TEMPOROMANDIBULAR DISORDERS AND ITS

MANAGEMENT
Temporomandibular disorders embrace a wide spectrum of
specific and non-specific disorders that produce symptoms of pain
and

dysfunction

of

the

muscles

of

mastication

and

temporomandibular joints.
Temporomandibular Joint Dysfunction is applied in a more
restricted sense to smaller cluster of related, relatively non-specific
disorders of TMJ and muscles of mastication that have many
symptoms in common.
SIGNS AND SYMPTOMS OF TMJ DYSFUNCTION
SIGN: Objective clinical finding revealed during an examination.
SYMPTOM: A description or complaint by the patient.
The commonly occurring symptoms are:
1) Pain.
2) Joint sounds.
3) Limitation of mandibular movements.
4) Ear symptoms.
5) Recurrent headache.

1) Pain:
Origin

Muscles, TMJ, Dentition

Muscle:
-

Pain felt in muscle is called myalgia.

Two main factors of myogenic pain are:

Mechanical trauma, Muscle fatigue.

Mechanical trauma:
-

Macrotrauma arises from an external force such as

blow to the face.

Microtrauma arises in the absence of external force and

is commonly associated with parafunction such as bruxism.

Muscle fatigue:
-

Sustained static muscle contraction can cause localized

ischaemic and an alteration in muscle fibre membrane
permeability that results in local oedema.

Localized tender areas of muscle which may be

associated with firm bands or knots of muscles are known as
trigger points and is termed myofascial pain.
2

Myogenic pain is a type of deep pain and if it becomes

constant can produce central excitatory effects which may
present as referred pain, secondary hyperalgesia or even
autonomic effects.

Articular pain
-

It can arise as a result of inflammation of articular and

periarticular tissues caused by overloading or trauma to those
tissues.

Dentition:
-

These

are

commonly

associated with breakdown

created by heavy occlusal forces to the teeth and their

supportive structures.
a)

Mobility

- Due to loss of bone support

- Heavy occlusal forces.

-

Loss of bone support is primarily due to periodontal

disease.

When heavy horizontal forces are applied to the bone,

the pressure side of the root shows signs of necrosis and
opposite side shows signs of vascular dilation and elongation
of periodontal ligament. This increases the width of
periodontal space on both sides of the tooth which is initially
filled with granulation tissue which changes gradually to
collagenous and fibrous connective tissue. This increased
width caused increased mobility.

b) Tooth wear:
This is observed as shiny flat areas of the teeth that do not
match occlusal form of tooth. This area of wear is called wear
facet, the etiology stems almost entirely from parafunctional and
not-functional activities.
2) Joint Sounds
There are two types of joint sounds:
a)

Crepitus

This is a grating or scraping noise that occurs on jaw

movement which can be noticed by the patient and often can be
palpated by the clinician. It is said by the patient to feel like sand
paper rubbing together. It is caused by roughened, irregular
articular surfaces of the osteoarthritic joint.
b)

Clicking
This is caused by uncoordinated movement of condylar head

and TMJ disc.

Causes of TMJ clicking (Klienberg, 1991)
Dysfunction:
1. Click associated with deviation in form of condyle, disk and
temporal fossa.
2. Click associated with neuromuscular dysfunction.
3. Eminence click.
4. Click (reciprocal) with anterior disc displacement.
5. Click associated with hypermobility.
6. Teethered disc click.
5

Cause:
i.

Remodelling and morphologic changes of the

articular surfaces and disc perforations may provide
mechanical obstruction to condylar translation.

ii.

Uncoordinated

movement

may

be

due

to

dysfunction of controlling muscles, the lateral

pterygoid or masseter muscles.
iii.

Eminence click occurs in association with a forced

joint opening with a protrusive opening arc. This
can occur unconsciously for example with Class II
occlusion or as a delibrate movement.

iv.

The anterosuperior part of the mandibular condyle

is normally related to central fossa of the disc. The
disc in some cases however may become displaced.
Anterior displacement of the disc in the joint space
causes a click to occur as the condylar head moves
across the posterior ridge of the disc. This takes
place both on opening and closing movements of

the mouth. A double click is thus produced and is

referred to as reciprocal clicking. This condition
may progress to closed clock when head of condyle
becomes unable to pass across posterior ridge. This
will result in limitation of opening of mouth.
v.

Hypermobility click occurs when the head of the

condyle clicks over the anterior ridge of the disc
when the mouth is wide open.

vi.

Teethered disc click. A posterior disc attachment

that has been damaged as a result of trauma may
prevent the translation of TMJ disc that should
occur on opening the mouth. Reciprocal clicking
may occur as the head of the condyle passes over
the anterior band of the meniscus on opening and
closing the mouth.

