TMJD Flashcards
Size of the problem (3)
Percentage of population with signs (at some point in their life) 50-75%
Percentage of population with symptoms (at some point in their life) 20-25%
Percentage of population who seek treatment 3-4%
Anatomy of the TMJ (5)
• Mandible bone -condyle -coronoid process • Temporal bone -mastoid process -digastric muscle -external auditory meatus • Temporomandibular joint • Zygomatic arch • Movement and muscles • Cervical spine and TMD
What envelopes the joint? (1)
The fibrous articular capsule
Describe the articular disc (2)
Biconcave disc
Disc divides joint into upper and lower compartments
Hinge joint - lower compartment (1)
Condyle rotates about the disc
Hinge joint with a moveable socket - upper compartment (1)
Condyle and disc translate along eminence
How much should the mouth open? (2)
35-50mm
3 fingers
Describe mouth opening in terms of TMJ (2)
First half of opening mainly hinging (rotation of condyle in the fossa)
Second half of opening mainly forward translation of condyle along eminence
Muscles in TMJ movements (4)
Combination of muscle action produces the rotation and translation movements
Geniohyoid and digastric pulls the chin down and backwards
Lateral pterygoid - forward translation of condyles and discs
Temporalis (posterior fibres) - backward translation of condyles
Temporalis, masseter and medial pterygoid elevate the mandible
Protrusion - distance and muscles (3)
10mm
Symmetrical forward translation of both condyles
Both lateral pterygoids pull condyles (and discs)
Retrusion - movement and muscles (2)
The return to rest position from protrusion position
Both temporalis muscles (posterior fibres) pull condyles
Lateral excursion - distance and movement
10mm
The condyle of opposite side is pulled forward
Condyle on the same side performs minimal rotation around vertical axis
Contraction of the lateral pterygoid muscles on opposite side
Combined with temporalis muscle on the same side contracting to hold the rest position of the condyle
Diagnostic classification - non TMDs (other facial pains) (3)
Dental
Salivary gland
Pharynx etc.
Diagnostic classification - uncommon TMDs (specific) (3)
Inflammatory arthritis
Neoplasms
Growth disturbance etc.
Diagnostic classification - common TMDs (5)
Acute or chronic (>3 months) Muscular Articular -disc displacement -osteoarthritis -subluxation -adhesions Muscular and articular
Common TMD - stats (2)
Account for over 95% of all referrals
Diagnosis is made on the basis of history and
examination
Define common TMD (4)
A collective term embracing a number of clinical problems that involve: o the masticatory muscles o the temporomandibular joint & associated structures o or both
Classification of common musculoskeletal TMD (3)
• Masticatory muscle disorders
• Temporomandibular joint disorders
• Headache attributed to TMD
Mixed presentation is common
Masticatory muscle disorders (2)
Local myalgia
Myofascial pain
• Commonly associated with painful guarded muscles of mastication
• Parafunctional activity believed to be common driver
Masticatory muscle disroders - sign and symptoms (3)
- Pulling / tight aching sensation
- Pain with jaw activity
- Tenderness on palpation
Myofascial pain (3)
• Presence of trigger points (TPs)
• Hyper-irritable taut band of muscle tissue which
on palpation reproduces local and referred pain
• Inactivation relieves pain
Myofascial pain - cause of TPs not well understood (3)
? Neuro-chemical changes:
o Hyperalgesia due to sensitisation of NS
o Elevated levels of pain mediators have
been found near trigger points in muscle
TMJ arthralgia (4)
Disc displacement o With reduction o Without reduction Osteoarthritis / osis Hypermobility & subluxation Adhesions
Disc displacement with reduction (DD + R) (2)
- Progression of TMJ hypermobility
- TMJ becomes more lax and the ideal disc position is no longer maintained in relation to the condyle throughout the range of motion
Disc displacement with reduction (DD + R) - signs and symptoms (2)
Click with opening/ closing
Deviation to ipsilateral sides
Disc displacement without reduction (DD - R) (2)
- Progression of disc displacement with reduction
