TMJ Management

Question 1

What are the clinical features associated with myalgia?

Answer 1

• Dull aching pain
• Masseter and temporalis affected
• Pain at rest, worsens during function
• Limitation of movement possible
• Radiated pain

Question 2

What are the features associated with myalgia?

Answer 2

• More localised sharp pain
• Situated TMJ, surrounding tissues and ear
• Aggravated during during loading and function
• Often associated with a displaced disc or locking/clicking
• Limitation of movement is possible
• TMJ arthritis

Question 3

What is the aetiology of TMD?

Answer 3

1. Parafunction (bruxism, clenching, gum chewing)
2. Psychological
   (stress, anxiety/depression, hypervigilance)
3. Occlusion (severe skeletal discrepancy)
4. Pathology (trauma history to TMJ, inflammatory disease)

Question 4

How do we undertake a joint examination, muscle examination and functional examination?

Answer 4

1. Joint examination
   * Pain evoked by digital palpation of TMJ and wide opening
   * Joint sounds on opening, closing and excursions
   Either due to anterior disc displacement popping back into place or crepitus due to arthritis
2. Muscle examination
   Digital palpation of:
   * (Neck and shoulder muscles)
   * Extra-oral muscles of mastication (working to back of neck to the shoulders)
   * Intraoral muscles of mastication
3. Functional examination – see jaw in function
   * Deviation and pattern of opening
   * Vertical range of motion
   How big can they open their mouth? Does it deviate to one side?

Question 5

What are you looking for when doing an extra-oral examination?

Answer 5

*External palpation TMJs
– Tender
– Clicking: very common and not associated with pain
– Crepitus
– Dislocation

*External palpation of muscles of mastication
– Patient to clench
– Masseter: see if they feel hypertrophic from overuse
– Temporalis
– Tenderness / hypertrophy

*Mouth opening
– normal = 35-45 mm / 3 finger width – of patient’s own fingers
– Measure inter-incisal distance/ finger width
*Deviation of mandible on opening
*Mandibular excursions: can they perform these?

Question 6

Explain the differences between a healthy joint, anterior disc displacement with reduction and anterior disc displacement without reduction

Answer 6

Healthy joint: articular disc sits between the base of the skull in the glenoid fossa and the surface of the condyle

Anterior disc displacement with reduction: on opening, the disc becomes squashed and there will reduce back over the area of the condyle leading to a popping sound.

Anterior disc displacement without reduction: disc is anteriorly displaced but when the patient opens and the condyle rotates and translate forwards, it impinges on the disc and the disc will not move back over to the condyles.

Question 7

What is the intra-oral assessment for the TMD?

Answer 7

Muscles of mastications insertions:
- Lateral pterygoid (distal to upper 8)
- Medial pterygoid (lingual to lower molar region)

Dentition:
- Tooth wear (occlusal/incisal edges)
- Linea alba (Result of bruxism
- Tongue scalloping

Question 8

What is involved in first line management for TMD?

Answer 8

• Patient education
• Avoidance of parafunctional habits e.g. do not chew gum
• Resting jaw
• Hot / cold application
• Analgesics
• Exercises
• Relaxation & mindfulness
• Physiotherapy
• Acupuncture: to reduce pain intensity
• CBT
• Pharmacological: paracetamol, NSAIDS, benzodiazepines
  , corticosteroids
• BOTOX
• Steroid injection

Question 9

What are some irreversible management options for TMD?

Answer 9

• Occlusal therapy
• Prosthodontic reconstruction
• Orthodontics
• Surgery

Question 10

Which TMD conditions require surgical correction?

Answer 10

• Mandibular growth disturbances
• Ankylosis
• Fractured zygomatic arch
• Neoplasms
• Tumours
• Fractures of condyloid process with dislocation
• Anterior disc displacement

Question 11

What are the 4 main TMD surgeries?

Answer 11

1) Arthrocentesis - flushing out the joint
2) Arthroscopy - lysis + lavage - keyhole surgery to check and repair joints
3) Arthrotomy - disc repositioning
4) Extra-articular surgery e.g. condlyectomy,

Question 12

What can impaired growth of the mandible be due to?

Answer 12

• Trauma
• Infection
• Neoplasia
• Systemic arthropathy (systemic arthritis)
• Condylar asplasia/hypoplasia
• Microsomia
• Treacher – collins (genetic condition affecting facial development)