3) Limitation of mandibular movement

a)

Muscular restriction:

The restriction is caused by contraction in a group of muscles

and can be produced by forceful stretching of muscle or its
synergists or as a response to pain, either in the muscle or its
synergists, or around the joint. Difficulties in opening the mouth
after complicated tooth extractions and mandibular nerve blocks
might be caused by reflex muscular inhibition or intramuscular
haemorrhage.
b)

Disc displacement : closed lock:

An anteriorly displaced disc may prevent the forward

translation of the mandibular condyle which results in limitation

of opening of the mouth, i.e. closed lock. Clinical signs are
reduced opening capacity, mandibular deviation on opening and
tenderness to palpation of the affected TMJ. The early or acute
closed lock may result in interincisal opening of less than
35mm.
c)

Ligamentous Restrictions:

Sometimes

ligaments

become

stretched

and

thus

hypermobility results with possible sequele i.e. dislocation of

the

joint

rather

than

restriction

of

movement.

the

sphenomandibular ligament can sometimes be too short to

permit a normal mouth opening capacity.
d)

Dislocation:
On wide opening of the mouth the head of the condyle

normally passes over the articular eminence occasionally a

patient may be unable to close the mouth because the condyle
cannot return into the fossa. The mouth will be wide open and a
feeling of panic is observed.
e)

Ear symptoms:
Subjective ear symptoms are commonly associated with TMJ

dysfunction. Symptoms include tinnitus, itching in the ear, a

blocked feeling and vertigo. The symptoms are probably due to
functional disturbance of the Eustachian tube. The masseter

hyperfunction may lead to vibration and clones of tensor

tympani muscle which is also innervated by trigeminal nerve.

10

f)

Recurrent headache
It frequently accompanies pain and tenderness in the

masticatory muscles. Bruxism can produce temporal headache in

the absence of other subjective symptoms but the temporal
muscle is then usually tender to palpation and is often a
symptom of generalized tension related to an associated anxiety
state.
AETIOLOGY
The aetiology of symptoms of TMJ dysfunction are generally
multifactorial. They have been described as being:
1. Predisposing.
2. Precipitating.
3. Perpetuating.
1. Predisposing factors:
Various anatomical, physiological and biochemical factors
predispose an individual to TMJ dysfunction as may occur in
genetic or inherited

disorders. In addition, neurological,

11

vascular, nutritional or metabolic disorders can affect the

musculoskeletal tissues and predispose an individual to TMJ
problems.
Travell pointed out that when muscles are subjected to
noxious stimulation of various sorts (mechanical, emotional,
infectious, metabolic or nutritional) they develop spasm and
shorten. A muscle in spasm will be unable to relax voluntarily
and it resists passive lengthening which results in poor
neuromuscular coordination.
2. Precipitating factors
a.

Stress Psychological factors:

Chronic stress plays a crucial role in aetiology of symptoms

of TMJ dysfunction. The pathogenesis of stress related symptoms

in TMJ dysfunction is believed to be related to increased autonomic
activity causing increased facial muscle activity. Harris et al, 1993
postulated that emotional stress could stimulate the release of
neuropeptides which could induce painful capsulitis or synovitis.

12

Stress is also associated with habitual tooth clenching and bruxism

which produces TMJ dysfunction. Various necrotic conditions such
as anxiety neurosis, minor stress disorders and post traumatic stress
syndrome are also associated with increased muscular activity and
may be important aetiologic factors in TMJ dysfunction.
b.

Bruxism:
It is defined as purposeless rhythmical habitual tooth

clinching or grinding movements which may occur either while

awake or during sleep.
Aetiology
i)

Psychic stress:
Investigations

have

confirmed

that

stressful

daytime

situations such as domestic quarrels, violent cinema films etc.

evoke an immediate increase in muscular activity and such stressful
situations are found to be correlated with high levels of tooth
grinding at night.

13

ii)

Occlusal interference:
Premature occlusal contacts on closure of the mandible in the

retruded contact position and balancing side interferences have

been found to be relatively more frequent in bruxism.
iii)

Other factors:
-

Magnesium deficiency and other dietary factors may

elicit muscular hyperactivity.

Muscular hyperactivity is a side effect of amphetamine

for weight reduction and levodopa in Parkinsons
disease.

Diagnosis:
-

Occlusal sounds during sleep.

Functional tooth surface wear.

Periodontal changes.

Masticatory muscle fatigue / pain specially on waking.

Masticatory muscle tenderness.

Recurrent head aches.

Fractured fillings or split teeth.

14

Soreness of oral mucosa below dentures.

Tenderness upon percussion of teeth.

Mucosal ridging of tongue and cheek.