* Here the disc no longer relocates
Disc displacement without reduction (DD - R) - signs and symptoms (4)
Acute / subacute – ‘closed lock’ • Limited opening (< 25 mm) • Ipsilateral deviation with opening • Limited contralateral excursion Chronic • Joint can become stretched to allow nearly full ROM
Osteoarthritis / osis (1)
Common and ‘may’ be an added source of pain and limited ROM
Osteoarthritis / osis - signs and symptoms (3)
TMJ crepitus Tenderness on palpation of TMJ Radiographic (OPG) -joint space narrowing -osteophytes -subchondral sclerosis (increased opacity) -subchondral cysts
Hypermobility and subluxation (1)
TMJ hyprtmobility can result in recurrent condyle subluxation
Hypermobility and subluxation - signs and symptoms (3)
- Excessive AROM with opening (> 40 mm)
- Click at EOR opening
- Open lock
Adhesions - possible causes (5)
Adhesions limit extensibility of TMJ capsule – possible causes:
o Chronic inflammatory condition
o History of trauma or surgery
o Immobilisation
o Chronic articular disc displacement without reduction
Adhesions - signs and symptoms (3)
- Limited opening
- Ipsilateral deviation with opening
- Limited contralateral excursion
Headache secondary to TMD - signs and symptoms (4)
- Ache in temple area/s
- Aggravated with jaw movement, function, or parafunction
- Pain on movement testing
- Pain on palpation of temporalis muscle/s
History of disorder - clicking (5)
oOn opening or closing oAggravating / relieving oTiming oTemporary or persistent oAssociated with pain Other joint noises
History of disorder - limitation of opening / trismus (3)
o Duration
oAggravating / relieving
oAssociated with pain
History of disorder - locking (4)
- On opening or closing
- Timing
- Temporary or persistent
- Associated with pain
History of TMJD (8)
Clicking Other joint noises Limitation of opening/ trismus Locking Altered occlusion Sensory disturbance History of trauma Parafunctional activity
History of disorder - parafunctional activity (3)
o Clenching / grinding
o Nail biting
oLip biting
Chronic pain in TMD (4)
TMD that lasts for a considerable period of time may lead
to substantial psychological distress and behavioural
reactions. For example:
o Not working
o Restricted social pattern
o Depression
This is then termed ‘dysfunctional pain’
Three risk factors for TMD as chronic pain (3)
- Predisposing – trauma
- Initiating – microtrauma and strain
- Perpetuating – psychological and parafunctional
Possible PMH for chronic TMJD (5)
- Systemic arthritis
- Previous malignancy
- Mental health (depression / anxiety)
- Fibromyalgia
- Hypermobility syndrome
What is fibromyalgia? (3)
• 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
History suggesting fibromyalgia (5)
History of cancer (may suggest metastasis).
Pain that is abrupt in onset, severe, or precipitated by exertion, coughing, or
sneezing, or that interrupts sleep (may suggest intracranial pathology or cardiac ischaemia).
Weight loss (may suggest cancer).
Fever (may suggest septic arthritis, osteomyelitis, intracranial abscess, tooth
abscess, or mastoiditis).
Neurological symptoms or signs (may suggest a tumour or other intracranial
pathology).
Facial signs/ symptoms of fibromyalgia (5)
Swelling of the temporomandibular joint,
mandible, or parotid gland (may suggest tumour, infection, or inflammatory
arthropathy).
Facial asymmetry (may indicate a tumour).
Unilateral headache or scalp tenderness, jaw claudication, or visual symptoms (suggests giant cell arteritis).
Nasal symptoms — persistent loss of smell (anosmia), purulent discharge, nasal
blockage, or epistaxis (may suggest a nasopharyngeal tumour).
Neck mass or persistent cervical lymphadenopathy (may suggest infection or
tumour).
Change in occlusion (how the teeth meet together when the jaws are closed). This
may suggest a tumour or bone growth (for example in acromegaly) around the
temporo-mandibular joint, or inflammatory arthritis; but can also be seen in other
temporomandibular disorders.
Decreased hearing on the ipsilateral side (may suggest a nasopharyngeal tumour).
Increasing pain or limitation in function despite initial management (may suggest a
tumour).
