Temporomandibular Joint Disorders Flashcards
What percentage of the population have TMD with signs?
50-75%
What percentage of the population have TMD with symptoms?
20-25%
What percentage of the population have TMD who seek tx?
3-4%
Women more likely
What skeletal components make up the masticatory system?
Temporal bone
Maxilla
Mandible - condyle, angle (masseter overlies) , coronoid process
What muscles attaches to the mastoid process?
SCM
Digastric muscles
What does the masseter overly?
Zygomatic arch
Angle of mandible
How does the TMJ work?
The fibrous articular capsule envelopes the joint
Reinforced by the temporomandibular ligament
Articular disc divides joint into upper and lower compartments
Lower compartment - condyle rotates below the disc (hinge like motion)
Upper compartment condyle and disc translate along the articular eminence (gliding)
How far can the TMJ move open?
35-50mm
What types of movement are made within the TMJ?
1st part of movement is mainly hinging (rotation of condyle in the fossa)
2nd half of opening mainly forward translation of condyle along eminence (gliding)
What muscles are involved in the opening of the joint?
What do the muscles facilitate?
Muscle action facilitates rotation and translation
Geniohyoid and digastric pull chin down and backwards
Lateral pterygoid - forward translation of condyles and discs
What muscles are involved in the closing of the joint?
Temporalis (posterior fibres) - backward translation of condyles
Which muscles elevate the mandible?
Temporalis, masseter and medial pterygoid
How does protrusion occur? How far can we protrude?
Symmetrical forward translation of both condyles
Both lateral pterygoids pull condyles and discs forward
Can protrude 10mm
What is retrusion? How does retrusion occur?
= The return to rest position from the protrusion position
Both temporalis muscles (posterior fibres) pull condyles back
How far can we move the jaw laterally? How does lateral excursion occur?
10mm
The condyle on opposite side is pulled forward
Condyle on the same side performs minimal rotation around a vertical axis
Contraction of lateral pterygoid muscles on the opposite side
Combined with temporalis muscle on the same side contracting to hold the rest position of the condyle
What can TMD be mistaken for?
Dental pain
Salivary gland pain
Pharynx pain
What are the types of uncommon/specific TMDs?
Inflammatory arthritis
Neoplasms
Growth disturbance
Common TMD types?
Acute or chronic >3 months
Muscular Articular - Disc displacement - Degenerative joint disease - Subluxation Mixed diagnosis
How to diagnose common TMD?
History and examination
Account for 90% of referrals
Define TMD
A collective term embracing a number of clinical problems that involve:
- The masticatory muscles
- Temporomandibular joint and associated structures
- Or both
Classifications of common musculoskeletal TMD?
Masticatory muscle disorders
- Myalgia:
1. Local myalgia
2. Myofascial pain
3. Myofascial pain with referral
Temporomandibular joint disorders
- Arthralgia
- Disc disorders:
1. DD and R
2. DD and R with intermittent locking
3. DD-R with limited opening
4. DD-R without limited opening - Degenerative joint disease
- Subluxation
Headache
- Attributed to TMD
Signs and symptoms of masticatory muscle disorders?
Familiar pain in muscles on jaw function/parafunction, palpation and movement tests
Myofascial pain with referral?
Report of pain at a site beyond the boundary of the muscle being palpated
- Headache
- Earache
- Toothache
Myofascial pain with referral?
Report of pain at a site beyond the boundary of the muscles being palpated - may feel like toothache, headache and earache
TMJ arthralgia signs and symptoms?
Familiar pain in the TMJ on jaw function/parafunction, palpation or movement tests
TMJ - disc displacement with reduction?
Signs and symptoms?
Common
The disc position is no longer maintained on the condyle throughout the range of motion - disk is anteriorly displaced and reduced
TMJ clicking on function and movement tests (e.g. opening)
Familiar pain in TMJ on function, palpation and movement tests
Ipsilateral deviation with opening (which corrects)
TMD - Signs and symptoms of disc displacement with reduction with intermittent locking?
Intermittent TMJ locking/sticking
A maneuvre may be required to open mouth
TMD - Disc displacement without reduction?
