Download Classification and diagnosis of tempro

Dr. Sahar Taha, BDS, MS, Dip-(ABOD)
 Temporomandibular
disorders: conditions
producing abnormal, incomplete, or impaired
function of the temporomandibular joint(s)acronym: TMD
The Glossary of Prosthodontic Terms, 2005
 TMD
is a common disorder; 38% of the
population has at least one symptom of TMD.
Rutkiewicz et al., 2006
 Females
are usually more affected.
 It is common also in adults.
Selfadministered
questionnaire
Oral history
(taken by
the dentist)
Supplemental:
•Radiography
•EMG
Clinical
examination
 Radiographs
are advocated if there is
crepitation in the joint as radiologic
findings will determine whether a TMJ
patient should receive extended dental
treatment. The use of EMG in diagnosis
and treatment of TMD did not add any
additional information beyond that
obtained form patient history, clinical
examination and, if needed, appropriate
imaging.
Acute muscle disorders
Disc-interference disorders
Joint inflammatory disorders
Chronic hypomobility disorders
Growth disorders
 Common
symptoms

Muscle pain (myalgia) is the most common
complaint given by patients with functional
disturbances of the masticatory system.

Restricted mandibular movements (extracapsular in origin).

Acute malocclusion (occasionally).
 Restricted
mandibular movements is not
intracapsular. It is induced by the inhibitory
effect of pain. It is also not related to any
structural change in the muscle itself.
Acute muscle
disorders
Muscle
splinting
Muscle
spasms (MPD)
Muscle
inflammation
(myositis)
Muscle splinting
1.
It is the first reaction to altered proprioceptive and
sensory input.
Such alterations may arise from dental treatment,
gingival pain (e.g. denture irritation) or even the
administration of local anesthetics.
Short duration; disappears when the etiological
factor is resolved.
Signs and symptoms:








Pain that originates in the muscles especially upon
contraction
Muscle weakness
No restriction to jaw movement except to avoid
concomitant pain
No acute muscle-induced malocclusion
 Short
duration is few days long.
 If the etiological factor is not corrected, this
condition may progress to a more chronic
form of the disease.
Masticatory muscle spasms (Myofascial Pain
Dysfunction Syndrome) MPD
2.



Continuous muscle splinting can lead to muscle
spasms.
As the pain of muscle splinting continues, it
feeds back and influences the general state of
the muscle, increasing the activity of the
gamma efferents, which in turn increases
muscle activity.
Contributing factors:



General and physical fatigue
Systemic illness
Emotional stresses
 Any
of the etiological factors that cause
splinting can lead to spasms if not controlled
or eliminated.
Masticatory muscle spasms (Myofascial Pain
Dysfunction Syndrome) MPD
2.
Secondary effects of MPD:



Increased interarticular pressure in the TMJs due to
the increased activity of the masticatory muscles.
This increase may predispose to disc-condyle
interferences during function.
Acute malocclusion.
Signs and symptoms:



Pain in the muscles during contraction and
stretching (soft end feel).
Specific to the muscles involved.
 The
spasms may alter the resting position of
the mandible and an apparent change in
occlusion.
 The change in mandibular movements is said
to be of extra-capsular origin. Anything that
starts in the joint itself is said to be intracapsular.
Masticatory muscle inflammation (Myositis)
3.


As myospasms continue, inflammation may
arise in the muscle tissues.
Etiology:




Same etiological factors as splinting and
myospasms.
Local injury (trauma) and subsequent infection to
the muscles.
Direct extension of an inflammatory condition
from nearby structures.
Signs and symptoms:


Pain and soreness in the muscle at rest and during
contraction.
Restriction of mandibular movements.
 Elevator
muscles are usually affected with
this condition.
Acute muscle disorders
Disc-interference disorders
Joint inflammatory disorders
Chronic hypomobility disorders
Growth disorders
 Commonly
referred to as Internal
Derangement.
 Involves the breakdown of discal
attachments, resulting in anterior and
medial displacement of the disc.
 Internal
derangement describes one of the
most commonly encountered disc
interference disorders.
 The disc should move along with the
movement of the condyle. If the disc does
not follow the condyle, this is when internal
derangement is apparent.
 Caused
by trauma or muscle hyperactivity.
 Signs and symptoms:





Joint tightness
Clicking
Crepitation
Jaw locking
Altered or restricted mandibular movements
 Signs
Reciprocal click (Click
is evident both upon
opening and closing),
or reproducible
opening click
 May have deviation in
active vertical
mandibular range of
motion and/or in
protrusion
 No restriction in
active vertical
mandibular range
motion

 Signs



No TMJ sounds
(possibly crepitus)
Restriction in active
vertical mandibular
range motion and
laterotrusion
May have deflection
in active vertical
mandibular range of
motion and/or in
protrusion
 Disc
interference problems may present as
a complete disc dislocation in its most
severe form.
Acute muscle disorders
Disc-interference disorders
Joint inflammatory disorders
Chronic hypomobility disorders
Growth disorders
 Continuous
deep pain accentuated by function
 Referred pain
 Excessive sensitivity to touch
 Increased muscle spasm activity
 Classified into:



Synovitis or capsulitis
Retrodiscitis
Inflammatory arthritis
 2-4
points are called secondary excitatory
effect.
Synovitis or capsulitis
When the synovial membrane or capsular
ligament become inflamed, the joint area may
be tender to palpation and will occasionally be
swollen.
 Discomfort during mandibular movements.
 Etiology: trauma, wide opening, abusive
movement or spreading of an adjacent
inflammation.
 Continuous pain originating in the joint area is
often described.
 Acute malocclusion

 If
inflammation increases joint fluids, it will
displace the condyle inferiorly causing
disclusion of the posterior teeth on the
ipsilateral side.
Retrodiscitis
 Trauma is the most frequent cause (external
or internal)
 Swelling accompanied by acute malocclusion
 If trauma is extensive, intercapsular bleeding
(hemarthrosis) can occur with ankylosis of
the joint
 Pain accentuated by clenching in centric
occlusion and relieved by clenching on a
separator
 External
trauma like a blow to the face.
Internal trauma when the disc functions on
the retrodiscal tissues.
 The displacement of the condyle and disc is
forward causing a class III interference.
There will be disclusion of the ipsilateral
posterior teeth with heavy occlusion on the
contralateral anterior teeth.
Inflammatory arthritis
 Involves articular surfaces
 Results in the destruction of the articular and
subarticular osseous structures of the joint
 Constant pain that is accentuated by
movement
 Subclasses:





Traumatic arthritis
Degenerative joint disease
Infectious arthritis
Rheumatoid arthritis
hyperuricemia
Inflammatory arthritis

Traumatic arthritis


When a joint receives trauma, the initial response is
often synovitis. Other structures in the joint can also be
injured.
Degenerative joint disease




It is primarily a non-inflammatory disease in which the
articular surfaces of the joint and their underlying bone
deteriorate.
Precise etiology is unknown; however, it may be
associated with mechanical overloading.
Patients usually complain of pain that worsen as the day
progresses and crepitation.
Diagnosis is supported by radiographic evidence of
changes in the subarticular surfaces of the joint.
 Degenerative
joint disease has been referred
to as osteoarthrosis.
 Radiographic evidence like flattening,
osteophytes, erosions to the condyle or
fossa.
Inflammatory arthritis

Infectious arthritis



Associated with systemic diseases, a bacterial invasion
or an immunologic response.
Diagnosis is established by the history, symptoms,
clinical examination, blood studies and sometimes
examination of fluids aspirated from the joint cavity.
Rheumatoid arthritis



It is an inflammatory disorder of the synovial
membrane. (may extend to other stuructures)
As force is placed on the articular surfaces, the
synovial cells will release enzymes that damage the
joint tissues, especially the cartilage.
In severe cases, osseous tissue may be resorbed. Acute
malocclusion may occur.
 Although
small joints like the hand are
primarily involved with RA, TMJ can also be
affected. Diagnosis is confirmed by symptoms
of other involved joints and blood tests.
 In rheumatoid arthritis, an anterior open bite
may result.
Inflammatory arthritis

Hyperuricemia


Commonly known as “gout”
Precipitation of uric acid in the synovial fluid of the
joints, due to high serum levels.
 Affects
old people and the great toe
primarily.
Acute muscle disorders
Disc-interference disorders
Joint inflammatory disorders
Chronic hypomobility disorders
Growth disorders



It is a long-term painless restriction of mandibular
movements.
Pain only arises when trying to force the mandible to move
beyond its limitations.
No associated acute malocclusion.
Chronic
mandibular
hypomobility
Contracture of
the elevator
muscles
Myostatic
contracture
Myofibrotic
contracture
Capsular
fibrosis
Ankylosis
o
o
o
o
o
o
Contracture of the elevator muscles refers to reducing the
resting length of the muscle without affecting its ability to
contract. Limiting mouth opening.
The two subtypes of elevator muscle contracture can’t be
differentiated easily clinically.
Mysotatic contracture results when a muscle is restricted from
full relaxation (stretching) for a prolonged time.
Myofibrotic contracture results due to excess tissue adhesions
within the muscle or its sheath. Usually follows myositis.
Capuslar fibrosis associated with a history of trauma or
inflammation. Results when capsular ligaments become fibrotic.
It limits all mandibular movements. Mandible will deflect to the
ipsilateral side upon opening.
Ankylosis can be fibrotic due to a previous hemathrosis from
trauma, or osseous due to a history of infection. It limits all
mandiblar movements. Mandible will deflect to the ipsilateral
side upon opening.
Acute muscle disorders
Disc-interference disorders
Joint inflammatory disorders
Chronic hypomobility disorders
Growth disorders
 Hypoplasia
 Hyperplasia
 Neoplasia
 Asymmetry
may be noticed in such cases.
 Radiographs and bone scans are extremely
beneficial for the diagnosis.