Extra-oral examination for TMJD (4)
Observation Neurological Vascular/ arteries -temporal arteritis Lymph nodes -infection, inflammation, neoplasm
Intra-oral examination (6)
Signs of clenching/ grinding -tongue scalloping/ buccal mucosal ridging -attrition/ wear facets -hypertrophic masseter muscles Occlusal assessment -interfering contacts -recent changes in occlusal scheme -skeletal pattern - class II 'posturing'
Musculoskeletal examination
Observation of movement -opening: pattern, range, overpressure, sounds -lateral excurstion -protrusion Palpation -temporomandibular joint -muscles (extraoral, intraoral)
Bruxoprovocation test (1)
1 minute clench test
Investigation
Radiographic
Treatment - main forms (3)
Education
Exercises - physiotherapy
Splint therapy
Treatment - other forms (6)
Medication Occlusal adjustments Botulinum toxin Arthrocentesis Surgery Review
Treatment: education (3)
Information
Principles of treatment
Reassurance
Aims of intervention (5)
Reduce pain Recover function Improve psychological status Self-manage Be safe!
Persistent TMD will usually be associated with (2)
a complex combination of driving factors
that can coexist to maintain an ongoing
cycle of pain and disability
Driving factors of TMD (8)
Lifestyle BIOLOGICAL Patho-anatomical Neuro-psychological Physical Comorbidities/ genetic PSYCHOSOCIAL Cognitive Psychological Social
Explanation of psychological intervention (7)
Crucial for addressing psychological driving factors
-helps reassure and reduce threat of symptoms
Improves compliance with tx
-helps motivate by providing a rationale
Based on assessment findings, reinforce benign TMD ‘diagnosis’
Explain how ongoing cycles can be maintained
Ask the pt about their main problems and goals
Ask what they could do to help break their cycle of pain
How can I reduce stress/ strain on my jaw joint and jaw muscles? (6)
Avoid oral habit e.g. clenching, nail biting, lip sucking etc.
Regularly check your ‘relaxed’ jaw rest position
-remember to keep tongue up, teeth apart
Avoid a ‘forward’ head posture (increases activity in neck and jaw muscles)
Eat soft diet, cut food into small pieces, chew slowly
Avoid caffeine
Avoid excessive or prolonged mouth opening
-there are lots more
Trigger-point inactivation/ acupuncture (3)
• To facilitate muscle relaxation and reduce pain
• ‘It appears that the mechanical disruption of the trigger point by the needle provides the therapeutic
effect’
• Follow this with muscle stretching
Passive joint stretch/ self-mobilisation (3)
- On side to be stretched slide sticks
between the back teeth to take up slack, maintain relaxed open position - Holding sticks, gently and slowly move in upward direction so you feel a gentle stretch on your jaw
joint on that side - not a forced stretch
• 10 repetitions every 2 hours
Active-assisted stretch (4)
Slowly open as wide as comfortable
Assist opening with index finger and thumb ‘scissor action’
3x10 second holds, every 2 hours
SLOW movements without pain or undue force
TMDs and occlusal splint therapy (2)
Interocclusal appliance therapy (occlusal splint)
-removable device usually made of acrylic resin, which fits between maxillary and mandibular teeth
How do splints work? (6)
- Occlusal disengagement
- Maxillo-mandibular realignment
- Restored vertical dimension
- TMJ repositioning
- Cognitive awareness
- Placebo effect
Types of splint (4)
Directive -anterior repositioning splint (ARPS) Permissive -soft bite guard -anterior bite plane (Lucia jig) -stabilisation splint (Michigan, Tanner)
Anterior repositioning splint (2)
• Used to direct the mandible more anterior to ICP
• Provides a better condyle-disc relationship to
allow time for the tissues to adapt or repair
Indications of anterior repositioning splint (2)
• Disc derangement disorders (especially anterior disc displacement with reduction)
• Can be useful for intermittent / chronic
locking of the joint (often caused by disc displacement)
Advantages of soft splints (3)
Sometimes tolerated better by patients
Easily constructed
Cheap
Disadvantages of soft splints (3)
Difficult to adjust
Can encourage patient to brux
In some cases muscle pain either does not change or occasionally increases
Lucia jig (2)
• Used to disclude posterior teeth and allow relaxation
of the muscles of mastication
• Patients “forget” their ICP position (neuromuscular
deprogramming)
Uses of the Lucia jig (3)
• To help locate centric relation
