus, jaw deviation to the left upon opening.
Radiograph shows articulating disc of left TMJ is displaced anteriorly when the mouth is closed, but is in normal position when the mouth is opened

d. 3 clinical features that can accompany TMJ pain/ dysfunction (3)

Answer 5

 Headache, arthralgia, otalgia, muscles tenderness, limited range of motion (trismus), joint sounds, deviated pathway

Question 6

32 y.o. female, busy bank clerk, complained of left TMJ pain, patient mentioned about occasional clicking. pain on palpation of MOM, trismus, jaw deviation to the left upon opening.
Radiograph shows articulating disc of left TMJ is displaced anteriorly when the mouth is closed, but is in normal position when the mouth is opened

e. What are the 2 types of internal derangement? (2)

Answer 6

 Disc displacement with and without reduction

Question 7

32 y.o. female, busy bank clerk, complained of left TMJ pain, patient mentioned about occasional clicking. pain on palpation of MOM, trismus, jaw deviation to the left upon opening.
Radiograph shows articulating disc of left TMJ is displaced anteriorly when the mouth is closed, but is in normal position when the mouth is opened

f. What can be observed on plain radiograph if the px has internal derangement?(1)

Answer 7

 Nothing as it doesn’t show the disk (fibrocartilage)

Question 8

32 y.o. female, busy bank clerk, complained of left TMJ pain, patient mentioned about occasional clicking. pain on palpation of MOM, trismus, jaw deviation to the left upon opening.
Radiograph shows articulating disc of left TMJ is displaced anteriorly when the mouth is closed, but is in normal position when the mouth is opened

g. Arthroscopy is used for imaging and diagnosis. Which joint space (upper/lower) can be visualized? Choose the adequate answer. (1)

Answer 8

 Upper

Question 9

32 y.o. female, busy bank clerk, complained of left TMJ pain, patient mentioned about occasional clicking. pain on palpation of MOM, trismus, jaw deviation to the left upon opening.
Radiograph shows articulating disc of left TMJ is displaced anteriorly when the mouth is closed, but is in normal position when the mouth is opened

h. 2 imaging techniques for investigating the condylar disc (2)

Answer 9

 MRI, computed tomography

Question 10

32 y.o. female, busy bank clerk, complained of left TMJ pain, patient mentioned about occasional clicking. pain on palpation of MOM, trismus, jaw deviation to the left upon opening.
Radiograph shows articulating disc of left TMJ is displaced anteriorly when the mouth is closed, but is in normal position when the mouth is opened

i. 3 conditions that will affect TMJ (3)

Answer 10

 Rheumatoid arthritis, systemic joint laxity (hypermobile joint syndrome), hormonal change (elevated estrogen during menstrual cycle), osteoporosis

Question 11

32 y.o. female, busy bank clerk, complained of left TMJ pain, patient mentioned about occasional clicking. pain on palpation of MOM, trismus, jaw deviation to the left upon opening.
Radiograph shows articulating disc of left TMJ is displaced anteriorly when the mouth is closed, but is in normal position when the mouth is opened

j. Is TMD a kind of clinical manifestation of mental disorders? (1)

Answer 11

 Yes. TMD may occur secondary to stress induce involuntary clenching

Question 12

32 y.o. female, busy bank clerk, complained of left TMJ pain, patient mentioned about occasional clicking. pain on palpation of MOM, trismus, jaw deviation to the left upon opening.
Radiograph shows articulating disc of left TMJ is displaced anteriorly when the mouth is closed, but is in normal position when the mouth is opened

k. Name 3 adequate treatments for the patient in dealing with her conditions (3)

Answer 12

Counselling
Pharmacological therapy
Physiotherapy
Occlusal splint therapy

Question 13

32 y.o. female, busy bank clerk, complained of left TMJ pain, patient mentioned about occasional clicking. pain on palpation of MOM, trismus, jaw deviation to the left upon opening.
Radiograph shows articulating disc of left TMJ is displaced anteriorly when the mouth is closed, but is in normal position when the mouth is opened

Why is counselling an adequate treatment for the patient in dealing with her conditions?

Answer 13

 Reassurance and explain condition

 Rest, self-relaxation, cognitive behavioral therapy

Question 14

32 y.o. female, busy bank clerk, complained of left TMJ pain, patient mentioned about occasional clicking. pain on palpation of MOM, trismus, jaw deviation to the left upon opening.
Radiograph shows articulating disc of left TMJ is displaced anteriorly when the mouth is closed, but is in normal position when the mouth is opened

Why is Pharmacological therapy an adequate treatment for the patient in dealing with her conditions?

Answer 14

Analgesic, NSAID, muscles relaxant, antidepressant

Question 15

32 y.o. female, busy bank clerk, complained of left TMJ pain, patient mentioned about occasional clicking. pain on palpation of MOM, trismus, jaw deviation to the left upon opening.
Radiograph shows articulating disc of left TMJ is displaced anteriorly when the mouth is closed, but is in normal position when the mouth is opened

Why is Physiotherapy an adequate treatment for the patient in dealing with her conditions?

Answer 15

Thermal, massage, acupuncture, magnetic therapy

Question 16

32 y.o. female, busy bank clerk, complained of left TMJ pain, patient mentioned about occasional clicking. pain on palpation of MOM, trismus, jaw deviation to the left upon opening.
Radiograph shows articulating disc of left TMJ is displaced anteriorly when the mouth is closed, but is in normal position when the mouth is opened

Why is Occlusal splint therapy an adequate treatment for the patient in dealing with her conditions?

Answer 16

 Anterior repositioning splint to eliminate clicking by guiding the mandible into a forward and
downward protrusive position so displaced disc can return to a more normal therapeutic position,
elasticity of disc will reposition upon time
 Soft bite guard is for emergency acute TMD
 Localized occlusal interference splint is for breaking bruxism habit
 Stabilization splint is for presence of occlusal interference

Question 17

Case:
Chronic pain of temporal area, particularly during mouth opening and chewing
Joint clicking during extra oral examination

a. Working diagnosis for pain and click (2)

Answer 17

 Disc Displacement (Internal Derangement)

Question 18

Case:
Chronic pain of temporal area, particularly during mouth opening and chewing
Joint clicking during extra oral examination

b. Diagnostic approach of TMD (2)

Answer 18

 Jaw pain
 Difficulty opening
 Clicking
 Tooth grinding/clenching  Poorly rested

Question 19

Case:
Chronic pain of temporal area, particularly during mouth opening and chewing
Joint clicking during extra oral examination

c. Possible etiology is joint problem (4)

Answer 19

 Trauma
 Psychological
 Occlusal
 Degeneration/inflammation

Question 20

Case:
Chronic pain of temporal area, particularly during mouth opening and chewing
Joint clicking during extra oral examination

d. Goal of treatment of joint problem (4)

Answer 20

 Lessen the pain
 Restore function
OR
(A Clinical Guide to Temporomandibular Disorders)
 Treatment of the symptoms
 Treatment of the underlying cause
 Treatment of predisposing factors
 Treatment of the pathological effects