Diseases of the Temporomandibular Joint

Structural Aspects Developmental Disorders Inflammatory Disorders Osteoarthrosis Functional Disorders Loose Bodies Neoplasms Age Changes in the Jaws & TMJ Trismus & Dislocation

Developmental Disorders: Condylar Aplasia

Extremely rare.
May be unilateral or bilateral. Most reported cases associated with other facial anomalies.

Developmental Disorders: Condylar Hypoplasia

Congenital: unknown causes, unilateral or bilateral. Acquired: trauma (birth injury or fracture), radiation, or infection usually extension from middle ear.

Developmental Disorders: Condylar Hypoplasia

The earlier the damage, the more severe is the resulting facial deformity.

Rare.

Developmental Disorders: Condylar Hyperplasia

Self-limiting.
Unknown cause.

Facial asymmetry and deviation of mandible to opposite side and malocclusion. Becomes apparent during 2nd decade of life.

Generally unilateral.

Inflammatory Disorders: Traumatic Arthritis

Damage to joint following acute trauma may lead to traumatic arthritis or hemarthrosis. Usually resolves if tissue damage is not severe. Otherwise, scar tissue formation may lead to ankylosis.

Inflammatory Disorders: Infective Arthritis

Rare. Infection may reach TMJ by: Direct spread from adjacent focus, e.g. middle ear or surrounding cellulitis. Hematogenous spread from distant focus. Facial trauma. Staphylococcus aureus most common isolate. TMJ may be involved in patients with infective polyarthritis, e.g. gonococcal or viral arthritis.

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Inflammatory Disorders: Infective Arthritis

Clinical Features:

Complications:

Pain.

Fibrous or bony ankylosis.

Trismus.
Deviation on opening. Signs of acute infection.

Inflammatory Disorders: Rheumatoid Arthritis

Non-organ specific autoimmune disease with articular and extra-articular manifestations. Commonly begins in early adult life. Affects women more frequently than men. Systemic distribution in which joint involvement is the main feature. Other features include*: Anemia. Weight loss. Subcutaneous nodules over bony prominences and joints. 10% of patients may show features of Sjgren syndrome.

Inflammatory Disorders: Rheumatoid Arthritis

Smaller joints are usually affected, particularly in the hand. Distribution tends to be symmetrical. TMJs involved in 20-70% of cases, although few complain of TMJ pain. When symptomatic, TMJ involvement presents as: Limitation of opening. Stiffness. Crepitus. Referred pain. Tenderness on biting. Severe disability is unusual.

Inflammatory Disorders: Rheumatoid Arthritis

Joint involvement starts as synovitis with intense infiltration of lymphocytes and plasma cells. Inflamed synovial tissues proliferate and synovial membrane becomes hyperplastic.

Inflammatory Disorders: Rheumatoid Arthritis

Synovial membrane forms folds which extend over articular surfaces, clothing them in a vascular pannus.

Inflammatory Disorders: Rheumatoid Arthritis

The pannus causes resorption of articular surfaces, which may extend into adjacent bone. Articular surfaces may become very irregular and fibrous ankylosis may result, either in the lower joint compartment or with total destruction of articular disc and complete ankylosis.

Inflammatory Disorders: Rheumatoid Arthritis

Erosion of condyle may be seen radiographically. .

Inflammatory Disorders: Rheumatoid Arthritis

Serological findings:

Presence of rheumatoid factor (RF) in 85% of patients. RF: an IgM-class autoantibody against chemical groups on IgG molecules. Its significance in RA and other CT diseases is unknown, but immune-complex deposition may be the mechanism involved.

Osteoarthrosis (Osteoarthritis)

A degenerative disease which mainly affects weight-bearing joints. In the TMJ it differs from other joints probably because: It is not a weight-bearing joint. The articular surface is covered with fibrous tissue rather than hyaline cartilage.

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It is rare in TMJ before 5th decade of life, but after that it increases proportionately with age.

Osteoarthrosis

Clinical features: Pain. Crepitus. Limitation of jaw movement.

Deviation on opening.
Many cases are clinically silent.

Osteoarthrosis

Clinical features: Clinical studies suggest a relationship in some cases between later development of osteoarthrosis and: untreated myofascial pain-dysfunction syndrome, loss of molar support, disc displacement. Spontaneous resolution is common.

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Osteoarthrosis

Histological changes: Early changes consist of uneven distribution of cells in articular covering of condyle +/- some osteoclastic resorption of subarticular bone. Vertical splits (fibrillation) develop in articular layer. Followed by fragmentation and loss of articular surface with eventual denudation of underlying bone.

Osteoarthrosis

Histological changes:

Reactive changes in exposed bone lead to thickening of trabeculae and formation of a dense surface layer-eburnation (bony sclerosis ).
Osteophytic lipping on anterior surface may occur.
Osteophytes: peripheral bone formation

There may be eventual perforation of the articular disc.

Osteoarthrosis

Radiographic changes:

Variable and not pathognomonic.

Focal or diffuse areas of bone loss on articular surface of condyle. Flattening and reduction in total bony size of condyle. Reduction in joint space. Osteophytes may be seen at anterior edge of condyle. If large, they may fracture off and present on radiographs as loose bodies.

Osteoarthrosis

Loose Bodies

Radiopaque bodies apparently lying free within the joint space are common in major joints but rare in TMJ. They may cause discomfort, crepitus, and limitation of movement. The main causes in TMJ are: Intracapsular fractures. Fractured osteophytes in osteoarthrosis. Synovial chondromatosis.

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Loose Bodies
Synovial Chondromatosis:

disease of unknown etiology characterized by formation of multiple nodules of cartilage which may calcify and ossify, scattered throughout the synovium. They may be released in the joint space and appear as loose bodies.

Neoplsams

Primary neoplasms of the TMJ are rare. Benign tumors such as chondromas and osteomas are more frequent than sarcomas arising from bone or synovial tissues.

Age Changes in the Jaws & TMJ

Atrophy of alveolar bone is mainly related to tooth loss. Its extent increases with age, and is probably accelerated by osteoporosis. It results in loss of facial height, upwards and forwards posturing of the mandible, especially in the absence of dentures.

Age Changes in the Jaws & TMJ

In the TMJs, it is difficult to distinguish changes due to ageing from those related to osteoarthrosis.
The main changes are related to remodeling of the articular surfaces and disc in response to functional changes following tooth loss. Remodeling may result in anterior displacement of the disc. There may be perforation of the disc, particularly of its posterior attachment with progressive joint damage and osteoarthrosis.