Effect on masticatory muscles:

Masticatory muscle pain and fatigue.
Effect on teeth:
An early sign is the presence of shiny facets on the functional
surfaces of teeth or restorations. Further Bruxism leads to greater
attrition of enamel, which occasionally flakes off. Cupping of
exposed dentine occurs and in excessive tooth wear pulpal exposure
may take place.
Effect on periodontal tissues:
Protective reaction by periodontal tissues to compensate for
heavy occlusal forces results in hypertrophy of periodontal tissues.
Thickening of alveolar bone, exostosis formation, increased
trabeculation

of

alveolar

process,

thickened

periodontal

membrane consisting of heavy collagenous fibres and increased

periodontal fibre attachment to the cementum are observed.
15

c.

Oral Habits parafunction

A common finding in patients with TMJ dysfunction is that

they unconsciously perform purposeless jaw movements which

results in increased physical load on the masticatory muscles. The
habits involved are nailbiting, cheek biting, pencil biting, chewing
gum and occupational conditions like biting thread in textile
factories.
d.

Trauma
-

Trauma, such as blow to the jaw may lead to

inflammation and tissue damage perpetuating factors
like bruxism may delay healing.

Microtrauma may be caused by repetitive strain type

injuries that also might damage the TMJ or muscles of
mastication.

Some

patients

who

have

suffered

cervical

hyperextension / hyperflexion (whiplash) injury may

complain of the onset symptoms of TMJ dysfunction.

16

Symptoms of dysfunction are particularly common

after unilateral subcondylar fracture with significant
fracture displacement.

e.

Occlusal abnormalities:

i)

Occlusal deficiencies:
-

A common finding is that TMJ dysfunction occurs

when there is loss of molar support, which forces the
patient to chew on the anterior teeth rather than to use
them purely for incision which results in consequent
risk of overuse and pain.

Unilateral loss of natural teeth will result in unilateral

mastication. This will require increased action by
ipsilateral lateral pterygoid and contralateral masseter
muscle.

ii)

Interferences:
-

Introduction of an occlusal interference e.g. by an

inadequately contoured restoration may lead to TMJ
dysfunction.

17

Following extraction of teeth, drifting and tilting of

remaining teeth in the arch can take place.

Occlusal interferences can be created which cause

deviation of the lower jaw into an eccentric position
leading to tension and pain in the musculature.

iii)

Vertical dimension
Alteration of occlusal vertical dimension may produce

symptoms of dysfunction.
Over closure for long periods and sudden increase in vertical
dimension may also be a etiological factor in TMJ dysfunction.
iv)

Incisor relationship:
Increased overjet / overbite and open bite may also be

initiating factors in production of symptoms of TMJ dysfunction.

3. Perpetuating factors
They may be related to any combination of predisposing or
precipitating factors. Psychoimmunological changes may also
act as perpetuating factor.

18

CLASSIFICATION
[American Academy of Orofacial Pain] McNeil
1)

Articular
a)

Developmental
Deviation of form.

b)

Disc displacement
With reduction.
Without reduction.

c)

Hypermobility.

d)

Dislocation.

e)

Inflammatory
Synovitis.
Capsulitis.

f)

Arthritides
Osteoarthrosis.
Osteoarthritis.
Polyarthritides.

g)

Ankylosis
Fibrous / bony

2)

Non-Articular
a)

Masticatory muscle disorders.

Myofascial pain.
Myositis.

19

Spasm.
Protective splinting.
Contracture.
Neoplasia.
ARTICULAR
a) Developmental:
The embryonic development of TMJ is frequently disturbed,
leading to many kinds of abnormalities. Common growth
disturbances of the bones are agenesis (no growth), hypoplasia
(insufficient

growth),

hyperplasia

(too

much

growth)

or

neoplasia (uncontrolled, destructive growth).

Etiology
Trauma affecting condylar head
Genetic determination
Disease of adjacent structures, such as middle ear.
-

It is not completely understood.

Trauma may be a contributing factor especially in

young joint, can lead to hypoplasia of the condyle
resulting in asymmetric shift or growth pattern. This

20

ultimately causes an asymmetric shift of the mandible

with an associated malocclusion.
-

Trauma can cause hyperplastic reaction resulting in

overgrowth of bone commonly seen at the site of old
fracture.

Some hypoplastic and hyperplastic activities relate to

inherent

growth

activities

and

hormonal

body

imbalances (e.g. acromegaly).

History:
The clinical symptoms reported by patient are directly related
to structural changes present. Since these disorders usually produce
slow changes pain is not present and patients commonly alter
function to accommodate the changes.
Clinical characteristics:
-

Clinical asymmetry.

Pain is secondary to structural changes.

21

Definitive treatment:
It must be tailored specifically to the patients condition.
Generally

treatment

is

provided

to

restore

function

while

minimizing any trauma to associated structures.