Progression of disc displacement with reduction
Here the disc no longer relocates
TMD - Disc displacement without reduction signs and symptoms?
Disc displacement without reduction without limited opening?
Acute/subacute - closed lock
- Limited mouth opening <25mm - interferes with ability to eat
- Limited contralateral excursion
- Familiar pain in TMJ on function, palpation or movement tests
- Ipsilateral deviation with opening that does not correct
Chronic
- Joint can become stretched to allow nearly full ROM
= Disc displacement without reduction without limited opening
TMD - Degenerative joint disease - what is seen on the radiograph?
On OPT:
- Joint space narrowing
- Osteophytes
- Subchrondral scelrosis (increased opacity)
- Subchrondral cysts and erosions
Common and may be an added source of pain and limited ROM
TMD - degenerative joint disease signs and symptoms?
Common and may be an added source of pain and limited ROM
Crepitus on function and movement tests
Familiar pain in TMJ on function, palpation or movement tests
Limited mouth opening
TMD - What can hypermobility result in?
TMJ hypermobility can result in condyle subluxation
TMD subluxation signs and symptoms?
TMJ clicking and locking in a wide open position
Excessive mouth opening >50mm
Familiar pain on function, palpation and movement tests
How to differentiate hypermobility and subluxation?
If the pt is able to reduce the dislocation = subluxation
If the dislocation requires an interventional reduction = luxation
Headache attributed to TMD signs and symptoms?
Familiar headache in temporal area on function, palpation of temporalis muscle and movement tests
How to take a history regarding the TMJ?
PC
- SOCRATES
Clicking
- On opening or closing
- Aggravating/relieving
- Timing
- Temp or persistent
- Associated with pain
Other joint noises
History of disorder: Limitation of opening/trismus: - Duration - Aggravating/relieving - Associated with pain Locking - On opening or closing - Timing - Temporary or persistent - Associated with pain
Altered occlusion Sensory disturbance History of trauma Parafunctional activity - Clenching/grinding - Nail biting - Lip biting
PMH
- Systemic arthritis
- Previous malignancy
- Mental health (depression/anxiety)
- Fibromyalgia
- Hypermobility syndrome
Chronic pain - what can TMD that lasts for a long time lead to?
Psychological distress and behavioural reactions:
- Not working
- Restricted social pattern
- Depression
= Dysfunctional pain
Risk factors for chronic/dysfunctional pain regarding TMD?
Predisposing - trauma
Initiating - microtrauma and strain
Perpetuating - psychological and parafunctional
What is fibromyalgia?
Widespread pain and sensitivity to palpation at multiple anatomically defined tissue sites
Often accompanied by depression and insomnia
Thought to be due to CNS neurosensory amplification
What suggests intracranial pathology of cardiac ischaemia?
Pain that is abrupt in onset, severe or precipitated by exertion, coughing or sneezing
Interrupts sleep
What can swelling of the TMJ, mandible or parotid gland suggest?
Tumour
Infection
Inflammatory arthropathy
What can facial asymmetry indicate?
Tumour
What suggests giant cell arteritis?
Unilateral headache, scalp tenderness, jaw claudication (cramping pain) or visual symptoms
What can a neck mass or persistent cervical lymphadenopathy suggest?
Infection or tumour
What can changes in occlusion suggest?
Tumour or bone growth (e.g. acromegaly) around the TMJ, or inflammatory arthritis
What can an increase in pain or limitation of function suggest after initial management?
Tumour
Contributing factors to TMJ pain?
8 removal = macrotrauma
Parafunctional activity = trauma
Hypermobility and fibromyalgia = Systemic condition
Overclosed or occlusal interference = abnormal position
Nail biting, stress and anxiety = Grinding/clenching = Parafunctional activity
What to note on extraoral examination?
Masseter muscle atrophy Protrusive habit Clenching Poor neck postural habits Asymmetry Lymph nodes Arteries - superficial temporal artery and temporal arteritis
What to note on intraoral examination?
