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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.