Supportive therapy:
Since most bone growth disorders are not associated with
pain or dysfunction, supportive therapy is not indicated. If pain or
dysfunction arises, then treatment is rendered according to the
problem identified.
a) Deviation of form:
Etiology: It is caused by actual changes in the shape of articular
surfaces i.e. either condyle, fossa and / or the disc. Alterations
in form of bony surface may be a flattening of the condyle or
fossa or even a bony protuberance on the condyle. Changes in
the form of the disc include both thinning of the borders and
perforations.

22

History:
It is usually a long term dysfunction that may not present as a
painful condition. Often the patient has learned a pattern of
mandibular movement (altered muscle engrams) that avoids the
deviation in form and therefore avoids painful symptoms.
Clinical characteristics:
Most deviations in form cause dysfunction at a particular
point of movement when a click or deviation in opening is noted, it
will always occur at the same position of opening and closing. It
may / may not be painful.
Definitive treatment:
The definitive approach is to return the altered structure to
normal form which is often accomplished by a surgical procedure.
In case of bony incompatibility the structures are smoothened and
recorded. If the disc is perforated or misshaped, it is repaired
(discoplasty). Since surgery is a relatively aggressive procedure it
should be considered only when pain and dysfunction are

23

unmanageable. Most deviations in form can be managed by

supportive therapies.
Supportive therapy:
-

The patient should be encouraged, when possible, to

learn a manner of opening and chewing that avoids or
minimizes the dysfunction.

In case of increased interarticular pressure associated

with bruxism/muscle relaxation appliance is indicated
to decrease muscle hyperactivity.

If pain is associated, analgesics may be necessary to

prevent development of secondary central excretory
effects.

b) Disc Displacement:
Rotational and sideways displacements of the disk are most
typically

found

with

the

mouth

closed,

rotational

disc

displacement is characterized by an anterior, and medial or

lateral position of the disc with respect to an ideal position

24

between condyle and the eminence. The sideways displacement

consists of either a medial or lateral displacement.
Classification
a.

Disk displacement with reduction:

The disk is displaced from its position between the condyle

and the eminence to an anterior and medial or lateral position, but

reduces on full opening, usually resulting in a noise.
b.

Disk displacement without reduction:

A condition in which the disk is displaced from normal

position between the condyle and the fossa to an anterior and

medial or lateral position, associated with limited mandibular
opening.
c.

Disk

displacement

without

reduction

without limited opening:

A condition in which the disk is displaced from its position
between the condyle and the eminence to an anterior and medial or
lateral position, not associated with limited opening.
25

d.

Disk displacement with reduction:

Etiology: It results from elongation of the capsular and discal

ligaments coupled with thinning of the articular disc which
commonly results from macro/microtrauma. The other causes are
orthopedic instability plus joint loading.

History:
When macrotrauma is the etiology the patient will often
relate an event that precipitated the disorder. The patient will also
report the presence of joint sounds and catching sensation during
mouth opening.
Clinical characteristics:
Clinical examination reveals a relatively normal, range of
movement with restriction only associated with the pain. Discal
movement can be felt by palpation of the joints during opening and
closing. Deviations in the opening pathway are common.

26

Definitive treatment:
Definitive approach is to reestablish a normal condyle-disc
relationship. The treatment goal is to reduce intracapsular pain and
not to recapture the disc.
A muscle relaxation appliance should be used whenever
possible because adverse long term effects are minimal. When this
appliance is not effective, an anterior repositioning appliance
should be fabricated. The patient should be initially instructed to
wear the appliance always at night during sleep and during the day
when needed to reduce symptoms. This part time use will minimize
adverse occlusal changes. As symptoms resolve the patient is
encouraged to decrease the use of the appliance. These adaptive
changes can take 8 to 10 weeks or even longer. After elimination of
the appliance if symptoms return and orthopedic stability is
present, dental therapy to correct this condition is indicated.

27

Supportive therapy:
The patient should be educated to the mechanics of the
disorder and the adaptive process that is essential for treatment.
Softer foods, slower chewing, smaller bites should be promoted. If
inflammation is suspected, NSAIDs should be prescribed moist
heat or ice can be used if the patient finds either helpful. Passive
jaw movements may be helpful and on occasion destructive
manipulation by a physical therapist may assist in healing.
Disc dislocation without reduction:
Etiology:
Macrotrauma and microtrauma are the most common cause.
History:
Patients most often report the exact onset of this disorder. A
sudden change in range of mandibular movement occurs that is very
apparent to the patient. The history may reveal a gradual increase in
intracapsular symptoms (clicking and catching) prior to the
dislocation.
28

Clinical characteristics:
Examination reveals limited mandibular opening (25-30mm)
with normal eccentric movement to the ipsilateral side and
restricted eccentric movement to the contralateral side.
Definitive treatment:
The initial therapy should include an attempt to reduce or
recapture the disc by manual manipulation. In patients with longer
history, success by manual manipulation decreases rapidly.
Technique for manual manipulation:
The lateral pterygoid muscle must be relaxed. If it remains
active by pain or dysfunction it should be injected with local
anesthetic prior to any attempt to reduce the disc. Definitive
treatment begins by having the patient attempt to reduce the
dislocation without assistance. The patient is asked to move the
mandible to the contralateral side as far as possible. From this
eccentric position the mouth is opened maximally. If it fails,
assistance with manipulating is needed. The thumb is placed

29

intraorally over the mandibular second molar on the affected side.