Signs of clenching/grinding:
- Tooth scalloping/buccal mucosa ridging
- Attrition/wear facets
- Hypertrophic masseter muscles
Occlusal assessment
- Interfering contacts
- Recent changes in occlusal scheme
- Skeletal pattern - class II
Mucoskeletal examination:
- Observation
- Range of movement (ROM): Gap between 2 upper and 2 lower central incisors, deviations, joint sounds
- Local palpation of M of M intraorally and TMJ
How to examine the range of movement (ROM)?
Reference point - gap between 2 upper and 2 lower front incisors
Overpressure
Joint sound
Deviations
What to palpate?
M of M - intraorally
TMJ
How to treat TMJ pain?
Education - Info - Principles of tx - Reassurance Physical therapy Splint therapy Medication
Psychological Occlusal adjustments Botulinum toxin Surgery Review
What are the aims of intervention?
Decrease pain
Improve jaw function
Improve psychological status
Self management
Guidelines for safe and effective management?
Early diagnosis and intervention to help prevent development of chronic symptoms
Use of conservative, reversible and evidence based interventions
- Education, physical therapy, splints, medication and psychological support
- Don’t produce irreversible changes/less risk of harm
Even longstanding and severe symptoms do not usually require invasive tx
Failure of conservative interventions does not indicate need for irreversible tx e.g. occlusal adjustment surgery
2ndry care = physiotherapy referrals
How to reduce stress/strain on TMJ and muscles?
Avoid oral habits
- Tooth contact, Grinding, clenching
- Nail biting
- Pen chewing
- Chewing gum
- Lip sucking
- Habital protrusion
Monitor oral habits
Tongue to roof of mouth
Check jaw rest position
Avoid a forward head posture
Eat a soft diet
Chew slowly
Avoid caffeine = increased muscle activity
Avoid sleeping on front
Physical intervention to treat TMJ pain?
Self management to promote sense of control and to improve coping
Soft tissue techniques to facilitate muscle relaxation and reduce pain
Acupuncture as an adjunct can reduce pain and facilitate muscle relaxation
Manipulative therapy to help restore TMJ mobility
What is active assisted stretch?
Slowly open mouth as wide as comfortable
Gently assist opening with your index fingers and thumbs - Thumbs on upper canines, index on lower incisors
Hold gentle stretch for 5 seconds
3x daily
What is an occlusal splint?
Removable device usually made of acrylic resin, which fits between the maxillary and mandibular teeth
How do splints work?
Occlusal disengagement Maxillo-mandibular realignment Restored vertical dimension TMJ repositioning Cognitive awareness Placebo
What are the types of splint?
Directive - anterior repositioning splint
Permissive
- Soft bite guard
- Anterior bite plane - lucia jig
- Stabilisation splint - michigan, tanner
What does an anterior repositioning splint do?
Used to direct the mandible more anterior to ICP
Provides better condyle disc relationship to allow time for the tissues to adapt or repair
Indications for anterior repositioning splint?
Disc derangement disorders (especially with anterior disc displacement with reduction)
Can be useful for intermittent/chronic locking of the joint (often caused by disc displacement)
Advantages of soft splints?
Sometimes tolerated better by patients
Easily constructed
Cheap
Disadvantages of soft splints?
Difficult to adjust
Can encourage pt to brux
In some cases muscle pain either does not change or occasionally increases
What does a lucia jig do?
Used to disclude posterior teeth and allow relaxation of the M of M
Patients forget their ICP position
Uses:
Helps locate centric relation
As a diagnostic tool for pts with TMD symptoms
As a quick fix for pts with acute symptoms, prior to constructing a more definitive appliance
Other names for a stabilisation splint?
Michigan splint (upper) Tanner appliance (lower) Interocclusal appliance Occlusal splint Ramfjord appliance
Features of stabilisation splint?
Maxillary splint
Heat cured acrylic
Full coverage to prevent over eruption
Uniform contact in centric relation
Canine guidance to separate posterior teeth in eccentric excursions
Anterior guidance to separate posterior teeth in protrusion
= Splint creates an artificial ideal occlusion
Clinical stages of splint construction?
Visit 1
- Upper and lower alginate impressions
- Jaw registration in centric relation
- Facebow transfer
Visit 2
- Fit splint - seat and adjust fitting surface as necessary (bilaminate splints make fitting easier)
- Adjust contacts in lateral and protrusive excursions
- ICP=RCP
- Anterior guidance and lateral guidance
Subsequent visits
- Review and adjust as necessary
When should TMD patients wear a splint?
