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Chapter 10
Diseases Affecting the
Temporomandibular Joint
•Copyright © 2014, 2009, 2004, 2000, 1996, 1992 by
Saunders, an imprint of Elsevier Inc.
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• Outline
Anatomy of the Temporomandibular Joint
• Normal Joint Function
• Temporomandibular Disorders
• Tumors of the Temporomandibular Joint
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Diseases Affecting the Temporomandibular
Joint (TMJ)
• Disorders of the TMJ include myofascial pain and
dysfunction (MPD), internal derangement syndrome,
osteoarthritis, and rheumatoid arthritis
• Benign and malignant tumors can also affect the
TMJ
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Anatomy of the Temporomandibular
Joint (TMJ)
• The TMJ is an articulation between the condyle of the
mandible and the glenoid fossa of the temporal bone
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Anatomy of the Temporomandibular Joint
• Fibrocartilage covers the
bony articulating surfaces
• Ginglymoarthrodial
movement
• An articular disk divides
the space
• Avascular and devoid of
nerve fibers
• Synovial fluid provides
nourishment and
lubrication
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Anatomy of the Temporomandibular Joint
• A synovial membrane lines the joint and produces synovial
fluid that nourishes and lubricates avascular surfaces
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Anatomy of the Temporomandibular Joint
• Palpation of the muscles of mastication may be
done to determine whether muscle spasm or
dysfunctional muscle activity is occurring
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Masseter
Temporalis
Medial pterygoid
Lateral pterygoid
Anterior digastric
Mylohyoid
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TMJ: Associated Muscles
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Normal Joint Function
• In the position of maximal occlusal contact, the mandibular
condyle rests within the glenoid fossa
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The articular disk is situated between the condyle, roof of the
glenoid fossa, and the articular eminence
• The first phase of opening is characterized by a rotational
(hinge) movement of the condyle followed by an anterior
translation (sliding)
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Temporomandibular Disorders
• Pathophysiology of temporomandibular joint
disorders
• Patient evaluation
• Types of temporomandibular disorders
• Treatment of temporomandibular joint disorders
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Temporomandibular Disorders (TMDs)
• TMDs are caused by abnormalities in the function
of either the joint itself or associated structures
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Majority of patients are female
Between 20 and 40 years of age
Female sex hormones play a role
Depression
Rheumatoid arthritis
Chronic fatigue syndrome
Chronic headache
Fibromyalgia
Sleep disturbances
Irritable bowel syndrome
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Pathophysiology of
Temporomandibular Joint Disorders
• Trauma
• Direct (assault)
• Indirect (whiplash injury)
• Resulting from parafunctional habits such as clenching or
bruxism
• Psychosocial factors (stress)
• Dentofacial deformities
• May be associated with disorders in growth and
development as in condylar hyperplasia or
hypoplasia
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Pathophysiology of Temporomandibular Joint
Disorders
• Abnormalities are associated with a number of systemic
diseases:
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Depression
Rheumatoid arthritis and osteoarthritis
Chronic fatigue syndrome
Chronic headache
Fibromyalgia
Sleep disturbances
Irritable bowel syndrome
• Female sex hormones play a role
• Iatrogenic cause
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Patient Evaluation
• Dysfunction may be caused by disorders of muscles
of mastication or by internal derangements of
components of the joints
• Evaluation involves a comprehensive history and
thorough clinical examination
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Chief complaint
History: Chief complaint, medical, dental
Examination
Imaging
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Patient Evaluation
• Patient management:
• Reduced mouth opening
• Shorter appointments
• Pain control
• Three cardinal features of temporomandibular
disorders:
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Orofacial pain
Joint noise
Restricted jaw function
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History
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Ask questions!
Medical/dental history
Precipitating events
Circumstances that exacerbate or diminish symptoms
Onset and progression of symptoms: Sudden or gradual
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Joint symptoms (clicking, popping)
Pain
Problems with mastication
Trismus
Malocclusion
Parafunctional habits (bruxing, clenching)
Extensive dental or orthodontic treatment
History of surgical treatment of the jaws
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Investigate Patient’s History
• Orofacial pain: What is causing it?