The fingers are placed on the inferior border of the mandible
anterior to thumb position. Firm but controlled downward force is
then exerted on the molar and at the same time upward force is
placed by the fingers. The opposite hand helps stabilize the cranium
above the joint that is being distracted. While the joint is thus being
distracted, the condyle is brought downward and forward which
translates it out of the fossa. It may be helpful also to bring the
mandible to the contralateral side during the distraction procedure
since the disk is likely to be dislocated anteriorly and medially and
a contralateral movement will move the condyle onto it better. Once
the full range of laterotrusive excursion has been reached, the
patients is asked to relax while 20-30 seconds of constant
destructive force is applied to the joint. The patient then lightly
closes to the incisal end to end position on the anterior teeth and
after relaxing for few seconds open wide and returns to this anterior
position. An anterior repositioning appliance is immediately placed
to prevent any clenching on the posterior teeth which would likely

30

redislocate the disc. If the disc is not successfully reduced, a

second and possibly a third attempt will be needed.
Supportive therapy:
Patients should be encouraged not to open too wide
especially immediately following dislocation. The patient should
also be told to decrease hard biting, no chewing gum, and generally
avoid anything that aggravates the condition. If pain is present, heat
or ice may be used. NSAIDs are indicated for pain and
inflammation. Joint distraction and phonophereses around the joint
area can be helpful.
Surgical considerations for condyle disc derangement
disorders.
Surgery should be considered only when conservative therapy
fails to resolve adequately the symptoms and or progression of the
disorder.

31

Arthrocertesis:
-

Most conservative surgical procedures.

Two needles are placed into the joint and sterile saline
solution is passed through lavaging the joint. The
lavage is thought to eliminate much of the algogenic
substances and breakdown by products that produce the
pain.

Pumping the joint:

In cases of disc dislocation without reduction a single needle
can be introduced to the joint and fluid can be forced into the space
in an attempt to free the articular surfaces.
Arthroscopy:
An arthroscopy is placed into the superior joint space and the
intercapsular structures are visualized on a monitor. This procedure
appears to be very successful in reducing symptoms and improving
movement. It helps in improving disc mobility.

32

Arthrotomy:
It is a open joint surgery. A variety of arthrotomy procedures
can be performed when disc is displaced or dislocated, the surgical
procedure of choice is plication during which a portion of the
retrodiscal tissue and inferior lamina is removed and the disc is
retracted posteriorly and secured with sutures.
Disectomy:
When disc is damaged and can no longer be maintained for
use in the joint the disc is removed. It leaves a bone to bone
articulation which is likely to produce some osteoarthritic changes.
Another choice is to remove the disc and replace it with a substitute
Discal implants which include medical silastic, proplast-Teflon,
Dermal and auricular cartilage grafts.
Imaging of disk displacements can be done by:
-

Transcranial radiography.

Tomography.

Arthrography.

Computed tomography.

33

Magnetic resonance imaging.

Arthroscopy.

Ultrasonography.

c) Hypermobility:
Hypermobility does not necessarily represent a pathologic
condition. The term hypermobility implies there is radiographic or
clinical evidence that the mid axis of the mandibular condyle is
translating beyond the peak of the articular eminence.
It is also preferred to as subluxation. Clinical observations of
affected joints reveal that as the mouth opens to its fullest extent a
momentary pause occurs, followed by a sudden jump or leap to
maximally open position. The jump does not produce a clicking
sound but instead is accompanied by more of a thud. During
maximum opening the lateral poles of the condyles will jump
forward, causing a noticeable preauricular depression. Subluxation
is more likely to occur in a TMJ whose articular eminence has a
short setup posterior shape followed by a longer flatter anterior
slope. During opening the steep eminence requires a significant

34

amount of discal rotation to occur before the condyle reaches the

crest. As the condyle reaches the crest, the disc rotates on the
condyle to the posteriorly maximum degree allowed by the anterior
capsular ligament. In subluxating joint maximum rotational
movement of the disc is reached before the maximum translation of
the condyle. Therefore as the mouth opens wider the last portion of
the translatory movement occurs with a bodily shift of the condyle
and disc as a unit. This is abnormal and it creates a quick forward
leap and thud of the condyle disc complex.
Definitive treatment
-

Surgical alteration of the joint.