Every night
During periods of increased muscular stress/activity
For pts with severe symptoms, as often as possible
Design features of the tanner appliance?
Mandibular appliance Heat cured acrylic resin Full occlusal coverage Simultaneous, even contacts with all opposing teeth in RCP Appropriate anterior guidance Absence of posterior interferences
What to do following splint therapy?
If successful in reducing/eliminating symptoms consider long term splint wear
Do not assume further intervention will provide same benefit
What should be considered as one of the first line treatments for pts with TMD?
Provision of an inter-occlusal appliance (usually upper hard acrylic splint)
Medications for TMD?
Paracetamol
NSAID - ibuprofen
Anxiolytics
- Tricyclic antidepressants - muscle relaxation and analgesic
- Benzodiazepines - caution
Botulinum toxin
Arthrocentesis
- Injection of steroids
- Upper joint space
Arthroscopy
- Adhesiolysis
- Lavage
- Biopsy
- Miniscal plication
Advantages of arthrocentesis and arthroscopy?
Minimally invasive
Diagnostic info
Disadvantages of arthrocentesis and arthroscopy?
Limited scope for reconstructive surgery
Requires a high level of operator skill
Surgical options for TMD?
Condylar hyperplasia Trauma Ankylosis Tumours Internal derangement and severe chronic pain - that is refractory to non-surgical treatment
Surgical risks?
Auriculotemporal nerve Facial nerve (zygomatic, temporal branches)
What is diskoplasty?
Disc repositioning (plication)
What is diskectomy?
Disc removal and alloplastic material / temporalis muscle flap
Trauma that can cause TMD?
Traumatic arthritis/effusion
Dislocation
Fracture
What is osteoarthritis?
Also known as degenerative arthritis or degenerative joint diseases or osteoarthritis, is a group of mechanical abnormalities involving degradation of joints - including articular cartilage and subchondral bone
= Painful inflammatory erosive phase lasting 3 yrs followed by a period of resolution
Clinical features of osteoarthritis?
Pain centred on the joint Tender joint Crepitus Limitation of mouth opening Limitation of translatory movement Radiological signs (erosions, spurs)
Osteoarthritis treatment?
Symptomatic
- Splint
- BRA
- NSAID
Arthrocentesis = syringe to collect synovial fluid from a joint capsule
Infective arthritis - where can it spread?
Spread to middle cranial fossa therefore must be treated urgently
Clinical features of infective arthritis?
Pyrexia Very restricted opening Suppuration Erythema Swelling Long term ankylosis
Infective arthritis treatment?
IV antibiotics
Drainage
Extracapsular ankylosis and limited opening?
Opening normally more than 40mm
Trauma = fibrosis (burns, trauma, lacerations)
Infection
Tumours (fibrosarcomas)
Periarticular fibrosis (radiation, prolonged immobilisation)
Inflammation (dental)
Intracapsular ankylosis and limited opening?
Opening normally more than 40mm
Trauma = fracture (forceps delivery at birth)
Infection
Systemic arthritis
Tumours
Synovial chondromatosis (multiple cartilaginous nodules within the TMJ) - very rare
Pseudo-ankylosis?
Opening normally more than 40mm
Mechanical interference with mouth opening (e.g. zygomatic fracture)
Trismus checklist - for pts with reduced mouth opening?
Opening less than 15mm
Progressively worsening trismus
Absence of history of clicking
Pain of non-myofascial origin (neuralgia)
Swollen lymph glands
Suspicious intra-oral soft tissue lesion
If any of the answers are yes - consider radiograph and arrange review with senior clinician
How to treat recurrent dislocation of TMJ?
Physiotherapy
Botulinum toxin (lateral pterygoid)
Fibrosis of the tissues
Surgical
Types of inflammatory arthritis?
Rheumatoid (also juvenile) Psoriatic SLE Ankylosis spondylitis Gout
How and when to replace the TMJ?
Made of 2 parks - ball and socket system
Reserved for cases where all other tx modalities have failed