• As a diagnostic tool for patients with TMD symptoms
• As a “quick fix” for patients with acute symptoms, prior to constructing a more
definitive appliance
Ask stabilisation types (5)
- Michigan splint (upper)
- Tanner appliance (lower)
- Interocclusal appliance
- Occlusal splint
- Ramfjord appliance
Features of a stabilisation splint (6)
• 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
Clinical stages of splint construction (3)
Visit 1 • Upper and lower alginate impressions • Jaw registration in centric relation • Facebow Visit 2 • Fit splint Subsequent visits • Review and adjust as necessary
Clinical procedures in splint construction (3)
• Maxillary and mandibular alginate impressions
• Facebow transfer
• Centric relation jaw registration
• Records to laboratory
• Fitting the splint - seat and adjust fitting surface as necessary
-bilaminate splints make fitting easier
Pattern and duration of splint wear for TMD patients (3)
• Every night
• During periods of increased muscular activity/ stress
• For patients with severe symptoms, as often
as possible during the day also
Design features of a Tanner appliance (6)
• 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
Following splint therapy (2)
• If the splint therapy is successful in
reducing/ eliminating symptoms consider
long-term splint wear
• Do not assume that further intervention
(e.g. occlusal adjustment) will provide the same benefit
Anxiolytics for TMD (3)
Tricyclic antidepressants
-muscle relaxation
-analgesia
Benzodiazepines - caution
Arthrocenesis (2)
Injection of steroids
Upper joint space
Arthroscopy (4)
Adhesiolysis
Lavage
Biopsy
Miniscal plication
Advantages (2) and disadvantages (2) of arthrocenesis and arthroscopy
Advantages: -minimally invasive -diagnostic information Disadvantage -limited scope for reconstructive surgery -requires a high level of operator skill
Surgery for TMD (5)
- Condylar hyperplasia
- Trauma
- Ankylosis
- Tumours
- Internal derangement and severe chronic pain that is refractory to non-surgical treatment
Risks of surgery (2)
Auriculotemporal nerve Facial nerve (zygomatic; temporal branches)
Diskoplasty (1)
Disc repositioning (plication)
Diskectomy (1)
Disc removal ± alloplastic material / temporalis
muscle flap
Trauma and dislocation (3)
- Traumatic arthritic / effusion
- Dislocation
- Fracture
Osteoarthritis definition (2)
also known as degenerative arthritis or degenerative joint disease or osteoarthrosis, is a group of mechanical abnormalities involving degradation of joints
– including articular cartilage and subchondral bone
Clinical features of osteoarthritis (6)
- Pain centred on the joint
- Tender joint
- Crepitus
- Limitation of mouth opening
- Limitation of translatory movement
- Radiological signs (erosions, spurs)
Treatment for osteoarthritis??***
Symptomatic o Splints o BRA o NSAID Arthrocentesis
Infective arthritis - description and clinical features (8)
Rare May spread to middle cranial fossa therefore must be treated urgently Clinical features • Pyrexia • Very restricted opening • Suppuration • Erythema • Swelling • Long term ankylosis
Treatment for infective arthritis (2)
- Antibiotics (IV)
* Drainage
Extracapsular features of ankylosis and limited opening (5)
- Trauma → fibrosis (burns, trauma, lacerations)
- Infection
- Tumours (e.g. fibroscarcomas)
- Periarticular fibrosis (radiation, prolonged immobilization)
- Inflammation (dental, other)
Intracapsular features of ankylosis and limited opening (5)
- Trauma → fracture (forceps delivery at birth)
- Infection
- Systemic arthritis
- Tumours
- Synovial chondromatosis (multiple cartilaginous nodules within the TMJ) – very rare
Pseudo-ankylosis (1)
• Mechanical interference with mouth opening (e.g. zygomatic fracture)
Trismus checklist (6)
For completion in pts with reduced mouth opening
-opening less than 15mm
-progressively worsening trsimus
-absence of history of clicking
-pain of non-myofascial origin (neuralgia etc.)
-swollen lymph glands
-suspicious intra-oral soft tissue lesion
If any are yes consider radiograph and arrange review with senior clinician
Recurrent TMJ dislocations (4)
- Physiotherapy
- Botulinum toxin (lateral pterygoid)
- Fibrosis of the tissues
- Surgical
Inflammatory arthritis associations (5)
- Rheumatoid (also juvenile)
- Psoriatic
- SLE
- Ankylosing spondylitis
- Gout
TMJ replacements (2)
• Made of two parts – ball and socket system
• Reserved for cases where
all other treatment
modalities have failed