Eminectomy
It reduces the steepness of the articular eminence and thus
reduces the amount of posterior rotation of the disc on the condyle
during full translation.

35

Supportive therapy:
The patient must learn to restrict opening so as not to reach
the point of translation that initiates the interference. On occasion,
when the interference cannot be voluntarily resolved, an intraoral
device to restrict movement is employed. Wearing the device
develops a myostatic contracture of the elevator muscles, thus
limiting opening to the point of subluxation. The device is worn for
2 months and removed, allowing the contracture to limit the
opening.
DISLOCATION
Spontaneous dislocation:
This is commonly referred to as an open-lock.
Etiology:
When the mouth opens to its fullest extent, the condyle is
translated to its anterior limit. In this position the disc is rotated to
its most posterior extent on the condyle. If the condyle moves
beyond this limit, the disc can be forced thorough the disc space
36

and trapped in this anterior position as the disc space collapses as a

result of the condyle moving superiorly against the articular
eminence. This same spontaneous dislocation can also occur if the
superior lateral pterygoid contracts during the full limit of
translation pulling the disc through the anterior disc space. When a
spontaneous dislocation occurs the superior retrodiscal lamina
cannot retract the disc space. Spontaneous reduction is further
aggravated when the elevator muscles contract, since this activity
increases the interarticular pressure and further decreases the disc
space. The reduction becomes even more unlikely when the
superior/ inferior lateral pterygoid experiences myopasms, which
pull the disc and condyle forward.
History:
The patient reports this condition immediately following a
wide opening movement such as a yawn or a dental procedure.

37

Clinical characteristics:
The patient remains in a wide open mouth condition. Pain is
commonly present secondary to the patients attempts to close the
mouth.
Definitive treatment:
Definitive treatment is directed toward increasing the disc
space, which allows the superior retrodiscal lamina to retract the
disc. When attempts are being made to reduce the dislocation the
patient must open wide as if yawning. This will activate the
mandibular depressors and inhibit the elevators. At the same time
slight posterior pressure applied to the chin will sometimes reduce
a spontaneous dislocation. If this is not successful, the thumb
placed on the mandibular molars and downward pressure is exerted
as the patient yawns. This will usually provide enough space to
recapture normal disc position.

38

When spontaneous dislocation becomes chronic or recurrent,

definitive treatment may consist of surgical procedure directed
toward correcting the structures that contribute to the disorder.
Supportive therapy:
Most effective method is prevention. When spontaneous
dislocation is recurrent the patient is taught the reduction. Chronic
recurrent dislocations are treated by surgical procedure.
Inflammatory disorders:
They are generally characterized by continuous joint area
pain, often accentuated by function. Since the pain is constant, it
can also result in secondary central excilatory effects such as cyclic
muscle pain, hyperalgesia and referred pain.
The four categories are:
a) Synovitis.
b) Capsulitis.
c) Retrodiscitis.
d) Arthrritides.

39

e)

Synovitis and capsulitis:

These both can be distinguished only by visualizing the

tissues through arthroscopy or arthrotomy.

Etiology:
Trauma

Macro
Micro

Infection from adjacent structures.

History:
History of macrotrauma such as a blow to the chin. Trauma is
most likely to cause injury to the capsular ligament when teeth are
separated.
Clinical characteristics:
Any movement that tends to elongate the capsular ligament
will accentuate the pain which is reported to be directly in front of
the ear and the lateral aspect of the condyle is usually tender to
palpation.

40

Definitive treatment:
Since the etiology is self limiting there is no definitive
treatment indicated when recurrence of trauma is likely, efforts are
made to protect the joint from any further injury.
Supportive therapy:
-

The patient is instructed to restrict all mandibular

movements within painless limits-soft diet, slow
movements and small bites are necessary.

Patients with constant pain should receive mild

analgesics.

Moist heat 4-5 times a day for 10-15 minutes.

Ultrasound therapy 2-4 times / week.

Single injection of corticosteriod to the capsular

tissues. Repeated injections are contraindicated.

41

b) Retrodiscitis
It is a inflammatory condition of retrodiscal tissues. It is a
common intracapsular disorder.
Etiology
Trauma

Extrinsic
Intrinsic

Extrinsic: Created by a sudden movement of the condyle into the

retrodiscal tissues. These tissues often respond to this type of
trauma with inflammation which leads to swelling and on occasion
trauma to the retrodiscal tissues cause intercapsular hemarthrosis.
Intrinsic trauma: Occurs when an anterior functional displacement
or dislocation of the disc is present.
History
Patients experiencing retrodiscitis caused by intrinsic trauma
will report a more subtle history with a gradual onset of the pain
problem. They are also likely to report the progressive onset of the
condition (clicking cathing).