• Referral may be necessary
Differential Diagnosis:
TMDs
Pericoronitis
Caries
Cracked tooth syndrome
Infection
Pulpalgia
Mucosal disorders
Burning mouth syndrome
Headache
Neuralgia
Fibromyalgia
Otitis media
Sinus infection
Cervical spine pain
Salivary gland pathology
Tumor
Trismus
Oral surgery procedures
Local anesthetic
Facial bone fractures
Radiation therapy
Medications
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Clinical Examination
• Includes examination of the joint, muscles of mastication, oral
cavity, and cervical spine
• Auscultation
• Palpitation
• Are joint noises such as clicking, crepitus, or popping related to
mandibular movement?
• Evaluate movement of mandible in a normal rotation and
translatory cycle
• Measure interincisal opening and note any obvious deflection to
the right or left side
• Note lateral excursions, protrusions, deviations, and deflection
• Evaluate occlusion
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Imaging
• Panoramic
• Transcranial
• Tomography
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• Computed tomography
• Magnetic resonance imaging
• Arthrography
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Imaging
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MRI Imaging
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Types of Temporomandibular Disorders
• Myofascial pain and dysfunction
• Internal derangements
• Arthritis
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Myofascial Pain and Dysfunction
• A dysfunctional muscle hyperactivity with regional
pain, tenderness in affected muscles, and variable
amounts of reduced opening and complaints of
malocclusion
• Comprises at least 50% of all TMDs
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Internal Derangements
• An abnormal positional relationship of the disk
relative to the mandibular condyle and the
articular eminence
• Continuous pain exacerbated by jaw movement
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Disk Displacement
• With reduction
• It may be displaced anteriorly and returns to normal
position when the mouth is opened or movement is away
from the affected side
• Without reduction
• It may act as an obstacle to the sliding condyle
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Patients may complain of problems such as intermittent
locking of the jaw; a sudden onset of limited mouth
opening, usually associated with cessation of joint sounds;
deflection of the mandible, with a midline correction on
opening; and restricted lateral excursive movements away
from the affected side
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Arthritis
• Inflammation of the joint
• Osteoarthritis
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Characterized by degenerative changes of the cartilage
Pain symptoms that are worse in the evening
Limited opening
Muscle splinting
Crepitus
• Rheumatoid arthritis
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An inflammatory, immunologic disorder of the joints
Symptoms that are worse in the morning
Limited opening
Occlusal changes
Preauricular edema
Tenderness
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Hypermobility Disorders
• Dislocation
• When one or both of the condyles translates anterior to the
articular eminence, leading to an open lock the patient
cannot reduce
• Subluxation
• Hypermobility in which the patient can relocate the
mandible back into the glenoid fossa
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Ankylosis
• Immobility of the condyle caused by fibrous or
bony union between articulating surfaces
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Joint infection after trauma accounts for 50% of all cases
30% result from trauma without infection
• Classified by:
• Tissue type (fibrous, bony)
• Location (intraarticular, extraarticular)
• Extent of fusion (complete, incomplete)
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Tumors of the Temporomandibular Joint
• Osteochondroma
• Osteoblastoma
• Chondroblastoma
• Osteoma
• Synovial chondromatosis:
Most common benign
neoplasm of the synovium
• Osteogenic sarcoma:
Commonly occurring
malignant bone tumor
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Treatment of Temporomandibular Joint
Disorders
• Nonsurgical treatment
• Surgical treatment
• Multidisciplinary treatment
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Nonsurgical Treatment
• Goals involve improving function and reducing pain
• Pharmacologic therapy: Pain medication, muscle
relaxants, and antianxiety agents
• Moist heat
• Physical therapy
• Soft mechanical diet
• Jaw stretching
• Coordination exercises
• Occlusal adjustments
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Nonsurgical Treatment
• The second phase involves the use of occlusal
appliances
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These may relax muscles, protect dentition, stabilize and
protect the joint, and provide biofeedback by making
patients aware of their bruxing habits or by relieving the
load on the disk
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Surgical Treatment
• Arthrocentesis
 Lavaging the joint through a needle
• Arthroscopy
 Allows direct visualization and manipulation of the
joint
• Open joint surgery
• Used to perform disk reconstruction with a prosthetic device
or autogenous graft
• Eminectomy
• Removal of the articular eminence of the temporal bone
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• 331992 by Saunders, an imprint of
Elsevier Inc.
Multidisciplinary Management
• Patients may require referral to specialists such
as a neurologist or an otolaryngologist
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Discussion Questions
• How is normal joint function defined?
• What are some of the symptoms of
temporomandibular disorders?
• What are some nonsurgical treatment methods
for temporomandibular joint disorders? Surgical
methods?
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Saunders, an imprint of Elsevier Inc.
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