42

Patients experiencing retrodixites caused by extrinsic trauma

will report the incidence in the history.
Clinical characteristics:
-

Constant periauricular pain that is accentuated with

jaw movement.

Cleansing the teeth, increases the pain.

If the tissues swell a loss of posterior occlusal contact

can occur on the ipsilateral side.

Definitive treatment from extrinsic trauma:

Since etiologic factor of trauma is generally no longer
present there is no definitive treatment. When trauma is likely to
occur, care must be taken to protect the joint.
Supportive therapy for retrodiscites from extrinsic trauma:
If no evidence of acute malocclusion is found, the patient is
given analgesics for pain and instructed to restrict movement to
within painless limits and begin a soft diet. To decrease the

43

likelihood of ankylosis, movement is encouraged. Ultrasound and

chemotherapy are often helpful in reducing pain. If pain persists, a
single intracapsular injection of corticosteroids may be used in
isolated

cases

of

trauma,

but

repeated

injections

are

contraindicated. A muscle relaxation appliance should be fabricated

to stabilize the occlusal condition and eliminate further loading of
the retrodiscal tissues. On occasion when acute malocclusion
results from extrinsic trauma, intermaxillary fixation may be
indicated

to

reestablish

the

proper

occlusal

conditions.

If

intermaxillary fixation is used, the mandible should be freed at

least twice a day for atleast 10 minutes of movement.
Definitive treatment for retrodiscites from intrinsic trauma:
Definitive

treatment

is

directed

towards

eliminating

traumatic condition. An anterior repositioning appliance is used to

reposition the condyle off the retrodiscal tissues and onto the disc.

44

Supportive therapy for retrodiscitis from intrinsic trauma:

Supportive therapy begins with voluntary restricting use of
the mandible to within painless limits. Analgesics are prescribed
when

pain

is

not

resolved

with

repositioning

appliance.

Thermotherapy and ultrasound can be helpful in controlling

symptoms. Since the inflammatory condition is often chronic intraarticular injection of corticosteroids is generally not indicated.
Arthritis:
Arthritis means inflammation of the articular surfaces of the
joint. The different types are:
Osteoarthritis
Osteoarthrosis
Polyarthritides
Osteoarthritis
-

These are the most common arthritis. They are also

referred to as degenerative joint disease.

45

Etiology
Overloading of the articular structures of the joint. This may
occur when joint surfaces are compromised by disc dislocation and
retrodiscites.
History:
Report of unilateral joint pain that is aggravated by
mandibular movement. The pain is usually constant but often
worsens in the late afternoon or evening.
Clinical characteristics:
-

Limited mandibular opening is characterized because

of joint pain.

A soft end feel is common unless the osteoarthritis is

associated with an anteriorly displaced disc.

Crepitation can be typically felt.

Lateral palpation of the condyle increases the pain as

does manual loading of the joint. The patient may have

46

symptoms for as long as 6 months before there is

enough

demineralization

of

bone

to

show

up

radiographically.
Definitive treatment:
-

The mechanical loading should be decreased.

The condyle-disc relationship, anterior repositioning

appliance therapy should be used. When muscle
hyperactivity

is

suspected,

muscle

relaxation

appliance is indicated. Any oral habits that create pain

in the joint must be identified and discouraged.
Supportive therapy
It begins with an explanation of the disease process to the
patient. Along with the fabrication of an appliance in a comfortable
mandibular position. Pain medication and anti-inflammatory agents
are prescribed to decrease the general inflammatory response. A
soft diet is instituted. Thermotherapy is usually helpful in reducing
symptoms.

47

Osteoarthrosis:
Etiology
-

Joint overloading.

History
Since osteoarthrosis represents a stable adaptive phase
symptoms are not reported by the patient.
Clinical characteristics:
Ostearthrosis is confirmed when structural changes in the
subarticular bone are seen on radiographs but no clinical symptoms
of pain are reported by the patient.
Definitive treatment
Since osteoarthrosis represents an adaptive process, no
therapy is indicated for the condition. The only treatment that may
be considered is if bony changes in the condyle have been
significant enough to alter the occlusal condition.
Polyarthritides:
The six categories are:
-

Traumatic arthritis.
48

Infectious arthritis.

Rheumatoid arthritis.

Hyperuricemia.

Psioratic arthritis.

Ankylosing spondylitis.

Traumatic arthritis
When the condyle receives sudden macrotrauma a secondary
arthritic condition can develop. This traumatic arthritic condition
can lead to sudden loss of subarticular bone.
Definitive treatment:
Definitive treatment is not indicated when future trauma is
expected, he should be protected (e.g. a mouth protector for sports).
Supportive therapy:
It begins with rest, jaw use should be decreased and soft diet
is instituted.
Non steroidal antiinflamamtory medications are given to
reduce the inflammation. Moist heat is helpful. A muscle relaxation
appliance is indicated if there is increased pain to occlude the teeth

49

or if bruxism is present. Dental therapy should not begin until

symptoms have been totally resolved.
Infectious arthritis:
The common cause is trauma such as a punctured wound. A
spreading infection from adjacent structures is also possible.
Definitive treatment
Initiate appropriate antibiotic medication to eliminate the
invading organism.
Supportive therapy
After the infection has been controlled, supportive therapy
may be considered and should be directed at maintaining or
increasing the normal range of mandibular movement to avoid
postinfection

fibrosis

or

adhesions.

ultrasound may be helpful.

50

Passive

exercises

and

Rheumatoid arthritis
This condition produces a persistent inflammatory synovites
that leads to the destruction of the articular surface and subarticular
bone.
Definitive treatment:
There is no definitive treatment
Supportive therapy
It is directed toward pain reduction. Sometimes a muscle
relaxation appliance can decrease forces on the articular surfaces
and thereby decrease pain.
Hyperuricemia (gout)
It is an arthritic condition in which an increase in serum urate
concentrations precipitates urate crystals in certain joints.
Definitive treatment
It is directed towards lowering serum urate concentration.
The most effective method may be merely the elimination of certain

51

foods from the diet. However since this is a systemic problem, gout
is usually best managed on a medical basis by the patients
physician.
Supportive therapy
The patients physician will be treating the patient on a
medical basis.
Psoriatic arthritis
Definitive treatment
Since etiology is unknown there is no definitive treatment
available.
Supportive treatment
Often NSAID is helpful. Gentle physical therapy to maintain
joint mobility is important since hypermobility is often a
consequence of this disorder. On occasion moist heat and
ultrasound therapy may reduce symptoms and increase joint
mobility.

52

Ankylosing spondylitis
The clinician should be suspicious of ankylosing spondylitis
when a patient reports with a painful, hypomobile joint, no history
of trauma, and neck or back complaints.
Definitive treatment:
No definitive treatment is available.
Supportive therapy
Gentle physical therapy to improve joint mobility is
indicated, but care should be taken not to be too aggressive and
increase symptoms. On occasion moist heat and ultrasound therapy
may also be helpful.
Ankylosis
It means abnormal immobility of joint. It may be
Bony
Fibrous
A fibrous ankylosis is most common and can occur between
the condyle and the disc and the fossa.

53

A bony ankylosis of the TMJ would occur between the

condyle and fossa and therefore the disc would have to have been
lost already from the discal space.
Etiology:
Common

etiology

Haemarthrosis

secondary

to

macrotrauma. Fibrous ankylosis represents a continued progression

of joint adhesions that gradually create a significant limitation in
joint movement.
History
Patients report limited mouth opening without any pain. The
patient is aware that this condition has been present for a long time
and may not even feel that it poses a significant problem.
Clinical characteristics
The condyle can still rotate with some degree of restriction
on the inferior surface of the disc. Therefore the patient is usually
able to open approximately 25mm interincisally, lateral movements
are restricted. The clinical examination discloses a normal range of

54

lateral movement to the affected side. During mouth opening

pathway difficult to the ipsilateral side. No condylar movement is
felt or visualized on a radiograph.
Definitive treatment
If function is inadequate or the restriction is intolerable,
surgery is the only definitive treatment available.
Supportive therapy
Since ankylosis is normally asymptomatic generally no
supportive therapy is indicated. However, if the mandible is forced
beyond its restriction, injury to the tissues can occur. If pain and
inflammation result, supportive therapy is called for and consists of
voluantarily

restricting

movement

to

either

painless

Ankylosis along with deep heat therapy can also be used.

55

limits.

References:
1. Zarb A. George : TMJ and masticatory muscle disorders,
Ed. 2.
2. Friction R. James : Advances in pain research. Vol. 2.
3. Okenson P. Jeffrey : Management of temporomandibular
disorders and occlusion. Ed. 3.
4. Trowell Janet: Temporomandibular joint pain referred from
muscles of the head and neck. J Prosthet Dent 1960; 10: 745763.
5. Bruno A. Sebasteen : Neuromuscular disturbances causing
temporomandibular dysfunction and pain. J Prosthet Dent
1971; 26: 387-397.
6. McNeill

Charles

Management

of

temporomandibular

disorders. J Prosthet Dent 1997; 77: 510-22.

7. Okenson P. Jeffrey : Non surgical management of disc
interference disorders. Dent Clin North Am 35: 29-48.
8. Vaughan Cree, Homer: Temporomandibular joint pain. J
Prosthet Dent 1954; 4: 695-708.

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